A Month in an ICU

A Month in an ICU
by SW
Click the highlighted words for an appendix of abbreviations

I've never known what aspect of a hospital has the power to strike fear into the hearts of people. For a layperson, the labyrinthine structure is full of mysterious machines purportedly capable of saving a person's life. Equally mysterious are the many denizens that make this medicinal menagerie function. To an outsider, a hospital is the epitome of black box magic—someone goes in, something happens, and then they come out. Perhaps part of the apprehension surrounding the establishment is that people don't always come out alive. The whole life-death thing adds an element of danger to anything—especially when one is unable to understand the many nuances of modern medical care.

I've arrived at this hospital with the knowledge that I am more on the inside than most. In less than a year, my name will forever be prefixed with the title 'Doctor' based on six years of intense study. My field is pharmacy—a field with more issues than a newsstand, both positive and negative. At one time, a pharmacist was nothing more than a doctor's medical secretary, doling out medicines to patients with total submission to a medical doctor's practice. With drug therapy becoming the common theme of modern medicine, the pharmacist's emphasis began the shift to pharmacotherapy. I live in a time when pharmacists are beginning to wake up to the realization that their expertise in all things pharmacological can have a vital and crucial impact on the lives of patients. It is an exciting time—a time of promise and potential. But before I get on to making my contribution, I have to make it through these rotations.

For all the knowledge I have about the workings of a hospital, this rotation struck a fearful chord with me from the beginning. My assignment would place me in the Intensive Care Unit among some of the most critically ill and injured people in the entire hospital.

* * *

We left my preceptor's office and proceeded around the corner to the stairwell. The unit near her office is quiet today—no nurses, no doctors, and no patients. Advances in therapy have left this wing bereft of post-surgical clients. The carpet still springs back after each step, and the luscious scent of a new building permeates the air. We proceed down the echoing stairwell and through another series of corridors before reaching our destination.

A pair of wide rectangular doors stood nestled in an alcove just large enough to accommodate them. Above the alcove, a rectangular sign proclaimed this section's title in white letters on a bold red background: Neurotrauma ICU. Thin wire-reinforced windows were covered with paper from the inside, obscuring anyone from peeking past the barrier. The silver door handles leapt into a graceful arc before reconnecting to the wooden door with powerful metal bolts. I examined the multicolored placards giving instructions to all who laid eyes on them: No wireless devices beyond this point. Everyone must wash their hands upon entering and exiting the unit. A piece of white paper with hand-written letters caught my attention

"The sign says knock before entering," my preceptor told me, as she reached for the door, "but you don't have to worry about that, we can just go in." The door uttered a muted moan as my preceptor pulled it open and led the way in.

"That's good to know," I said, looking at the massive doors with a reverent gaze.

I elected not to tell my preceptor about the weeks prior to this moment. It would do little good to start our relationship divulging the many nights I had spent staring at the ceiling, wondering what it would be like when I finally stepped onto the floor of an intensive care unit. The didactic portion of our schooling gave me a broad spectrum of therapeutic knowledge, but there was no specific training in how to deal with this environment. Questions tormented me at unusual times: Would I be able to perform there? For that matter, what does it mean to perform in an ICU? Could my knowledge save someone's life? Could my actions end it?

I made it three steps into the unit before I was assaulted.

It started with my ears. The beep of telemetry and monitoring equipment went on and off sporadically in what seemed like every pitch imaginable. Tones of an almost musical quality sounded from rooms with equivalent randomness. I searched my mind for any logic or pattern but found none. The only tone with which I was intimately familiar was the long, high pitched whine associated with a flat-line. It was a sound that was absent, but seemed as if it could happen at any moment.

My eyes joined the assault, imbibing the brightly lit scene. Patient rooms were separated from the main desk by floor to ceiling panes of clear glass emblazoned with the room number. Some of the rooms were darkened with sleeping residents while others had nurses moving in and out providing care. Charts and clipboards littered the central desk without logic as people moved back and forth. Occasionally, someone would stop to scribble something before leaving the chart for someone else, take a sheet from a clipboard and wander into the room, or add to the growing sheaf of written information.

