MOUNT HOPE

LIFE AND DEATH AT THE HOSPITAL

A TENDER TERROR - Dec. 3 Pg. 2

The hospital saved his life — brave, strong hospital! — but didn’t consider what kind of life it might be saving. Hospitals make us feel less human when they do this, so we resent them. Then the moment of clarity slurps back into the murk of the health-care system, into a thousand competing agendas and complaints, and also into a strange pinging noise.

Right, photographs of baby Zachary Bastead’s parents and family are taped to the plastic of his incubator. Below, surgical staff operate on Zachary so his lungs will clear. Bottom, a suture is snipped during surgery.

Zachary’s blood-oxygen level is falling like a broken elevator. The anesthetist is grabbing for a blue bulb to ventilate him by hand. As the level drops, so does the tone of the blood-oxygen monitor. There are dozens of tones in a hospital’s pediatric intensive-care zone, and each one means something different. On a busy day in the overcrowded Mount Sinai neonatal ward, the pings and beeps and bongs and boops seem to syncopate into an ultramodern symphony, something Schoenberg might have composed to remind us not to get our hopes up.

•     •     •

Eleven floors above the neonatal intensive-care ward where babies are gasping to enter the world, patients in Mount Sinai’s adult intensive-care unit are struggling not to leave it. The man in Room 1808 doesn’t want to go. He has been in the ICU for months. A bed here costs roughly $2,700 a day. The man has no choice, however: In his 30s, a father of young children, he has fatal leukemia, and was disabled by a bonemarrow transplant. Now he needs a machine to breathe. He can’t speak because of his tracheotomy, the breathing-tube stuck in his throat. Overnight, he has developed a new pneumonia. He is awake but dying. But does he know he is about to die? That’s what his doctor, Tom Stewart, wants to know: Will he let the ICU doctors turn off his ventilator?

OPERATING MANUAL Mount Sinai’s Medical Supply Use In the 2004-05 fiscal year. Bandages/dressings: 430,000 Examination gloves: 3,100,000 pairs Surgeons’ gloves: 250,000 pairs IV solution: 482,000 bags Masks: 385,000 Suturing needles: 18,000 Syringes: 1,330,000 Surgical screws: 20,000 Surgical sponges: 2,135,000 Surgical staplers: 4,000 Sutures: 100,000 MOUNT SINAI’S SURGICAL MENU Operations performed at Mount Sinai Hospital in the 2004-05 fiscal year, by discipline. Gynecology: 3,972 Endoscopy: 3,785 Ophthalmology: 2,014 Orthopedics: 1,660 General surgery: 1,572 Urology: 1,054 Otolaryngology: 744 Oral surgery: 583 Urogynecology: 363 Plastic surgery: 332 Vascular surgery: 128 Miscellaneous day surgery: 18 Total: 16,225 Source: Mount Sinai Hospital

Dr. Stewart is the director of the Mount Sinai intensivecare unit, as well as ICUs in the other teaching hospitals associated with the University Health Network. He’s 42, babyfaced, plays hockey, likes to have either dinner or breakfast with his kids every day, and lives in Oakville, just west of Toronto. He’s famous for being positive and decisive, ideal traits in a critical-care doctor. When Saudi Arabia’s King Fahd was dying last spring, Dr. Stewart was one of the specialists flown in from around the world to care for the ruler.

ICU doctors make decisions: They dispassionately compare a range of options, and choose one. Making a decision is pare a range of options, and choose one. Making a decision is pletely right, but you can always make a better decision. Critical care is a coming specialty: There’s an ICU in many of our futures. When Dr. Stewart thinks about that, he says things like, “How do we shape that demand? The point is, we have to start thinking like a business more.” If he sounds cold and unfeeling, it’s because compassionate pragmatism ultimately serves patients better. When Dr. Stewart and his team investigated their own ICU, they discovered that they didn’t need more ICU beds. They needed “better patient outflow.” They cut everyone’s sedation, and unhooked postoperative breathing machines sooner. Guess what happened? Survival rates improved.

There have been 160 patients admitted to the ICU in the past two months. Eighteen died, and three are still here. The most common diseases Dr. Stewart sees are acute respiratory distress syndrome, septic shock, overdoses, pneumonia, complications from cancer — common stuff, the crabgrass of medicine. But two or three times a week, the team shuts down a machine that is keeping someone alive. Imagine that job. So it is perhaps not such a surprise that Dr. Stewart, the calculating genius of outcomes, is also an evangelical Christian who believes in creationism. He finds the idea a comfort. “I believe there’s a God,” he tells me one day. “And that God created things. Does that mean I don’t necessarily believe in evolution? That would be crazy.” He figures evolution is like Henry Ford’s assembly line; it pumps out life, but it took Henry to crank up the first Model T.

The dying man in Room 1808 is also a devout Christian. He and Dr. Stewart have bonded over their faith. But the man is also hoping for a medical miracle, a remedy the doctor never counts on. The man’s wife wants to take him home — like a lot of understandably emotional family members, she fires off agitated e-mail messages to the ICU team. She thinks he’ll recover at home — even though “you can basically see him dying before your eyes,” says Randy Wax, an ICU doctor. It’s a common drama up here on the top floor of Mount Sinai, so close to heaven. The dying man is torn: He trusts his wife, but he trusts the The dying man is torn: He trusts his wife, but he trusts the yesterday, as they frequently do, to explain the psychodynamics of the man’s family to the team. The shrinks’ diagram, three giant interlocking circles covered with arrows, is still on...

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