ICU Transfer I

It turned out to be a windfall that my first month was in the VA ICU and the second month was on the VA wards. The ICU is a weird, isolated world. We get frighteningly sick patients who require lines and tubes out of every orifice, and we nurse them to health, slowly removing one tube here, one IV there until they are ready for the "floor." On being transferred to a regular medicine service, we pat ourselves on the back and forget about those patients as new ones roll in. But when I was on medicine after the ICU, I began receiving those transfers. I knew these patients. I was invested in their care. And now, I could see that slow rehabilitative process to get them home.

We often dread the ICU transfer. Patients could have been there for months, coming with volumes of records, with multiple organ systems involved. But because I had taken care of some of these unit patients, I already knew their stories and they were not difficult admissions. It was also enlightening for me to see that tough road for patients even after their acute medical issues had been stabilized. I got a few ICU transfers who made it out the door to a nursing facility, which was very gratifying.

Unfortunately, I also had a few transfers who went back to the unit for respiratory failure or hypotension. This was really hard for me. I had a gentleman who suffered a massive pulmonary embolus that required every intervention short of tPA - we even gave him inhaled epoprostenol. He was intubated for weeks, almost buying himself a tracheostomy, but finally we got the tube out of him. We started anticoagulating him for the pulmonary embolus when he then had a massive retroperitoneal bleed. I was off the ICU service at the time, but I heard that it was a nightmare; there were 4 anesthesia attendings present resuscitating and reintubating the patient. When he came down to me in the step-down unit, I had a lot of trouble getting him better. He required a lot of oxygen and even small activities would cause him to desaturate. Unfortunately, he bounced back to the ICU when he started retaining CO2. He came back to me a week later and I continued to struggle to decrease his oxygen requirement. Unfortunately, he may get that tracheostomy if we can't get him better, and he may require a prolonged stay at a nursing facility.