My nose was the next thing to kick in, thankfully. It took a moment to realize that I had not taken a breath since entering the unit. The scent was not immediately displeasing. In fact, it was far more pure than I expected. I smelled a number of things—plastic, antiseptics, soaps, and clothing. Just when I was beginning to think how the unit smelled fresher than expected, the stinging scent of concentrated feces wafted under my nose and was gone before I could flinch. It was so potent that I could almost taste it.

All these sensations hit me at one time with the force of a speeding ambulance. Dozens of unfamiliar stimuli teased the curious portion of my brain into wonderment and hesitation. This was truly an alien world.

"We always have to remember to wash our hands," my preceptor said, walking over to a sink nestled in the corner. "The sink is foot operated so you don't have to touch anything."

I observed her tap the hot water pedal with her toe and rinse her hands before flattening a bubble-like apparatus under the sink with her foot. Conveniently located just to the right of the arced faucet, an angular box connected to a plastic nozzle burped out a shock of creamy white foam into her waiting hand. She pumped a few squirts of the foam before vigorously rubbing her hands together and rinsing them clean under the water. As she pulled a few paper towels from the nearby dispenser to dry her hands, I stepped up and mimicked the process—not before noticing that the soap we were using was expired. The morbid part of my mind suspected it would not be the last time I saw something expired on this unit.

With so much going on, I wondered how I would ever be able to figure out a way to understand it all. My preceptor talked to me about how rounding works. We check the day's medications, check the physical assessments and compare with labs, check PRN(that means, 'as needed' for you non-medical folk) usage, and try to put together a concept of what we were going to do for this person—within the scope of pharmacy practice of course. It was an efficient system that would eventually serve me well—but the first day; it was more like chaos on the brain. Every time I would try to focus in on what my preceptor was telling me, something would distract me. It could be the chiming of some piece of equipment whining for attention, or maybe the nurse who just walked by me with an open jug of a frothing yellow liquid that could have been urine. No matter what, I only heard half of what I was told the first day. The other half I heard was my mind trying to convince me that I was really there. With so much action and activity going on, I felt like I was outside myself looking in.

"And after we finish going through all our patients, then everyone will come together for rounds," my preceptor told me.

"Rounds?" I asked, feeling as if I had been reduced to a child, "What are those like?"

"It's very informal here," I was told. "If we had critical care residents then it would be much longer because the doctors would have to stop in order to go over things with them. But since it's just nursing and pharmacy students, we have what we call 'rocket rounds'."

"Rocket rounds?" I wanted to smack myself for sounding like such an idiot, repeating everything I was hearing. Then again, I should have been grateful that my jaw wasn't hanging open like I felt it should be.

"Yes, that's just when we go from patient to patient. Everyone says their piece, and eventually we finish. Once we're done, we break. It's as simple as that."

Simple. Right.

Before I could embarrass myself again by asking another dumb question, my preceptor whipped around to catch a passing nurse. "Mark, do you have a moment?"

Mark turned to her. "Sure, what can I do for you?"

"I had a question. You're working with Miss Harriet, right?"

Mark nodded. "Yep, I've got her today."

"Good, I wanted to talk about her neostigmine…"

As they began to converse, I took a moment to note the features of Mark. He had experience written all over him. It was not an aged look, but certainly bespoke its own maturity. I would come to find out that he had spent years working Intensive Care, a floor that most nurses don't last long in. It didn't take much imagination to realize that a career of working closely with people dependant on you for their lives can have an emotional impact. Mark seemed like the kind of guy who could keep a stiff upper lip about it, despite the bushy mustache on his otherwise clean cut face. He was not as tall as I, but seemed almost a head taller than my preceptor.

Then, a peculiar phrase from Mark to my preceptor broke my internal dialogue. "Would you like to see it?"

