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Intensive Care Medicine

, Volume 45, Issue 4, pp 552–556 | Cite as

An intensive midsummer night’s dream

  • Filippo Vitale
  • Cesare Gregoretti
  • Antonino Giarratano
  • Andrea CortegianiEmail author
From the Inside

Any resemblance to real events and/or to real persons, living or dead, is by chance. This is just a dream experienced by an ICU physician on a midsummer Sicilian night.

August the 15th*

*In Italy this is the mid summer vacation day by definition

Thirty-five degrees Celsius in the shade, latitude 38°07′55″, longitude 13°20′08″, population reduced by around 50%. It is an inverse demographic osmosis where the town gets empty and beaches are invaded.

An obese patient, Mr. A, is going to be admitted to the ICU for a multiorgan failure. Creatinine to the stars, transaminases equal in number to the leukocyte count of a normal individual, urea soaring. Chest CT scan: “eclipse of the lungs”. In front of the lung a big heart, the epicenter of the disorder, usurping all the aerial spaces.

Abdomen CT scan shows small kidneys, wrinkled, looking like two badly growth transgenic beans. In short, the patient’s organs are “freely represented”, as if it had a multiorganic homunculus unknown to the human species… a sort of cubistic work.

While outside he is a “Botero” inside he is a “Picasso”.

The family meeting

The time comes for the medical consultation. From the number of people coming to hear about the clinical condition of their kin, I have the impression that there is not enough space to contain them and at the same time guarantee oxygen levels of at least 21%.

I open the door. First to enter are Mr. A’s relatives. They gain the “pole position” after convincingly competing with each other.

I realize that it is not diplopia on my part… there really are 20 of them! I have a growing and disturbing feeling that such a level of participation is a tacit recommendation to give exclusively good news. But I have not any good news at all!

I start to rummage into their looks… I try to track down one of them who at least had an expression… I do not say accomplice, but at least not hostile. In these cases, we know, it is important to assume that someone would not be prejudicial to us… and finally, I find one. It’s a guy without an arm. His handicap gives him a certain degree of empathy towards misfortune. He has the soul ready to use in thorny matters like this… he also has a gentle, pleasant smile featured by an ungenerous squint that make me unable, to be honest, to be sure he’s watching me.

The visual hooking cannot work any longer, so I change objective; I focus on a woman I guess to be the patient’s wife sitting in front of me and to a man—I sense that he is the eldest of the patient’s sons, a face that promises so much misunderstanding.

On my left side is going to sit down a small, stocky, grizzled man, with the glasses worn lower than the hump of the nose. This look gives him an interested expression, one who demands greater intimacy of communication, and who has more tools than the others to understand the situation. I’m not wrong; he promptly introduces himself! It surprises me; he knows my name and greets me with a mature confidence; but I do not have the same impression… I do not know who he is!
  • Duttù, nuautri ni canusciemu, chiddu ru puimminu i pruviatti… (“Doctor, we know each other, I am one of the workers who carries the blood samples to the lab”).

  • I’m sorry, but… I do not remember… maybe we met each other somewhere… but I really do not remember…

  • U Signor A. è me cugnatu! (“He is my brother-in-law!”).

I allow a kind smile and I begin to communicate the current clinical status of their kin. I especially address his wife. She keeps her eyes down with her chest bent over the table which she approaches with only one arm, the other holding her bag, her legs bent at his knees: she has the position of someone waiting to get away.

I use some hydraulic analogies when needed to describe the clinical picture—those never fail. I see that they understand me and their faces also leak satisfaction, seemingly liking my way of speech. However, I can not avoid repeating the same scene, always the same, as if it were a sketch already written in a recondite score of their DNA: whenever I mention an organ, for example the liver, and confine myself to reporting its damage, one of the delegation addressing Mr. A’s wife says:

“U viri, tu rissi, è muoitto, nun c’è chiù nienti i fari!” (“I told you. He is dead! There is nothing else to do!”).

I am going to finish the “safari tour” of the compromised organs while trying to give them a balanced prognosis that it is obviously not as good as they would like it to be.

Mr. A’s brother-in-law—“Mr. Test Tube”, my supposed acquaintance, asks for permission to speak… I do not need to give my consent as he is already giving his lecture. He does his speech, getting up from his chair, turning to everyone. I invite him to sit down… he listens to me, sitting back again. He picks up his glasses moving them at the root of his nose:

Allura, u capissivu, avi u cuari quantu na casa, nun puampa chiù, i rugnuna acqua unni piscianu chiù, l’acqua si nni va nei puimmuna, è anniatu. Uora ci misiru u pumpaggiu ra machina ra dialisi, accusse l’acqua a spuigga fuara… ricu giussu duttù?

