- Email: [email protected]
Intensive care
TheJoumalof
Emergency
Medicine,
Voi 10, pp 377-380,
1992
INTENSIVE CA
Department
of Pediatrics, The New York Hospital-Cornell Medical Center, New York, NY 1002’ Reprint Address: Glenn Flores, MD, Department of Pediatrics, Room N-406, The New York Hospital-Cornell Medical Center, 525 East 66th Street, New York, NY 1 OO2i
is too busy with drug rehabilitation. ilccas’ his aunt or grandmother visit briefly” Tkey st in the corner, looking awkward, co~~f~~c~~ ally exhausted. At times I try to u child’s status, but they seem to interested, as if they kno will budge the hopeless tion. I walk into the room next to There is an empty sanitized sheets an occupant has been obliterate one of the most comforting feelings was s tween the fresh clean sheets of a newly But a newly made bed i Unit seems tired. It still reeks of longed immobility or painful ~r~~~~ from some useless
I push the small cold metal plate on the wall, and the automatic doors abruptly swing open. I am confronted by the Pediatric Intensive Care Unit. At first I always feel a peculiar calm upon entering. Rhythmic susurrating sounds hypnotize me. The soft whooshing tempos of mechanical ventilators seem to reassure me that gentle creatures rest under sheets, behind curtains, and in oxygen tents in the dark. The comforting metronome of a cardiac monitor conveys the strong yet fragile reality of a human heart. Steady streams of oxygen flow in the backIntermittently, I hear soothing feminine voices. The words that I can discern come from mothers and nurses who assuage, cajole, scold, and sometimes plead. I walk into Room One, The mechanical ventilator sounds here are a little more rapid, a little more irregular. A tiny child lies very still, almost lost in a comparatively huge bed. His body is dimly lit by scattered lights randomly emanating from apartment buildings that I see through the panoramic window behind him. Andy looks too peaceful lately. He lies supine, his legs splayed unnaturally to the sides, paralyzed by potent drugs so that he can receive the powerful echanical ventilation that barely keeps him alive. is mother had syphilis and abused intravenous drugs while she was pregnant. His father is also an intravenous drug abuser. Andy is now five months old. Last month he was diagnosed with AIDS, shortly after acquiring Pneumocystis Carinii Pneumonia. He has a fungal infection of his urine. Multiple pockets of air riddle his chest and abdomen, unfortunate side effects of strong mechanical ventilation and devastating disease. He has little time left to hve. One day soon his heart will fail, and he will be allowed to die quietly. His mother has never visited him since he came to the hospital. She lives on the streets. I3i.s fat er has come once; he says he
RECESVED:
4 June 1991; ACCEPTED:
and the involuntary
urine and feces
ing over the rest of the room. An unuse next to the bed sporadically flashes random
in the shadow
brought
in by the paramedics.
