Sunday, September 30, 2012

Yes. I want to see you feed a mouse to your snake.

This year I have mulled over the contrast between working in the Emergency Department and the Intensive Care Unit.

Working ED is mundane, in the sense: "of or pertaining to this world or earth as contrasted with heaven; wordly; earthly". Rather than the pejorative sense: "common; ordinary; banal; unimaginative." The Intensive Care unit exists in a theoretical realm of controlled physiology and patients devoid of personality and social context.

In ED I see patients who are largely ensconced in their normal life.  Their stories commence with them sitting at their desk or cooking dinner, when injury or illness intervenes. They are still contemplating how this new illness or injury will fit in around their work, children or interstate trips.  They wear their work clothes and apologise for not having shaved their legs.

When patients are admitted to ICU the rupture from normal life is complete: they have entered the sick realm.  They are unable to tell their stories, which are instead condensed to medical short hand: "4 days of abdominal pain and fever".  They wear only hospital gowns.

In ICU our physiological theories appear to fit more neatly, often because we have 'taken control' by, for example, ventilating the patient. One of the more unpredictable situations in ICU is weaning the artificial support and returning the patient to their mundane existence: breathing for themselves.

Which leads me to another grand and ridiculous dichotomy:

Mundane; real world; clinical medicine in general; emergency medicine


Theory and ideas; philosophy; academia; intensive care medicine.

When I am working in Emergency I enjoy the vagaries of working with 'real people', but get frustrated that clinical theories and decision making tools poorly explain their problems.  And when I am studying philosophy or working in intensive care medicine I revel in the self-contained theories but crave for the conversation.  At worst: Emergency is full of frustration, Intensive Care is full of people who take themselves too seriously.

And whenever I find myself waxing lyrical about encounters with 'real people' in the ED, I am  reminded of the scene in 'Almost Famous' where Russell runs off from the band in search of a real experience. He ends up going to a high school house party with some 'real Topeka people':

Russell Hammond: You, Aaron, are what it's all about. You're real. Your room is real. Your friends are real. Real, man, real. You know? Real. You're more important than all the silly machinery. Silly machinery. And you know it! In eleven years its going to be 1984, man. Think about that! 
Aaron: Wanna see me feed a mouse to my snake? 
Russell Hammond: Yes.

So, there it is folks: 

Intensive Care Medicine: I am a golden god!!
Emergency Medicine: Yes. I want to see you feed a mouse to your snake.