Amazing

I am sometimes astounded by the human body. This year I have seen physiologic disturbances that I would have thought non-survivable, but patients somehow make a slow recovery. I suppose this is a way in which clinical experience teaches things that books simply cannot. My last call, my nineteenth admission (a personal record) was a patient who came in with a panoply of diagnoses. As we put the story together (which happened a day into admission as things were quite scattered when he first arrived), he was an alcoholic who developed pancreatitis from drinking too much. This lead to such severe vomiting that he tore part of his esophagus, leading to a gastrointestinal bleed. Either this GI bleed or his pancreatitis lead to a systemic infection of gut bacteria and an uncontrolled blood sugar to over 900. On arrival, his lactate, glucose, and liver enzymes were all higher than our lab's maximal levels. What I thought he was going to die from, though, was a severe acidemia. The body's normal pH is 7.4, and the body tightly regulates it because our proteins, enzymes, and metabolic processes only work in a narrow pH range. Even small pH changes of 0.05 from 7.4 are abnormal. When pH drops below 7.2, I start worrying that our blood pressure medications have limited effect because the receptors where they act become deformed. The highest pH I've seen was 7.7 (the cause was inexplicable). This patient had the lowest pH I've seen anyone survive - 6.7. The imminent cardiovascular collapse I expected never happened. With aggressive fluid resuscitation, antibiotics, insulin, and blood products, we got the pH closer to normal within hours and saved his life.

2000

Dear readers,

This is the 2000th post! The last month has been really tough with clinical responsibilities which is why blogs have been a little sluggish. I need some time to recharge so I will take the holidays to catch my breath. This Christmas, I'm on call on the 23rd, post call on the 24th, and back on call on the 26th, so I have a nice 48 hours off to visit my family. I hope that you and your family enjoy a warm, safe, and happy holiday season. This next year, I hope to write fewer but longer posts, become more integrated into the social media milieu, and cap off the journey through residency and fellowship.

Warm regards,
Craig

Busy

So what is a busy shift like in the ICU? This week, I've been the triage resident for the afternoon and evening. I arrive at 2 and stay until the party quiets down. Tuesday night was a particularly insane day. Over a period of about ten or eleven hours, from the afternoon to midnight, I evaluated seventeen patients and admitted fourteen of them to the intensive care unit. Some were routine, planned admissions such as post-operative admission after neurosurgery for close neurologic monitoring. But most were truly sick patients requiring a lot of intensive interventions. A ninety-year-old gentleman presents with systemic infection from a urinary tract source leading to confusion, kidney injury, and heart strain. He wants everything done even understanding that his likelihood of making it out of the hospital is quite low. A young woman strokes because of intracranial blood vessel stenosis and requires artificial elevation of her blood pressures to perfuse her brain. A man with a near drowning is flown up from Monterey because of severe neurologic injury and intractable seizures. A patient with both heart failure and widespread infection comes to us because the cardiologists feel uncomfortable managing him. A post-operative patient from an orthopedic surgery has a massive heart attack with troponins exceeding our lab's upper limit. A patient on the lung transplant list has deteriorating interstitial lung disease requiring a breathing tube. A patient misses dialysis and comes in with arrhythmias from high potassium. A man who just received a bone marrow transplant has profound diarrhea, a bloodstream infection, and resulting low blood pressure. A crack-cocaine addict comes in with sky-high blood sugars. A woman with schizophrenia who attempted suicide last year unfortunately intentionally ingests an unknown cleaner fluid.

What makes my job especially challenging is that these patients don't arrive neatly in order, pre-packaged by other physicians. Our emergency department is swamped, our operating rooms are full, our consultants are running around the hospital. For most of these patients, I have to dig through records, talk to family, place invasive lines myself, order diagnostics, make therapeutic decisions. The patients and consults come in clumps and I have to multitask yet micromanage. I try to delegate tasks to my residents as I can, but some patients arrive within minutes to hours of potentially dying, and sometimes, it is all I can do to stabilize, triage, and move on. You should see my notes at the end of the night; I've learned to be much more organized because in this business as a critical care fellow in a tertiary center, you feel overwhelmed every day I step into the hospital.