sive brain hemo and abdomen. and its skin h mother said that her boy while she was at work. choked while eating scram
5 July 1991 377
378 the table, then fell backward to hit the back of his head on the floor. The abuser’s telltale story is always custom made to fit the injuries. I pictured the boyfriend, hands still stinging from recently delivered blows. He angrily looked down at the child, crumpled on the floor, scrambled eggs trailing out of his mouth onto the carpet, staring the glassy-eyed stare into infinity of the just dead. Smoothly, effortlessly, the boyfriend concocted the story as he realized that this time he had finally gone too far. Freddy’s mother and aunt were simply inappropriate. The nurses told me that, at first, the mother collapsed onto Freddy’s bed, sobbing fitfully. When I walked into the room, she was sitting bedside with a stunned, solemn look, but it appeared contrived, as if she were starring in a bad soap opera. I ventured some sympathetic remarks in Spanish, but she cut me off, angrily snapping that she knew English. Freddy’s aunt stood next to the mother, and she introduced herself to me. She was obese, but wore very tight stone-washed jeans which only accentuated her corpulence. She seemed cheerful, and barely able to contain her excitement. She slyly volunteered that whenever the mother’s boyfriend babysat for Freddy, he would be left with several new unexplained bruises afterward. The mother interjected that Freddy always seemed to be running around and bumping into things, and she never thought anything of bruises on his body. I asked them how Freddy acted around the boyfriend. The aunt replied that Freddy would always cry whenever he entered the room, cowering behind her or his mother. Even when the boyfriend was not around, if she were to accidentally raise her arm, Freddy would wince and cringe as if he expected to be struck. We had already established that Freddy could not breathe on his own and had absolutely no blood flow to his brain. We only needed one more test of his inability to breathe 24 hours later. We would declare him dead, disconnect the ventilator, and send him to the morgue. We would then call the police to officially charge the boyfriend with first-degree murder. I returned to Freddy’s room. The mother and aunt were laughing. As I checked Freddy’s vital signs sheet, I heard them discussing new clothes they were going to buy, their friends, and guys they knew. I walked in front of where they sat, chatting at the bedside, in order to draw blood from Freddy. I looked at Freddy, and noticed that he had a rosary placed around his head, with a cross hanging onto his forehead. The pink beads crossed over large black and blue bruises on his temple. As I bent over to draw the blood, the aunt gushed, “Ooh, you know,
Glenn Flares
you have a nice ass.” I said nothing. My first impulse was to yell at both of them for their breezy, disrespectful attitudes. Then I reminded myself that they had endured poverty all their lives, and to have survived this long, whatever coping skills they possessed deserved my respect. So I thanked her, albeit hesitatingly. I soon was made to regret it. The aunt then proceeded to produce a five minute discourse to the attentive, entertained mother on how much she “enjoyed men’s asses” and what great fun she spent mutually groping hindparts with her boyfriend. I ended up drawing blood and ordering medications on Freddy all through the night. Although technically he was dead, metabolically he had to be perfectly stable, according to regulations, or he could not be officially declared dead. As the night turned into morning, his complications got worse, my efforts intensified, and the conversations of the mother and aunt became more superfluous. They would ask me about cashing welfare checks, where to get snacks, and even to look at the aunt’s sore knee. As I drew the twentieth and last blood of my 28-hour shift, mother and aunt still happily spoke.of what to have at McDonald’s for breakfast, as the child lay dead next to them. Lily died this morning. It happened only two days later, in the same bed where Freddy died. Lily’s mother had finished giving her child a bath. The bath had been drained; the water was still running. Lily lay on her back, clean, contented and playful. Her three-year-old brother began crying in the next room. Lily’s mother went to check on him, and on the way back, stopped to grab a towel for Lily. She insisted later that she hadn’t been gone for more than a few minutes. When she returned to the bathroom, she found Lily on her back on the bottom of the tub, submerged under several inches of water. Lily’s mother frantically plucked her out of the bathtub and carried her over to the bedroom. She tried pushing on her chest a few times, but did not know CPR, and the child lay there, lifeless. She rushed over with the child to her neighbors, since she had no telephone of her own. The paramedics instructed her over the phone how to do CPR, but when they finally arrived, Lily was still lifeless. Lily’s mother also flung herself onto her child’s bed when she first saw her, entangled in the intensive care unit accouterment of IVs, EKG wires, drips, monitors, a ventilator and a Foley catheter. Lily, like Freddy, was really already dead, but by regulations needed one more trial to prove she was unable to breathe on her own. Until then, we did not tell the mother anything except that the child was in critical
‘ntensive (4are