(“His heart is big like a house, but it doesn’t work anymore. His kidney don’t produce urine anymore. The water goes into the lungs, like drowning. They start dialysis to remove water, doctor is that right?”).

I recognize that what he is saying has its internal consistency, and consistency always has a pacifying effect on the listener… So what does it cost me to say yes? “Yes!” I say, it is about that, and they all nod in unison!

I keep watching Mr. A’s wife; her eyes go from one side to the other like a pinball machine, saying no to everything the congregation say. It is at this point that I perceive that the relationships between them are not idyllic.

I will let you come into the ICU as soon as possible. I beg all of you to stick to our rules.

The “thanks doctor” arrives at the same time as an “amen”. They give me a handshake one by one… I do not withdraw, despite the tenth squeeze of 20 beginning to cause some epidermal difficulty. I feel myself less and less human and more mechanical, like they were putting their token in a machine that validates their exit from the room.

Lastly, Mr. Test Tube remains, his glasses still lowered. He leans out in front of me. He is keen to acknowledge the quality of his performance. He assures me that they understood.

I greet all of them with a smile. Honestly, I feel sorry.

Crisis risk management

Shortly after, I’m talking to other people looking for other words to describe their drama. We are suddenly interrupted by sounds of hostile tone. In the turmoil, I recognize the metallic rumble of the inlet chute, acute estrogenic greek mourning cries, an open slap, another… Then, androgenic screams like roars of lions; they are distant and then closer; they are screaming with “Doppler effect”. I apologize to the people I am talking to. I explain to them that this is a family misunderstanding; they are clearly displeased. I hear a nervous knocking at the door.
  • Please, come in.

  • Doctor, doctor, go upstairs quickly! There is a lady on the ground… foam coming from her mouth… maybe she is having a seizure.

I jump upstair, arriving in the ranch of the ground floor… a stream of people. I force my way to find a space but I cannot walk. Around me are a whole council of mouths; they babble the first syllables of a tragedy. I feel like John Rambo looking for a way to escape out of the forest. Then I look down and I see a woman on the ground. I recognize her; she was part of the first group. Actually she seems to be in the throes of an hysterical crisis, skillfully mimicking epileptic seizure. The foam is voluntary. I admit that she knows how to do it well, thick and white; she has experience… it is not the first time, I guess.

Facing her, at a 90-degree angle, another woman is lying supine on the ground. From what I understand, it is her sister; she is an hysteric who plays the part of the hysterics.

The former shakes her feet; the second woman shakes her head and repeats in croaking loop: “me suaru muriu, me suaru muriu” (“my sister is dead, my sister is dead”).

I perform a quick triage: the self-styled epileptic has the priority. She made the best simulation and she has stolen the scene… Now everyone is in pain for her.

Mr. A no longer seems to be their foremost priority.

Mr. Test Tube suddenly rushes to the lady. He puts his hands on mine; suddenly a pile of fingers clogs the lady’s mouth. I invite him to leave the scene.

He lets go of his grip, and it is at this point that one of the most enlightening things I have ever seen during a disaster scene happens: it is an act whose power is of mystical, magical, apotropaic order.

A young scion seizes the hand of the epileptic woman and brings it firmly to the ankle of the hysteric sister. He commands the hysteric woman to move the foot and the epileptic woman to shake her hands around the ankle. He reassures each of them of the voluntary act of the other, and he intones: “Are you seeing me? You are alive, come on, touch yourself…”. It reminds me of when the polarities of two batteries are brought into contact to allow energy to flow. It is Chinese medicine, it is tantra, it’s a miracle! Everything stops! In a flash the two protagonists are pacified, healed, they returned to their orthostatic lives, and I no longer have doubts about the Gospel. Now I know, God is there!

Call the police!

I leave the stage to the ICU nurses. I go out. I want to look at the sky before coming back to the ICU. I feel inspired, but I do not have the time to focus on my thoughts. At a distance of about 50 m, like scattered clouds, I see groups of arms randomly flailing; some slaps reach their target, some others don’t. There are three or four simultaneous fights among men of the same herd, who are now divided into factions, human bonfires of mid-August. This thing does not concern me at heart…

I continue giving clinical news to the other relatives. I apologize to them, but they do not give the impression of understanding. Nevertheless, the environment surrounding us remains “polluted”.

I approach the video intercom to tell the ICU personnel to let the relatives come inside the ICU, but I do not have time to give the order; someone activates the video intercom. I see a policeman in uniform on the monitor. I can imagine the reasons for this visit.
  • Good morning, is there the doctor in charge of ICU here?

  • Yes, it’s me!

  • Doctor, you must do something!

  • Please!

  • Please let all Mr. A’s relatives enter the ICU!

  • Please!