Liver Disease II

Many patients get transferred from outside hospitals to our ICU for evaluation for liver transplant. As the medical ICU fellow, my job is to optimize these patients as best I can for potential surgery and prevent ICU complications while the determination of their transplant candidacy happens. Transplant eligibility is determined by each individual institution by a group of medical hepatologists and transplant surgeons. The United Network for Organ Sharing distributes organs within a geographic region based on blood type and the recipient's disease severity (their MELD score). Unfortunately, in our geographic area, we have so many people on the list and so few organs that by the time patients reach the top of the list, they are critically ill.

I think this creates a lot of problems. I see patients with widespread rampaging infections, severe encephalopathy, respiratory failure, circulatory shock states, renal injury, disseminated bleeding, and other liver complications. They are often too sick to survive transplant, and sometimes, too sick to even survive in the ICU. Once the liver completely fails, time starts ticking as the patient runs into one complications after another. Even as I staunch each problem, another one springs up. We've had several patients who were being considered for transplant who were declined an organ because they were too sick to survive. Sometimes, transplant eligibility is denied because of other factors such as ongoing drinking or poor social support. Ultimately, though, a substantial number of our liver patients pass away from decompensated disease.

I write about this serious topic because it's really affected me as an ICU physician. I think ultimately, the best solution is to increase the organ supply so that potential liver recipients get organs before their disease becomes too tenuous. That may be a topic for a future post. However, for now, I think it is paramount to recognize that liver disease can be a terminal illness and that not everyone can get a liver transplant. By the time someone reaches my care in the ICU, they only have days to weeks to get a new organ before their disease ultimately proves fatal.

Image of cirrhotic liver is in the public domain, from Wikipedia.

Liver Disease I

Over the last six months in the intensive care unit, I've found that one disease we underestimate in medicine is cirrhosis. When family practitioners see patients with decompensated congestive heart failure, oxygen-dependent chronic obstructive pulmonary disease, or metastatic cancer, they bring up the end of life. They talk about hospice, palliative care, and the fact that their disease is so severe, they will pass away from it. For whatever reason, liver disease doesn't seem to evoke the same responses. When I talk to patients admitted to the ICU with decompensated liver failure, they aren't aware of the mortality of their illness. They don't know what their liver disease, why liver disease affects every other organ in the body. For many, it's a black box, and it's our responsibility as physicians to fill that box in. The data is clear; MELD scores predict three month mortality, and these patients deserve a talk about the end of their life. I don't like being morbid, but I also don't think it's fair to surprise someone with the fact that they will die from a disease we've known about. In the same regard, this is why prevention of cirrhosis is so important; counseling for alcoholism, vaccines against hepatitis, and mechanisms to decrease acetaminophen overdose will save lives. It's imperative for us all to educate ourselves and our patients on what liver disease looks like and how to prevent it. Its imperative for us to guide our patients through the end of life if their liver disease is end stage. I see too many patients in the intensive care unit without a clue, a problem we need to address.

Image shown under Fair Use, from urbanities.com

Book Review: What If?

Those who know me or have followed the blog long enough know I'm a big fan of Randall Munroe, writer of the comic strip xkcd. He also published a series of articles called, "What If?" He looks at bizaare, absurd, and wonderful scientific questions and poses a scientific, reasoned answer. Looking at questions like "What if everyone who took the SAT guessed on every multiple-choice question? How many perfect scores would there be?" to "If you had a printed version of the whole of Wikipedia, how many printers would you need in order to keep up with the changes made to the live version?" he has entertaining and educational ways of looking at these problems. What If? is a great book that picks the best questions and answers and lays it out in an easily accessible format accompanied by amusing comics and doodles. Not just limited to science geeks, this book has something for everyone.

Image shown under Fair Use, from xkcd.

