Wednesday, September 17, 2014

No Benign Procedure

A 20 year old considering a career in professional athletics has a benign congenital heart defect. It causes him no symptoms on a day-to-day basis but it's felt by his coaches and trainers that he should have it repaired. The procedure ought to be a simple one; in fact, the bypass time is only half an hour. He is young, and no one expects any complications. After all, we do open heart surgery on octogenarians. His surgery appears to be uneventful and he comes to my care in the CVICU post-operatively.

We extubate him and wean off his cardiovascular drips. He's meeting all our goals and parameters, but upon working with physical therapy, he notices something odd. He is slightly weak on one side. We rush to scan his head, and there's evidence of a completed stroke, likely from the OR. We are all devastated. In getting an elective heart surgery for a career, a complication makes it impossible for him to pursue that career. He will be fine for everyday activities; he's improved with physical therapy and he was quite strong to begin with. But he will never play professional sports again.

This was one of the saddest cases I had in the CVICU. We all know that complications are a risk of any surgery, but it's easy to assume they would never happen to a healthy young patient. To see someone with such potential lose so much hope - my eyes filled with tears in talking to him. It is a grave reminder that everything we do in medicine has risk, and we should never undertake any procedure lightly. I am glad I am not a surgeon, but as an anesthesiologist and intensivist, I will have similar circumstances and situations. Reminders like this make our responsibilities as a physician feel so much more raw and poignant.

Sunday, September 14, 2014

If I Could Make a Living by Writing

I could never do spine surgery, but a part of me wishes I could be a writer. Image shown under Fair Use, from http://thisisindexed.com/ by Jessica Hagy.

Saturday, September 13, 2014

Observations in the CVICU

No one has actually taught me this, and I'm not even sure it's true, but anecdote sometimes drives medicine. To me, it seems that after cardiac surgery, patients either fly through recovery or they linger with complication after complication; there isn't a middle ground. I almost want to do a study on the length of stay in the CVICU; I'd guess there'd be a bimodal distribution with a bunch of patients leaving 2 to 3 days after surgery and a bunch leaving around 2 weeks. I'm not sure why this, but I have a few guesses. Perhaps run-of-the-mill surgeries - a routine CABG or valve replacement - represent the quick, reliable in-and-out ICU stays and the emergent cases, complex referrals, and high-risk surgeries buy a longer stay. Or perhaps patients receiving cardiac surgery have such little reserve that any complication will set their course back by weeks. In any case, this seems to be the type of observation that an administrator might want to know because the long-term players tie up critical care beds and cost the hospital and the health care system a lot of money.

Tuesday, September 09, 2014

Catastrophic

There are some events that are simply catastrophic, events I consider non-survivable. Even though sometimes we can tide patients through the acute phase, I worry that these disasters set the patient back so much that recovery is impossible. It's a terrifying realization, really, because sometimes you feel that you have a patient who has no hope for survival. Sometimes you just hope that your intuition is wrong.

A patient with alcohol related heart failure receives a left ventricular assist device. The LVAD is a continuous pump that assists the heart by sitting in the left ventricle and pushing blood out to the aorta. Post-operatively, these patients are incredibly tenuous because only the left heart has assistance; the right heart remains in failure. They often stay in the CVICU for weeks while we tend to the right heart and address all the usual ICU complications. These patients seem to develop more ICU-related morbidity than standard patients, probably due to their tenuous hemodynamics and implanted hardware. It often takes us weeks to wean epinephrine, dopamine, milrinone, vasopressin, inhaled nitric oxide. And during this time, we struggle with ICU delirium, pain management, pulmonary hypertension, infections, ileus, renal failure, and glucose management.

