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Intensive Care: A Doctor's Journal

Copyright Date: 2000
Edition: 1
Pages: 311
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  • Book Info
    Intensive Care
    Book Description:

    Intensive Careis an affecting view from the trenches, a seasoned doctor's minute-by-minute and day-by-day account of life in the Intensive Care Unit (ICU) of a major inner-city hospital, San Francisco General. John F. Murray, for many years Chief of the Pulmonary and Critical Care Division of the hospital and a Professor at the University of California, San Francisco, takes readers on his daily ward rounds, introducing them to the desperately ill patients he treats as well as to the young physicians and medical students who accompany him. Writing with compassion and knowledge accumulated over a long career, Murray presents the true stories of patients who show up with myriad disorders: asthma, cardiac failure, gastrointestinal diseases, complications due to AIDS, the effects of drug and alcohol abuse, emphysema. Readers will come away from this book with a comprehensive understanding of what an ICU is, what it does, who gets admitted, and how doctors and nurses make decisions concerning life-threatening medical problems. Intensive care for critically ill patients is a new but well-established and growing branch of medicine. Estimates suggest that 15 to 20 percent of all hospitalized patients in the United States are treated in an intensive or coronary care unit during each hospital stay, so there is a real possibility that the reader will either be admitted to an ICU himself or herself or knows someone who will be. Murray not only offers a real-time account of the diagnosis, treatment, and progress of his patients over the course of one month but also conveys a wealth of information about various diseases and medical procedures in succinct and easy-to-understand terms. In addition, he elaborates on ethical dilemmas that he confronts on an almost daily basis: the extent of patient autonomy, the denial of ICU care, the withdrawal of life support, and physician-assisted suicide. Murray concludes that ICUs are doing their job, but they could be even better, cheaper, and--most important--more humane. His chronicle brings substance to a world known to most of us only through the fiction of television.

    eISBN: 978-0-520-92902-9
    Subjects: Health Sciences, Sociology

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
    (pp. ix-xiv)

    An unseen hand flings open the door to the intensive care unit. Then appears the back of a woman wearing a green scrub suit. She has a stethoscope draped around her neck—probably a medical resident. At her side is another woman in green, who helps her pull a bed in from the corridor by wrenching one end through the ICU door, which a nurse runs over to hold open. The other end of the bed is simultaneously pushed and guided by a young man who is shouting directions. He is flanked by a respiratory therapist doing his best to...

  4. DAY 1 Thursday
    (pp. 1-17)

    I walked onto the ICU a little before 8:00 A.M. to find three third-year medical residents—Dr. Ella Andrews, Dr. James Shotinger, and Dr. Ian Trent-Johnson—waiting for me. Each had a big smile. They had arrived early to familiarize themselves with our patients and already knew a lot about them. Their smiles were not only welcoming but inquiring. We were all going to spend the next four weeks together, and they were curious to see how well I would help them handle the formidable problems that lay ahead of us: would I be an aid or an obstacle, a...

  5. DAY 2 Friday
    (pp. 18-27)

    The key people in any ICU are the nurses, like Molly Wolford, Imelda Tuazon, and Jack Cramer. These motivated and proficient women and men are specially trained for their demanding responsibilities in an eightweek course that mixes classroom teaching and supervised preceptorship in the units. Trainees emerge from the indoctrination as “novice” ICU nurses, which means they can work in an ICU but require extra support and guidance. After two years of apprenticeship, their experience qualifies them to work in any unit completely on their own.

    One nurse generally takes care of two patients, never more. When a patient requires...

  6. DAY 3 Saturday
    (pp. 28-35)

    Saturday already. Life goes on as usual in the ICU so far as the patients are concerned, but today there are a few changes: the two head nurses take the weekend off; daily assignments of the residents are varied so that some can have a well-earned day of rest on either Saturday or Sunday; and only two of our three third-year residents make ward rounds with me. Today, it is Ian Trent-Johnson’s turn to be on call, his first of the month. Bespectacled, with a serious demeanor and abundant black hair always in need of a trim, he looks like...

  7. DAY 4 Sunday
    (pp. 36-47)

    Great cities have great city hospitals. San Francisco is no exception. The present SFGH is a direct descendant of the first, supposedly temporary, infirmary established in 1850 during a cholera epidemic. In 1872, a new city hospital was dedicated at its present location south of Market Street. Patients with bubonic plague were treated here, first in 1900 and again in 1908. After the hospital became infested with rats and plaguecarrying fleas, the buildings were burned and the patients were moved to a temporary facility located in an old racetrack. The replacement hospital was built in 1911, and the new medical...

