You Don't Always Need an Answer

Physicians and scientists love answers. When something is wrong, we want to know why. The most beautiful internal medicine notes are designed to explain the status of each problem, the possible diagnoses, the tests to probe each suspect, and the treatment plan. (Unfortunately, in the era of high volume medicine, this degenerates from a well-articulated thought process to a few unhelpful phrases, but when I teach medical students, I emphasize the importance of the proper method of thinking).

But in the intensive care unit, sometimes we struggle just to keep someone alive. They are dying, and instead of probing why (if it is not immediately apparent), we race to support each organ system. The note is organized by each of the body's core systems (brain, heart, lungs, kidney, nutrition, hematology, infections) and how we are protecting or rescuing each.

A woman with a complex cardiac history of multiple heart surgeries comes in with acute cholecystitis. This is a fairly simple problem; a gallstone gets stuck in the gallbladder leading to inflammation and infection. Before she had surgery, she was transitioned from one blood thinner to another; because she had artificial heart valves, anticoagulation was necessary to prevent clotting of the valve. The surgery (removal of the gallbladder) went smoothly, but afterwards, she had worsening pain, a dropping hemoglobin, and a CT that showed that multiple vessels in her abdomen were dissecting. Nobody could explain why; this is a strange phenomenon that causes us to think of rare rheumatologic or immunologic illlnesses. When she came up to the intensive care unit, her liver began failing. Her numbers were so scary, we called hepatology and transplant surgery immediately.

We did not know why this was happening and despite my fervent desire to know why, I knew that supportive care was what would keep her alive. Despite not knowing the cause of the liver injury or the dissecting vessels, I adjusted medications to safeguard those organs, transfusing blood as necessary, and balancing those risks of anticoagulation with the benefits. Over the following days, the liver enzymes returned towards normal, the skin lost its yellow hue, and the laboratory tests had fewer "critical value" flags. Soon she was ready to return to the regular ward. We never learned (and may never know) the ultimate cause of what happened, but in the immediate setting, why is less important than how to fix it.