The best description of the intensive care unit comes from the people who have been inside it. One patient describes it this way: ICU is the station modern science has built at the border of death — on the far shore of the river, at the far end of the bridge.
Every patient there, except the ones under observation, would have been dead a hundred years ago. Modern technology is what still holds them to this world. Since it is the land of the dead, it extracts the price of the land of the dead.
The horror of ICU is not death. It is being caught between life and death — endless pain and fear, with complete helplessness.
The first thing that comes back: breathing
The truly critical patients lie in deep sedation, a state close to death that is not frightening at all. You feel nothing; time stops existing; everything is void. If you die in that state, you die — a parallel crossing.
But if you do not die, if ICU holds you back, then the journey back across the border of life and death costs skin. To return to the world, they reduce your sedation and let you wake. Sensation returns to your body. The respiratory system is one of the first.
You feel something pumping air into your lungs — the ventilator. You try to take a slow breath; a rush of air slams into your lungs. You instinctively fight it; the airflow vanishes. You cannot breathe, try a deep breath, and the airflow comes back harder, indifferent, nearly bursting your lungs. You struggle, and the airflow grows more chaotic with your breathing, the ventilator fails to synchronize, and it starts screaming.
Your trachea feels full of foreign matter. You cough involuntarily, but the balloon of the endotracheal tube seals your airway, and the ventilator amplifies every cough into agony without letting you clear the secretions. Your face turns red, your mouth fills with saliva, you cannot breathe, cannot swallow — you are sure you are dying.
The nurse hears the alarm, sees your distress, comes over. Water enters your trachea. You choke, cough desperately. Then something moves down your airway — pain like a knife cut, itching like a feather duster shoved inside. Tears pour out; you want to escape and cannot. That is suctioning: refuse it and you choke in agony; accept it and you suffer needle-cut pain, repeated every few minutes in bad stretches, several times a day at minimum. The suction tube can even cut your trachea, doubling the pain each time.
The tube passes your epiglottis; the balloon sits below your vocal cords. Your oral secretions cannot go down the digestive tract and pool at the balloon — you always feel a pool of water in your throat. You feel you are suffocating, drowning; you panic, and you can do nothing.
Occasionally another plastic tube goes into your mouth, suctioning secretions while probing your throat. Your abdomen twitches; you want to vomit. Someone says with satisfaction, "Good, he has a gag reflex." You do not understand what they are saying, or why they keep probing your throat, while your whole body aches with every twitch, and you can do nothing.
You instinctively reach to pull out the hated tube — and discover your hands are tied. You want to, but you cannot. You can do nothing.
The test that decides whether you can leave the machine
To end your suffering, to free you from the ventilator, they decide to test and train your spontaneous breathing. They lower the ventilator settings and force you to breathe with your own muscles. Breathing instantly becomes heavy. You try, but you are terribly weak; you struggle in suffocation for an hour and can no longer pull air. The tidal volume alarm goes off. A voice says, "That's enough for today. We'll try again tomorrow."
Every day, you struggle through this suffocation, reliving the fear of dying. Right now, unable to breathe, you are a dead person. But if you want to return to the world of the living, this is a gate you must pass. How long it takes — no one knows. Some cross it in one step; some never do.
Pain returns, then withdrawal
As sedation and analgesia are reduced, pain returns. You ache everywhere. Every so often someone pinches your finger hard with a pen or syringe like an instrument of torture. You scream, but you are so weak that all your effort only opens your eyes. A voice says, "No response to pain? Try again." Someone rubs your sternum with something hard; waves of pain crash; your heart rate and blood pressure spike. You want it to end, but you can do nothing. Finally they give up: "I think I saw his face twitch... let's try again later." You want to say, please let me die, but you cannot.
Pain is the sensation a living person must have. Returning from the land of the dead means passing through more and more pain. Slowly you gain the strength to respond — you can grimace, localize pain, and they stop testing so often. Then withdrawal begins.
The analgesics you were given were all opioids. Your sedation drugs may have included benzodiazepines, and propofol — the "little milk" that gave you death-like sleep. All of them are addictive. You are anxious, agitated; you see strange things, hear terrible sounds; ten thousand ants seem to crawl inside you; you wish you could burn yourself into a flame and be done. But if you cannot bear even this, you cannot return from the land of the dead.
The body swells, the skin leaks
You want to move a finger, but your fingers are too swollen. Your whole body is swollen. To support your blood pressure they poured liters upon liters of fluid into you — medication, nutrition, all liquid. But your kidneys fail; tens of liters of extra fluid accumulate in your body. Your skin swells transparent, leaking sticky drops like a saturated sponge.
Dignity becomes logistics
The feeding tube does not hurt much, because it was placed while you were unconscious. But you cannot control defecation. To reduce your gut burden, they keep you in a state of diarrhea with various drugs. You cannot control it. You lie in your own excrement, hoping a nurse has time to clean you. Feces irritate your skin; your entire private area is red, swollen, even ulcerated — painful and itchy. If you happen to be a decompensated cirrhosis patient, your diarrhea is more frequent to excrete blood ammonia, and you may experience lactulose enemas several times a day: stripped, turned, enduring the strange humiliation of an enema, then letting go completely. Every day, several times. Humiliating and painful — and you can do nothing about any of it.