condition. It made it all the more poignant to see Lily’s mother lying across the dead child, sobbing, saying “no no no’* over and over. When I first heard Lily’s story, I must admit I susp child abuse. I was not sure whether my susp stemmed from the sheer innocence of the story, all of the child abuse I had recently seen (especially dy), or just being hardened by the sadness and d of the intensive care unit. But I saw the intensity of guilt, horror, shock, and sadness in the of Lily’s mother, whether she held her child’s or wandered by me in a daze. I was convinced that this scene could only be a result of tragic events, not vicious deeds. Early in the morning a priest came by to talk to Lily’s parents. He spoke quietly to them as they searched his eyes desperately for some shred of hope and forgiveness. After he left I came back to check on the patient in the next bed. Lily’s parents pored over Spanisb pamphlets about Jesus and how God has His reasons when a child dies. Lily, like Freddy before her, also now had a rosary around her head with a crucifix on her forehead. A simple silver cross also rested on her chest, raised up slightly by a cardiac monitor lead that it covered. We were on morning rounds next door in Andy% room when the shrieking began. A pane of glass separates intensive care unit rooms, so the staff can see in case of a cardiac arrest. We looked over to the next room, where Lily’s bed was. The neurologist stood nearby the bed, head down, hands handing limply at Me had just told Lily’s mother that the child She was alternately wailing “no no no” and rry.” While she lay sobbing on Lily, clutching her corpse, I furtively watched Lily’s mother with sadness, attempting to feign requisite attention to the other doctors, who quickly returned to discussing and arguing s futile laboratory values as if nothing coul mportant . It is tcult not to become very attached to Charles. When he is more awake and alert, he focuses on me with his soft blue eyes and gently grabs my hand and squeezes it casually but earnestly. I loathe having to jab a needle in him each morning to draw blood. I dig around his flesh with the needle trying to iocate one of his all too scarce veins. He continues to regard me innocently and almost forgivingly despite his obvious discomfort. Charles is seven months old and has terminal neuroblastoma. A huge calcified t r occupies most of his left chest and abdomen astases invade his bones and skull. The tumor in his chest is so large that it shoves his heart and llsngs over to the opposite side of his chest, caus-
ing him serious difficulties Charles has partially re “objective criteria,” his Charles’s parents down to earth. gentle and ~nass~ not moving when Charles fall cause he knows Charles easi sleep anywhere el Charles’s disease tion. She constan tions and is extre plans, as long as they are
hen I took the illness, they seemed so in tune way they recounted disease set
other, and they are almost always
they will divorce once Charles leaves
Charles’s mother refuses to tell
confided to me one night that future for their marriage, but for her many times let alone Charles’s Late at ni with Charles, I let him loo as only he can. And I hope
far.
idly, not because he is merit is excruciatingly the slow choreography of I must inflict a painful pro
380
almost ethereal. His scream is silent because of a tracheostomy, his attempts to struggle are feeble and in slow motion because of disease, and too weak to turn his head, his eyes strain to fixate on me, filled with horror. Sometimes we share a happy moment. We once went over the body parts of his stuffed green elephant, I naming the part, he in slow motion pointing it out, both of us sharing a triumphant smile each time he was correct. But visiting Phil is literally to enter limbo. His bed is in the furthest corner of the intensive care unit because he is almost well enough not to be there but so sick that he could die at any time. At night the congregation of stuffed animals his parents have placed around him seem hostilely to surround and envelop him. His slow shaky movements, terror-filled eyes, and silent scream only underscore that he is a powerless prisoner of his disease, soon to be sent home to die. A few lazy orange rays of the new morning wash the cold winter sky outside. But inside, in this place, the air is still, oppressive, and stale with premature death and devastation. That staleness seems to be an intrusive living entity, a sickness that makes my mouth taste foul and pasty, sapping all of my will and physical strength. I take a last stroll around the intensive care unit before my 28hour shift ends. The first stop of my tour finds Baby Boy Orozco. He has Severe Combined Immunodeficiency Syndrome. His inability to fight infections has left him in a coma because his brain was essentially liquefied by his last infection. His father insists on heroic efforts to sustain his life because he has already lost three other sons to this sex-linked disease, which has arbitrarily left him a single healthy daughter. In the next room rests Albert. He too has an atrophied brain, and already has had several convulsions. His parents are both 18 years old, and have agreed that, given Albert’s condition, he must be institutionalized for the rest of his life. The last stop is Chester. His mother abused crack freely during her pregnancy and, as a result, one day shortly after his birth the blood flow to Chester’s gastrointestinal tract spasmodically ceased, causing his whole gut to die. When his mother found out, she left the hospital and has never returned. The attending physicians wrestle each day about how and when to discontinue his life support
