ICU


More codes last night. That makes the intern happy; she still thinks it’s a game. Which is all well and good, but I’m the one running the code, and I don’t think it’s quite so much fun any more.

In a way, yes. It’s the nice that the nurses say, “Oh Dr. Alice, it’s great that you’re here. This isn’t your patient, is it? What do you want us to do?” Um, you’re doing good compressions, and I see we’re ventilating nicely, and you paged anesthesia to intubate (that’s how it’s done at my hospital). (These nurses are good. I much prefer codes in the ICU.) How about finding the doctors whose patient it really is? Because I’m getting tired of running codes that I’m not even responsible for. The medical people are supposed to be responsible for codes at night, especially on their own patients. So why am I the only one there for twenty minutes?

So my interns work on lines (they’re good enough with lines on still patients; people bouncing around they’re not so good at yet; we’ll have more practice), and I work my way through every single drug in the ACLS protocol, first-line, second-line, and last-resort. We intubate nicely, and defibrillate more times than I can count. I ask the nurses in the hallway, for the third time, if they would please make sure we’ve paged the medicine folks. By the time they show up, much to my own surprise, we have a perfusing rhythm, a central line, and even an arterial line (which is nice in a prolonged code because it tells you for sure whether there’s a pulse or not, and how much good it’s doing).

I’m a little ambivalent about the value of what I did. After a 45-minute code, I’m skeptical that the patient will have much neurological function left, or that he will even survive till morning. But I couldn’t have decided to stop earlier, without knowing anything at all about his background, and without having managed to get in touch with the primary team. (Also the arterial blood was bright red the whole time, which made me think we were oxygenating and perfusing pretty well, so there was no urgent need to stop.)

On the other hand, I’m making myself a reputation for successfully running codes while also placing impossible lines. A reputation for invincibility doesn’t hurt, until it breaks. It is true, though: the key to being relaxed while someone else learns how to do a procedure is being confident that you can fix it. I knew I could get the lines any time I really wanted them, so it was ok to let the interns try for a while. Next time, maybe I won’t have to run the code, and I can coach them through it better.

(I guess that paragraph definitely qualifies me as a cocky surgery resident. I never thought I would be that person, so I’m going to enjoy it, until it breaks in a night or two.)

(Next time I’m going to see if I can think coherently enough not to have to ask the nurses every five minutes what the patient had been admitted for. They must have told me the same thing six times, and I just kept asking again, as though they had a secret that would tell me why the patient arrested.)

The first patient we rounded on is worse again, and we run back over to see. One of the multiple devices keeping them alive seems to be malfunctioning. . . or is it that their cardiac function is suddenly deteriorating even more dramatically? The device rep happens to be around, but can’t seem to come up with a solid answer; and if he can’t tell what his own device is doing, it’s pretty hopeless. The cardiology attending shows up, and one of the cardiac surgery attendings. A lengthy discussion, and finally out of the confusion, a decision: an OR room has been opened, the patient is going there right now. It’s an immediate decision, laid down by the attending, but it takes nearly half an hour to execute: the cardiac anesthesia team has to come over, get at least slightly acquainted with the myriad drips and machines surrounding the patient, and then a procession is organized to move the patient (being bagged), three iv poles, and two machines at the foot of the bed, through the twisty corridors to the OR.

I try my best to urge the intensivist to finish rounds expeditiously, without actually saying that I want to escape over to the OR. Finally, an hour later, we’re done, and I leave him considering some more electrolytes, and slip over to the OR. It’s an emergency case, so the fellows are tied up in the scheduled procedures, which means I can scrub in and assist with the PAs. I’m not much good in a normal cardiac case, let alone an emergency, but I have learned enough not to be in too much danger of tripping over the bypass cannulas, and I’m starting to be able to see what the attending is trying to accomplish, and help get that done. I think about putting on my loupes before scrubbing in, but decide that it’s going to be a long case, the structures are big enough to see without, and I’d rather be able to see the operative field, and help with the equipment, than be trapped in the tiny field inside the loupes.