  8. DAY 5 Monday
    (pp. 48-58)

    A regular part of most training programs in internal medicine is Morning Report, an enjoyable and popular teaching session. The time and format vary from one institution to another, but at SFGH two or three of the most interesting or difficult newly admitted patients are discussed by the chief of medicine, or sometimes by invited specialists, and all the residents who are free to participate. Morning Report is held every weekday morning in the chief’s spartan office, where there are no chairs and only about thirty feet of couch space along three of its walls; many residents have to sit...

  9. DAY 6 Tuesday
    (pp. 59-67)

    On Tuesdays we have Medical Grand Rounds, a formal didactic presentation of a medical topic, usually given by a member of the local faculty, but sometimes by a visiting professor from another medical school. Grand Rounds, as the name conveys, is the main event of the week in many academic institutions, where it is still conducted as in a painting by Rembrandt: all the faculty are there, sitting formally in the first few rows—although now without the dark robes and red velvet hats. Behind them are all the medical housestaff and students assigned to the medical service. The audience...

  10. DAY 7 Wednesday
    (pp. 68-78)

    One of the most popular, and certainly the best-attended, of the regular organized teaching sessions, the Morbidity and Mortality Conference, more simply “M & M,” is held every Wednesday at noon. The purpose of M & M is to sharpen diagnostic acumen and improve clinical proficiency by reviewing confusing or complex cases, analyzing causes of complications, usually those that might have been prevented, and examining how and why patients died, especially if death was unexpected. For young doctors it’s a good opportunity to sort out the problems and anxieties that accompany unforeseen disasters and to emphasize the importance of one...

  11. DAY 8 Thursday
    (pp. 79-91)

    As they say around here, Ella Andrews, our high-spirited ICU resident, “got bombed” yesterday: seven new ICU admissions, including the transfer back of a patient we had cared for briefly a few days ago. To complicate matters further, our eleven patients are spread out among three different units, which adds to the logistical difficulties. As planned, I show up at 7:30, a half hour early, to meet with the head of urology and his chief resident to decide if it is safe for Alfredo Fiorelli to have his operation. Bart Reston looks sullen, says nothing, and sticks close to his...

  12. DAY 9 Friday
    (pp. 92-100)

    In 1964, Associate Justice Potter Stewart, unable to define obscenity in delivering his opinion of a case that had been heard before the Supreme Court, wound up with what has become one of the most widely quoted judicial pronouncements of all time: “but I know it when I see it.” In a similar sense, with just a little information plus intuition, experienced ICU physicians “know” that a patient has pneumonia, gastrointestinal hemorrhage, or stroke when they see them. That is a valuable beginning, but it is not good enough: we must know more. Effective treatment requires knowledge of thecause...

  13. DAY 10 Saturday
    (pp. 101-114)

    Another weekend is starting, which means that most of the housestaff I meet will be wearing Robin Hood–green scrub suits, a loose-fitting blouse and baggy trousers originally designed to be worn only in the operating rooms but now worn by all medical residents and students when they are on call. It is easy to tell residents who are finishing a night on duty, not only from their sleep-seeking eyes but because their scrub suits are rumpled and sometimes spattered with blood or vomit. Oncoming residents are clad in the same uniforms, but pristine and occasionally even ironed. Most of...

  14. DAY 11 Sunday
    (pp. 115-124)

    We worry a lot about oxygen in the ICU. Without oxygen to the brain, a person becomes unconscious in about thirty seconds and is dead a few minutes later. Oxygen is needed for the heart to beat, for the liver to synthesize proteins, for the kidneys to manufacture urine, for all cells to live and function. Oxygen keeps the “fires of life” burning by furnishing metabolic fuel for all creatures in the animal kingdom, from microscopic amoebas to colossal blue whales. Nature has designed highly refined pathways to transfer oxygen from the surrounding water or air to the chemical furnaces...

  15. DAY 12 Monday
    (pp. 125-131)

    The master diagnostician of the turn of the century made almost as good use of his sense of smell as of his sight. Tales are still told about the astute clinician, on his way into a crowded ward with his entourage, stopping and sniffing at the threshold, then saying, “There is someone with a lung abscess in here.” All the students, knowing that such a patient had been admitted the night before, would marvel at this wizardry. Some lung abscesses really do stink, and even I can recognize them at the bedside, though seldom at the entrance to the ward,...

  16. DAY 13 Tuesday
    (pp. 132-140)

    Decades ago when I was a medical student and then a resident in internal medicine, ward rounds were always held from beginning to end at the patients’ bedside. The participants would approach the bed in a group but then would station themselves in strict order. The person who was presenting the history and findings (usually a student or first-year resident) stood at the head of the bed on the patient’s left side, and the person being presented to (an outside attending physician or member of the faculty) was directly opposite; the remaining residents and students disposed themselves in between. Presenting...