Glenn Flares
and let him die. No one goes to his bed anymore because he has lately developed the stench of decomposition. I return to Room One, Andy’s room, sit down at the window, and watch the polluted East River flow by. Only a few more minutes until I get to sign out to the next shift. Watching the flowing water makes me think. There are only three kinds of patients I see in the Pediatric Intensive Care Unit. The first are those for which there is an intensive lack of care: Andy, Freddy, Chester. It is difficult not to wish them a speedy death, for it will be a deliverance from their short, intensely cruel lives. The second kind is the occasional happy story. Sometimes patients I can really help come to the unit, a severe asthmatic or one with congenital heart malformations after surgical repair. I quickly and cheerfully transfer them out, as if they never belonged here, and they are soon forgotten. But the third kind are the ones I never forget. They are the terminal breaths of misfortune, young children like Phil and Charles who will die in spite of every medical innovation, trick, and plea. I realize now why I despise the Pediatric Intensive Care Unit so profoundly. It is not only because of the brutally long hours that I must endure. Nor is it just the unremitting family misery and tragic children. I detest this place so fiercely because it makes me feel that my own death is so potentially immediate and so entirely beyond my control. Each time I anticipate finishing my shift in the unit, I must suppress a fearful recurring vision: As I happily cross the street to flee the hospital, a truck runs me down. After some time I feel that I am awake, and I am lying in the intensive care unit, but I soon comprehend that I am powerless and dying. Then it hits me: like Freddy and Lily, I am really already dead. My mother is sobbing over my lifeless body. A doctor is about to ask her whether my organs will be donated. My shift is finished. I leave the intensive care unit. I am outside. For a while, at least, I will taste the sweetness of the cold new winter morning and escape to restorative, nurturing sleep. But first thing tomorrow morning, I will climb the stairs to push the small cold metal plate on the wall once more. The automatic doors will abruptly swing open. I must confront the Pediatric Intensive Care Unit again.
Emergency
Medicine,
Voi 10, pp 377-380,
1992
INTENSIVE CA
Department
of Pediatrics, The New York Hospital-Cornell Medical Center, New York, NY 1002’ Reprint Address: Glenn Flores, MD, Department of Pediatrics, Room N-406, The New York Hospital-Cornell Medical Center, 525 East 66th Street, New York, NY 1 OO2i
is too busy with drug rehabilitation. ilccas’ his aunt or grandmother visit briefly” Tkey st in the corner, looking awkward, co~~f~~c~~ ally exhausted. At times I try to u child’s status, but they seem to interested, as if they kno will budge the hopeless tion. I walk into the room next to There is an empty sanitized sheets an occupant has been obliterate one of the most comforting feelings was s tween the fresh clean sheets of a newly But a newly made bed i Unit seems tired. It still reeks of longed immobility or painful ~r~~~~ from some useless
I push the small cold metal plate on the wall, and the automatic doors abruptly swing open. I am confronted by the Pediatric Intensive Care Unit. At first I always feel a peculiar calm upon entering. Rhythmic susurrating sounds hypnotize me. The soft whooshing tempos of mechanical ventilators seem to reassure me that gentle creatures rest under sheets, behind curtains, and in oxygen tents in the dark. The comforting metronome of a cardiac monitor conveys the strong yet fragile reality of a human heart. Steady streams of oxygen flow in the backIntermittently, I hear soothing feminine voices. The words that I can discern come from mothers and nurses who assuage, cajole, scold, and sometimes plead. I walk into Room One, The mechanical ventilator sounds here are a little more rapid, a little more irregular. A tiny child lies very still, almost lost in a comparatively huge bed. His body is dimly lit by scattered lights randomly emanating from apartment buildings that I see through the panoramic window behind him. Andy looks too peaceful lately. He lies supine, his legs splayed unnaturally to the sides, paralyzed by potent drugs so that he can receive the powerful echanical ventilation that barely keeps him alive. is mother had syphilis and abused intravenous drugs while she was pregnant. His father is also an intravenous drug abuser. Andy is now five months old. Last month he was diagnosed with AIDS, shortly after acquiring Pneumocystis Carinii Pneumonia. He has a fungal infection of his urine. Multiple pockets of air riddle his chest and abdomen, unfortunate side effects of strong mechanical ventilation and devastating disease. He has little time left to hve. One day soon his heart will fail, and he will be allowed to die quietly. His mother has never visited him since he came to the hospital. She lives on the streets. I3i.s fat er has come once; he says he
RECESVED:
4 June 1991; ACCEPTED:
and the involuntary
urine and feces
ing over the rest of the room. An unuse next to the bed sporadically flashes random
in the shadow
brought
in by the paramedics.
