Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!