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In the Danger Zone

1.

To enter a hospital is to pass into a zone of occasional and unusual danger. Many illnesses invite well-tried treatments with normally uncomplicated outcomes. But unintended catastrophe is always at hand. In John Murray’s unsettling account of life on the intensive care unit at San Francisco General Hospital, one story exemplifies the intrusion of unexpected disaster.

Day 26 of Murray’s month on service. Julius Upshaw, who drinks too much, injects himself with heroin, and earns a lean living as a panhandler, has been admitted three weeks before with an infected human bite. The story is that he has been caught in a brawl, the outcome of which has left his hand trapped between the clenched jaws of his opponent. The human mouth is a paradise for bacteria, and Mr. Upshaw’s swollen hand is now oozing thick pus. Crimson threads—infected lymph vessels—track toward his armpit.

Treatment is straightforward: intravenous antibiotics. But without a ready supply of alcohol, Mr. Upshaw quickly begins to shake uncontrollably from acute withdrawal. He is sedated, and immediately aspirates vomit into his lungs. A nasty pneumonia ensues that, in the presence of a serious blood infection, tips his kidneys into failure. He develops a syndrome in which his entire body swells with fluid, turning him into a ball of human flesh. The retained fluid begins to spill into Mr. Upshaw’s lungs. Quite reasonably, it is decided to remove some of this fluid with a needle to prevent him from drowning. The lung, less reasonably, collapses and surgeons are summoned to place a tube into his now hollow chest cavity. By this time, there is only one safe place for this unlucky patient to go: the intensive care unit.

Murray’s diary of daily patient admissions—sixty in all—puts the reader at the center of the tense decision-making that frequently takes place in a crisis setting. San Francisco General is a tough front-line city hospital for the disadvantaged, founded in 1850 during a bitter cholera epidemic. It faces the raw edge of urban living.

Despite these pressures, Murray’s style is methodical. Each day’s account opens with a brief introduction to a large issue—misdiagnoses, the language of medicine, the threat of infection—which is then illustrated by a case or two from the day’s admissions. Murray ties his narrative together by interweaving the stories of patients already in the ICU with the experiences of his new patients.1 This device enables him to select and discuss aspects of their clinical course that throw light on both the inexact arts of intensive care and intensely personal issues, such as how one dies.

His “chief purpose” is “to inform people about what really goes on in ICUs…. Few have this information, but it concerns everyone.” By writing in depth about this one specialty of medicine, and for a broad general audience rather than for other physicians alone, Murray follows a long twentieth-century tradition of clinical narratives. This genre was inaugurated by William Carlos Williams in The Doctor Stories.2 In essays such as “The Use of Force,” medicine was shown to be a messy affair, with many predicaments that seem far away from the orderly clinic or antiseptic operating room.

The approach that Williams used so well has been further and finely developed by Richard Selzer, a surgeon, who, in books such as Letters to a Young Doctor and Mortal Lessons,3 used the confessional and interpretative essay to describe some of the most unexplored trenches of medicine. An example of a recent new voice in this tradition is Frank Huyler’s The Blood of Strangers.4 This narrative vein of medical writing has become gorged to such a degree that its study has become an academic discipline in its own right.5

But Murray has a larger purpose than simply to develop the heritage of doctor as writer or to open a window for those curious enough to look through. He is disturbed that the view of ICU medicine presented to the public seriously distorts the truth. For instance, the success rate for resuscitations acted out in television series such as ER is 75 percent. The true figure is 15 percent. Murray’s observations—he has worked in intensive care for much of his career—lead him to two conclusions. First, “that death is an ever-present part of the ICU story.” And second, “that death is not a correctable biological condition—it is everyone’s ultimate destiny.”

We might think that ICUs work miracles. They do not. They fail more often than they succeed. That reality is not a comfortable one to admit, but it matters because it forces us to confront issues such as physician-assisted suicide with an honest understanding of what medicine can fairly be expected to achieve. The evidence that Murray accumulates from his sixty patients allows him to construct a persuasive argument. In sum, it is “that the current decision-making process [in ICUs] can and should be improved.”

This critical look at intensive care is a surprising and important departure for Murray. His academic reputation rests largely on his co-editorship of a comprehensive review of respiratory medicine,6 which was first published in 1988. A third edition will come out this year. In the preface to the first edition, Murray and Jay Nadel emphasize their belief in the logical scientific basis of respiratory medicine: “A strong foundation in these basic sciences will make possible a rational and scientific approach to the more specialized clinical material.” In the past twenty years, his research and other writings have concentrated on tuberculosis, HIV, and the interplay between these two lethal infections. In other words, Murray has been a sober academic commentator on a highly technical discipline. Something striking seems to have taken place to lead him to write for a new audience.

Murray’s sardonic description of the tribal nature of hospital life makes his case that much more convincing. He creates a telling picture of the ICU. At the apex of the tribal hierarchy is the attending physician who has overall responsibility for patient care and who gives out “orders” each day. A cadre of young doctors—from confident first-year residents to wiser third-year residents—carry out these instructions, do the scut work, and cover nights while their bosses sleep or, as Murray once admits, sneak off during the day to play the occasional game of tennis. Residents throughout the world have a highly variable sense of respect for their attending physicians. Murray is self-consciously aware that his ways are seen as old-fogeyish by some of his younger colleagues.