  17. DAY 14 Wednesday
    (pp. 141-150)

    Having a clinical eagle eye may not be as indispensable now as it used to be, though it still helps. There was a time when practically the only way of making a correct diagnosis was by finding a definitive abnormality during the physical examination. The master diagnostician Sir Matthew Hope, in Henry James’sThe Wings of the Dove,must have had this talent. There was no other way at the time. When I was a medical student and resident, I met a few old-timers who could diagnose scurvy (vitamin C deficiency) by spotting a telltale “corkscrew hair,” and who could...

  18. DAY 15 Thursday
    (pp. 151-165)

    In 1969, the Surgeon General of the United States, W. H. Stewart, told the Congress that it was time “to close the book on infectious diseases.” This heady requiem was based on twenty-five years of dazzling successes in the prevention and control of several of the great pestilences of mankind. Smallpox was on the road to extinction, and polio, tetanus, and diphtheria were expected soon to follow. Devastating diseases like pneumonia and meningitis had been beaten by antibiotics; others like measles and whooping cough were prevented by vaccines; and even the mightiest scourge of them all, tuberculosis, was slated for...

  19. DAY 16 Friday
    (pp. 166-174)

    When I walk into the 5R unit this morning, I guess from the huge smile on Ian Trent-Johnson’s face that something fabulous has happened. Indeed it has: there have been no new admissions to our ICU service during the last twenty-four hours. None at all. Ian has had a busy night, but in keeping with his studious habits, he managed to spend time in the medical library where he read up on Group A streptococcal infections. He spurns the “orthopedic library,” which is where the housestaff go to lift weights and exercise. We still have eight very sick patients, but...

  20. DAY 17 Saturday
    (pp. 175-180)

    Last night the telephone next to my bed started to ring, triggering an old reflex, one acquired long ago when I was a first-year resident and used to get called several times a night. Such intrusions are much less frequent now, but each one still unleashes the same surge of adrenaline in my bloodstream. By the time I have finished saying hello, I am wide awake and ready to respond to anything, even when it is a wrong number. My wife scarcely notices the calls; our cat Walter, however, who sleeps on the foot of our bed, reacts as I...

  21. DAY 18 Sunday
    (pp. 181-190)

    Each year at least 30,000 Americans commit suicide. Elderly men have the highest rate of suicide, but nowadays the largest number of victims are young adults. Suicide is the third most common cause of death among adolescents. But these figures pertain to acute deaths from suicide, not to what is called “chronic habitual suicide.”¹ We deal with chronic habitual suicide almost every day, from drugs, alcohol, or high-risk sexual activity.

    Suicide raises conflicting issues about the sanctity of life and the concept of autonomy. The prevailing view until recently was that a person attempting suicide did not know what he...

  22. DAY 19 Monday
    (pp. 191-200)

    Before 8:00 A.M. every weekday, all three thirdyear residents get together in the ICU to plan ward rounds and to assemble one of the housestaff teams. This way, they are ready to start when I arrive, a time-saving feature I much appreciate. Today I showed up late for the first time this month, and everyone glared at me when I walked in. But it was not my fault; it was my cat’s. Walter skipped out on me.

    Walter and I got up at the regular time this morning, and on my way upstairs to make coffee, I let him out...

  23. DAY 20 Tuesday
    (pp. 201-211)

    The answer to the question “When is someone dead?” has changed during my professional career. At the beginning, we would pronounce a person dead when he or she had no heartbeat and no spontaneous breathing. Now, with drugs and devices to sustain the heart and circulation, and ventilators and oxygen to substitute for breathing, we look to the brain to determine if someone is dead. Patients with untreatable structural damage to their brains—provided they have no drugs or metabolic abnormalities that might cause coma, and are not hypothermic or in shock—are brain-dead when: there is no response to...

  24. DAY 21 Wednesday
    (pp. 212-217)

    Every day so far this month, at least one of our patients has been in the ICU for treatment of a disorder related to too much alcohol: acute intoxication or one of its hazards (injury from falls, hypothermia, pneumonia) or alcohol-induced cirrhosis of the liver or one of its complications (bleeding, spontaneous bacterial peritonitis, coma). Other serious problems from excessive alcohol that haven’t turned up yet are delirium tremens, pancreatitis, and poisoning of the heart muscle. Overindulgence also causes accidents on the road, at work, and at home as well as several kinds of cancer, and increases blood pressure and...