Rain, Rain Everywhere

In the last few days, we've been getting lots of warning about this California rainstorm that poured today. With flash flood warnings, a highway shut down, a high wind speeds, this has become quite a commotion. I know for most people in the Midwest or East Coast, a thing like this seems trivial, or at least typical, it's riled up us Californians quite a bit. Other than earthquakes, which feel so infrequent that we ignore them, we don't have too many natural disasters. It's kind of impressive that a little rain has caused people to cancel their doctor's appointments, employees to work from home, and stores to run out of rain boots, but after all, it was big enough to warrant a blog.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Morbidity and Mortality

Morbidity and Mortality rounds date back from the early 1900s when an MGH surgeon Dr. Codman decided to review the end results for all his patients. He hoped by looking at how his patients did, he would gain insight to errors, mistakes, or areas of improvement for his practice. He actually lost privileges at the hospital when he suggested that surgeons be evaluated for their performance.

Now most hospitals have M&M rounds. These rounds, closed to the public, are a confidential internal quality review. I lead the last M&M for the intensive care unit. I pulled up all the data on deaths in the ICU in the last month and reviewed those cases. Were there things we could have improved? Were there things we should have done differently? I engaged the primary treatment physicians to understand their thinking and thought process. I solicited feedback from physicians who were not involved for their opinion. Then, I examined a few cases in detail, trying to understand if there are any processes or protocols that can be improved. I identified several key teaching points and areas where we could improve. It ended up being a very well attended conference, and I was pleased with the outcome.

In these M&M rounds, I don't find that any individual person is ever at fault; most often, the things we decide to change are system-level improvements. No one wants to hear that physicians are still working out the kinks. But I think it would be worse if we were so arrogant to think that we did everything perfectly. We don't. And we need to have a process for constant evaluation and improvement in order to take the best care of our patients that we can.

Sick

Ill with a gastroenteritis this weekend, I remembered what it is like to be sick. Fevers, chills, rigors - I felt miserable. The cytokine storm landed me on the couch enshrouded in blankets as I tried to prepare my M&M talk this coming week. Every time I get ill, I imagine what it must feel like to be a patient and I write a blog about it. But I really can't imagine and wouldn't want to know what it's like to feel this shivery and sick, and be in a strange place with generic blankets, people constantly poking and prodding me, surrounded by the beeping and alarms of machines. How hard it must be to feel like this and be asked to work with physical therapy. How discouraging it must be to be stuck in this state for days, weeks, months. How emotionally traumatic it must be to be restrained to a bed or to lose the ability to think and communicate. If I feel so awful with a simple stomach bug, imagine how an octogenarian must feel admitted for pneumonia or urinary sepsis. When I think of why I go into medicine, I think of trying to alleviate suffering and pain, but instances like this remind me how raw such discomfort feels and rekindles my motivation to alleviate the suffering of others.

A Typical Day in the ICU

For a couple weeks this month, I've been an ICU team fellow. The role is designed to be a junior attending role where I direct rounds, run a team, teach, and oversee big picture questions for our patients. I arrive a little before 7 to get sign-out on my patients. The list usually runs somewhere between 12-20 patients so it's quite manageable, and every night, I expect about 5 or so new patients. I see the sicker patients before rounds at 8. As an anesthesiologist, my modus operandi is to do quick and efficient rounds. I have simply lost the capacity to do never-ending rounds in the way infectious disease or neurocritical care runs, though I do respect them a lot for it. I try to come up with a few five-minute teaching pearls because I think it helps me solidify my knowledge and its the best way to get information to stick with the residents and students. After observing different attendings run rounds in their own distinct way, I've adopted a style where I try very hard not to interrupt. I also give residents as much independence as is safe to make clinical judgments and decisions. I read a recent JAMA article about this - how attending micromanagement is becoming the norm - and I'm trying to find a middle ground. The best way to learn is to make decisions, and it's how I became confident with my clinical skills through my training. So rather than tell my residents what to do, I try my best to guide and nudge them to figuring things out themselves.

I try to get through rounds in an hour or two, and then I give residents space to get work done, write notes, and decompress. In a way, I think of Ender's Game where a captain needs to know when to give her team space. On the computer, I hover in the background, making sure things are ordered and labs followed up. I attend multidisciplinary rounds. I meet families. Before noon, we have radiology rounds where we review all the imaging studies on our patients. Then, we attend noon conference. In the afternoon, I tie up loose ends, supervising procedures, determining whether interventions we made in the morning helped, and attending meetings. My attending and I divvy up the work so that by sign out rounds at 3, most of our patients are tucked in. Usually we start getting new admissions in the afternoon, but I actually rely heavily on my co-fellows to stabilize the new patients while I take care of the old ones. After sign-out rounds, I make sure my non-call residents can go home and my call resident feels comfortable. I usually stay in the hospital a few hours afterwards to work on presentations and teaching materials. To be honest, the day is not bad at all, and much easier than a resident's life. But I really enjoy it, and this month, I've been lucky to have a great team.

