In commemoration of being nearly done with cardiac surgery, and in atonement for having posted so sparsely lately, here’s a look at a typical (ok, maybe a little extra exciting) day in the cardiac ICU:
In before 5am to collect data and write notes on some 12 patients, only to discover that two more were admitted overnight, and one of them is very sick. I sit down to look at vital signs in the computer, and two minutes later the charge nurse walks up: “I know you just got here, Alice, but this patient is hypotensive. In fact, the systolic is getting below 40.” Hurry over to that bed, and hastily try to collect the key facts about a patient who was admitted overnight, in extremis, already on three pressors, and deduce from a 50-word summary of their history, delivered by the charge nurse, what is the next pressor to add, and whether or not fluids would be a good idea. (It’s been hard for a person trained in general surgery to adjust to the fact that fluids may not be good, and lasix may be quite beneficial, in the peri-operative period.) Quick calculation: two inotropes, running at maximum dose, not keeping the pressure up; CVP and PA pressures are already quite high enough, so fluids not needed; vasoconstrictor would be the easiest drip to get going just so perfusion pressure doesn’t get too low while we’re thinking, but will have to be careful to use only a touch, and better get the pharmacy working on our third (and last) inotrope. . . Once that drip is running, stay for a minute to make sure it works, and look over the various pumps (balloon pump, and/or temporary VAD, and/or a form of ECMO), inspecting the numbers and trying to look as though I know what on earth all the tubes are doing.
Back to scribbling furiously to get all my notes finished in the allotted time, which is further reduced by all the nurses coming up to ask for supplements on potassium and magnesium. In cardiac patients, one likes to run these electrolytes on the high end of the normal spectrum. Even if you write prn sliding scales for replacements, there’s always a special circumstance necessitating giving more or less, and the nurses would much rather catch me while I’m sitting there in plain sight, than page the overnight call person.
6am, rounds with the fellows. Try to deliver all the information I’ve collected, examine the patients as a group, hear the nurses’ reports and concerns, and make plans for the day, in time for the fellows to leave for the OR, hopefully not much later than 7am, as they need to review the cardiac catheterization films a final time before the cases start. I have the remnant of the 7:00 hour to finish my notes, pull all the chest tubes from the day before, get started on transfer orders for the patients who can leave the unit, and reorder sedation drips and restraints as needed, before the cardiac attendings start coming in one by one. They each expect me to give them my undivided attention as we look through their individual patients, and I give an account of how much lasix we have or have not given, who needs a transfusion, who’s ready to go upstairs, who’s still on an epinephrine drip and why, and who didn’t get extubated overnight, and why haven’t I fixed that already. (The usual procedure in our unit is for the patients to come over from surgery intubated, then be quickly weaned off the vent over the next 4-6 hrs as they wake up. If the patient is slow to progress, and the overnight call person is not aggressive, sometimes people are still intubated the next morning, which throws the schedule off, as they can’t be fed and mobilized and moved upstairs to make way for the next round. Plus the patients and their families don’t appreciate it, either.)
Hopefully I manage to fit coffee in before the critical care attending arrives around 8am, ready for “real” ICU rounds – ie, slow ones. With my luck, there’s usually at least one important arterial line down by this point, and my conscience does not allow me to look for coffee or breakfast before all the lines are fixed and chest tubes pulled. Our unit is between one-half and one-third populated by LVAD patients – those with ventricular assist devices, whose arteries have no pulses, and who are thus especially challenging to get a-lines in.
Then there’s the patient whose blood pressure is spiraling down, increasing NG output, decreasing mental status – time for an intubation. New lines are called for. Once those are in, they have to be gotten down to CT, and sure enough, time for another consult to general surgery for ischemic gut. Have to find a general surgery resident who hasn’t learned, in the last few weeks, not to to take my calls, and a general surgery attending who isn’t sick and tired of operating on sick cardiac patients. These complications – a nuisance to the cardiac surgeons – are very distracting to me, because I find myself much more interested in the patient’s abdomen than in their cardiac status, and I wish I could just stay with the general surgery residents as they work out their plan.
Back to critical care rounds. Someone’s sodium is either too high or too low, and I’m supposed to pay attention while we calculate the free water deficit. . . I know it’s a serious moral failing, but I cannot get myself to care about the sodium. Potassium, yes, but sodium, unless under 118 in a trauma patient, and threatening seizures, really doesn’t hold my attention, no matter how hard I try. (Some days I don’t try too hard.) Then we have to look at a vancomycin trough (why is everybody’s blood growing staph at once, and in how many of them is it real, and how many are just contaminated cultures?) and adjust the dose, and the pharmacist wants to adjust the cefepime dose due to rising creatinine. . . My attention is wandering, and I notice a nurse at the other end of the hall looking anxiously out of the door of an isolation room (meaning that once inside, she can’t just come running out in the hallway without stopping to take off the isolation gown). I slip away from the intensivist and the pharmacist eagerly discussing renal dosing of various cephalosporins, and verify that yet another patient is hypotensive, and I guess I can’t forestall putting in another a-line. If I’m lucky, I can do it in less than ten minutes; maybe the rest of the team won’t even notice that I’ve left rounds. . . grab the supplies, prep the wrist. . . I’m getting pretty good at guessing the location of the radial artery in hypotensive patients (in whom there’s only a faint, semi-imaginary pulse, and if you were really going by touch, it would take a long time). Verify that the pressure is indeed as low as the cuff suggested, start a pressor, order some blood and sputum cultures, and go back to suggest a bronchoscopy to figure out whether or not this ventilated patient actually has pneumonia or not.
While the attending is looking at xrays, trying to decide how serious the left lower lobe consolidation is, I see the case manager out of the corner of my eye. Quick, better talk to her now, and reiterate that two or three of these chronic patients are about ready to leave, and I really hope she has a place at a rehab facility for them when they’re ready (because people who stay in the ICU even a few days longer than necessary have an unpleasant habit of developing pneumonia or bacteremia, and delaying their transfer indefinitely).
Ok, better pay attention to these next few patients with the attendings. I have another bad habit. When a patient has been hopelessly sick for more than a few days, and I can’t figure out what’s wrong with them, my mind starts blanking them out. I can’t stand to think about how little progress they’re making, and I’ve already gone in circles trying to figure out why they’re sick, and then I can’t concentrate on them any more. . . which means I make myself pay even closer attention when the attending is discussing them.