Thursday, April 16, 2015

Transvenous Pacemaker

A woman being worked up for other medical problems develops a supraventricular tachycardia, an arrhythmia where her heart is racing. She is given some beta blockers to slow her heart rate, but they work too well, and she goes into complete heart block. The atria which normally send signals to the ventricles to contract stop communicating. Her heart beats a rate of 30. A rapid response team is called within the hospital, and a cardiologist determines that she will eventually need a permanent pacemaker. For now, she will need a temporary pacemaker.

She is sent to my service in the intensive care unit, and the cardiologist asks us to place a temporary transvenous pacemaker. I'm pretty excited since this is a rare procedure and one of the few opportunities I've had to place a pacemaker. While it's not needed frequently, when the need comes up, I need to know how to put one in.

In fact, the procedure is not all that difficult or different from other lines I've placed. After placing a 5 French introducer sheath into the right neck, I float the pacemaker into the patient's internal jugular vein, superior vena cava, right atrium, and then the right ventricle. The balloon-tipped catheter follows the flow of blood returning from the head to the heart. By using an electrode at the end of the catheter, I can track the electrical activity of the heart and determine where we are. As this one proved a little tricky, we actually got fluro to help us. We used real-time X-ray to follow the path of the pacemaker until it found an effective location in the right heart. When we applied external electrical impulses, the heart followed. That way, we could speed it up as fast as we needed. It gave us peace of mind that her heart block would not be a problem while we scheduled her for the placement of a permanent device.

Image of transvenous pacemaker components shown under Fair Use, from calsprogram.org.

Sunday, April 12, 2015

Ambulance Ride

Stanford's cancer center is an interesting entity. It's physically connected to the main hospital by a skybridge but technically counts as a freestanding outpatient center. When a code is called in the cancer center (most commonly in the infusion treatment center where outpatients get chemotherapy), the inpatient code team (including myself) responds. At the same time, the staff usually calls 911 as is the policy in any freestanding outpatient center. The Palo Alto Fire Department usually responds.

When I arrive at the code, a patient who has received a bone marrow transplant for malignancy is getting ongoing chemotherapy. He has a rapid supraventricular arrhythmia. After making a few interventions to make him more stable, I know that he will need more workup: labs, imaging, studies, and consultations that we cannot provide in the cancer infusion treatment center. As he's currently an outpatient, he will need to go to the emergency department for evaluation. Strangely, though, the protocol is to take the patient to Stanford's emergency department by ambulance. Though it requires more resources, it's probably more efficient than going across the skybridge and down to the emergency department.


Since the patient was modestly unstable, I decided to ride with him in the ambulance. It was the first time I'd been in an ambulance, it was a lot of fun. I was fascinated by the equipment, resources, and capabilities of the vehicle and thoroughly enjoyed the five minute ride. How do you compactly array everything you might need, from an infant to an adult, from trauma to a heart attack? How do you harness things in a moving vehicle? I was impressed. The patient was quite stable and we got him safely to the emergency department.


First image is in the public domain, second image shown under Creative Commons Attribution Share-Alike License, both from Wikipedia.

Thursday, April 09, 2015

Failure

In Samuel Shem's House of God, the residents espouse a law of medicine: the patient is the one with the disease. This crude and insensitive statement has a very important purpose: when a bad outcome happens, as it inevitably must, the physician should not (in most cases) be wrought with guilt. Although some people might read the sentence as a grossly mean thing to say about a patient, I recognize what it stands for. We (and especially those of us in intensive care) all have patients who die despite everything we do, get worse despite our surgeries, fare poorly despite our medical decisions. We sometimes question ourselves, but almost always, it is not lack of doctor that kills the patient. It's not a lack of knowledge or dearth of skill. It is simply the ravages of disease and injury and the limitations of what modern medicine can promise. Patients aren't the only ones who expect miracles. Sometimes as physicians, we devote ourselves so entirely, invest ourselves emotionally, physically, and mentally to such an extent that we cannot tolerate failure. And when it happens, we are devastated. We second guess ourselves, question our judgment. Could we have averted a crisis? Were our skills inadequate? Could there be a scenario where the patient sprang back to life?