sive brain hemo and abdomen. and its skin h mother said that her boy while she was at work. choked while eating scram
5 July 1991 377
378 the table, then fell backward to hit the back of his head on the floor. The abuser’s telltale story is always custom made to fit the injuries. I pictured the boyfriend, hands still stinging from recently delivered blows. He angrily looked down at the child, crumpled on the floor, scrambled eggs trailing out of his mouth onto the carpet, staring the glassy-eyed stare into infinity of the just dead. Smoothly, effortlessly, the boyfriend concocted the story as he realized that this time he had finally gone too far. Freddy’s mother and aunt were simply inappropriate. The nurses told me that, at first, the mother collapsed onto Freddy’s bed, sobbing fitfully. When I walked into the room, she was sitting bedside with a stunned, solemn look, but it appeared contrived, as if she were starring in a bad soap opera. I ventured some sympathetic remarks in Spanish, but she cut me off, angrily snapping that she knew English. Freddy’s aunt stood next to the mother, and she introduced herself to me. She was obese, but wore very tight stone-washed jeans which only accentuated her corpulence. She seemed cheerful, and barely able to contain her excitement. She slyly volunteered that whenever the mother’s boyfriend babysat for Freddy, he would be left with several new unexplained bruises afterward. The mother interjected that Freddy always seemed to be running around and bumping into things, and she never thought anything of bruises on his body. I asked them how Freddy acted around the boyfriend. The aunt replied that Freddy would always cry whenever he entered the room, cowering behind her or his mother. Even when the boyfriend was not around, if she were to accidentally raise her arm, Freddy would wince and cringe as if he expected to be struck. We had already established that Freddy could not breathe on his own and had absolutely no blood flow to his brain. We only needed one more test of his inability to breathe 24 hours later. We would declare him dead, disconnect the ventilator, and send him to the morgue. We would then call the police to officially charge the boyfriend with first-degree murder. I returned to Freddy’s room. The mother and aunt were laughing. As I checked Freddy’s vital signs sheet, I heard them discussing new clothes they were going to buy, their friends, and guys they knew. I walked in front of where they sat, chatting at the bedside, in order to draw blood from Freddy. I looked at Freddy, and noticed that he had a rosary placed around his head, with a cross hanging onto his forehead. The pink beads crossed over large black and blue bruises on his temple. As I bent over to draw the blood, the aunt gushed, “Ooh, you know,
Glenn Flares
you have a nice ass.” I said nothing. My first impulse was to yell at both of them for their breezy, disrespectful attitudes. Then I reminded myself that they had endured poverty all their lives, and to have survived this long, whatever coping skills they possessed deserved my respect. So I thanked her, albeit hesitatingly. I soon was made to regret it. The aunt then proceeded to produce a five minute discourse to the attentive, entertained mother on how much she “enjoyed men’s asses” and what great fun she spent mutually groping hindparts with her boyfriend. I ended up drawing blood and ordering medications on Freddy all through the night. Although technically he was dead, metabolically he had to be perfectly stable, according to regulations, or he could not be officially declared dead. As the night turned into morning, his complications got worse, my efforts intensified, and the conversations of the mother and aunt became more superfluous. They would ask me about cashing welfare checks, where to get snacks, and even to look at the aunt’s sore knee. As I drew the twentieth and last blood of my 28-hour shift, mother and aunt still happily spoke.of what to have at McDonald’s for breakfast, as the child lay dead next to them. Lily died this morning. It happened only two days later, in the same bed where Freddy died. Lily’s mother had finished giving her child a bath. The bath had been drained; the water was still running. Lily lay on her back, clean, contented and playful. Her three-year-old brother began crying in