My fourth year began with my one month Sub-Internship (Sub-I) in the adult Intensive Care Unit (ICU). For those unfamiliar, as sub-I’s, fourth year medical students are typically given similar responsibilities as an intern (first year resident) in acting as the primary provider and communicator for their patients. This invaluable experience helps medical students enhance critical thinking and decision-making before entering residency, because it allows students to participate in all aspects of care including: evaluating, examining, diagnosing, treating, and managing the patient (of course with supervision).
I had been in the ICU a few times on clerkships during 3rd year for a few of our patients for extra monitoring, and had come to form my own assumptions that it was an intimidating place filled with lots of machines, chaos, and irreversible sickness. The view I had painted was one of fear, exhaustion, and sadness. However, like most things in life, you never know what something is truly like until you experience it. I admit that some of the ways I had envisioned the ICU were inescapable and true. However, once I learned how the ICU operated and understood how tough situations and complex decisions were thought out and managed in a piece by piece manner, my perspectives about this part of the hospital significantly changed and this ended up being one of my favorite rotations to date.
In the ICU, I saw the delicate tug between fragility and resilience in patients. The individuals on these units are often very sick, fighting for their lives. It is remarkable to see patients who you thought were not going to make it, suddenly improve after caring for them for weeks, creating a truly joyful moment for both the medical team and the family. Unfortunately, there were also many patients who did not make it despite our best efforts. However, as a team we had the privilege of caring for and providing comfort until the end to allow them to pass in peace and with dignity.
I saw first hand the difficulties in sometimes separating emotions from clinical medicine when trying to make decisions. This highlighted the significance of communication and transparency with patients, their families, and within medical teams to allow patients to live the end of their lives in the most comfortable way possible based on their morals, beliefs, values, and what matters most to them.
I came to realize the ICU embodies qualities of a patient and family centered environment. For those patients who are unable to voice their choices of medical care, family members become integral members of the team by giving input about their loved one’s perceived wishes (or what they think the patient would have wanted), which helps guide our decisions regarding how much or how little intervention to proceed with. Open communication with the family plays an important role because that allows the family to build a more trusting relationship with the team. This then translates into better patient care because the family is more comfortable and better able to make decisions about what is best for the patient, which can sometimes mean using minimal intervention to sustain life and keep the patient comfortable near the end.
Families coming together to make decisions on behalf of their loved ones at the end of life placed me in unfamiliar and uncomfortable situations, yet allowed me to realize the importance of these intimate, tough conversations. As medical students in the first two years, our focus is learning how to diagnose, maintain health, and treat. Rarely are we taught about end-of-life topics in the pre-clinical years and the ethical and complicated dilemmas that tend to come with such situations. Exposure to these clinical situations occurs during clerkships. At first it is hard to let go of the mindset that we should use all the tools at our disposal to sustain life, rather than accept that in some scenarios additional medical interventions may be futile and cause more harm than good, especially when the intervention will not change the outcome or prognosis and further hinder quality of life.
In addition to the medical treatment, this rotation further emphasized the equal importance in compassionately supporting, comforting, and being there for the patient and their family members. Even if medically nothing else can be or should be done, listening, empathizing, caring, spending time with the patient, hearing stories from family members and investing in the patient beyond illness can create a sense of healing.
The fast-paced, dynamic, busy environment of the ICU kept me on my toes. Constant learning, partaking in family discussions with our team and other sub-specialists, observing and performing procedures, understanding how ultrasound aids in diagnosing and decision-making, and having the support of the palliative care team allowed for an intense, rewarding experience.