I recently had the anesthesiologist's nightmare: a patient who could not be intubated, could not be ventilated, and in fact, was a near-impossible cricothyrotomy. Although the patient was a known difficult airway, those of us who respond to codes through the hospital did not know that (as he was not on the medical intensive care service). He has all the risk factors of difficult airway: morbid obesity, obstructive sleep apnea, large neck circumference, poor mouth opening. He also had many inpatient risk factors: recent head trauma, altered mental status, and an intubation course of over a week. After extubation, he developed stridor, and after severe desaturation, the code was called.

Despite all the tricks I and four other anesthesiologists who responded had, despite all our video laryngoscopes, fiberoptic bronchoscopes, different types of LMAs, we could not put a breathing tube into the windpipe. We asked a surgeon to try to access the windpipe by cutting into the neck, but this was complicated by severe bleeding. Even the ear-nose-throat surgeons had tremendous difficult getting to the airway. The patient passed because of an impossible airway, the one thing that gives anesthesiologists nightmares.

My first reaction was to question my decision-making and my skills. And although I know there are a lot of things I could improve, and perhaps the right person could have put the breathing tube in, after talking to all the other anesthesiologists, I was reassured that I had no glaring errors or deficiencies. I was reminded that despite the importance of reflecting on our clinical experiences - and especially - failures, we cannot be locked into the idea that we are guilty and at fault for everything that goes awry. When I say the patient has the disease, I don't mean anything bad about the patient, but simply that he had an injury or disease process that lead to a code blue. As an ICU fellow, I was simply a responder who put all my heart, skills, acumen, and ability for over an hour in resuscitating him and it was not enough. At the end, we held a moment of silence for his passing.

Wednesday, April 08, 2015

Judgment

"Good judgment comes from experience, and experience comes from bad judgment." So much of what we do in medicine is by gestalt, recognition of patterns, and clinical hunches. This never made much sense to me when I was young and naive, but after a few years of experience, I'm starting to develop that hard-to-pinpoint decision making where my gut tells me something just doesn't feel right. I'm learning to trust in it and finding that more often than not, it guides me in the right direction. The intensive care unit is full of these quandaries, and spending month after month here, I'm recognizing that I don't know all that many more facts now than I did a year ago, but the experiences I've had really put some perspective and depth into my clinical judgment.

Saturday, April 04, 2015

Work

In How Google Works by Eric Schmidt and Jonathan Rosenberg, the authors make an argument against work-life balance, a common phrase thrown about in medical education. They think that work should be an integral part of life, that a manager's job is not to create work hours that allow an employee to maintain free time outside work, but rather to transform work into an engaging, fun, and indispensable activity for the "smart creative" employee. And perhaps in Silicon Valley's tech industry, this is possible, with workplaces brimming with infinity pools, relaxation pods, gourmet meals, and a culture that meshes identity and one's job. I think we are still far from that in medicine and especially medical education. In this spectrum, I am actually very different than my colleagues; I am closer to Silicon Valley's ideal vision of work than my co-residents and co-fellows. I love it and going to work energizes me. I stay late, I don't mind doing more, I search out new opportunities and experiences, I try to pass my passion onto the medical students I teach. Especially as I go further in training, I get closer to the crazy statement in House of God that interns fight over each admission because it gives them another chance to show how good of a doctor they are. We all know doctors who clock in and clock out, who avoid any extra work, who shun admissions, who find the easy way out. And sometimes I can commiserate; burn-out is widespread, and sometimes we just wish we picked a job where we could see our family each night or make plans for every weekend. In any case, this blog is simply an outpouring of reactions as I realize I've finished my last 24 hour in house weekend call but also got "volunteered" to take an extra overnight shift due to a scheduling error. It's funny to understand my reactions: I had a great sense of relief with the former but gave a shrug with the latter.