the next room. Lily’s mother went to check on him, and on the way back, stopped to grab a towel for Lily. She insisted later that she hadn’t been gone for more than a few minutes. When she returned to the bathroom, she found Lily on her back on the bottom of the tub, submerged under several inches of water. Lily’s mother frantically plucked her out of the bathtub and carried her over to the bedroom. She tried pushing on her chest a few times, but did not know CPR, and the child lay there, lifeless. She rushed over with the child to her neighbors, since she had no telephone of her own. The paramedics instructed her over the phone how to do CPR, but when they finally arrived, Lily was still lifeless. Lily’s mother also flung herself onto her child’s bed when she first saw her, entangled in the intensive care unit accouterment of IVs, EKG wires, drips, monitors, a ventilator and a Foley catheter. Lily, like Freddy, was really already dead, but by regulations needed one more trial to prove she was unable to breathe on her own. Until then, we did not tell the mother anything except that the child was in critical
‘ntensive (4are
condition. It made it all the more poignant to see Lily’s mother lying across the dead child, sobbing, saying “no no no’* over and over. When I first heard Lily’s story, I must admit I susp child abuse. I was not sure whether my susp stemmed from the sheer innocence of the story, all of the child abuse I had recently seen (especially dy), or just being hardened by the sadness and d of the intensive care unit. But I saw the intensity of guilt, horror, shock, and sadness in the of Lily’s mother, whether she held her child’s or wandered by me in a daze. I was convinced that this scene could only be a result of tragic events, not vicious deeds. Early in the morning a priest came by to talk to Lily’s parents. He spoke quietly to them as they searched his eyes desperately for some shred of hope and forgiveness. After he left I came back to check on the patient in the next bed. Lily’s parents pored over Spanisb pamphlets about Jesus and how God has His reasons when a child dies. Lily, like Freddy before her, also now had a rosary around her head with a crucifix on her forehead. A simple silver cross also rested on her chest, raised up slightly by a cardiac monitor lead that it covered. We were on morning rounds next door in Andy% room when the shrieking began. A pane of glass separates intensive care unit rooms, so the staff can see in case of a cardiac arrest. We looked over to the next room, where Lily’s bed was. The neurologist stood nearby the bed, head down, hands handing limply at Me had just told Lily’s mother that the child She was alternately wailing “no no no” and rry.” While she lay sobbing on Lily, clutching her corpse, I furtively watched Lily’s mother with sadness, attempting to feign requisite attention to the other doctors, who quickly returned to discussing and arguing s futile laboratory values as if nothing coul mportant . It is tcult not to become very attached to Charles. When he is more awake and alert, he focuses on me with his soft blue eyes and gently grabs my hand and squeezes it casually but earnestly. I loathe having to jab a needle in him each morning to draw blood. I dig around his flesh with the needle trying to iocate one of his all too scarce veins. He continues to regard me innocently and almost forgivingly despite his obvious discomfort. Charles is seven months old and has terminal neuroblastoma. A huge calcified t r occupies most of his left chest and abdomen astases invade his bones and skull. The tumor in his chest is so large that it shoves his heart and llsngs over to the opposite side of his chest, caus-
ing him serious difficulties Charles has partially re “objective criteria,” his Charles’s parents down to earth. gentle and ~nass~ not moving when Charles fall cause he knows Charles easi sleep anywhere el Charles’s disease tion. She constan tions and is extre plans, as long as they are
hen I took the illness, they seemed so in tune way they recounted disease set
other, and they are almost always
they will divorce once Charles leaves
Charles’s mother refuses to tell
confided to me one night that future for their marriage, but for her many times let alone Charles’s Late at ni with Charles, I let him loo as only he can. And I hope
far.
