ICU


Overnight call in the cardiac ICU is one of the most stressful things I’ve ever done, partly because all the patients are extremely sick, but also because of the number of people I have to answer to. By this time I am a little used to sick patients, who don’t necessarily respond as expected/desired to my maneuvers, forcing me to keep thinking of new things to try. But in this unit, I have not only a large number of cardiothoracic surgeons as attendings to answer to (and they are the most forceful and demanding of the surgeons I’ve worked with), but there are also the critical care attendings (with a level of expertise and devotion to detail that are also new to me, and a penchant for asking for evidentiary backing for my decisions), as well as the fellows, again a level of hierarchy that I haven’t dealt with much before. So many people with the potential to second-guess me in the morning make even simple decisions stressful, let alone hard decisions.

The funny thing is, with all of that pressure, I’m not getting questioned about my actions as much as I had expected. I think I’ve moved to a different level in the resident-attending relationship. In some hospitals, the interns are put in the cardiac unit, and it’s a wild ride. Here, we take a safer route, and the residents on cardiac are expected to have a fair amount of ICU experience, and to be prepared to take extensive responsibility in the unit. As a result, when not doing something absolutely incorrect, I think we’re starting to share in the collegial tolerance that exists between “grown-up” doctors. We know that there are several acceptable ways of getting the same thing done (you could use fentanyl, versed, or propofol for sedation; you could use one super-antibiotic, or two weaker ones with cross-coverage; you could operate based on clinical findings, or you could double-check with a CT – no big deal as long as things are stable), and so we learn not to criticize colleagues who don’t do it exactly our way – as long as the job gets done, and the differences in method don’t threaten the patient.

It’s a strange sensation, but I think I’ve started to reach a point where I’m allowed to make some decisions in that atmosphere. We might have an academic discussion because the critical care attending prefers fentanyl to ativan, whereas my experience has been to avoid narcotics unless I think pain is contributing to the agitation; but I’m not in trouble for doing it one way or the other, unlike how I might have been last year, three weeks ago. The more I think about it, though, that only increases my responsibility. . .

In one day, I managed to get two people in the unit I started working in to hug me; got one person to yell at me; got three attendings to call me by my first name without reminders; and put in two Swans (as much as in the previous year together). If I can get these to balance out, the next month might not be too bad. (Although I was starting to get that uncomfortable vibe that becomes so familiar to residents, where on the first day of the month all of the attendings claim to be delighted to have you around, and foretell plenty of hands-on learning, whereas within a few days it becomes obvious that you’re still only a scut monkey.)

Yesterday I also had the biggest fight I’ve ever had with a nurse. Previously, when people say I don’t get along with nurses, I’ve been puzzled. This one was not puzzling. My patients were falling apart. I was moving somebody to the ICU every hour or two, without having the time to stop and think about why exactly they were deteriorating (which makes me extremely nervous and snappy) and there were consults from the beginning of the night still waiting to be seen, and major procedures waiting to be done – and the nurse was trying to quiz me about why I’d decided to do this and not that. I tried explaining nicely, I tried telling her I’d cleared it with my attending, I tried offering to discuss it with any other doctor in the unit whose toes she thought I might be stepping on, but she wouldn’t stop harassing me. Eventually I turned my back on her and told her I was done talking (after she’d carried the argument into the room of a conscious patient whom I was trying to assess for a pressure of 80/40 on pressors). After she finally left, the other nurses in the area had a few rude words for her communication methods, so I know I wasn’t the only one feeling annoyed and frustrated.

I’ve mentioned before how some of the senior residents tease me about doing procedures at the drop of a hat. It’s been a while since I acted like that. Lately, working nights, I’ve been so tired and frustrated that I’ve avoided procedures as much as I can. But in the last 24 hours it all started coming back, I think related to being now responsible for only one ICU instead of four (and thus not having to fear what could happen in a distant corner while I’m tied up in a sterile field), and that the most acute ICU in the hospital (cardiothoracic), where there’s no time or leisure for avoiding lines and tubes. I’m reacquiring my knack with sharp objects, and it feels good; surgeons are supposed to be comfortable moving quickly with knives and needles. When I was avoiding procedures, I felt an uncomfortable camaraderie with the naval captains in Patrick O’Brian’s books, questioning their courage when they decided it was wisest to avoid an engagement with the enemy – but not any more.

