Weekend ICU call. I started my day with a mission in mind. I would find Mr.F a bed in an ICU in a tertiary care center that could do something more for him than watch him bleed to death while struggling to keep his organs alive with transfusions, ventilators and vasopressors.
We’d worked the phones the last 24 hrs after banding his bleedings varices and placing a Sangestaken-Blakemore tube when he re-bled. One hospital had no ICU beds; another could not accept him due to ‘Insurance Issues’.
I struck gold with my first call of the day ‘Yes, I have a bed and I’ll be happy to take him for TIPS. Just make sure the family understands that he might not survive the transit and might not even survive with the procedure.’ I called his children one by one .They would talk things over and let me know soon. Anne, the youngest daughter, appointed spokesperson, said she had talked about this before with everyone and knew it was okay, but she would be here in an hour and confirm the decision to transfer. I gently reminded her that these arrangements take time and I wouldn’t want to lose that precious available bed.
A couple of hours passed and I decided to go ahead and start the arrangements for transfer. Two of his daughters arrived while I was busy with another patient. Margaret, his nurse, walked up to me and said, ‘They’re here and they’re angry.’ “ Who authorized the transfer, we didn’t say it was okay yet and the nurse says the ambulance will be here in an hour?” As this commotion broke out the lab called, his electrolytes were way off, and I’d have to replace his electrolytes prior to transfer to minimize the risk of complications on the way. I walked into his room, introduced myself and apologized for taking matters into my own hands ,but assured them that we would never have transferred him without their consent ‘I called it in only because I didn’t hear back from you and I knew the arrangements would take at least a couple of hours more’. Anne calmed down. I explained to them that in any case, the transfer would be delayed until we could ensure he was at minimal risk for complications en route. A doctor would accompany him.
The oldest daughter, Lily, quiet, poised had just arrived from out of town. She wanted to know more about all that had happened to him. I explained to her all about her father’s condition as best as I could. Anne, cell phone glued to her ear, constantly dashing out of the ICU to update the anxious family members, hung around for a while so she could get a clearer understanding of the problems and then came back and said – ‘OK,go ahead with the transfer’.
We set the wheels in motion again. The ambulance could only be here at 10 pm, after my shift would end. The nurses would like the consent papers for the transfer signed before I left, Margaret told me. The rest of my shift went by in the usual flurry of activity-Septic shock, central lines, strokes, intubations and extubations. I kept checking on Mr.F to see how he was doing .I saw different people at different times by his bedside. I spoke with family and friends, called a priest to pray with some.
My shift ended and I came back to his room. After all, I’d promised Margaret I would get the papers signed before I left. Lily was there, sitting by his bedside when I walked in. She smiled as I came in. I smiled back, asked if Anne was around. ‘She stepped out, she’ll be back in an hour’ I told her I just needed Anne to go over the transfer papers and sign the consent for transfer ‘Wait a minute, Why do you need Anne for that? I’m the oldest daughter, I can sign for it too. Who made Anne head of the family while dad is sick?’, she asked me angrily. I had no idea what had happened, but I’d just stepped into a minefield of family conflict.
I stopped for a second to think about how to handle this. I said ‘ Lily,I thought all of you appointed Anne spokesperson because she lived next to him and has been here from the beginning. But that’s not the point. You’re as much his daughter as she is and you have a say in everything too. This is a decision you made together for him. It doesn’t matter whose signature is on the consent. Let this not be about power and who calls the shots. This is about his family getting together to take some decisions in his best interest to give him the best shot at getting back to health. He’s fighting for his life right now and he needs all his children to be together, not fighting over who will sign the papers. We request families to assign spokespersons to prevent conflict. It doesn’t mean she loved him more or knows better.’ I could see her struggle with something deep inside.
‘This is not the time for these thoughts. I’ve watched your father’s friends and relatives rally around to support all of you and pray for him. Clearly, he is a man who inspired a lot of love. You’ve lived away for a while and saw him last when he was a picture of health and vitality. I can’t imagine how hard it must be for you to see him fighting for his life with tubes sticking everywhere .You seem to be a very strong woman. Don’t let any other thoughts besides doing what is right for him get in the way now.’
I sank down to sit on the floor next to her chair. She sat with her back ram-rod straight, eyes glazed with tears- anger, fear, and sorrow. She told me ‘You know I just lost my son in a crash 3 months ago. And now this!’ .I had no words for her. I took her hands in mine and said ‘ I’m sorry’ and just held her hands. Now I understood .This strong woman felt powerless, helpless, unable to do anything for her father just as she had been for her son.
I told her ‘I guess you’re feeling like you can do nothing to help him. But I’ve seen you all day, keeping a vigil over him, talking to him, lending your strength to the rest of the family. I’ve seen you pray. I’m sure he feels your love. As a doctor, I can only try my best to keep him pain free and comfortable. But you’ve done more with your love. Believe me.’
She smiled through her tears and nodded. I started to rise and slowly pulled my hands away, when she suddenly pulled me back down. I looked at her and she stared at me intently and asked ‘Are you a doctor?’ I was confused. She repeated insistently: Are you a doctor? I said ‘ Yes, I am a doctor’She squeezed my hands and said ‘Promise me. Stay sweet’. Confused, I mumbled , ‘I promise’ ,hugged her and left for the day.