It’s amazing how good a solid night of studying makes you feel. I only got paged about urology issues, which are also very satisfying, since they call for a quick, relatively risk-free and painless procedure which makes the patient feel better pretty quickly.
So far I’m 30% of the way through The ICU Book (300/1000pp) (and only 3% of the way through The House Officer’s Guide to Urological Emergencies, which perhaps I ought to be reading more of, but somehow it’s not very gripping).
I’m starting to have mixed feelings about the book. On one hand, it certainly contains such wildly relevant and fascinating subjects as, five continuous intravenous vasoactive medications (otherwise known as the five pressors, which about half the ICU population are on, and about which I’ve been frightened and curious for the last nine months, but never before found a concise explanation of), and, three easy algorithms for managing acutely decompensated heart failure (as well as how to differentiate between right and left sided, systolic and diastolic, subjects which are of very little interest to surgeons, but of intense interest to the gremlins responsible for coding diagnoses in such a way as to extract the utmost amount of compensation from the insurance companies) (and one of these days when a senior resident remarks, “ah, ejection fraction of 65%, their heart is fine,” I will reply, “65% is actually a little high, and if you notice, the report also mentions left ventricular hypertrophy and decreased wall relaxation, which means actually they have a fair component of chronic left-sided diastolic heart failure;” so far, to my personal disappointment, I have faint-heartedly kept quiet at every such opportunity).
(Please I don’t want any commentary on the grammar of that paragraph; all the quotation marks and parentheses are closed; I am experimenting in the stream-of-consciousness style. . .)
On the other hand, at least 50% of the book’s extensive cogitation seems to lead to the inexorable conclusion that sphygmomanometric blood pressure measurement is inaccurate and useless; direct arterial blood pressure measurement (in most circumstances) is inaccurate and useless; central venous pressure monitoring is inaccurate and useless; pulse oximetry is inaccurate and useless; pulmonary capillary wedge pressure measurement is inaccurate and useless; CPR is useless; crystalloid is useless; blood transfusions are useless and dangerous; pressors are useless and dangerous (with qualifications). You get the impression that only certain arcane measurements of systemic oxygen uptake, which require special bedside laboratory equipment, are of any value in directing patient care. Which makes me wonder, if everything the author is telling me about is so useless, why I’m taking the time to try to understand the equations with which he proves the futility and vanity of all ICU activity?
Besides, what I’ve gathered of surgical ICU care so far is rather simpler and more basic: we like fluids. Fluids are good. Push fluids. [cave-man accent, you understand] What’s a little pulmonary edema between friends? And don’t infuse pressors through peripheral ivs (a course of action which the MICU here pursues on a regular basis, leading to pressor extravasation into the hand and arm, which is not pretty; and then they consult plastic surgery, or vascular surgery for IJs in the carotid), or without placing arterial lines.
My senior resident this month is getting a little wary of mentioning procedures to me. He remarks that some stitches here, or a line there, might be useful, and when he turns around, I’ve done it. So far, so good; but perhaps next time I should wait to hear the end of the sentence (he had to go see an emergency, and I assumed he was done with the instructions). I think it’s a problem if even among the surgical residents I’m remarkable for liking sharp objects. I think the trick is to pretend to be a little more blase about it. On the other hand, I’m satisfied that I’m now competent at using the little throw-away suture removal kits as procedure kits. You open the kit, and arrange the paper cover and the little plastic tray in such a way that they make a tiny sterile field that you can put sutures and needles onto. Then you pretend that the flimsy blunt-tipped pickups are useful for holding tissue with, and you force the scissor’s jaws shut over the needle till they snap past each other and lock the needle between them. Then, if you move very carefully, this will hold the needle steady enough to take a stitch with it. This method is primarily desirable in that you don’t have to go hunt a procedure tray out of the OR or the ER (even most of the medicine floors have suture removal kits, though some benighted units don’t); you can throw the whole thing away when you’re done; and you can place a suture and cut the suture with the same instrument – versatility, you see. Plus, you feel like a surgical Boy Scout. (I believe there’s an Eagle badge if you perform an entire appendectomy in this manner.) Even a few months ago, I couldn’t handle the break-the-scissors-in-order-to-hold-the-needle maneuver, and always had to be fished out by a senior. I am now ready to teach this technique to next year’s interns.