In the Name of the God, the Compassionate and Infinitely Merciful

In the May 22/29 issue of JAMA, the Journal of the American Medical Association, there was a quite significant article published that piqued my interest as a critical care specialist. It was a randomized trial which compared early vs. late placement of a tracheostomy tube.

Many times, patients are admitted to the ICU with severe illnesses that require long stints on the ventilator, or breathing machine. Quite commonly, critical care physicians make a clinical judgment as to who will likely need long-term ventilator support. In these patients, a surgical procedure called a “tracheostomy” is performed.

This is a procedure where a small incision is made in the neck and a plastic tube is then inserted into the trachea, or windpipe. The ventilator can then be connected to that plastic tube. It is much more comfortable, and it allows for easy disconnection from the ventilator without worrying about respiratory compromise.

It has long been debated among us critical care physicians whether placing such a tube early on in the course of a prolonged critical illness is beneficial. Studies have been done trying to answer this question, and it still has remained unclear. This most recent article seemed to give an answer…and it was one that surprised me.

The study authors, based in the UK, concluded thus:

For patients breathing with the aid of mechanical ventilation treated in adult critical care units in the United Kingdom, tracheostomy within 4 days of critical care admission was not associated with an improvement in 30-day mortality or other important secondary outcomes. The ability of clinicians to predict which patients required extended ventilatory support was limited.

This means that they found very little benefit to placing a trachesotomy tube early on in a patient’s critical illness. Yet, the key phrase – from a spiritual perspective – was the last sentence: “The ability of clinicians to predict which patients required extended ventilatory support was limited.”

That’s doctorspeak for: “We doctors are not God.”

For many reading this, this clearly goes without saying. Yet, there are some in my field that think otherwise. We must always remind ourselves – and science has proven this – that we are not omniscient or omnipotent. That’s why I am reticent to answer questions such as, “How long do I have to live, doctor?” or “How long do you think it will take for me to get better?”

I have no idea.

Now, my experience and scientific research can allow me to make an educated guess. But, it is just that: a guess. The medical field, especially critical care medicine, has kept me honest. There have been many a patient who, when I first examined them, I was certain were going to die and subsequently lived and walked out of the ICU.

And, unfortunately, there have been patients who I thought would do well and did not. So, when I’m asked a question that causes me to speculate about the future, I give a cautious, measured answer because – and I have to be honest with myself and the patient – I simply do not know for certain.

I tell the questioner: “You know, that’s a difficult question to answer,” but I try to give my best guess. And in my experience, I have found that patients and their families appreciate the honesty. I remember once when, before even a diagnosis was made, an ER physician told a patient who had a spot in his lung: “You have six months to live.”

As a result, he was clearly dejected by the time I saw him. I said, “Hold on…we haven’t even made a diagnosis.” And he went on to live many months after that initial meeting. I will never do something like that because there is no way I could know something like that for certain.

Bottom line, just as the study says, “The ability of clinicians to predict which patients required extended ventilatory support was limited.” In fact, you can insert any outcome into that statement and be telling the truth. We can try to guess, but we can never know anything for certain because…we are not God.