"Yes, I think that might be helpful." She turned to me. "Would you care to join us?"

"Sure," I said, as if I had been following every turn of the conversation. The truth was I had no intention of letting a few ill patients or grotesque traumas get to me. I've always had a steel stomach and an iron will. As awed as I was by the environment, I felt it important to establish early to the nurses, my preceptor (and perhaps even to myself), that I could manage physical assessment in this environment. So I went, and in the process met my first patient.

She lay motionless; barely clothed in what amounted to opaque tissue paper. She could have been mistaken for dead except for the screens in the corner giving readouts on vital signs and the rhythmic click-hiss of the ventilator signaling each breath. Youth was in her face—I would find out she was no older than 19. Disheveled black hair wandered over closed eyes and under a crinkled blue tube that disappeared into her mouth. There were at least four tubes extending from her body into various receptacles—some empty and others filled with what looked like melted raspberry ice cream. It was clear to see that she had a distended, rotund belly that repeatedly drew my attention. A chill swept through me as the thought of a pregnant female in the ICU came to my head.

Mark removed the tissue paper covering over her belly and revealed its true nature. It was not, in fact, a pregnancy. Her bowel—for whatever reason—had become distended. The technical details of this are interesting in an academic sense, but not exactly the kind of conversation one has over tea and scones. Midline, beginning just below the sternum and extending downward to the navel, was an offensive looking scar. Blackened outlines gave way to angry looking skin before fading back to her normal tones.

"She's not looking too good," my preceptor said. I managed a sideways glance at where she stood next to me. If my preceptor had any emotional reaction to the scene, she was remarkable at not showing it. Similarly, I had no intention of adding such a distraction and buried it inside.

"Dr. Beaker thinks she needs to be decompressed."

My preceptor agreed. "Neostigmine would definitely be indicated in this case."

"You should feel her belly," Mark said, reaching out and pressing gently on the border between the right upper and lower quadrant. "It's totally hard as a rock."

My preceptor reached forward and did so. "Hmm, you're right. I don't get any give at all—" and then she turned to me. "You should feel this."

Cute. I thought. My first day, and I'm already groping an unconscious woman. I would discover that such a whimsical sense of mental humor would save me more than once during this rotation. I reached forth and gently pressed with two fingers, careful not to disturb anything. The experience was thrilling in a bizarre way. After all the time talking, worrying, learning, and considering, the touch was a subtle but powerful message that said this is real. A real patient—a real problem—and hopefully a real solution. I paused and concentrated on the sensation before me.

"Amazing," I think I said as I removed my hand. "How fast will the neostigmine work?"

Mark chuckled and covered her up again. "Pretty fast."

My preceptor turned to me. "Neostigmine is an acetylcholinesterase inhibitor. As such it will increase the level of acetylcholine available and therefore parasympathetic tone. This will decompress the bowel pretty quickly, mostly because one of the side effects of acetylcholine is diarrhea, right?"

I nodded. As soon as she said 'acetylcholinesterase inhibitor', I knew what was about to happen—another something that doesn't exactly go over well at the dinner table. I made up my mind to be somewhere else and busy when that process began.

My preceptor looked back at Mark. "Do we need to write for that, or has Dr. Beaker already done so?"

"I think he may have done it on his way through this morning, but you'll have to check the chart to be sure."

I looked at the chaotic chart table and winced at the thought of swimming through it all. A number of faces began to hover over the central station, chatting to each other and exchanging banter that seemed remarkably lighthearted compared to the environment. Entering from the direction we had come in was a man of short stature but stocky build. Despite the lab coat, you could discern a certain power in his arms that bespoke of workouts—or a career made using his hands and body. I didn't venture to guess his age, but with a full head of hair he certainly would have looked much younger. One could tell almost instantly that he was the resident intensivist by the subtle weight with which he walked—either that, or the words on his lab coat that said 'Dr. Beaker'.

