Thread by @TheRealDoctorT

Sometimes, when I’m in the room of a critically ill patient, I feel the urge to turn and look towards the window.

I can’t explain it.

I usually go ahead and look.

I’m not sure what I expect to see.

Someone standing there, perhaps, looking back at me in silence.

A memory. 1/

The Path Forward is the most desirable of medical treatment plans.

Maybe not a cure, maybe not a firm diagnosis, but at least a clear path forward.

Decisions being made, in a sort of harmony between everyone involved.

But every now and then a path can end up in a heavy fog. 2/

I’m sitting at the computer workstation in the ICU, reading the notes in my patient’s chart.

I’ve known this patient for almost a decade. It took years to earn his trust. For years he barely had a spare word to say to me.

But he came to every appointment.

Now here we are. 3/

I take off my glasses and rub my eyes wearily. Words echo in my mind.

Sepsis, multi-system organ failure, cardiac arrest, anoxic brain injury.

We wrap up the worst things in such clinical terms, to smooth their jagged edges, and turn them into pills we can swallow. 4/

The kidneys do their work with mathematical precision, with breathtaking beauty.

When they are failing, the data can spiral out of control with dizzying rapidity.

The lab values are all red. “CRITICAL” the computer helpfully points out, repeatedly.

My patient is dying. 5/

I glance at the workstation next to mine. My patient sits at the chair.

I know he’s not really there. But just this one time, let me imagine.

“Hey doc. Doesn’t look good does it?”

I shake my head, “No. Not good at all.”

He nods, “Straight shooter. I like that.” 6/

I get up and make my way to the patient’s room.

There he is, intubated, on the ventilator, tethered to those tubes that snake from him to the bags of medicine.

His face is swollen, barely recognizable, arms and legs too.

We call it “anasarca.”

Smooth words, jagged things. 7/

“Jesus, look at me.”

I look up, and there he is, standing at the bedside looking down at himself.

The room is empty, except for he and I.

“I’m sorry,” I say.

“Nah, we all gotta go. I just didn’t think it would be like this. I look like the Michelin Man.”

He’s not wrong. 8/

I go through my physical exam. Listening with my stethoscope.

“Doc what are you listening for-“

“Shhh,” I say, “just a moment.”

I listen to the crackling of fluid building up in his lungs, the murmuring of blood squeezing past a hardened and narrow valve in his heart. 9/

When I look up, he’s sitting on the chair at the bedside.

“So. How much longer do I have?”

I shake my head, “Not long, depends on what your family wants to do.”

He seems to ponder this, then sits up. “Yeah, my family… Where are they?”

“They’ll be in soon.”

He sighs. 10/

“It’ll be tough on my wife. My kids are… resilient. But I’m worried about her heart. We’ve been married longer than you’ve been alive.”

I nod, then smile, “You never told me that! What’s the secret?”

He rubs his chin, “Be kind, and don’t shirk responsibility.” 11/

I thank him for the advice and leave the room to write my note.

The ICU nurse standing outside the room quirks a brow, “Were you talking to someone?”

I shake my head, “Just myself.”

As I write my note I know that we need to have a family meeting.

We need a Path Forward. 12/

The family meeting happens later in the day, in the consultation room.

The patient’s wife is there, and the children.

I was expecting clarity, but it quickly becomes obvious that we are in a fog. The family is splintered into factions, wanting aggressive care or to let go. 13/

I glance towards the window in the room at one point, as they are arguing amongst themselves, and I see the patient.

He is shaking his head.

“What are they doing? I told them my wishes many times! It was supposed to make this easy!”

I exhale deeply, murmuring, “Sorry.” 14/

The family meeting continues.

Other members of the healthcare team are there too. Between us all, we try to focus the discussion on quality of life and the patient’s known wishes.

We are getting nowhere.

The fog can be heavy.

This is never easy.

Hearts cling. 15/

Days pass, and we reconvene for several meetings.

Hope is that quintessential human trait. But sometimes it can work against us.

I stand at the patient’s bedside. The room is empty, except for, well, him.

He is standing by the window, looking wistfully out.

I walk over. 16/

He doesn’t look at me, his gaze is fixed beyond the horizon.

My voice is quiet, “What do you see?”

“Light. My path forward. Doc…” he turns to look at me, “Let me go.”

I sigh, lowering my gaze, my throat feeling dry.

He lies in bed, unresponsive.

Quietly, I leave. 17/

Eventually, his family does decide to let him go.

They are gathered around, as he lies in his bed.

His wife kisses his forehead. Goodbyes are said, and tears flow.

I leave the room to give them privacy, but I also feel my own vision getting blurry.

He was a good man. 18/

Sometimes, when I’m in the room of a critically ill patient, I feel the urge to turn and look towards the window.

I can’t explain it.

I usually go ahead and look.

I’m not sure what I expect to see.

There’s nobody there.

Just light streaming in, from beyond the horizon.

Afterword

“When you leave,
weary of me,
without a word I shall gently let you go.”

-Kim Sowol

The idea for this thread first occurred to me many years ago.

It isn’t about any specific patient or family.

It’s about a recurring experience.

A wish, a light, and a path forward.