I didn’t want to ask for help because it would be a confession of weakness. But my patient was dying, really dying, all of a sudden, out of nowhere, and I didn’t know why, and I didn’t seem able to do anything to stop him. I figured it would be even worse if he died because I didn’t ask for help. So I did. I don’t know what’s worse, that I was weak enough to ask, or that the person I asked didn’t really know any more than I did, and didn’t do any more than what I was about to do anyway. The patient survived, mostly thanks to the nurses, and due to what they and I did before the help arrived. I guess it’s good, in a way. I’ve proven to myself that I can get through anything (with the right nurses). I need to stop using the comfort blanket of asking senior residents for help. If I could just not get so worried by my patients dying, or trying to, that I can’t seem to think straight. . . and why do they always do it at 3am, when I can’t think straight anyway?

I’ve mentioned the ghosts before – memories of other times when things went wrong. They’re starting to add up now, so whenever I have a really sick patient, there’s usually an analogous memory, where things didn’t turn out well. I don’t know whether it’s good, to have those to make me paranoid and anxious to check into every possible explanation or treatment option, or whether knowing the answer to those old puzzles sets me thinking down one track, unable to see what might be different about this time.

Medicine is full of superstitions. Anyone reading medical blogs has heard about not saying “quiet night” or “not busy,” for fear that the opposite will immediately happen; or that appys and AAAs and other things come in threes; or that patients who say they’re about to die probably are.

One of the less well-known has to do with specific hospital rooms: When you’ve seen something bad happen in one room, there’s a visceral reluctance to have another of your patients stay in the same room, especially soon afterwards. This is of course irrational, being that we’re in a hospital, and something bad has happened in every single room, more than once.

The floors aren’t too bad. The patient turnover is high, only a couple of days usually per patient per room, so most of the rooms don’t have strong associations with any one person; or if they do, there are several other patients also associated with that room.

But the ICU is different. We had a patient die last week, and a day later another patient, of the same attending, from the same demographic group, was put in the room. The attending frankly begged the charge nurse to change the room, and the chief and I were murmuring agreement. We compromised on transferring the patient out of the ICU within twelve hours.

Our surgical ICU has a little more than two dozen rooms, and as I walk around it in my mind’s eye, I can picture a tragic death in one room after another: the trauma patient from June in that room; the one who died within 24 hours of surgery in that room; another trauma patient here, this one from August; and this last patient in another room. It’s not so much deaths in general that bother me, but the ones that were preventable, the people who weren’t expected or “supposed” to die when they came in; the ones about whom I think that if only I had done something differently, they would have survived. Probably it’s not true, but what wouldn’t I give to be able to rewind the clock and find out.

There’s one room in particular that I don’t really look at at all. Six months later, I still try to ignore its existence; fortunately, I haven’t had a patient in there since it happened. This one wasn’t so much that I thought I could do something differently; but I spent a month fighting for that guy. Literally a month; he’d already been there a while when I came on service, and he died a day or two before the end of the rotation. I spent most of every day in or near his room; I did so many procedures, lines and chest tubes, that I could probably fill out all my procedure requirements just on him, if I’d thought to keep notes. He died anyway; it was pretty hopeless from the beginning, but we kept trying, watching every 5mmHg improvement or decline in his pO2 intensely.

By the end of residency, every room in the unit will have its own ghost. I’ll have to get over it.

Some peculiarity in the schedule this year has arranged that I’ve spent most of my time so far on rotations which are not part of the general call pool; and when I have been in the call schedule, it’s mostly been for the short, 12-hour shifts. So handling all the surgical services at night is still a little new to me. The last such night went much better than I had expected, and seems to augur well for the next month, which will be all nights. (You’ll have to excuse some elaborate phrases; I’m reading Mallinson and O’Brian, historical novelists of the British cavalry and navy in the early 1800s, and their latinate constructions are catching.)

One of the first highlights was a call from the OR holding area: “The vascular patient your attending is expecting has arrived, direct by ambulance.” Which did not sound good: a patient being admitted directly to the OR for vascular surgery? And of course the attending, having said that he would take the patient, and informed the OR, had not felt a need to tell the residents about it. Fortunately, a tourniquet, although limb-threatening, had the bleeding well under control.

A little later things became more complicated. One intern had a patient on the floor with progressive shortness of breath and hypertension, while supposedly hemorrhaging – altogether a puzzling picture. While he was being transferred to the ICU, the other intern called me with a patient in the ER, who had a dramatic CT scan and peritonitis. By the time I got down to the ER, the patient was unwilling to talk much; whether because she was tired of explaining to multiple doctors, or because she was actually so ill, was unclear to me. But she had rebound on exam, and the CT was clear, so I called the attending and the chief resident to come in from home, and told the OR to set up for them.