"I see Dr. Beaker has come to the floor," my preceptor said. "We're probably getting ready to start rounds. We'll just have to play it by ear," she told me, "and get an idea of what the plan is for everyone."

Within a few minutes, the nurses came from their respective rooms, specialists stood around the gathering, and the doctor took a position caddy corner to where people sat at the table. Duly situated, the nurses started to tell the story of their patients—in Greek.

Well, it wasn't really Greek, but it might as well been.

Acronyms and numbers flew back and forth across the table readily. Questions were asked and answered in terms of letters and numbers. Elaborate procedure names and conditions sparked animated discussion about the best course of therapy. On occasion, I was fortunate to catch a drug name here or there—or the occasional English preposition or verb. As I listened, I felt the incredible urge to gape. They were speaking their own language down here, and it was absolutely not one that I was familiar with. The sense of worry began to seep back into my brain as I hopelessly pretended to pay attention.

The effort left me shot. My preceptor led me through a few more patients here and there. We sat down and talked about a few medications for a few people. Once or twice, we (rather she) answered a particular question from a nurse or another doctor on the floor. I was numb and mute through it all. The shock of the new environment, the experience of being up close to a patient, and the horrifying reality of needing to learn an entirely new language smacked me around like a piñata. And the sensations kept coming—the gurgling noise of mouth suction, a cough that sounded more like drowning than breathing, the rhythmic hiss of ventilation, the gentle bump of percussion, and the occasional soft moan from behind a closed curtain. I had been as useless as I felt for a little over two hours when my preceptor finally looked over and said.

"We're done. We should probably go get some lunch and then finish up with a few more things."

"Now you're speaking my language!" I said with a smile.

My preceptor brought her lunch. That gave me a few blessed moments to wander to the cafeteria and gather my mind. It would be over the many solo meals at the cafeteria that I would get the chance to process a little of what I was seeing. Naturally, it was not the best place to contemplate the pins through someone's legs or hips, nor the glorious site of a patient's exposed intestines. Hunger and general confusion overcame any kind of gastrointestinal dismay I had on the first day.

That afternoon, my preceptor loaded me up with a five pound stack of studies and sent me on my way. I do not fear reading—but it'd be a bold lie to say that I have a profound joy in reading medical literature. The first stack of papers was on ventilators—machines that breathe for patients (not to be confused with the mythical respirators, since respiration is a process not performed by these breathing machines). It went into my bag with a solid thud. I spent the next almost eight hours reading and attempting to process the foreign information. Dinner was my only interruption when I smelled a failed attempt at cooking from my roommate—and thought it smelled good.

The tremendous over-stimulation and fatigue from previous nights seemed to have been minor compared to what I was sensing at this time. I knew that this would be an experience that will either make or break me—my last thought before unconsciousness took hold.

* * *

The disorientation began to clear when definitions became tenable and the opportunities to learn abounded. The slivers of time spent connected to myself left me with two distinct senses. First, disappointment—for I found it hard to justify feeling like I knew nothing after working so hard for the last four years. Secondly, hunger—the kind of hunger one gets when they feel on the cusp of a great discovery and the glimmer of success is just around the corner. For me, it was more the former than the latter.

I found myself going home at night with a horrible feeling but having no clue why. Maybe it was because of the stories involved—the partially failed suicide attempts, the car accident of elderly siblings where only a few survived and a youth with intractable seizures. A pair of patients was being managed with an open belly technique. This particularly unhappy situation arises when the intestines swell to sizes greater than a person's gut can handle. To relieve the pressure, the patient's gut is opened and the coils are allowed to spill outside the body until they decompress and can fit the cavity again. It looks every bit as gruesome as one might imagine, and I found that these images stay with you whether or not you mean them to.

One morning I had the unusual pleasure of talking directly to a patient. Between the propofol, morphine, and other sedating drugs, I spent most mornings conversing with the nurses who observed these almost catatonic people. A motorcycle accident brought him here. I knew before I came down that we were talking about head trauma, multiple fractures, and skin shredded like lettuce. Admirably, the surgeons had him patched up such that one only need imagine the injuries and not stare at them. Still, the wild look of someone who'd seen life passing by was in his eyes as I spoke to him.

