I was doing chest compressions on a 29-year-old woman who had just come up from the Emergency Room, and I was trying not to look at her face. She was gravely sick, intubated, and we had no idea what was wrong with her. When she went pulseless, we started the American Heart Association’s Advanced Cardiac Life Support (ACLS) algorithm for pulseless arrest. It is the intern’s job to do chest compressions, a somewhat apt metaphor for their lowly but absolutely necessary position in the medical hierarchy of healthcare training institutions. The intern is the workhorse, the one both performing and enduring the brute and long labor of modern healthcare.

The teaching goes that if you’re not breaking ribs, you’re not doing chest compressions correctly. You have to be doing at least 100 compressions a minute. With your hands, you are literally trying to physically pump the blood out of the heart to the brain and other critical organs. Violence is absolutely necessary here.

I think about this woman’s life and my life. We are roughly the same age, brought together by the most unfortunate circumstances. I wonder what her voice sounds like. I will never hear it. As sweat drips off my face, I realize, sadly, that I am getting physical exercise for the first time in a week. It is during this moment that I have a glimmer of recognition that there are so many upstream structural forces that shape the texture of my day-to-day experience in the hospital, as well as the experiences of the patients we serve. This is something that I feel deeply in my fatigued, deconditioned body under the acute stress of this incident.

After thirty minutes or so of performing the ACLS algorithm, the ten or so people in the room appear fatigued. You can tell that the person who has her fingers buried in thigh flesh, feeling for the femoral artery, is tired, her hand possibly cramping from pressing so hard. Finally, one of the patient’s family members had arrived, and we conveyed to her the gravity of the situation. To everyone’s relief, she gave permission for us to stop the efforts, but many times, family members want us to “do everything.” In other ICUs across the country, they post signs about “medical futility.” We get lectures on “compassionate extubation” and how to re-orient families to the patient’s suffering and quality of life rather than the prolongation of it.

In many ways, modern American ICU medicine is somewhat primitive, even as we apply million-dollar therapies like extra-corporeal membrane oxygenation (ECMO, or a heart-lung bypass machine) and ventilators for many of our patients. My thoughts drift to Julie Livingston’s work on care in an oncology ward in Botswana. She writes about improvisation, how “examining processes of making do, tinkering, and ad-libbing help us to better understand the nature of biomedicine in Africa and the work of African healthcare workers, for whom improvisation is inevitably the modus operandi” (2012: 21). I think that this work is not so different from much of the work we do here in Boston. Sure, we follow algorithms for pulseless arrest and have all the physical space, staff, and technology to better stave off death, but in the end, a surprising amount of ICU care is still about improvisation. Give intravenous fluids; take fluids off by hemodialysis or making the patient urinate; decrease the tidal volume of breaths given on the ventilator; increase the respiratory rate the ventilator is breathing for the patient. Even though we understand the intricate physiology of the lungs, the heart, the kidneys, we still can’t predict how each particular person will respond to our array of standard techniques for the critically ill. And we don’t have any particularly great insights into discerning who has the physiologic reserve to “make it” and who doesn’t. Much is made of the different clinical situations in Western biomedicine and how it is theorized and practiced around the world. But there are so many similarities as well.

Much of the work of ICU physicians is in preparing patients and families for death. Most of the time patients are too sick to communicate themselves. As I talk to family members about their loved ones, I think of Michael Jackson’s work in Sierra Leone. He writes of the fundamental anxiety, danger, and insecurity associated with hope, arguing it is universal in both the global north and south:

“At times we imagine that the lost object was once in our possession… it was there before we realized what we had; it slipped from our grasp or was stolen, leaving us to hope that it might be restored to us, as well as to dread that it is irrecoverable. At times we imagine that what we need lies ahead, promised or owed but as yet undelivered, unrevealed, or unpaid, not yet born” (2011: xii).

It is this existential yearning for another reality, the sensation of possibility, albeit slight, that makes the encounters and conversations in the ICU so fraught. Add this on top of the uncertainty that exists about each individual’s unique pathophysiology and disease process, and you can see how difficult it is for everyone.

I think back to the 29-year-old who died within three hours of entering the hospital. Something real overwhelmed her physiologic reserves. Her death was violent because of its speed, its attack on the young; it was traumatic for all of us involved, although we had to shut down our emotions and quickly get back to caring for other patients. But her life circumstances leading up to when she came to the hospital, including the structural violence that undoubtedly made her more vulnerable to an early death, are what we should be thinking about. Really, when I see her, it is too late, the eleventh-hour consequences of a lifetime of inequality, and here I am struggling against the inevitable, the downstream consequences of many upstream social forces, like lack of access to vaccines that prevent cancer, or healthy foods, or good schools. And this is where anthropology and the social sciences have so much to offer: enriching our knowledge of the structural and sociopolitical forces that bear down on people in their everyday struggles, and elucidating concretely and pragmatically how we might better equip people to stay healthy, so that I am not again doing chest compressions, trying to avoid looking at another young face.

 

Kimberly Sue, MD, PhD, is a first-year Internal Medicine-Primary Care resident physician at MGH/Harvard Medical School, Boston, MA. She recently graduated from the Harvard MD-PhD Social Sciences Program with a PhD in sociocultural anthropology in 2014 and an MD in 2015. Her research interests include substance use disorders, addiction, incarceration and structural violence, and structural competency in medicine.