Review by Amitha Kalaichandran, M.D.
The intensive care unit (ICU) in any hospital is the most high-tech, and the least interactive, in terms of doctors and patients.
I often think back to two patients in the pediatric ICU—one who had a recurrence of metastatic cancer resulting in multi-organ failure, and for which every last intervention was done before death in that very ICU. The second was a case of pertussis that was misidentified due to many red herrings and errors in clinical decision-making, which led to an extensive workup for everything from a rare rheumatologic issue to a rare infection. Safe to say, the ICU is sometimes where rationality prevails, but also where cognitive errors are frequently made due to an over-reliance on the quantitative data from typical physiology. It’s also where emotions run high given the reliance on machinery that sustains life.
Matthew Morgan’s new book, Critical (Simon and Schuster UK, 2019) promises to take a deep dive into what takes place in an ICU through a review of the medicine as well as Morgan’s personal reflections on patient cases that have most deeply resonated with him.
As an intensivist (also known as a “critical care physician”) himself, Morgan begins the book by describing a friendly conversation he had with a man at a Dublin bar after a medical conference. The man asks him about Morgan’s line of work. Morgan responded with, “I’m an intensivist,” after which the man exclaimed, “What on Earth is that?” A lightbulb went off for Morgan—perhaps what was obvious to him may not be for most people, and considering that a large percentage of us will eventually die in an ICU, it’s crucial we know something about it.
The book is organized into nine chapters, including an introduction describing the field of critical care, or intensive care, medicine. Morgan names each chapter according to the ‘system’ that houses the most common conditions requiring a visit to the ICU: the immune system (which covers sepsis and other deadly illnesses that result in an auto-immune-based organ shut-down), skin and bones (which cover, among other things, severe burns), the heart (including deadly arrhythmias and post-surgical heart conditions), the lungs (including conditions requiring assisted breathing with a ventilator), the brain (and traumatic brain injury), and the guts (including liver cirrhosis).
The last chapter, entitled “the soul,” delves into questions about death in the intensive care unit, arguably the area of the hospital where patients are least likely to leave alive. Morgan pulls the curtain back on how death is approached and understood in the ICU, providing a prologue for a topic that books like Paul Kalanithi’s, “When Breath Becomes Air,” or Atul Gawande’s “Being Mortal,” explore more deeply.
What intrigued me most in Critical was Morgan’s two big hints about the future of intensive care medicine. In particular, he describes the issue of burnout among ICU physicians. It’s no secret that critical care medicine is often high-tech, and low-touch, and patient interactions, which may buffer that sense of isolation in other specialties, are less frequent. Research suggests that ICU physicians may, as a result, be more prone to burnout. Morgan’s deep reflections after difficult medical scenarios may, in a sense, help restore a sense of meaning. As well, Morgan soundly describes the promising pilot initiative of having intensive care continuity clinics in some hospitals. These aim to provide ICU doctors with feedback about their care once a patient leaves the unit, while also helping restore the traditional patient-doctor-relationship.
Other medical writers such as Sandeep Jauhar, Siddhartha Mukherjee, Brian Goldman, Atul Gawande, and Daniel Ofri have, respectively, covered cardiology, oncology, emergence medicine, surgery, and internal medicine well. Rana Awdish personally took us into her experience as an ICU patient and how that affected her approach to patient care. However, Morgan’s Critical offers a novel look into the medicine behind critical care, which is far from an exact science, while also providing a humanistic lens on caring for the sickest patients. And as such, Critical offers new lessons for patients, as well as both seasoned and new physicians.
Amitha Kalaichandran, M.H.S., M.D., is a resident physician and writer based in Ottawa, Canada. Follow her on Twitter and Instagram at @DrAmithaMD