"Mister Fielding, can you hear me okay?"

The man looked at me. He was heavy set with a head that looked comically large due to the bandages. He gave an abbreviated nod through the neck brace and spoke. "Yeah."

"Good morning," I said amicably. "I'm one of the pharmacists on the floor and I would like to talk with you about your home meds, if you don't mind?" Now, granted I was a pharmacy student at this time, but in the interest of professionalism and patient comfort, I seldom identified myself as one unless necessary. What I was doing was too important and complex to introduce the painful doubt that the word 'student' strikes into patients.

"Oh!" His face seemed to light up all at once. "Of course. Did my wife send you the list?"

"We had a list, but some of the details were missing. Are you familiar enough with the medications to discuss them with me?"

"Sure," he said. "I never miss one."

We spent the next few minutes going over his home meds. Indeed, he had his routine down to the letter—an admirable trait considering the eight medications he juggled as part of his life. I also discovered that his sense of humor was grossly intact, a trait that garners helpless endearment when wielded by the injured. When we had finished our medication chat, I smiled and put down the pad of paper with my notes.

"That's all I need at the moment," I said. "We'll try to get you fixed up and out of here as soon as possible."

"Thanks," he said. But when I started to turn, I heard the bed creak slightly as he reached out. "Doctor?"

It took a moment to realize that he was talking to me. I returned to his bedside. "Yes?"

His face took on a solemn look that I won't forget. "Don't let me die."

I hesitated long enough to give the impression that his words had been carefully mulled. "The team will do everything in our power to secure your recovery. Just relax for a while, and let your body heal itself." The confidence with which I spoke seemed to have a soothing effect on him, and he settled into the bed for a midmorning nap. I returned to my duties and immediately began reviewing the next patient. It was not difficult to put personal feelings aside to get back to work, but emotional appeals are almost as dangerous as promises in an ICU setting. An intrusive thought spiked through the construct of my mind: I wanted him to live.

The next morning, I found him intubated secondary to respiratory arrest. I was one of the last people he would talk to in his life.

* * *

The month did not get any easier. I remember sitting at the central workstation, going over patients and hearing the faintest whisper of a name spoken. Looking up revealed a small crowd of people in street clothing surrounding a bed. I didn't need to be a fly on the wall to know what they were discussing. I didn't envy them the unforgiving decision they would have to make about the fate of someone so clearly loved. But I had to keep pushing it out of my mind.

I saw some things that left a bruise on the already marred record of humanity. Messed up things, like the family of a 28 year old young man who was a 5th generation alcoholic—they were proud at how fast he made his liver "quiver". I learned a great deal about putting personal feelings aside when dealing with a doped up guy who got in a shootout with police and killed a cop. I felt my own mortality come into question as I watched an 18 year old football player spent his 19th birthday in the ICU due to brain spasms.

Over time, my attitude changed from frustration at being unable to understand to frustration at things that could not be changed. Standing witness to the full brunt of modern medicine is magnificent—a true testament to humanity's ever evolving knowledge of itself. Equally devastating is knowing that despite all the years of knowledge, a time comes when there's nothing that can be done.

My finest moments were the ones my preceptor never saw. I had complex conversations with doctors over renal dosing, debated the merits and limitations of antibiotic choices, and made accepted suggestions for medication alterations. I began to receive calls from doctors who asked specifically for me to answer questions for them, and felt my soul shimmer with their appreciation. The respect I gained from the nursing staff over time made me feel that perhaps I might have been worth something. I knew I was not perfect. I was distant from adequate, as far as I was concerned. And I could always count on my preceptor to readily shatter the fragile confidence I was developing by pointing out things that I should have caught…leaving me scarred with self castigation for being so stupid when lives were at stake.

