Nasty, Brutish and Short

On call in the mobile ICU. We get a call to join CPR in progress on a 6 year old. The feeling is always different when we know a child is involved. Not that it's more urgent but there is always more tension and more emotion. We arrive and a one EMT is performing chest compressions and another is breathing the child by mask. I examine the child who clearly has some birth defects, the pupils are dilated, the prognosis is grim. I could easily order rescusitation stopped. But I ask my team to continue and institute advanced life support techniques. I have three reasons: 1. I always make the effort until I receive the patient's medical history. 2. It's always more difficult emotionally for the team to "lose" a child. 3. CPR in children is relatively uncommon and it provides the younger members of the team valuable experience. While the paramedic and EMT's were working under my supervision, the family handed me a very organized notebook with all the child's medical documentation. To my surprise, the child was a bedouin adopted by a jewish family. He was born with an impossible constellation of birth defects: Microcephaly (a small brain), meningocoele, blindness, severe psychomotor retardation, obstructive sleep apnea and by the scars on his abdomen, had several operations. This family took in the child in an attempt to relieve the burden on his impoverished relatives. The daughter of the woman who adopted him told me what a miserable existence the child had. Looking at the deformed child reminded me of Hobbes' most famous quote: "life is solitary, poor, nasty, brutish and short". After 20 minutes of advanced life support with no response, I directed the team to cease and pronounced the child dead. Despite the outcome I thanked the team for their effort. I'm satisfied that this team will do well perhaps with another patient who has a chance at life.
Later that day we rendevouz with an ambulance from one of the outlying communities. A 65 year old gentleman with chest pain the first time in his life. We transfer him to our vehicle. I tell the paramedic and the student to make a mental note of the clinical picture. "This is as classic as it gets", I told them. We obtained an EKG which screamed MI (myocardial infarct). Time is of the essence. On route we administer drugs and I call the Cardiac ICU. This is where the advantage of hospital doctors in the mobile ICU is apparent. We've all worked with each other for years and trust each other's opinions. In addition, I'm an ACLS (Advanced Cardiac Life Support) instructor, so all the cardiologists know and respect me (hard won respect I assure you). I described the patient and the EKG and asked that we bring straight to cardiology and bypass the ER. The cardiologist said, "I'll do you one better, bring him straight of to the cath lab." This decision was critical because during myocardial infarction, saving time means saving heart muscle. We arrive at the hospital and go straight to the cath lab, I flash the EKG to the cardiologist who gets excited, a chance for a save.
Later that day we visit the ICCU. The right coronary artery was completely blocked. A stent was placed and a followup echocardiogram showed almost no residual dysfunction of the heart.

The Rabbi

Faithful (If I may be so bold) readers: The following incident was originally posted on a-to-remain-nameless-site a year and a half ago when my 3rd child was born. I haven't changed a word:

After 41 weeks my wife (finally!) gave birth to a strapping 3.9 kg (8.5 lbs.) baby boy.

I've had this ear-to-ear grin plastered to my face for the past week. I asked not to be on call the last few weeks so that I could be with my wife at a moments notice. Bad for the bank account, good for my family. Finally I can play with the children and actually stay awake at the same time; what a novel concept!

The evening before the Brit (the circumcision ceremony) we conducted "the Zohar," a tradition among Tunisian Jews (my mom-in-law came from Tunisia). But the prayer was delayed because Uncle Yosef was late. Finally, he arrived with news that the rabbi of his moshav (an agricultural settlement) is planning to surprise me and come to the Zohar. Filled with emotion, I tearfully recall my first meeting with the rabbi...

I had heard of him before I ever met him. Uncle Yosef once remarked that the rabbi's house burned down. Then one day, I was assigned to the ICU. The doctor presenting the cases mentioned that the quadriplegic in the bed in front of us was a rabbi.

Looking down at the chart, I saw on the admission sticker that the patient was from Uncle Yosef's moshav. After morning rounds I introduce myself to the patient and mention that I know Uncle Yosef, that he is my wife's uncle. He seemed relieved that there was a connection between us other than the patient/doctor relationship. He was indeed the rabbi of the moshav of whom I had heard.

Communication was limited: The rabbi had been severely injured in a motor vehicle accident and was paralyzed from the neck down. He was mechanically ventilated through a tracheotomy tube and unable to utter sounds. He "spoke" in croaked whispers and required some lip reading (which is not my forte). The rabbi was a rarity in the ICU. Since he did not suffer any brain injury he was fully conscious much of the time. Only when complications arose did we sedate him to allay any suffering. Every time I was on call in the ICU, I would make a point of greeting him and exchange a few words. I would always tell him what day it was and the time.

ICU patients who are conscious lose their sense of time since the fluorescent lights are on 24 hours a day. Telling them the day and time gives some sort of anchor. Despite his condition, he always seemed to be in good spirits. He always asked me about my family. Finally, after several weeks he was discharged to a rehabilitation facility.

A year later, at a the Bar Mitzva celebration of one of the cousins from the moshav, Uncle Yosef mentioned that the rabbi was there. I approached the rabbi. He was sitting in a motorized wheelchair. Dressed in a perfectly tailored suit. This was the first time I had ever met a former ICU patient outside of the hospital. I asked him if he remembered me. He said yes and thanked me for all the attention I paid him during his hospitalization. He inquired as to my family, I asked him about rehab. He said that it was a long difficult process.

This was the first time I'd heard his normal voice. He was breathing unassisted, and thanks to rehabilitation had regained partial function of his hands. He was able to feed himself, which is very important for one's quality of life (an important indication of a patient’s well being). I noticed that despite the din of the music he was reading the Gemarra that discusses thorny theological questions. I asked him how he could possibly concentrate. His answer: The Lord gave him the strength to recover from a horrendous car accident and the strength to ignore the noise around him and deal with higher matters.

Over the years, we met, mainly at such family functions. He never failed to show his appreciation for my concern. I told him that I felt blessed to have known him.

Whenever I think of the rabbi, I recall an incident which never fails to evoke a shiver.

One evening on call, I believe it was Sabbath eve, the patient in the bed next to the rabbi coded, necessitating resuscitation. During our resuscitation efforts, I heard the rabbi trying to call our attention. Being ventilated through a tube in his neck and quadriplegic, the only way he could grab our attention was to make a "tsk, tsk" noise with his tongue, which sounds sort of like the sprinkler jets for lawns. It is admittedly a grating sound. I saw on his monitor that all his vital signs were normal. Annoyed, I called to him that we were in the middle of resuscitation and that I would get to him as soon as possible. After a lengthy resuscitation, the patient improved. I approached the rabbi's bed. Somewhat winded from the effort, I tersely asked him if something was wrong. He asked if the woman in the adjacent bed was OK. I was embarassed by my lack of patience with him.

I was amazed, despite his own suffering, he was concerned with the patients around him. I'm not religious, and I claim no knowledge of what a saint is. But I think that this man is the closest I'll ever be to meet such a being.

The rabbi never made it to the ceremony. He wasn't able to secure the special vehicle he needs from the local council office at such short notice. I talked to him on the phone and told him that I was very moved by his intention to surprise me. I promised to visit him at the first chance. To have such a man bless my new baby is a special privilege indeed.

post script: 1. I still haven't been able to visit the Rabbi (shame on me).

2. The sharpest readers will note that this post is, in fact, a triple flashback (flashback
of a flashback of a flashback). A personal record.