Multidisciplinary Rounds

Every day in the medical ICU, I attend multidisciplinary rounds where I review my list of patients with a group of nurses, therapists, case managers, social workers, dieticians, and other health care practitioners. While sometimes it feels like a chore, it's really an incredibly important reflection of how patients get better. Although physicians would like to assume that it is our astute diagnoses, elaborate treatment plans, and active interventions that cure patients, my time in the ICU suggests otherwise. A patient certainly won't get better if the medical team isn't making the right decisions, but that is insufficient to treat a patient. I may make a brilliant rare diagnosis and start the perfect medication, but that won't get most patients out of the ICU. To recover, all of the hard work is done by the patient herself, and most of that in conjunction with the nurse, physical therapist, occupational therapist, dietician, and respiratory therapist. After being an ICU fellow for half a year, I find the sight of a patient walking around the unit the best measure of how someone's doing. I would much rather see a good session of physical therapy than an improving white blood cell count or creatinine or fever curve. As a result, I really take the time at these multidisciplinary rounds to advocate for my patients. Intensive care medicine is a team effort, and I want to recognize all those other practitioners who help my patients get better.

Thanksgiving in the Hospital

I've always wanted to know how holidays compare to a regular day in the hospital. In the intensive care unit, I don't know that there's a huge difference. Although we have no scheduled surgeries requiring post-operative ICU care, we do see an uptick in the wayward patient who overindulges. For example, when I was on my 24-hour Thanksgiving shift, I saw a couple patients who had a little too much salt. Although one avoided the ICU, the other had to come up for dialysis to take off that extra turkey brine and wine. I have a suspicion that the days after a major holiday might see an uptick in admissions with all those who were sick on Thanksgiving but didn't want to come in owing to the holiday. When I get back to work tomorrow, I'll find out. I hope your Thanksgiving was healthy, happy, and away from the hospital.

Thanksgiving

This year, I am thankful to be finally reaching the end of my training. It has been an awfully long road, so long that the sacrifices seem normal. I can't remember the last time I flew home to my parents' for Thanksgiving. That doesn't bother me per se, but rather the thought that my parents have missed out on me being home for the last eight years or so. Holiday after holiday, weekend after weekend, the hospital has become a second home, my co-residents a second family. All this changes in a little over six months, and I'm not sure how I'll take it. I've adapted to this lifestyle, and really, I love it. I enjoy the role I have in the hospital, the gradated learning, the work I do. It's immensely fulfilling and at the same time immensely tiring. I hope that when I finish fellowship, I'll find a career that offers me the same deeply satisfying work for a little better compensation and work-life balance. For that, this year, though I will be in the intensive care unit all day and all night, I am grateful.

Social Media

For a long time, I didn't bother much with social media. Although I think social media is exciting and has the potential to be influential, I tend to be a late adopter of technologies. I never craved garnering lots of followers or developing a social media reputation. However, over the last few years, I've slowly developed more of an online presence, and I like it. I've always tried to put good content up, and though I don't have flashy videos, graphics, or designs, I hope that some of my thoughts on medicine are worth readings.

Recently, several of my blogs for The American Resident Project have been picked up by KevinMD. Most recently, I wrote a commentary on quality ratings for health care providers in the U.S. A list of all the posts he's reblogged can be found here. I think cross-pollination is important because solving health care problems is a discussion, and I want to engage others (like you!) in conversation. I do appreciate it if you follow this blog, rebroadcast ideas, and leave comments. My goal isn't popularity or number of hits, but focusing attention on medical stories, problems, and ideas so we can improve health care as a whole. Thank you for those you already read, follow, or comment. It helps me justify those late nights researching and writing these blogs.