No sooner had that been settled, than the first intern called again to say his patient was struggling to breathe, and had an ABG on which the CO2 was nearly three times normal, whereas the O2 was one-third normal, and he was going to call anesthesia to intubate him. At our hospital, because of the presence of an anesthesia residency, anesthesia is responsible for all intubations – if they arrive in time. For a few minutes after I got upstair, as we were bagging the patient in an attempt to correct an oxygen saturation of 60% (which had developed after the intern called me), I thought I would really have to use the intubation kit which is kept in all the ICUs, and do it myself. However, anesthesia did arrive quickly enough that it was still safer to wait for them than to try it myself, and the patient was soon intubated and stable.

Which is an example of my dangerous inability to believe maxims without testing them for myself; like reinventing the wheel constantly. There’s an old saying: if you think about intubating the patient, just do it – don’t wait for things to get worse. And I had thought about it, after getting that man down to the ICU, before I left for the ER. His sats and blood pressure were fine, he just looked labored. I had thought he could wait a few more hours, or perhaps might improve with more aggressive care in the ICU. In this instance, the delay didn’t hurt anything, except that it created a commotion and meant the patient had to be intubated as an emergency. Next time, I would order the intubation a lot sooner. And for the future, I swear I’m going to actually follow all those maxims, rather than discovering them for myself.

After that the intern and I put in a line together. Which was for me a significant point: the first time I’ve guided an intern, not comfortable with lines, through the procedure by myself. That sounds ridiculous, for surgery residents more than halfway through the academic year. But picc lines (peripherally inserted central catheters) are so ubiquitous now that only in true emergencies in the middle of the night do we usually place central lines any more.

The rest of the night, while busy, was calm compared to that. No deaths on my watch, which was a relief after the last few calls, and after the signout I’d gotten on some of the more precarious ICU patients.

Another part of my role as a junior resident, rather than an intern, is to handle consults from the medical ICUs. There is always a constant stream of these: mesenteric ischemia in patients who’ve been hypotensive for too long for whatever reason (MI, sepsis); toxic C diff; upper and lower GI bleeds which elude medical management.

The consults themselves are not so bad. The patients are usually intubated, which means one simply examines them, and then collects data from the chart, and calls the attending.

The part that’s driving me crazy are the MICU residents and nurses. The surgery residents have a saying: if you get paged with a stat consult from the MICU, it’s probably nothing important, and you can take your time getting there. If, on the other hand, you receive casual notification, through a string of secretaries, of a consult for which the original order was placed some 12 or 24 hours ago, you’d better run, because that patient needs to go to the OR already.

Partly it’s sarcasm, but there’s a lot of experience behind it: innumerable stat pages regarding bowel obstructions which are really ileuses (ilei?), as determined by an abdominal xray, or for uncontrollable GI bleeds which have after all only received two units of blood, and haven’t been scoped (or sometimes even seen) by GI yet (we have to have a scope, or some other study, showing where the bleeding is coming from; you can’t operate at random), or for mesenteric ischemia in which the patient has no abdominal pain, and is severely acidotic from urosepsis and lack of resuscitation; and so on.

Then there are all the times when a CT scan is done early in the evening for abdominal pain, and when radiology reads it around noon the next day, then we’re notified about the gross free air, the occluded superior mesenteric artery, the glaring small bowel obstruction in a toxic patient: all patients in whom 18 hours lost between the initial complaint and the OR time could mean, if not death, certainly a dramatic increase in morbidity. Why can’t they look at their CT scans? I’m not asking for detailed reads, just a glance: gross free air (as opposed to a microperforation) shouldn’t need an official radiology reading to be acted on. I know I’m no good at all at chest CTs, but I can see a saddle embolus, a lobar pneumonia, an aortic dissection. If I can stumble through the pulmonologists’ scans, can’t they look at the abdominal ones a bit?

And the nurses: I’ll stick to one chief complaint: NG tubes. It’s like a trap. No matter how many times I check on the NG (nasogastric) tube, by the time the chief comes to see, it will not be to suction. It may be buried under the pillow, or under the blanket, or down the side of the bed; it may be tied in a knot, or the connecting piece may have been artfully abstracted and lost. Somehow, the MICU nurses seem to believe it would be detrimental to the patient to actually leave the NG to suction. (For your information: an NG is a sump pump, meaning it has an air port, so there is no danger of damaging the stomach mucosa by leaving it to continuous low suction. On the other hand, it stents open the upper and lower esophageal sphincters, so having it in place increases the patient’s risk of aspiration, unless it is being used as intended, to suction.) If the MICU team sincerely believes that their patient has a bowel obstruction, why on earth do they insert an NG tube, and then not put it to suction? It’s not a surgical thing; it counts as medical management! Even three written orders to that effect will frequently not prevail on the nurses to put the thing to suction (I’ve tried).

