During a break between clinical rotations in medical school, I was 6 miles into a hike in Kings Canyon National Park. Surrounded by stunning scenery—expansive mountain vistas, towering forests of redwoods, and the first streams of sunlight shining on the valley dirt path—I found myself staring at a rock. Not a particularly notable rock, except for the vibrant, neon green moss growing on its side. As I leaned in to get a closer look, I watched tiny ants navigating their way through the stalks of the moss forest. Tiny step after tiny step, each fork in the road a new critical decision point in reaching their destination. They navigate their moss as I navigate the redwood forest.
“Silly ants,” I thought, “they don’t even know how much more moss there is on this rock. They don’t even know that this rock is just a single rock in a whole pile of rocks set atop a mountain, which itself is a giant rock.”
Flashback to my first week on my intensive care unit elective: I too felt lost in the forest that was patient care in the ICU. Surrounded by very different scenery—peaks and valleys scrolling on the ventilator screen with each patient breath, tangles of IV tubing spilling from towering poles above the bed, bands of fluorescent light reflecting on tile illuminating the path down the hall.
The following series of pictures depicts my progression in thinking about patient care.
Left: Feeling like the ant in the moss of day-to-day decisions: Can we decrease positive end-expiratory pressure from 10 to 8 today? Is the arterial line giving us the accurate blood pressure or should we titrate pressors based off the cuff? Should we give fluids? Or are they already volume overloaded?
Center: Stepping back to their current illness trajectory: Once we get them off continuous renal replacement therapy, will they need dialysis indefinitely? How much longer will they stay in the ICU? Should we start talking about a tracheostomy at this point? What sort of cognitive recovery can they expect?
Right: Seeing their life as a whole, not limited to their illness: What matters to them in life? What makes life worth living to them? Will we be able to get them home to enjoy a Sunday afternoon ice cream cone with their grandchildren? What were they looking forward to before this admission?
As students/clinicians/ants, let us all humbly aspire to escape the forest within the moss to see the magnitude of scope in caring for each patient.
Acknowledgments
The author thanks Pratik Pandharipande, M.D., M.S.C.I., professor of anesthesiology and surgery (Vanderbilt University Medical Center, Nashville, Tennessee), for his incredible teaching and thoughtful reflections during the author’s time in the intensive care unit.