And then there were the dreams—the horror of seeing people you knew there, seeing patients that reminded me of home. Twice I saw familiar names from addresses that looked familiar, only to find that the resultant stabbing fear was unwarranted. I battled the subtle terror of the future—wondering whether or it would happen to someone I love or whether this was just a preview for another time when it was going to happen to them. I didn't sleep well. It was like being pulled down against my will. The intense workload complicated matters, leaving me little time for clarifying introspection. I justified the sacrifice by believing it necessary for the lives that would depend on me the next day. And, as I had done so many times before, I read, worked, and learned myself into a stupor—perhaps just so that I could validate the nagging truth in the back of my mind that I was not as good as I needed to be. And that, above all, bothered me the most.

* * *

I took the reins in my final days. Most mornings I went down without my preceptor and began the assessment process independently. Working up a patient was second nature by now, and I had become ever more efficient at it. After washing my hands, I grabbed the first flow sheet I could find and went to the patient's bedside. Mark was there to greet me.

"Morning, Mark," I greeted. At this time, my voice probably sounded strained as fatigue tainted the cheeriness of my salutation.

"Morning," he greeted, leaning over with a hose. "Give me just a second; I need to finish this suction."

"No problem," I said absently, flipping through the flow sheet. Things began to jump out at me immediately. By the time Mark finished extracting the slightly colored viscous fluid from the patient's mouth, I was ready to go. "So, what's the status?"

"Well, she's doing a little bit better. BP and heart rate are steady. Temperature spiked a bit last night, 101.3."

"That was what I saw too, but it seems to be trending downward."

"They bronched her last evening and it was pretty purulent. They put her on some cefipime and gentamicin last night that could possibly be working."

"Cefipime and gentamicin would be fine if she had a nosocomial," I said. "She's only been here since last afternoon. This is probably more community acquired."

"Oh really?" Mark said, interested.

"Yep," I said, making a note on my chart, "I'm going to see about getting that changed. You could use a fluoroquiniolone or some kind of beta-lactam with a macrolide to cover it. We can change based on what the smear shows. How's her respiratory status?"

"They went from CMV to SIMV yesterday."

"Any clue when she'll start moving to CPAP?"

"None," Mark said, "but respiratory was talking PEEP soon."

"I guess that means she'll stay intubated a little longer. I don't see any stress ulcer prophylaxis on her," I made another note. "We'll get some pepcid started."

"I was hoping that you'd write for some peridex too," Mark said. "Seems like it got left out."

"Duly noted," I said with a smile. "What about GI?"

"No bowel movements. Metabolic support will be placing an NG tube later today. Urine output is good. She seems to be concentrating okay, but is a little dry."

"The BUN seems to agree with you," I said. "She may need some free water added. I'll bring it up at rounds and see what they think. Her other 'lytes look alright, but her potassium is just on the level. I'll bring up the K-Mag protocol too, just to be safe."

"Dr. Pennyrule is on today," Mark said. "He'll probably be okay with the change."

I nodded. "I noticed she's on 300 migs of phenytoin. Any sign of seizures last night?"

"None noted," Mark said.

"It's still too early to take a level, but we'll just have to watch it. I'll write for one in advance to be sure it isn't missed. What about this propofol?"

"Forty mics, kinda high for someone like this."

"We've still got a little bit of time, but I would like to start the wean to Ativan and morphine as soon as possible given that she has no head injuries. It looks like she didn't get too much PRN pain meds, so I'm not too concerned."

"Anything else?" Mark asked with a smile.

"I think I'm done interrogating you," I said with a twist of humor. "Let me go find this chart and see who else needs the tenth degree."

I took the green plastic flipchart from the rack and settled into a seat at the workstation. A subtle chuckle slipped out when I noted the irony of using the old paper system when so much could be found on computer these days. Later experience would dictate that it held its own advantages to other systems. I had finished assessing a number of patients when I felt someone come to a stop behind me.

"Hey there," a new voice said.