Fortunately, every now and then I encounter the surgical ICU nurses moonlighting in the medical ICU – a breath of fresh air, although they sometimes look fairly frustrated too.

(And yes, ok, neither I nor the surgical ICU nurses have much knowledge of steroid drips or neutropenic precautions or the intricacies of hyponatremia. . . but an NG is not that complicated!)

All quiet on the transplant front again. Seems like as soon as I come near the service the operations disappear.

Which leaves time to study for the ABSITE, a good thing since the test is coming up in. . . 8 days. I got to the neurosurgery part of the review book, and had a flashback to my neurosurgery rotation.

It was far enough in to the month that I was holding the call pager by myself most days. I got called to see a lady in the ER. She’d had a headache for a few days, but that day it was much worse, and her son had finally forced her to come to the ER. Her history of severe, poorly controlled hypertension was a red flag, and the ER doctors got a CT scan. By the time it was done, and they had recognized the subarachnoid hemorrhage, her mental status was deteriorating to the point that, while still fairly alert, she could no longer answer questions coherently. I didn’t waste much time on exam, just verified that her pupils were still equal and reactive, and there were no other gross neurological deficits yet (neurosurgery physical exam is the most abrupt and pointed of any specialty), then called the resident. He concluded that her worsening symptoms were due to a still-active aneurysm, and arranged for her to be taken to radiology for an emergent cerebral angiogram and coiling of the aneurysm. I saw her off, then tried to tackle some of the other pages that had been accumulating (hypotensive post-op patient; tachypneic patient failing a vent wean; rising ICP; hyponatremia in a trauma patient).

About half an hour later I got a stat page from radiology: “Your patient just had a bradycardic arrest on the table, maybe you should come down here.” I asked the nurse to please page my resident as he was the only really useful person, and then ran down the stairs.

I arrived (with the resident soon on my heels) to find that the report was very slightly exaggerated. She hadn’t completely arrested, just become so bradycardic that there had been several 20-second pauses between heartbeats. That had improved with atropine, and she was now awake. So awake, in fact, that she was insisting on leaving AMA.

Which posed a problem, since her vital signs were a classic case of Cushing’s triad, found in impending brain stem herniation: bradycardia, hypertension, and slow respirations. Well, actually, she was breathing just fine, since she was loudly insisting that we let go of her, give her clothes back, and let her leave.

The resident announced that he needed to put in a ventriculostomy drain now – right there, in the middle of the angio suite. He started finding the supplies – some of which had to be brought down from the neuro ICU. I was left to deal with the matter of consent. The patient herself was very dramatically not consenting. By now, it was taking the efforts of two nurses to keep her lying down (which of course wasn’t doing any good for her blood pressure or her intracranial pressure, which was what we intended to relieve by placing a drain). Her son, whom we knew to be somewhere in the hospital, had disappeared: either he was trying to get a bite of lunch, or the move to the maze in the depths of the radiology department had lost him. So when the supplies were assembled, we decided to proceed with the drain as an emergent procedure – no consent required.

Despite all of us knowing quite well that the patient’s protests were further evidence of altered mental status and injury from the blood now surrounding her brain, it was no fun to perform an invasive procedure on patient who spent the entire time protesting that we were kidnapping and abusing her, and who had to be held down by several staff members. Once the drain was placed, we ended up intubating her right there as well, as her level of consciousness continued to decline.

So by the time her son caught up with us, in the neuro ICU, we had the job of explaining that his mother had gotten significantly worse, and was now on a ventilator.

It was all downhill from there. Everything that can go wrong with subarachnoids went wrong with her: her ICP stayed up despite all measures to lower it; she had surgery to remove the aneurysm, but with no improvement; she remained in persistent vasospasm, despite every single treatment in the book being tried; she developed diabetes insipidus (seen in brain injured-patients when the hypothalamus stops producing anti-diuretic hormone, needed for the kidney to concentrate urine). After two weeks in the ICU, she died. So the last her son saw of her, conscious, was in the ER; and the last time any of us had talked to her had been while we were wrestling with her in radiology.

That’s why I hate dealing with subarachnoid hemorrhages, and I could never imagine being a neurosurgeon. Within twenty minutes she went from a pleasant lady with a headache to being delirious, then intubated and critically ill; and nothing we did could help at all.

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