This patient with an LVAD has had steady progress for over a month. We've been actively diuresing him to offload his right heart, but an unfortunate side effect of drying him out is severe constipation. His stool has become a cement sludge, and though you wouldn't think bowel movements are all that important in the CVICU, this story taught me differently. He was being evaluated daily by general surgery and medical GI consultants and had received several colonoscopic decompressions. I'd never seen anyone that happy to get a colonoscopy; he didn't want any sedation and enjoyed watching his own stool be disimpacted. Every day, we made a little progress with getting his bowels moving, weaning his oxygen, titrating down his inotropic drips.

Then one day, I got called because of severe abdominal pain. When I saw him, I knew something bad was brewing, and in fact, I can remember the very thought: this is what's going to kill him. His abdomen had peritoneal signs, indicating that he had perforated his bowel. I got an abdominal X-ray and as I watched them position him for it, I knew what it would show. A rim of gas was seen in his belly. We called general surgery, and even though he was at incredibly high risk - 3 vasopressors and a fresh LVAD - they took him to the OR.

That first night after he got back tested all my anesthetic and critical care abilities. He had high abdominal pressures concerning for abdominal compartment syndrome. He was maximized on four vasopressors, two of them at continuous code doses. His ventilation was poor because all the irritaiton in the belly had caused swelling, making it hard for us to deliver deep breaths. And the surgeons weren't confident about their bowel resection; they said that his intestines fell apart in their hands as they operated (a result of his vasopressors). The biggest challenge was fluid management. After large bowel surgery, patients become very dehydrated, and so he got a substantial amount of blood product and fluids. However, his right heart could not tolerate that sort of load. If his right heart failed, he would die.

We sat at his bedside all night, pushing medications, starting paralysis, doing serial echocardiograms, managing continuous renal replacement therapy (he had gone into kidney failure during this). And we managed to tide him through the acute catastrophe. But with ischemic bowel, raging peritoneal infection, right heart failure, kidney failure, prolonged paralysis and steroids, minimal nutrition, and increased hemodynamic support, I worry that this catastrophic event set him back a whole lot, and likely too much. Now I am in a hard place because we are doing everything we can to save this guy, but deep in my heart, I feel that he will never realistically recover enough to make it out of the ICU. I hope fervently I am wrong, but after a few years in medicine, I realize there are some catastrophic events where modern medicine can weather someone through a little bit, but not enough.

Saturday, September 06, 2014

Protoplasm

Physicians often use the word "protoplasm" to mean a patient's overall health and fragility. Protoplasm makes a big difference. A 70 year old with hypertension, hyperlipidemia, coronary artery disease, aortic stenosis, COPD, end stage renal disease, peptic ulcer disease, diabetes, and Parkinson's fares a lot worse from a flu than a 70 year old who walks his dog five miles a day and has no other significant medical problems. Someone who is bedbound, wheelchair-bound, or limited in mobility has a higher risk for complications than someone who ambulates on his own. A patient who is cachectic, who has little reserve, has a higher likelihood of dying from any physiologic perturbation.

All this is obvious, but some experiences in the CVICU really place a spotlight on "protoplasm." I was shocked to hear that one of our surgeons did a "triple valve" on an eighty-year-old. She had an aortic valve replacement, a mitral valve replacement, and a tricuspid ring. The surgeon was extremely skilled and the bypass time was fairly reasonable. But the patient's age, pre-existing pulmonary hypertension, baseline kidney disease, and frailty made the post-operative course a nightmare. We spent days weaning our inhaled epoprostenol and pressors. We had to be ginger not to provoke the right heart as she teetered on right heart failure. We managed to extubate her, but her poor pulmonary reserve required reintubation the following day. We struggled to get adequate nutrition for her. We could not salvage the kidneys and had to start continuous renal replacement therapy. In retrospect, she was not an appropriate surgical candidate. Although you may be able to operate on anyone, you shouldn't.