Tuesday, March 31, 2015

The Burden of Decision Making

Decision making in medicine has changed dramatically over the years. Several decades ago, paternalism was the norm; the physician would tell a patient or family what the best course of action was and that was that. Since then, we've swung way over to the patient autonomy side. We present a patient or surrogate decision maker with information about the risks, benefits, and alternatives of a course of action. We give them information about the diagnosis, tests, treatments. We may even expect them to do some research on the Internet. And what they decide becomes the course of action we take.

Sometimes, especially in constrained circumstances, this can become detrimental. In the intensive care unit, in shifting decision making to a family, we are also shifting the attendant burdens to them as well. Although we ask surrogates to make the decision in the patient's shoes with substituted judgment, they are still making weighty determinations and feel that pressure. I see this over and over again. There is a good amount of guilt that accompanies making someone do-not-resuscitate, even if it is the right thing to do and what the patient would have wanted. In writing the previous few blogs, I've encroached upon those situations where care is futile. Here, it is not the right thing to force the family to make a decision. If something is futile, it shouldn't be chosen, and that choice needs to be removed from the family's hands. When I have a patient who is moribund with no hope for recovery, I don't ask the family whether we should perform CPR if the heart stops. That's futile, and I make the decision and carry the burden of a DNR order. Though some say this is removing autonomy from families, I find that it in fact is relieving them of great stress, pressure, and expectation. I've had families express that my making the decision not to offer futile care made them feel so much better in knowing we were doing the right thing for our patients.

Sunday, March 29, 2015

Ethics and Medically Ineffective Treatment II

Most of our cases of medically ineffective treatment happen in the ICU. For me, in particular, it's an interesting experience. For the most part, I don't think the goals of a critical care physician and a clinical ethicist conflict; after all, we strive to be as ethical as we can. However, in the large gray of the end of life where decisions have real consequences but little evidence, treating physicians may want help navigating care that may be futile. I've had so many families pray for a miracle for a loved one when from a medical and scientific standpoint, there is nothing more to offer. How do we tread those circumstances? On the one hand, it is easy to simply continue everything, giving the family that one last hope. On the other hand, prolonging the inevitable which usually involves suffering and loss of dignity is rarely the right thing for a patient. From a systems standpoint, we cannot sustain a health care infrastructure if we provide interventions and treatments that have no benefit.

In situations where families pray for miracles, who is to say what is futile and what is not? This is something that ethicists have grappled with and written about, and a commonly accepted threshold is that if the last one hundred patients who were in this situation and received this treatment did not have any benefit, then the treatment is futile. This can be quite controversial, and some people argue for a stricter threshold while others think this is too narrow. I tend to agree with it. Since we commonly accept a scientific trial to be significant if there is less than 5% of doubt, then setting the threshold at less than 1% gives me reasonable certainty in determining whether an intervention is worthwhile.

Ethically, withdrawing and withholding treatment is equivalent. That is, if I believe putting someone on a ventilator is futile and I do not offer it, I can also discontinue the ventilator in someone already on it if it's futile there as well. For families, of course, this feels entirely different. Many people accept when an intervention like dialysis will not be offered. It's much harder to go to them and say that since dialysis is not helping and not expected to help, we will withdraw it. I encounter all these situations in the ICU both as a primary treating physician and as an ethics consultant.

Wednesday, March 25, 2015

Ethics and Medically Ineffective Treatment I

Probably the most common ethics consult we get is one surrounding perceived, potential, or proven medically ineffective treatment. At least in California, physicians are not required to provide care that is not beneficial. Sometimes this is called futile care, but that doesn't go well with the public and policymakers, so we instead call it medically ineffective care. I think the phrase stirs up emotions about rationing care, death panels, and the like, but it's really not meant to be that. Antibacterials do not work for the common cold. High dose vitamins do not work for brain cancer. An endotracheal tube does not cure decompensated liver failure. Physicians are not obligated to and should not do things that they do not believe will work.