  25. DAY 22 Thursday
    (pp. 218-225)

    If people think hard enough, they can probably recall hearing about some now dead member of their family, usually in their grandparents’ generation or even older, who had tuberculosis. Then this centuries-old scourge seemed to disappear. Though tuberculosis remained the leading cause of death in the United States as late as the early 1900s, improvements in housing, hygiene, and sanitation in the first half of this century, and effective antibiotics coming in the late 1940s, all contributed to a striking decrease.

    But in the 1980s, government funding for the tuberculosis control programs that were responsible for this extraordinary decline also...

  26. DAY 23 Friday
    (pp. 226-230)

    When I started medical school we were told that we would have to master a huge new vocabulary, said to be at least the equivalent of an entire foreign language. During my first year, I prepared and studied flash cards with new, specialized words like “polymorphonuclear leukocyte” and “natriuresis” written on one side and their definitions (“multilobed white blood pus cell” and “excretion of sodium in the urine”) on the other side, exactly as I did when I was studying German to qualify for admission. (The foreign language requirement, German or French, was dropped by most medical schools many years...

  27. DAY 24 Saturday
    (pp. 231-237)

    When one of our medical residents overlooks a common disease in favor of a rare condition, we invoke the “zebra syndrome.” It gets its whimsical name from the notion that medical students and young doctors in training are apt to interpret the sound of hoofbeats clopping down the street outside a high-powered academic institution by remarking, “Those must be zebras,” never ordinary horses, reflecting the ivory tower preoccupation with things rare and exotic.

    The zebra syndrome was hard at work a few months ago. I was attending in the medical ICU and saw a young Nicaraguan man who had been...

  28. DAY 25 Sunday
    (pp. 238-243)

    The Etruscan shrew, the world’s smallest mammal, breathes at the rate of 300 breaths per minute—six times faster than humans breathe, even during strenuous exercise. In relative amounts, this means that tiny shrews require six times more oxygen than vigorously exercising humans. Shrews, humans, and most other mammals breathe regularly at a fairly uniform rate and depth, but there are a few amazing exceptions. Elephant seals and sperm whales, for example, can chase underwater prey for up to two hours without breathing at all. The world’s record for breath-holding, though, belongs to a reptile, the common lake turtle,Trachemys...

  29. DAY 26 Monday
    (pp. 244-250)

    We live in a world of germs. Invisible microbes are everywhere: bacteria fill the crevices around our teeth, the canal of our intestines, and the hair follicles of our scalp and skin. Most of these microorganisms are harmless, but disease-producing bacteria are often mixed in and are constantly seeking ways into the body to cause infection. To withstand this unremitting onslaught, our bodies are magnificently equipped with an elaborate system of defenses that, first, prevents the entry of germs beyond certain barriers and, second, if some invaders should penetrate this outer perimeter of protection, quickly gobbles them up (technically “phagocytoses”...

  30. DAY 27 Tuesday
    (pp. 251-258)

    “Code Blue,” a frantic call for help, indicates that a patient (rarely a visitor or employee) has just died or is about to. A “code” usually starts with a nurse or aide discovering a patient who is not breathing or who has no pulse or blood pressure; the finder rushes to the nearest telephone and, using a restricted extension number, calls the hospital operator, who summons the Code Blue Team using a voice pager that announces the ward and room number of the victim. At SFGH, the third-year medical resident on call in the ICU (one of “my” residents this...

  31. DAY 28 Wednesday
    (pp. 259-266)

    For a research-minded physician like myself, the most frustrating part of working in an ICU is the impossibility of ever knowing whether each of the many decisions I make is right or wrong. There’s no doubtwhya particular option was chosen or how it turned out, but there is no way of knowing what might have happened had I made adifferentdecision. In contrast, a scientific experiment includes thoughtfully designed control studies to provide a clear explanation of the results, however they turn out. But there are no controls in the ICU. Once a decision is made to...

    (pp. 267-276)

    ICUs exist to save seriously ill people, who otherwise are likely to die, and to restore them to lives of length and quality. Did we successfully attain this goal for the sixty patients we cared for this month? We had at least seven gratifying rescues: Edward Ramsey (gastrointestinal hemorrhage and heart attack), Jaime Aguinaldo (gastrointestinal hemorrhage and achalasia), Barbara Rivera (pneumonia complicated by unconsciousness from lack of oxygen), Margarita Rojas (chloroquine overdose), Virginia Powers (asthma), Susan Levine (asthma and chronic obstructive pulmonary disease), and Eleanor Dutour (onset of diabetes mellitus with delirium and acidosis). Two more patients, Bi-Ya Ng and...

  33. NOTES
    (pp. 277-282)
    (pp. 283-284)
  35. INDEX
    (pp. 285-296)