idly, not because he is merit is excruciatingly the slow choreography of I must inflict a painful pro
380
almost ethereal. His scream is silent because of a tracheostomy, his attempts to struggle are feeble and in slow motion because of disease, and too weak to turn his head, his eyes strain to fixate on me, filled with horror. Sometimes we share a happy moment. We once went over the body parts of his stuffed green elephant, I naming the part, he in slow motion pointing it out, both of us sharing a triumphant smile each time he was correct. But visiting Phil is literally to enter limbo. His bed is in the furthest corner of the intensive care unit because he is almost well enough not to be there but so sick that he could die at any time. At night the congregation of stuffed animals his parents have placed around him seem hostilely to surround and envelop him. His slow shaky movements, terror-filled eyes, and silent scream only underscore that he is a powerless prisoner of his disease, soon to be sent home to die. A few lazy orange rays of the new morning wash the cold winter sky outside. But inside, in this place, the air is still, oppressive, and stale with premature death and devastation. That staleness seems to be an intrusive living entity, a sickness that makes my mouth taste foul and pasty, sapping all of my will and physical strength. I take a last stroll around the intensive care unit before my 28hour shift ends. The first stop of my tour finds Baby Boy Orozco. He has Severe Combined Immunodeficiency Syndrome. His inability to fight infections has left him in a coma because his brain was essentially liquefied by his last infection. His father insists on heroic efforts to sustain his life because he has already lost three other sons to this sex-linked disease, which has arbitrarily left him a single healthy daughter. In the next room rests Albert. He too has an atrophied brain, and already has had several convulsions. His parents are both 18 years old, and have agreed that, given Albert’s condition, he must be institutionalized for the rest of his life. The last stop is Chester. His mother abused crack freely during her pregnancy and, as a result, one day shortly after his birth the blood flow to Chester’s gastrointestinal tract spasmodically ceased, causing his whole gut to die. When his mother found out, she left the hospital and has never returned. The attending physicians wrestle each day about how and when to discontinue his life support
Glenn Flares
and let him die. No one goes to his bed anymore because he has lately developed the stench of decomposition. I return to Room One, Andy’s room, sit down at the window, and watch the polluted East River flow by. Only a few more minutes until I get to sign out to the next shift. Watching the flowing water makes me think. There are only three kinds of patients I see in the Pediatric Intensive Care Unit. The first are those for which there is an intensive lack of care: Andy, Freddy, Chester. It is difficult not to wish them a speedy death, for it will be a deliverance from their short, intensely cruel lives. The second kind is the occasional happy story. Sometimes patients I can really help come to the unit, a severe asthmatic or one with congenital heart malformations after surgical repair. I quickly and cheerfully transfer them out, as if they never belonged here, and they are soon forgotten. But the third kind are the ones I never forget. They are the terminal breaths of misfortune, young children like Phil and Charles who will die in spite of every medical innovation, trick, and plea. I realize now why I despise the Pediatric Intensive Care Unit so profoundly. It is not only because of the brutally long hours that I must endure. Nor is it just the unremitting family misery and tragic children. I detest this place so fiercely because it makes me feel that my own death is so potentially immediate and so entirely beyond my control. Each time I anticipate finishing my shift in the unit, I must suppress a fearful recurring vision: As I happily cross the street to flee the hospital, a truck runs me down. After some time I feel that I am awake, and I am lying in the intensive care unit, but I soon comprehend that I am powerless and dying. Then it hits me: like Freddy and Lily, I am really already dead. My mother is sobbing over my lifeless body. A doctor is about to ask her whether my organs will be donated. My shift is finished. I leave the intensive care unit. I am outside. For a while, at least, I will taste the sweetness of the cold new winter morning and escape to restorative, nurturing sleep. But first thing tomorrow morning, I will climb the stairs to push the small cold metal plate on the wall once more. The automatic doors will abruptly swing open. I must confront the Pediatric Intensive Care Unit again.