"Morning," I responded, glancing back to see my preceptor. It was almost time for rounds, but her mildly tardy appearance was no surprise to me. She seemed to grow exponentially busier as the month stretched onward. It was probably more a realization on my part of the vast number of projects she had a hand in.

"How far have you gotten?"

"I've finished most of the traumas," I said. "Just have a few more to go. Do you want to take the neuros so we can have something to mention at rounds?"

"Alright," she said, accepting the small sheaf of flow sheets I handed to her. "Let's discuss the trauma patients as soon as you finish them."

We split up and covered the floor. It all seemed so routine by now—perhaps even smooth in a strange manner. This patient had renal changes and thusly medications had to be altered. Another had been extubated and no longer needed stress ulcer prophylaxis or peridex. A pharmacokinetic adjustment in yet another patient's gentamicin regimen led me to realize even more the importance of why I was here. As a pharmacist, I had unique skills and knowledge with which to assist in patient care. The ICU setting is a constantly changing wave of information washing over those that work there, leaving them gasping at times for a breath to understand what's happening. It is only natural that things get missed—but sometimes what gets missed can cost someone their life. The stakes are too high and the costs are too great not to have a drug specialist on the floor. Whereas I left the first day wondering what I was to do on the floor, I left the final day with the sense that my absence would be felt.

My preceptor, who had been running all morning, told me she had to go as soon as rounds had ended. I was well used to it by now. The difference was feeling that I could manage. I went upstairs to the step-down unit to see a patient. He spoke little more than Spanish, and had been in the hospital longer than I. Complications from his injuries kept him bedridden and helpless for longer than anyone should be expected to endure. To make matters worse, he had contracted the dangerous MRSA—a bacteria resistant to all but the most powerful antibiotics and a serious infectious control risk. This required contact precautions that further emphasized the separation between patient and provider.

The precautions were still on when I arrived at his room, so I donned the baby blue scrubs, mask, and hairnet (ironic, since my head is usually shaved bald) before knocking on his door. "Señor Rodriguez?"

His brother answered the door. He was a man of small stature and advancing age. Jet black hair balded gently, in some places hanging on tenaciously. His face bore the lines and creases of worry. His eyes alternately shimmered with hope and despair—emotions that I could recognize in any language. He seemed pleased at my presence, and invited me in by name.

We discussed the case briefly in Spanish. I had near fluency at one time, but now it came as a mix of conversational lucidity and professional clumsiness. They were patient with me, as they had always been, and it did not take long to convey my message. A week earlier, Mr. Rodriguez reappeared on the ICU floor after having been sent to the step-down unit. His platelet count dropped to critical proportions and we scrambled to find an answer. To this day, I don't think anyone knows what happened, but providence (and a little off-label drug help) saw to it that he would survive the incident. Today, I brought news that his platelets were beginning to show signs of normalcy—and that this would be the last time I would be working the floor.

It was at this point that Señor Rodriguez spoke to me—and for the first time in English. "Thank you for your help and attention. You have made mi experiencia better."

"It's what we're here for," I said, giving a short head bow. "Vaya con dios, señor."

Go with God. It seemed an appropriate goodbye since he was not out of danger yet. A smile found my face as I pulled off the precautions gown outside the room. Such gratitude from a patient was an unexpected gift. It was not my place to take the credit, but I did take pride in what small part I had played. More than that—it was pride in what I had learned. It is too soon to tell whether or not this experience will 'make me', but as I left the floor I was certain that it did not 'break me'.

I stopped by the ICU one final time to give my thanks to the nurses and staff who had helped me so much during the month. They were warm in their goodbyes, even though there would surely be other students the very next day. I swallowed the expanding emotion, adjust my lab coat, and left the ICU. Doubt I'll ever be back…this is just one month in a string of eight rotations required for me to finish this program. But I left with a sense of great accomplishment. The moment burned with enough heat to melt the ice of the sleepless nights, the joyless study, and the personal struggle to survive in such an extraordinarily challenging environment.