Nurses, not doctors, hold the ICU together. They know more about their patients than any doctor and they are frequently more experienced than residents at the technical aspects of ICU care. There are competing specialists too. Surgeons are impatient aggressors, holding their scalpels poised to slice through the procrastinations of dithering colleagues. Murray is sensitive to their highly charged presence:

Surgeons routinely perform technical feats no internist would ever conceive of undertaking, and they bring those brilliant skills with them when they consult on a patient. But they often bring their giant egos and short fuses as well. A surgeon friend of mine has characterized his confreres as “Often wrong, but never in doubt.” By contrast, the call to arms for internists is “Don’t just do something, stand there.” It is undoubtedly good for the profession that it includes men and women of instant action as well as those of prolonged reflection; but when these polar temperaments meet at the bedside of a sick person, things can heat up.

Somehow these tribes do work together, in a balance of often ferocious suspicion.

Doctors also take part in rituals that strengthen their traditional tribal loyalties. At San Francisco General Hospital, as elsewhere, these rituals have included daily ward rounds, morning report, weekly grand rounds with a retinue of residents, and even “liver rounds,” at which a drink or three was taken to celebrate the end of the week. Murray is nostalgic about these rituals because he sees the ethos that they embody—and so the spirit that binds the medical team together—now being irrevocably eroded. Bedside ward rounds are being diminished by the false notion that to discuss a patient’s care next to the patient is somehow demeaning; grand rounds by academic arrogance and the perfidious intrusions of the pharmaceutical industry; and “liver rounds” by the replacement of beer and pretzels with more socially correct ice cream and cookies.

It is in the daily detail of an ICU at work that Murray wonderfully depicts a place of function and dysfunction. His account is based on the stories of his sixty admissions, all with various combinations of failing hearts, lungs, brains, kidneys, livers, and intestines. Causes of death range from bizarre accident (a carrot lodged in a bronchus) to repeated episodes of self-harm (alcohol, heroin, cocaine, and other undiscovered substances) to the familiar ravages of old age (cancer, stroke, and heart attack).

Murray shows that the ICU is a place of small successes rather than triumphant victories. He does not hide the rougher side of intensive care: the need for strong prison-like restraints to tie down agitated patients; the lethal presence of hospital-acquired infections; the crude indignities that a lack of privacy forces on ICU patients and their families; the psychic terrors that afflict some of those under his care; the threats of litigation from worried relatives (“We’ll be watching you…. Don’t pull the plug on him, Doc. Don’t you dare”); and the frustrations of a system stretched beyond the point at which it can operate safely (for example, missing radiographs: “I have complained to the chief of radiology, screamed at file clerks, and thrown fits in the reading room. Nothing has ever worked; now I just shrug—beaten by the system—and do what I can without the film”).

He also opens the usually closed issue of iatrogenesis—that is, illnesses caused by medical examination or treatment. Mistakes are common in medicine. A recently published American Institute of Medicine report7 estimated that as many as 98,000 Americans die each year from medical errors. The report argues that mistakes are so common that a Center for Patient Safety should be created to collect information about medical error. The US government’s response to this study has been uncommonly brisk. On February 21, President Clinton endorsed the report’s goal of cutting mistakes by half over five years.8

Murray describes several instances of iatrogenic illness during his month on ICU. One man was given intravenous penicillin, to which he was allergic. Astonishingly, he was given the same antibiotic again during the same admission, which gave him a ticket that took him immediately to the ICU. In another case, a woman with pneumonia was pushed into pulmonary edema—a condition in which the lungs fill with water—by overzealous infusions of intravenous fluids. Murray reports twelve cases of iatrogenic pulmonary edema during his month, and he rails at the “careless physicians” who paid too little attention to preventing this serious complication.

  1. 1

    Murray conveys this drama by repeatedly using war metaphors. The trauma service is “battle-ready”; despite considerable efforts, his team had “not won the war”; the ICU gets “bombed” with new admissions; a treatment plan is a “full-bore attack”; and antibiotics are “broad firepower” or “big guns.” These commonly used images do give a sense of the sometimes desperate atmosphere of an ICU. They also show, perhaps, the swashbuckling approach doctors take to this most acute of medical specialties.

  2. 2

    New Directions, 1984.

  3. 3

    Both Harcourt Brace, 1996. A new selection of Selzer’s medical essays, including two new pieces, has recently been published (The Doctor Stories, Picador, 1998). The book contains Selzer’s own account of his literary development as a doctor.

  4. 4

    University of California Press, 1999.

  5. 5

    See Kathryn Montgomery Hunter, Doctors’ Stories: The Narrative Structure of Medical Knowledge (Princeton University Press, 1991); and Trisha Greenhalgh and Brian Hurwitz, editors, Narrative Based Medicine (BMJ Books, 1998). The journal Literature and Medicine, published semiannually, aims to report original research in the medical humanities.

  6. 6

    See John F. Murray and Jay A. Nadel, Textbook of Respiratory Medicine (W.B. Saunders, 1994). Intriguingly, Murray’s literary interests are apparent in this treatise. Murray’s wife is the writer Diane Johnson, and she, together with Judy Nadel, wrote in a foreword that the work of textbook authors “had much similarity to a work of fiction,” since “their idea was of course to bring order and reassurance to the turbulent field of pulmonary medicine, rather as a novelist attempts to bring meaningful order to the chaotic events of reality.” I doubt that any fear-some three-thousand-page, two-volume medical textbook has ever received such a generous introduction.

  7. 7

    See Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, editors, To Err Is Human: Building a Safer Health System (National Academy Press, 1999).

  8. 8

    See Robert Pear, “Clinton to Order Step to Reduce Medical Mistakes,” The New York Times, February 22, 2000, p. A1.

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