Book Review: God's Hotel

I got several recommendations to read Victoria Sweet's nonfiction book, God's Hotel. An anesthesiologist who does creative writing and a resident in internal medicine both recently read this book and told me about it. When I looked at the jacket description, I knew why. Victoria Sweet explores the fascinating history and modern reimagination of one of the oldest institutions in San Francisco, Laguna Honda Hospital. For Bay Area physicians, it's especially personal because we've often sent patients to and received patients from Laguna Honda. Initially an almshouse, Laguna Honda inherited the role of caring for the poor and indigent of San Francisco, those who have nowhere else to go. It plays a critical role in the health care safety net of the city, a place for rehabilitation, AIDS patients, dementia, and chronic illness. Victoria Sweet paints a vivid picture of its history and occupants and describes its rocky recent history as budget cuts, increased regulations, and political powerplays threaten its existence. This, too, is relevant to me because when I was a medical student, I heard a lot about the various propositions regarding Laguna Honda. I drove past it regularly, but never investigated its character - its beautiful landscape, historic architecture, and unusual throwbacks to the past.

Along with describing the history of an institution, Victoria Sweet writes about her growth as a physician, interesting patient cases, and opinions on modern medicine. As a blogger who enjoys writing clinical vignettes, I liked reading her patient encounters, fun diagnoses, and descriptions of complex medical phenomena; she does a great job making it accessible to the lay public. I also agree a lot with her commentary on what's important in medicine. Although the book does not primarily seek to change the way medicine is practiced, she makes a case for returning medicine to its roots. She describes the growth of bureaucracy, regulation of medicine, influence of lawsuits, and tightening budgets affecting health care. I was shocked to learn how much administrators, politicians, and bureaucrats interfere with the delivery of medicine at Laguna Honda. I got a glimpse into the community, charity, and values of medicine of a by-gone era.

Lastly, Victoria Sweet weaves in her own personal interest, a journey into understanding medieval history of medicine. She describes tenants of pre-modern medicine such as how to treat the evil humors. She writes about her studies, sabbaticals, and pilgrimages to understand history of medicine. Though this was least interesting to me, it gave me appreciation of the many facets of our profession. Overall, God's Hotel was an enjoyable nonfiction book with a lot of relevance for a Bay Area doctor. Of the many books out there written by physicians, I thought this was one of the more unique and worthwhile.

Image from victoriasweet.com, shown under Fair Use.

Ondine's Curse and Other Unusual Causes for Respiratory Failure

There's a short list of really common reasons patients may need a mechanical ventilator in the intensive care unit: pneumonia, acute respiratory distress syndrome, pulmonary edema, hypercarbic respiratory failure, altered mental status. But at a tertiary referral center like Stanford, we get a few rare causes of respiratory failure. A few months ago, I admitted a patient who was simply too weak to take a deep breath. She was young, but she had a rhematologic illness that infiltrated her central (proximal) muscles. She went from working full time to being completely bedbound and gasping for air within months. After confirming the diagnosis with nerve and muscle conduction studies and a muscle biopsy, we started high dose immunosuppressants. Soon she was walking around the ICU on a ventilator. With good rehabilitation and rheumatologic followup, we hope that she will regain the ability to breathe.

Another patient has a more unfortunate disease. She has a tumor in her brainstem right at the center that controls subconscious breathing. This is a big problem; she is effectively cursed by Ondine. Ondine was a water nymph who had a unfaithful mortal lover, so she cursed him so that if he fell asleep, he would stop breathing (he had previously vowed that every waking breath was a testimony of his love). This patient suffered two cardiac arrests from apnea - she stopped breathing, and there was no automatic stimulus or drive to breathe. Normally, our brainstem regulates our breathing pattern while we are asleep, but the location of her brain tumor disrupts those signals. During the daytime, she is fine, but when she falls asleep, she needs a backup rate to breathe for her through a tracheostomy. She, too, will do fine; her brain cancer is benign, but she will need to be in a long term ventilator facility, and we need to see if chemotherapy and steroids shrink the tumor such that she remembers to breathe again.

First image of a mechanical ventilator shown under Creative Commons Attribution Share-Alike License, from Wikipedia. Second image of John William Waterhouse's painting of Ondine is in the public domain, from Wikipedia.