The problem in our current system is that pre-operative decision making doesn't include all the players. It is up to the surgeon to realistically set expectations on the recovery course and an anesthesiologist often ensures that things are as optimized as possible. They ensure that the surgery is feasible and that the patient will make it through, but don't always assess how rocky the post-operative course might be. As a critical care physician, I only meet these patients after the fact. And the truth is, for some patients and some surgeries, the stay in the ICU is harder than the surgery or anesthetic, and a patient ought to know what that might look like before committing to it.

Thursday, September 04, 2014

Back in the CVICU

Although one of my last rotations as a resident was in the cardiovascular intensive care unit, I was not gone for long as it was one of my earliest rotations as a fellow. The role of the resident and fellow is pretty much the same, and although the second time on the rotation was a little bit easier and made more sense, it was just as exhausting.

The thing about the CVICU is that the patient acuity is higher than anywhere else in the hospital. Our surgeons offer surgery to patients who have been deemed too high risk elsewhere. We take transfers of patients from all over Northern California and have expanded the procedures we perform. On "TAVR Tuesdays," the day where our surgeons and cardiologists perform minimally invasive aortic valve replacements (TAVR stands for transcatheter aortic valve replacement), we routinely get patients in their 80s and 90s.

All of these factors make post-op management incredibly challenging. I've had patients on six or seven inotrope, vasopressor, or pulmonary hypertension agents: epinephrine, norepinephrine, vasopressin, phenylephrine, methylene blue, inhaled nitric oxide, and epoprostenol. We struggle not only with complex cardiopulmonary physiology - I've seen pulmonary artery pressures 110/50 - but also with sepsis, gastrointestinal bleed, and anuric renal failure. Balloon pumps, ventricular assist devices, and transplants make up half our service. Compared to my previous month, we only had a few patients on ECMO, but the overall service was sick. I had to perform emergency trans-esophageal echocardiograms several times, rush patients back to the OR, and manage rocky intubations and extubations.

On some level, I loved it. I picked ICU medicine and anesthesia for the moments where someone's life depended on a thoughtful but immediate synthesis of an array of complex data. I like the adrenaline, the fear, and the thrill of seeing patients on death's door get better. But overall, the month sapped me. We had some staffing problems which put a lot of strain on the residents and fellows that month, and I really appreciated my colleagues who all put in more time than expected to care for our patients. There was a time when I could fill my life with work, food, sleep, and exhaustion, but when I think of a job in the future, I think I'll want something with less craziness.

Monday, September 01, 2014

Behavior Change

We talk about behavior change as if its impossible. We get teaching about the transtheoretical model where a person must go through various stages before behavior change happens: precontemplation, contemplation, preparation, action, and maintenance. When we meet a smoker of 50 years, we throw up our hands and give up. But should we? Is change really that tough?

Over a year ago, most of the counties around here started enacting laws that required grocery stores to charge for plastic or paper bags. It was a small thing to encourage behavior change. Consumers grumbled. We'd forget to bring our reusable canvas bag and we'd mumble about paying that extra dime or quarter. We wondered what we'd line our trash cans with. But deep down, we understood the environmental principles beneath this change. Now, whenever I go to the grocery store, I and most other customers I see lug along our reusable bags. It's ingrained in us now, and perhaps this small but universal change will help out our landfills some, reduce the plastic we produce and waste.

Similarly, a year ago, our ICU progress notes changed. The decision from the "higher-ups" was to change our notes from "organ-systems based" to "problems based." The details are unimportant, but this translated into a lot more work for the residents. I used to be able to jot out a note in a couple minutes; now, as I click through our electronic medical record to add problem after problem, the notes become much more time-consuming. There was a lot of resistance at first; we didn't understand why this needed to be. But now, a year later, it's how things are done.

To enact change, we'd like the person to be ready for it. We'd like all our smokers to be reading about alternatives, going to counseling groups, and talking to their families and friends about quitting. But in absence of such an idealistic world, we should not give up. We should continue to push for rules, regulations, incentives, and disincentives to nudge those along who need behavior change. I used to think that increasing the tax on cigarettes would not dissuade smokers, but I've come to question that notion. It's true that everything has pros and cons - and a tax like that might have a biased effect on a certain socioeconomic class - but behavior change is paramount for public health, and we should do everything we can to make it happen.

