Tale of Two Cities...

Charles Dickens' famous book began with these words:

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us..."

A week in the Critical Care Unit (CCU) reminds me of those very words. This is the tale of two 26 year olds -- one a young man and the other a young woman. No, this is not a romantic story, but the comparisons are eerie and such as only life can present.

26 year old Peter Chong (not his real name) belongs to an Asian community with strong cultural beliefs and traditions. His parents do not speak english. His 28 year old sister speaks both their language and english. She appears quite 'americanized' -- at least on the outside. He came in with a pneumonia that never got better. As a previously healthy 26 year old with no health problems, no tobacco use, no drug or alcohol consumption and no genetic or congenital problems, the persistance and worsening of his illness bewildered us. He proceeded over several weeks to develop full blown Acute Respiratory Distress Syndrome (ARDS) and was intubated and put on a mechanical ventilator to help him breathe. Every diagnostic test, every therapeutic intervention and every search for the cause and treatment of his disease ended in failure. His family worked with their shaman.

In my head, I could almost hear the parellel conversations...

the attending physician: "Let's keep him on the ARDS protocol and try a rotobed"

the Shaman: "We will change his name. This will confuse the spirits into thinking he is someone else."

Both interventions were tried and failed.

the attending physician: "We will diurese him and keep him on steroids"

the Shaman: "We will rename him with a female name and he shall wear pink. From now on, refer to Peter as 'she'. The spirits will think he is not the person they are to come for."

Both interventions were tried and failed.

It went on for some months.

Peter died at 4:17 am when I was on call. When his mother saw me come in to where the family were, she clung to me, hugging me and crying -- accusing? Pleading? Thanking me for all I tried to do? Or only spending her grief freely. What do you say to a mother of a 26 year old son who has died despite everything everyone did?

The other 26 year old was a female of a conservative caucasian christian community. This is a young girl. I shall call her that, because although 26, she lives with her parents and appears thin, frail, emaciated and pale looking much younger than her years. She suffers from Hodgkins lymphoma. She was brought to the unit in acute respiratory distress and was intubated before being transferred to us from an outside facility. As she lays in her bed, on the ventilator, her family and her refuse treatment! Although Hodgkins has one of the highest cure rates among the cancers (85 to 93%), she lays at death's door with a life expectancy (unless a miracle happens) of a few weeks. Her only wish: get this tube out of my throat and let me go home -- to die or to live. We tried taking the tube out. It had to be replaced 2 hours later when she could not breathe on her own. She now has a tracheostomy -- a tube placed in her throat from the outside. She will, if she lives long enough go home with a home ventilator. While the family, grudgingly almost, accepts help with breathing, feeding fluids and nutrition through IV, they refuse treatment of the underlying problem -- the lymphoma.

In contrast to the previous family in whom the grim and devastating progression of disease led us to offer them discontinuance of life support, which they refused, this family refuses all pleas to allow us to treat the lymphoma. While the Asian family went through numerous shamanistic rituals and insisted that 'everything be done' even when multiple systems failed and it was futile to continue mechanical ventilatory support, this family insists that as little as possible be done, even though the least intervention could be life-saving.

?????

There you have it -- a tale of two 'cities' in the CCU. It breaks my heart.