The case drags on and on. One obstacle after another, and with every one the patient’s blood pressure slips lower and lower, and the rhythm tracing looks more and more erratic. The mediastinum fills up with blood, and it’s a non-stop job to suction enough for the attending to see what he’s working on. I fight back an impulse to point out what the blood pressure is. He knows well enough already (there’s a large monitor placed to be visible to the surgeons), and pointing out how desperate the situation is won’t help him get a difficult job done faster. Another attending comes in to help, but things don’t get any better. Both of them start making pessimistic remarks, warning anesthesia that things are not going well, and are not likely to improve. The circulating nurse is occupied, either in a whispered argument on the phone with the blood bank, or searching through the supply cupboard for the increasingly exotic sutures that are being requested in the hope that they’ll hold where others have failed. The attending has the ICU charge nurse called to go convey to the family that things are not looking good, to prepare them for him to arrive with the bad news in a little while.

Eventually, he calls it. There’s so much blood in the mediastinum that it’s impossible to clear, let alone put stitches that have any chance of helping; the mean pressure has been around 30 for who knows how long; and then the heart goes into fibrillation right in front of us. One attempt at defibrillation, with the sterile paddles that are laid at the top of the table for every cardiac case with the hope that they won’t need to be used, and then we admit defeat. The attending scribbles on the requisite papers in the OR, and goes out, to talk to the family and dictate some approximation of a report, leaving the PA and me to close up. I’ve never actually been in the OR with a dead patient before (except on transplant, and that isn’t supposed to count; we weren’t trying any more to stop those deaths). I wish I were more shocked, but actually everyone knew what the outcome would be from the beginning of the day, let alone the beginning of the case. The PA offers to let me put in the sternal wires (too much chance of hitting lungs and major arteries for me to have ever been allowed to do that on a live patient), and with that excitement, and the thrill of having actually been first assist on a big case, I try to forget the family members I had seen crying in the waiting room all morning.

Then it’s back to the ICU. There are still more lines that need to be put in, consultants’ plans that need to be checked on. Have to go and see who was put on a spontaneous breathing trial this morning, who looks like they’ll get off the vent in a day or two, and who is still too sick to wean. Check on the chest tube output of the patients from the OR this morning, since there is nothing guaranteed to get a cardiac attending yelling at you faster than neglecting to inform them soon enough that the output has been approximately 200cc/hr for a few hours. (I know, because I’ve tried it more than once. If you keep checking every 15 minutes, somehow it doesn’t seem like so much blood; but then you add it up after two or three hours, and it’s a lot, enough to be worth opening for, and you get chewed out – again.)

Out by maybe 6pm, but too often, we end up opening a chest in the ICU from earlier in the day, when the volume in the chest tubes, and the amount of blood transfused, passes the attending’s threshold; and then we’re there even later. No rush, the next day is just going to be the same all over again.

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.

Two months in the ICU have given me about all the procedural practice I can handle. (As opposed to OR practice, that is.) I’ve gotten to do – or attempt – several intubations. I tried to explain to the attending today that I have a 50/50 record: half the ones I’ve done have been when he wasn’t there, and they all went fine. Half of them were with him around, and they all failed. He opted to reiterate the pharyngeal anatomy and technique of laryngoscopy again.

Also central lines. I got a subclavian line today, in an intubated patient with no access, and thus no sedation and no drips. First stick, right in. The attending (same one; I don’t think he has 100% confidence in my procedures, for some reason!) was setting up to do a femoral line, as being quicker and more reliable, but I got the subclavian in before he could do more than prep his site. (I wanted the subclavian for central venous pressure monitoring, plus you’re allowed to leave them in longer, so conservation of effort.)

On the other hand, I proceeded to struggle with femoral a-lines for the rest of the morning (for the nonmedical folks, these should be the easiest of all lines, whereas a subclavian in an unstable patient should be the most difficult). Something about putting them into patients with VADs (ventricular assist devices), and thus non-pulsatile flow, and thus no pulse at all, seemed to complicate matters. Invariably, as soon as the nurse gave up on me getting the line any time in the next 5-10 minutes, and went out of the room for a quick errand, I got the line (you need the nurse to attached the pressure tubing in a semi-sterile fashion, otherwise you risk contaminating the field and losing your brand-new line by reaching for wherever the nurse tucked it).

