ICU


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.

I think I mentioned before that, along with being the insane Christian conservative of the hospital, and being too polite to be a surgeon, the other residents tease me about doing procedures on anything that moves – or doesn’t move, more accurately.

Today I blew my last chance of pleading innocent. Being at loose ends (as seems to be usual for me on this rotation), I was just wandering around the ICUs to see what kind of trouble other people were having, and maybe cheer myself up that I wasn’t having to take care of those problems. I found a couple lines to put in – various people having too many things to do at once, needing to be in the OR, etc, so I volunteered to put in their lines.

The guys found me apparently lost in the MICU, in the middle of a real mess. “What’s up, Alice? Is this your patient?” “No, I’m just putting in a line.” They cracked up, and claimed not to believe my explanation of having a really legitimate reason for being involved.

The best part is, those were some of the hardest lines I’ve done – and they could see that they were hard sticks. I’ve decided to embrace this game. If I can’t be in the OR, placing tricky lines is stressful and satisfying enough that I’m happy to be the one who comes to mind when people want lines done. After all, that’s part of a community general surgeon’s practice.

Sorry folks, nothing useful to say. I’m going through another disillusioned-and-bitter phase; judging by precedent, it shouldn’t last more than a few days. Will return with regular programming then.

(The funny thing is that, even though I feel depressed and bitter and cynical, I’m still known for being cheerful and optimistic. The chiefs are still telling me, “Wait a few years and see if you’re still so happy about everything.” I feel like I’ve turned into all the cynical surgery residents I knew as a medical student, but apparently it doesn’t come across that way – yet. I guess that concluding every consideration of a patient’s worsening symptoms and grim vital signs with the hope that they could still turn around in the next two days has to count as incurably optimistic; and persisting in treating people who complain of pain seriously has to qualify as insanely credulous.)

(Although if they could hear my interior monologue when answering pages, they might understand better. I had another several of my favorites today, calls where the nurse goes on for several minutes, telling you normal vital signs and urine outputs and stating that the patient has taken all their medications as directed, and you keep waiting for some kind of punchline – what’s wrong enough to be worth calling me about? – and there never is a punchline, and you’re left to say as politely as possible, “Thanks for telling me.” Or my other kind of favorite, the one that invariably happens right after I scrub in, while I’m supposed to be prepping and draping, and the circulating nurse kindly answers the page, listens with a widening mouth, and then says tentatively, “Your patient in ICU room three has a pressure of – let me check – 62 over 30, is there anything you would like them to do?” Um, find me a time machine so I can be in two places at once. And the attending cheerfully motions to me to finish draping, remarking that this is one of the purposes of training, to learn how to juggle multiple serious responsibilities at once. Thanks sir, that really helps.) (The patient did very well in the end. I never calculated pressor doses that fast before.)

A patient I’d been taking care of all month died today. Like before, I wished I could join the family in their mourning, but that wouldn’t be right. I’m not really part of it, and they need their space. I didn’t know him when he was alive and a person, only when he was living on a ventilator with us sticking needles at him all the time. I didn’t even know any good words to say at all. “I’m sorry” – but you can’t go repeating that forever, and I couldn’t think of much else. I’m sorry, I tried to stop him leaving; I’m sorry, if I could undo this I would; I’m sorry, we’re not miracle workers after all.

Failing that, I wanted to go sit in a corner and not talk to anyone else. Talking to the coroner, always so businesslike, not high on my list. But you have to. And then there were all the other patients who needed to be paid attention to, and just because one person died is no reason to go neglecting or ignoring the others. So I went and did all the appropriate procedures, and they weren’t much fun. A needle here or there. . . but I couldn’t save the one guy who really needed help.

I don’t know which was worse, talking a family through their loved one’s death, when I’d only seen the patient for five minutes beforehand, and we only had an hour to work through it (like yesterday), or handling it after a month of struggling together, like today. Strangers or long-term acquaintances, it doesn’t get easier.

I’ve been calculating all month, and I work out my prospects for the rest of the year as follows: nearly all the second year rotations are unpleasant, and nearly all of them last for more than one month. So the chances of September being even more miserable than August are at least 70%. This is not good. Without hope, things fall apart.

