IT IS COLD AND RAINING OUTSIDE THE HOSPITAL—TYPICAL FOR THIS TIME of year. Rounds are about to start in the Intensive Care Unit. It’s going to be a long day, as the unit is full. There are many tests that will need to be ordered and reviewed, many treatment options to consider, and many conversations with patients and family members that will need to take place. The charge nurse calls for the team to gather: the lead attending physician, the nurses, the pharmacist, the social worker, a medical resident. The difficult business of tending to patients on the edge of life is beginning its daily cycle.
The first stop is the room of a seventy-year-old woman who came to the emergency room with abdominal pain. Her symptoms began a little more than a day before she called the ambulance and got progressively worse during that time. By the time she came to the ER the night before, she was pale, and her skin was cool and clammy. Her blood pressure was low, which is why she was sent to the ICU.
Now, twelve hours later, her pressure continues to remain low, and she has been given special medications called “pressors” to boost it. She is awake but drowsy, and she doesn’t respond much to questions. The team sweeps in and gathers around the bedside, looking over the paper chart, logging in to the portable laptop computer to review the labs, Shuffling around to accommodate the group in the small space.
The patient’s daughter and husband sit nearby. They are not asked to leave.
The medical resident summarizes the case for the team. Since coming in to the hospital, the patient has been given fluids and antibiotics. The resident explains that the on-call radiologist performed an abdominal ultrasound the previous evening.
“Why didn’t we get a CAT scan?” the attending physician asks.
“Her creatinine was 1.4,” the resident responds. “They wouldn’t give her the contrast.”
“So what did it show?”
“Normal bowel gas pattern, liver looked okay, not much else.”
“Do we know why her kidney function is so low?”
“No, we don’t,” says the resident, who then offers a few thoughts as to what might be the cause and how it might be worked up. “I think if she doesn’t improve, then we should call radiology and push for the CAT scan.”
“We could throw her into ATN,” the patient’s nurse observes. “And it may not help us with the diagnosis.”
None of this technical language is translated for the family, and the team doesn’t stop to unpack the subtleties of the diagnostic dilemma. This is rounding as it’s been done for generations in medicine: a highly specialized, fast-paced discussion to consider what is going on and what more needs to be done to restore a patient to health. What makes these rounds unusual is that this discussion is taking place directly in front of the family. There is no attempt to make it anything other than what it is, so the family has a direct window on how the team “really” functions. And although they have understood little of the jargon being bandied about, they heard the phrase “no, we don’t” quite clearly and understood exactly what that meant.
The discussion continues for several more minutes. They examine the patient, itemize the various issues involved in her care, and formulate a detailed plan for the day. At the end, as the team readies itself for the next patient, the attending physician turns to the husband and daughter and explains, this time in the language of laypeople, the plan, which mainly revolves around finding the cause of the pain and the low blood pressure. Finally, he asks if they have any questions.
“So, you don’t know why she’s sick?” the daughter asks.
“Right now, I’m not sure.”
“And you think it’s a good idea to get this CAT scan, or not?”
“At the moment, I’m not sure. I want some more tests to return before I decide on that. Normally the CAT scan in this case is the best test we could order, but with her that carries some real risk, mainly because of the fact that the contrast we use can damage the kidneys, sometimes irreversibly.”
“Do you think she needs antibiotics?”
“Yes. Of that, I’m pretty sure, at least until we have some other explanation that would clearly indicate we can safely stop them.”
And with that, the team leaves.
What this family just witnessed was a discussion in which they heard the phrases “we don’t know” and “I’m not sure” more than once. To some laypeople, that may smack of clinical incompetence or cluelessness, but actually such phrases are common currency in medical rounds. Nothing about this example is particularly unusual. Patients with unknown conditions and diagnostic dilemmas like hers are medicine’s daily bread. Yet, far from creating anxiety and distress, the husband and the daughter are satisfied with the care she is receiving, and the frank admissions of uncertainty leave them more confident in the team than they would be if they had not been allowed to observe rounds in its unadorned state.
The example is fictitious.
But this ICU, where doctors and nurses and other health professionals openly confess to uncertainty, in plain sight of patients and families, is real.