In practice, this gets muddy very quickly. We consulted on a pediatric patient who was started on a treatment by a community physician that has no evidence or even biologic plausibility for working (the disease is neurologic and the drug does not cross the blood-brain barrier). After being admitted to the hospital, the parents requested continuation of the drug, which the pediatrician believed was ineffective. Since the drug has side effects on the liver and kidneys (risks) with no benefit, we sided with the physician and found it ethical to stop that drug.

On the other hand, we had a similar pediatric case where the family was requesting a treatment that was not felt to help the child, but had few side effects or risks. Here, we said that it was ethically permissible to go either way - either to give the drug or to stop it. In looking at the ethical principles of beneficence of maleficence, we did not think the child would be harmed, and because the benefit was questionable, we left it up to the treating team to decide what was best. As with any other consultation service, we make recommendations of varying insistence. Sometimes, we find things ethically necessary, other times we find them simply ethically permissible.

Friday, March 20, 2015

Ethics and the End of Life

Most of our ethics consults involve patients at the end of their life. This is, of course, a sensitive time where each individual situation is different, and if there are many stakeholders, figuring out what's right for the patient can be obscure. Should a patient with both liver and kidney failure who is not a transplant candidate be offered dialysis? Say their liver disease and its complications are so advanced that life expectancy is only a few days; should they be offered dialysis? What if the goal was for them to be alive when family members fly in from other states and dialysis is necessary to bridge them to that point? What if you keep them alive for their family members? Do you then stop the dialysis?

It's easy to write generic summaries of these situations, but when you dig your teeth in, you find that every position is nuanced. From an ethics standpoint, we try to clearly capture all the factors going into a decision. What is the medical situation and what are the achievable medical goals? Can the miracles of modern medicine keep the patient alive, or is it futile? Can we keep them alive for a few days to achieve a short term goal? Can we keep them alive to reach evaluation for transplant? We try to understand the patient's preferences. What are her values and goals? Have prior preferences been given? Can the patient make decisions or do we rely on substituted judgment?

Most people jump to the third arm of decision-making: quality of life. What kind of life do we expect the patient to have, if medical care succeeds? What disabilities or dependencies might the patient have? How does the patient's values influence the way we weigh the quality of life for the patient? Lastly, we look at the context: are there conflicts of interest? Do legal, religious, or public health issues come into play? Who are all the stakeholders and what are their positions? Do we need to think about allocation of a limited resource?

In my experience, end of life conversations often hang up on just a few issues: probabilities and coping. In these situations, the likelihood of a "good" outcome is often nebulous, and both clinicians and family members struggle with the fact that the possibility of a good quality of life is low but not zero. If a surgery will work only a minority of the time, how do you weigh those risks and benefits? Coping is a challenge from family members who are ever optimistic. Primary teams struggle with having family members understand the severity of the situation, and when there is an incongruency between the family's wishes and the achievable goals, the ethics consult team often gets involved. Sometimes this is simply a communication or understanding issue, but more often than not, it's an acceptance issue. I completely understand how the end of someone's life can be hard to accept, but as an impartial ethics consultant, my goal is to objectively outline all these factors to do the right thing for our patients.

Sunday, March 15, 2015

Viper

Back in 2011, I found a snake whose venom became the drug captopril. Only recently did I find out another snake, the southeastern pygmy rattlesnake has a venom peptide that acts as an anticoagulant. To physicians, this molecule is known as eptifibatide, and it's commonly used in the treatment of heart attacks. For whatever reason, I've always had a fascination for the unique inventions of nature, and it astounds me that a drug that we use to save lives, which costs thousands of dollars, is made by snakes to kill. It's a weird and awe-inspiring thought.