"First, do no harm." This seems like an easy tenet to uphold, but here in the ICU, we occasionally see dreadful cases of iatrogenic harm; that is, problems caused by physicians. None of these are intentional or negligent; they are simply unfortunate outcomes that were foreseeable risks of the procedure they had.
When we get informed consent, we tell a patient or their surrogate of the risks associated with the procedure. Every procedure - from placement of an IV to heart surgery - has risks, and for all the large procedures, these risks include death. For the most part, these procedures proceed without a problem, but when a serious complication occurs, they come to the ICU.
We have a patient who had a bypass surgery but afterward, could not be successfully extubated; that is, we could not remove his breathing tube due to hemodynamic instability. Now, he has received a tracheostomy - an incision in the neck to allow access to his airway. He walked in expecting only one surgery, and now he's received another and has a prolonged stay in the intensive care unit.
How does the patient or family cope with this? Even if the best informed consent is performed, no one expects to go into surgery and come out worse off. Even if the surgeon performed everything as well as she could and this is simply an inevitable consequence or statistic, this is an awful outcome. I struggle to understand my emotions and my rational explanations of these circumstances, and I think families do as well.
Coronary catheterizations are incredibly common procedures to visualize the arteries of the heart to risk stratify heart disease or to intervene during a heart attack. Sometimes I think that cardiologists do them more frequently than indicated. But it was not until I saw a devastating complication that I have started to understand how this "simple" and "straightforward" procedure can kill someone. A patient walked into the cath lab for an elective angiogram and due to damage to his femoral artery, required massive transfusions, emergent vascular surgery, and now multiple life-support measures in the intensive care unit. After receiving so many blood products, his lungs began to fail. Then, his abdominal pressures started to climb. His kidneys could not filter out all the volume (and took a hit from the contrast). He went into heart failure. Multiple organ systems petered out, and now he may die.
A circumstance like this creates a profound emotional tension on the practitioners. We caused this. And that colors the picture. We feel immensely guilty about what happened, and we lose objectivity of the situation. As the picture became worse and worse, we were reluctant to admit it. We push the mortality statistic of multi-organ system dysfunction out of our heads because people who walk into the hospital for an elective procedure should not look like this. We avoid discussions about the end-of-life with family because that shouldn't happen, and yet it is happening.
Medicine is not a "safe" enterprise. Over the course of intern year, I've realized that we do good in this world, but not as much as I had thought, and what we do comes with enormous risk and responsibility.
When we get informed consent, we tell a patient or their surrogate of the risks associated with the procedure. Every procedure - from placement of an IV to heart surgery - has risks, and for all the large procedures, these risks include death. For the most part, these procedures proceed without a problem, but when a serious complication occurs, they come to the ICU.
We have a patient who had a bypass surgery but afterward, could not be successfully extubated; that is, we could not remove his breathing tube due to hemodynamic instability. Now, he has received a tracheostomy - an incision in the neck to allow access to his airway. He walked in expecting only one surgery, and now he's received another and has a prolonged stay in the intensive care unit.
How does the patient or family cope with this? Even if the best informed consent is performed, no one expects to go into surgery and come out worse off. Even if the surgeon performed everything as well as she could and this is simply an inevitable consequence or statistic, this is an awful outcome. I struggle to understand my emotions and my rational explanations of these circumstances, and I think families do as well.
Coronary catheterizations are incredibly common procedures to visualize the arteries of the heart to risk stratify heart disease or to intervene during a heart attack. Sometimes I think that cardiologists do them more frequently than indicated. But it was not until I saw a devastating complication that I have started to understand how this "simple" and "straightforward" procedure can kill someone. A patient walked into the cath lab for an elective angiogram and due to damage to his femoral artery, required massive transfusions, emergent vascular surgery, and now multiple life-support measures in the intensive care unit. After receiving so many blood products, his lungs began to fail. Then, his abdominal pressures started to climb. His kidneys could not filter out all the volume (and took a hit from the contrast). He went into heart failure. Multiple organ systems petered out, and now he may die.
A circumstance like this creates a profound emotional tension on the practitioners. We caused this. And that colors the picture. We feel immensely guilty about what happened, and we lose objectivity of the situation. As the picture became worse and worse, we were reluctant to admit it. We push the mortality statistic of multi-organ system dysfunction out of our heads because people who walk into the hospital for an elective procedure should not look like this. We avoid discussions about the end-of-life with family because that shouldn't happen, and yet it is happening.
Medicine is not a "safe" enterprise. Over the course of intern year, I've realized that we do good in this world, but not as much as I had thought, and what we do comes with enormous risk and responsibility.
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