  • Yes, you must let them in because they are going to kill everyone in order to decide who should enter…

  • I’m sorry, officer, but I have already told them that only three people can come in, no more; they can choose freely among themselves. I cannot do anything… there are rules that are not arbitrary; we do it to contain clinical risks, infections, etc.; we stick to precise provisions. Do you understand?

  • Doctor, I don’t think you understand; soon they all will enter the ICU like an army of crusaders in search of the Grail.

  • Excuse me, but are you here to protect me or to support them?

  • So, are you going to talk to them?

  • I have already talked to them about it. They have not expressed any hesitation. I do not understand what happened now…

  • They cannot get along with each other and they’re slaughtering each other. They’re wild.

  • I’m sorry, but you are exaggerating a bit! I think they prefer more immediate modes of interaction, that’s all; you’ll see that when it's all over, they will all have a beer together. It’s a ritual!

  • Please go and talk to them!

  • All right. I will go back.

A mystic vision

I get Mr. A’s wife and children and I address them from the side of a tunnel. I speak to the wife, to a son who has a new bruise pigment in the right eye, and to an enraged younger son, and eventually to a frightened minor (Fig. 1).
Fig. 1

An intensive midsummer night’s dream

I discourage the access of the youngest who has a hint of cough. Now the policeman is aware and competently supporting my cause. He looks at the child and says: “See this cough; there are germs, and because of them your father could potentially die…”.

I say, “Officer, you exaggerate always… eh eh…”.

The oldest son, after the extended contest, is now the one who has the scepter of representation. He seems to be more confident now. He has lost the terrified look of a few minutes ago during the previous speech. He looks at the man in uniform and says:
  • “io a me patre mu vasu…”. (“I want to kiss my dad…”).

A veil of confusion is drawn in the eyes of the policeman; he is speechless!

From the depths of the tunnel, which connect the ICU to a slipway, another round-shaped member of the family comes. He turns to speak to the eldest son; they exchange gestures with each other, their heads swinging upwards repeatedly. They seem to be the mirror image of each other. Then they approach cheek to cheek as if attracted by a magnetic ritual. They beat their breasts like two cocks, three or four times, accompanying the liturgy of the body with arcane, guttural sounds. There is something enigmatic; I dare not question myself… I can no longer distinguish the sacred from the profane.

Now we help the mother and her two sons to put on the protective devices, gowns, shoes, caps. But everything suddenly takes on a different form; it turns into an unexpected ritual, another one, a self-made investiture… I witness it. The eldest son takes the reins of the family; the new boss grabs the face of the mother… then he shakes her hands begging her not to listen to the rest of their people:
  • nun sannu a pimmeattiri ri tirarici piari o papà, uara cumannu io”. (“They must not think that my dad is going to die! Now I have the power!”).

He turns to his younger brother, facing him. He says:
  • U papà è bivu, è bivu, u caipissi?” (“Our dad is alive, alive! Did you get it?”).

I get them to the bedside. They embrace their father and all his organic and inorganic offshoots, including dialysis machine… I warn them that it is not a slot machine and ask them to be more cautious. They seem to understand. I look at them from a distance. Time is running out. My turn is also going to end…

Plump, I wake up at the alarm sound. I am confused! I can hardly recognize reality and dream by now...
  • Whoever you are, wherever you come from, love is what guides people’s actions in an ICU, and every love has its language, every love has its scene, every love its poetry.

  • Love is freedom! Love is respect! Love is life!

I have to go to work on a bright, lovely, Sicilian mid-summer Sunday. I am not sure that what I “lived” tonight was real or not, as it is for our patients in ICU, suspended between life and death; as it is for our patients in ICU, they too waiting for alarm time, maybe for God, maybe for Godot (Fig. 2).
Fig. 2

The intensivist waiting for… Godot?

  • The night is leaving… The dream is over…The morning is coming…

  • What is a dream?

  • A scenography of the fear?

  • The setting up of an untold desire?

  • A clue of the unconscious when you lose your way?

  • The night is leaving… The dream is over… The morning is coming…

  • What is an ICU?

  • Trust in man?

  • Hope in God?

  • Patience for Godot?

  • The night is leaving… The dream is over… The morning is coming…

  • And I.C.U. (I see you).

  • “I see you” man…

  • “I see you” God…

  • “I’ll see you” Godot?

Notes

Acknowledgements

We would like to thank Dr Emanuela Petrona Baviera for being a kind doctor, a lovely mother and the talented graphic illustrator of this manuscript.

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflict of interest.

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Department of Anaesthesia, Intensive Care and EmergencyPoliclinico Paolo GiacconePalermoItaly
  2. 2.Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.). Section of Anesthesia, Analgesia, Intensive Care and EmergencyPoliclinico Paolo Giaccone, University of PalermoPalermoItaly

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