Overall today was the worst possible of all my days in the cardiac ICU so far, except that I was with an attending I like and trust, which helps a lot. Without really verbalizing it, we split the unit in half: he took the most unstable patient, and the most hopelessly stable (no progress except in a steady downward direction), and I took all the others. It felt as though I was competing to see how many other procedural specialties I could involve in my patients’ care. By the end of the day I had a pretty full tally: general surgery, vascular surgery, GI, interventional radiology, plus some noninterventionalists: neurology, endocrinology, nephrology. At the same time, I managed to have fairly decent conversations with the families of four different patients, which is better than my usual ICU record. (Especially cardiac ICU: I usually feel as though I don’t know enough, or control enough, of the patients’ course, to be able to explain fairly.)

ICU rounds post-call ought to be banned by the Geneva Convention.

Come to think of it, really they’re already covered under the Fifth Amendment – cruel and unusual punishment.

If the computers weren’t so heavy, I would have been throwing them at the end of rounds. I hate it when the attending asks you the same question three times, and then makes a decision based on the information you told him not existing. Or when, on post-call rounds, he starts explaining in excruciating detail why you should never do – what his senior colleague did two days ago, and it’s now somehow my error.

It was funny to start with, but now I’ve had enough of this business of six different attendings each laying down the law to me about something, and then turning around and calling me a fool for having gone along with their colleague’s plan. Also it was a bit of a let-down, having kept a patient so sick we didn’t expect him to last three hours alive all night (honestly, by not touching him at all), and being a little pleased with myself on that score, to have the attending show up and be angry about the only single order I made on him all night. Come on, the guy is still alive. Isn’t that worth a little tolerance? Did you really expect me to cure him, too?

Right now, there are really only two things I want in life: to be senior enough that I can put in a chest tube without two people supervising me, and to be senior enough not to be the one holding pressure for 45 minutes after pulling out an intra-aortic balloon pump – for the second time in three days on the same patient!

(Although I have to say, the other day, when the attending paged me to come help in the OR and “just have a nurse hold pressure [on the site of the arterial sheath just removed] – I want you in here!” it was pretty sweet; usually the nurses refuse to do that for residents.)

Answering to one attending is difficult enough. Answering to three or four at the same time, about the same patients, is extremely tricky (I’m not going to try to explain the structure of this group of attendings; I still haven’t figured out exactly where the power lines are, which is no doubt part of my problem). When discussing any given decision in the patient’s management, the attending you’re currently talking to is liable to take exception, and start asking how that decision came to be made. You never know if he’s just trying to figure out which of his colleagues has taken the greatest interest in the case recently, or which of his colleagues is wrong-headed enough to be pursuing this particular plan. Or perhaps he knows (and you don’t, yet), that whatever you’ve been doing is so completely off-target that none of the other attendings could possibly have approved it, so either you misheard what they said, or you’re doing it entirely on your own; either way, you’re in trouble. Or perhaps his questioning is simply in the time-honored surgical variation of the Socratic method, in which he attempts to shake you off your commitment to a correct answer.

If you’re just doing the wrong thing, and you can figure that out, it’s relatively simple. Then you merely get to figure out why it was wrong, and what to do next. But if it was one of the attending’s colleagues doing something that he thinks was incorrect, and you’re left trying to explain it, the opportunities for committing a faux pas are endless. You could imply that his colleague was right, and he’s wrong to object; you could imply that he’s right, and you never agreed with his colleague, which is a little better, but still disrespectful to the colleague. Or you could inadvertently make plain that despite the apparent importance of the subject (since they’re all asking about it), you really don’t understand the difference between the two plans at all, or the significance of whatever the difference may be.

And the fellows want to know why I’m sometimes reduced to stuttering incoherently during rounds, as my life flashes before my eyes, and I try to pick which one of these equally impossible situations I want to get into, as I try to explain why the patient is on xyz medication. (Catch them ever helping with an explanation, even if they were involved in the decision! As the junior resident, I am perpetually assigned to be the one presenting on ICU rounds, and thus perpetually the one trying to explain myself.)

Some of the attendings are even more devious. We’ll be calmly proceeding with an operation (a setting where I’m usually safe from being questioned about details of ICU management, since it would be too distracting from the case at hand), and the attending starts what seems to be a friendly inquiry into how the rotation is going, and how the ICU is working. Next thing I know, I’ve somehow managed to say something incriminating about the actions of myself or the fellows. . . I ought to have figured out by now that these attendings are far too complex to ask pointlessly friendly questions. . .

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