Delicate. That’s how I would sum up my month of Pulmonary, Critical Care, and ICU.
I saw an incredible variety of cases – from hepatic encephalopathy, hepatorenal failure stage II, Charcot Marie Tooth, chronic idiopathic eosinophilic pneumonitis, pediatric sarcoid, hyperosmolar hyperglycemic non-ketosis state, and all sorts of shock (cardiogenic, hypovolemic, septic), to just name a few.
And if you don’t know most of these diseases, well don’t worry… neither did I beforehand.
Now the nature of Critical Care/ICU is that these people are sick. While it’s incredible to see someone in a coma intubated with drips wake up and walk out the hospital, there’s also tough moments. Sitting in family conferences discussing end of life and palliative care, I couldn’t help but feel oddly intrusive. Like, if I breathed too loudly, I would disturb the balance of life.
Sometimes choices are clear cut. As my attending told me, one can be stable and fight for life in the ICU only for so long before the body gives up.
After two weeks, one woman, Mrs. L, suddenly declined as her brain waves on the EEG got slower and slower. Her incredibly frail 90 year old husband (honestly, I kind of wanted to put Mr. L in the ICU too) had the legal power to make decisions on her behalf…barely. So he had to rely heavily on his nephew. Mr. L looked so sad during the conference but nodded almost imperceptibly to take off all aggressive measures. There’s so much formal legality and documentation about codes and family decisions which I had no idea before.
Sometimes it’s not so clear. One devoted grandmother fretted about her husband Mr. W, who had been in the ICU for weeks, neither improving nor worsening. “Do I let him go? Do I give him a chance? I don’t know… help me doctor, please tell me what to do.” Unfortunately, doctors have no crystal ball, and even they were arguing amongst themselves on the next options.
Initially, Mrs. W chose to let nature take its course after talking to my attending, then later she chose the more aggressive procedure after another doctor changed her mind. Mr. W thus got better, and when I saw him open his eyes for the first time and wave feebly at me from his ICU bed, I couldn’t believe how close he had been to meeting death. A second chance seemed clearly the right choice.
Alas, a few days later he decompensated, and the wife doubted her choice, “What can I do? He’s depressed about life and giving up, but I can’t just let him go at this point – his body is falling apart but his mind is now alert. Did I miss my chance to let him go peacefully?” It’s as grey as can be. All I could do was offer hugs and tissues.
Clinical judgement is managing medications (give Ms. K pressors to raise blood pressure to keep her heart and brain alive….but sacrifice her hands and feet as the constricted vessels no longer could deliver blood anymore?) and even harder, managing mismatched expectations. Ms. K’s family was absolutely convinced she was going to wake up and walk out the door in perfect health with fervent enough prayers, despite all the doctors stating a grim prognosis.
During the family meeting, the family asked over and over that we transfer her to another hospital to for even more aggressive care for her stage 4 cancer, and my attending said, “You can’t possible move her anywhere, she is too unstable! I’m sorry, but I promise we are doing all we can.”
Delivering compassion with honesty in the face of death is really the hardest task of all.
Anyways, here is a Black Forest Cake (Schwarzwälder Kirschtorte) adapted from Joy of Baking. I wanted a truly authentic German cake – I can’t stand the fake American chocolate cakes with sugar sweet buttercream and fake cherries. Alas, I didn’t have the cherry liquor, but cherry syrup will do.
Layer cakes take a LOT of work. Cutting the cake evenly is tricky, and balancing them so they stack up nicely is even harder. While photographing, I was so frustrated it wasn’t perfectly straight and fought with it for half an hour. Since it was soaked in syrup, the longer time went on, the more delicate and precarious the base layer became.
Finally, I gave up, so you can see a little lopsided tilt in this fragile cake. I guess it’s kind of like life in the ICU.
Black Forest Cake (Schwarzwälder Kirschtorte)
CHERRIES / SIMPLE SYRUP
1 cup canned cherries, with 1 cup syrup reserved from can
1/8 cup granulated white sugar
3 tablespoons hot melted unsalted butter
1/2 cup cake flour
1/4 teaspoon salt
1/3 cup unsweetened cocoa powder
4 large eggs
scant 2/3 cup granulated white sugar
1 teaspoon pure vanilla extract
1 cup heavy whipping cream, cold
1 teaspoon pure vanilla extract
1 tablespoon granulated white sugar
CHERRIES: Drain the cherries, reserving the liquid. Place 1 cup of the reserved cherry syrup in a small saucepan, along with the sugar, and heat until sugar has dissolved.
CHOCOLATE GENOISE: Preheat oven to 350 degrees F. Grease a 9 inch round cake pan and line with parchment paper
In a bowl, sift the flour, salt and cocoa powder.
In a heatproof bowl whisk the eggs with the sugar. Place over a saucepan of simmering water, and whisking constantly, heat until lukewarm (about 5 minutes). Remove from heat and transfer to the bowl of your electric mixer. Beat on high speed until the mixture is thick and pale yellow; batter falls in ribbons (about 10 minutes). Beat in the vanilla extract.
Sift the flour mixture over the egg mixture 1/3 at a time and and gently fold. Take 1 cup of the batter and fold it into the melted butter (to lighten it). Then gently fold it into the egg batter.
Pour into your pan, smoothing the top. Bake for about 20 – 25 minutes or until a toothpick inserted into the center comes out clean (cake starts to shrink from sides of pan). Cool before removing from pan.
WHIPPED CREAM: In your mixing bowl beat the whipping cream, vanilla extract, and sugar until stiff peaks form.
ASSEMBLE CAKE: Using a sharp knife, cut the genoise horizontally, into two layers. Brush the cake layer with 1/4 cup cherry syrup. Spread the whipped cream and cherries evenly on top. Brush the cut-side of second genoise layer with 1/4 cup syrup. Place cut-side down on top of the cherries, gently pressing to compact.
Cover the cake with your remaining whipped cream over top and sides of cake. Refrigerate the cake for several hours (or overnight) before serving. Decorate with fresh cherries and shaved chocolate.