Thursday, August 28, 2014

Odd Thoughts at Night

Do you remember way back when, perhaps in college, when you pulled all-nighters, and deprived of sleep and writing a paper, you'd stare at a word and wonder, "why is it so weird looking?" (Perhaps this an experience only I've had). In any case, sometimes on call, sleep-deprived and woozy, I have similar experiences. For example, why is paging called paging? My wife wonders whether it originated in the dark ages when to give someone a message, you'd send a page running after them.

Wednesday, August 27, 2014

Transfer Center II

This is a continuation of the post several days ago.

EMTALA is a law that often comes into play when interacting with the transfer center. If a patient at an another emergency department has medical needs that exceed the capability or capacity of that hospital, then we cannot decline the transfer (unless we feel that the patient will die en route or we don't have the capability or capacity to care for him).

I initially thought that an EMTALA call would be a no-brainer; my hands were tied so I'd take the patient. But it turns out this isn't always that clear-cut. A physician from an outside emergency department calls with an EMTALA request; a patient with septic shock from pneumonia needs intensive care. However, when I probe further, I find out that not only does that other hospital have an intensive care unit, but the patient may not need ICU level care in the first place. After two liters of fluid resuscitation, the patient's vital signs were normal and he had no evidence of end organ damage. When I directly asked the ED physician whether they really had resources to care for this patient, he admitted that he was not EMTALA. Needless to say, all transfer center calls are recorded.

Sometimes transfers are accepted because the patient is "ours." For example, one of our pre-liver transplant patients showed up at an East Bay hospital with hepatic encephalopathy. Although the hospital was perfectly capable of caring for that patient, out of courtesy, they let us know. This type of transfer, to me, is a preferable but non-urgent one. Depending on our bed situation and how adamant the hepatologist is, I could accept or defer that patient.

Other times, we want to make a patient "ours." A patient is referred to us because of an acute leukemia and disseminated intravascular coagulation. Our hematologist believes that getting the patient over to Stanford may really be that colloquial "life or death" difference. In that case, I do my best to make the transfer happen.

Ultimately, a lot of considerations - medical, ethical, resource-management, and legal - play into the calculation of whether to take a patient from another hospital to our medical ICU. It's something I look forward to learning, and a real challenge, especially since our beds are limited. I don't want to take a bed for a transfer and end up short on beds if multiple codes happen or the ED fills up with critically ill patients. Yet I don't want to deny someone else the chance to receive care here if it is necessary.

Monday, August 25, 2014

Gratitude

We don't get a lot of feedback in the ICU from our patients. When they come in, they are really sick, in extremis, and we get little appreciation when we run around sticking needles, tubes, and lines into them. Their families, scared to hear our dire news, have to sit and process. When they get better, they leave the ICU and go to the floor, their beds taken up by patients equally ill. There isn't a real time and place to hear out what our patients think and experience. But occasionally, we'll here from a patient who does well and send their regards. Here's an email excerpt I got for a patient I took care of:

"During the two episodes of ill health which brought me to Stanford Hospital, I've spent about two weeks being examined, analyzed and scientifically scrutinized. Observing those initial attributes a patient forgets that the motivation behind those actions are compassion and concern. I suspect normally the focus of most people who are injured and suffering so much personal, physical, and emotional pain and distress aren't considering how much compassion and concern with which they are being treated, and don't recognize either of those character traits while experiencing those treatments. All understandable. But both those concepts are the cornerstone of the system we inadvertently fall into when injured, and is the foundation of the motivation behind the system and all the processes and procedures which ultimately follow."

It is a beautifully written email and a wonderful reminder to us of our ultimate reasons for taking care of patients. I don't need thanks or appreciation from my patients, but it certainly warms my heart when I do hear it.