Every morning I make a resolution not to get into a conflict with any attendings for the day. I usually fail by 11am. I don’t know why. I guess I hate this service enough, and am irritated by some of the attendings enough, and wear my feelings on my sleeve enough, that that’s inevitable. I’m trying to help, but trying to help when I’d rather not be in the same unit at all really doesn’t do much good. At least it entertains the rest of the residents and the nurses, watching the fireworks. I just need to not talk in front of the attendings. At all.

I got to assist with a trauma ex-lap (exploratory laparotomy) today. The patient was just sick enough to need it, but stable enough that no one was really panicking. The attending and chief could spare a few seconds to tell me what they were doing. In textbook style, as soon as they opened the peritoneum, blood came pouring out onto the table. They packed all four quadrants with quantities of lap pads – I have no idea how they can ever keep track of how many went in where – until the bleeding was controlled. Then they started in the corner where they knew there were no problems, and proceeded to explore. Between me being there to be lectured and quizzed, the attending being an extremely conscientious character, and the chief being the inquisitive kind who wanted to see everything and visualize every possible maneuver (Kocher, Pringle, etc) while he was there, it was quite educational. And also beneficial to the patient, who did well.

(Kocher maneuver: reflecting the duodenum medially in order to visualize the head of the pancreas. Used in trauma to gain control of the IVC, and in surgical oncology to reach tumors in the pancreas. Pringle maneuver: clamping the porta hepatis (portal vein, hepatic artery, hepatic bile ducts) to get control of devastating hemorrhage from the liver that can’t be controlled with packing alone.)

The chief spent most of the day in the ER (nine patients in two hours on a weekday morning, as though all the old ladies in the city had decided to fall and hit their heads at once, while several un-drunk drivers managed to have serious accidents), and complained that he hadn’t been able to see the unit patients. I, on the other hand, had more than my share of the unit, and would gladly have bailed out of it to share in the chaos in the ER; but we each had to stick to our own responsibilities.

Halfway through rounds the medical students were asking me if I was all right. There was nothing wrong, just the insanity of the trauma unit, and my dysfunctional method of communicating with the chief and the attending. The chief and I have a very strange interaction; we like each other, and it’s certainly better when he’s around and responsible for things instead of me, but somehow he makes a day in the trauma unit even more complicated.

So the students are trying to help me, and I don’t even have the energy to be polite to them. All I can remember is the resident I knew when I was a student, trapped in the unit for months on end. He didn’t talk to students much either, although in my memory he was still more helpful than I’m being. That’s bad, because he had it even worse than I do – unless someone takes it into their head to schedule me into the unit some month in the near future. At this point, I can’t even finish my sentences; it feels like wading through molasses to get anywhere, and talking to people just takes too much effort; so I don’t talk.

I can’t believe it’s only halfway through the month. This seems to have been going on forever.

The attending for the next several days is another one with whom I clash constantly. The only good thing is that he’s predictable in his own unbearable way. (You may be asking whether there are any trauma attendings I get along with. There are two, and they’re sane only because they spend as little time in the unit as possible. Unfortunately, that’s not an option for me.)

I’m tired of trauma. I feel like I’ve been doing this forever, and it’s going to keep going forever. Every day starts out ok, and then goes on for a whole lifetime, with twenty lives in my hands, and thirty or forty people wanting something from me (ranging from the medical students wanting something educational or useful to do, and I don’t have the time I owe them to be educational, to the nurses as usual reminding me of what their patients need, to the attendings wanting me to do a dozen different things, reminding me of things I know I should be doing, or asking me the same question for the third time in five minutes, to the families, who need to be talked to, and all want more time than I have).

That is one thing I’ve figured out. I’ve decided which of all the trauma attendings is most difficult to work with: not the one who rounds for nine hours at a time, not the one who rounds so fast it leaves you breathless, not the one who listens to himself talking all day and gets nothing done. No, the one who lets you give a whole presentation, then asks you three times for information you stated at the beginning of the speech. And writes it down, looks at something else, and then asks you again. Halfway through rounds with him, I’m ready to scream.

Many of the nurses give me a vote of confidence by seeking me out to ask questions of. It’s nice to know they trust me to manage a lot of things – but it would also be nice if they asked the other residents sometimes!

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