First, Do No Harm

Pre-liver transplant patients have a unique clinical situation. Their cirrhosis is irreversible; the only way to treat the underlying cause of their problems is a liver transplant. But unlike other therapies, transplants are unpredictable; a "patient" (pun not intended) might have to wait two days or a month to get their transplant. Even worse, they may have a complication that takes them off the transplant list before they can get an organ. In our hospital, we have far more patients than organs so that those who get the organ have been waiting a long time, and consequently, have far more advanced disease.

Liver disease invites complications. If the liver cannot clear the evil humours in the blood, patients get confused which begets more complications. Cirrhosis decouples blood pressure regulatory mechanisms, it invites pulmonary arterio-venous malformation development, it changes pressures in the brain. The gastrointestinal system becomes engorged with blood, leading to risk for bleeding. The liver stops producing proteins and platelets that stop bleeding. If the liver's synthesis of anti-infectious agents wanes, then infectious become more common and more deadly. The liver's function is intricately tied to the kidney, and when the liver starts failing, the kidney is at risk to do so as well.

We see all these complications in our pre-transplant patients, and as their disease progresses, they come up to the ICU. They come because their confusion requires intubation, their infections require brood spectrum antibiotics, their gastrointestinal bleeds require massive transfusions, their kidneys require continuous dialysis, their blood pressures require continuous vasopressor support. But the most important thing for us to remember is for these patients especially, first do no harm. Our ultimate goal is to get them the transplant, so we have to be cognizant of every risk the patient is exposed to. If we place a central line that gets infected, if we give antibiotics that lead to a Clostridium dificile infection, if we fail to protect their kidneys, if we don't give adequate nutrition, they may lose their place on the transplant list. In contrast to the other patients in the ICU whose diseases we can reverse and who we can get better, we only hope to keep our pre-transplant patients where they are so they can get an organ.

It does work and amazingly so. A woman with alcoholic cirrhosis was on my ICU service three weeks getting daily transfusions and continuous dialysis. After waiting day after day, she finally got a liver. She was walking the second day after surgery and left the ICU four days after her transplant. We expect her kidneys to get better. She has a new life.

Both images are in the public domain, from Wikipedia. First image is a healthy liver. Second image shows cirrhosis.

Meta-analysis

Often considered the "best" type of studies, meta-analyses compile data from smaller, more primary studies to generate more powerful conclusions. It's like doing research on previous research. But how meta can you get?

Image is from xkcd, drawn by Randall Munroe, shown under Creative Commons Attribution License.

Grief and Loss

One of my friends from high school recently lost her husband to cancer. Watching her go through this ordeal really struck home to me that visceral feeling of grief and loss. Working in intensive care, we see so many families in distress with the illness or loss of a family member. I try to remain cognizant of these emotions and hope that I express enough empathy for these families. But it's really something different when it's someone you know, someone your age, someone whose shoes you really could have worn.

It is a terrible process, long, agonizing, fighting uphill every step of the way. I watched her struggle with insurance denials, second opinions, discouraging MRI and PET scan results, unexpected hospitalizations, and the struggle to transition to hospice. From a intellectual, medical standpoint, I understood everything; I've seen the process so many times. But it was pain and heartache, grief and loss hearing my friend go through this.

My thoughts go to all those struggling with medical illness and all those caretakers who put their whole heart into it and still come out heartbroken.

Teaching and Doing Procedures in the ICU

Placement of a central venous catheter is a core skill on most medical specialties. Emergency physicians, surgeons, internal medicine doctors, anesthesiologists, and pediatricians all have to learn to place a "central line." In principle, it's easy: place a needle into a central vein, thread a wire through that needle, and place a catheter over that wire. But in practice, there's a learning curve, and as an ICU fellow, I have to shepherd residents through that learning curve by supervising their procedures.

This has taught me a lot. I've learned where obstacles seem to crop up for trainees. Some are simply nuisances, inefficiencies, but some can be potentially harmful. I quickly learn to recognize how comfortable a medical student or resident is in the process; some just need a nod of reassurance, and some need me to scrub and hold their hand; some don't recognize how little they know, and some don't recognize how skilled they actually are. I spend a lot of time thinking of how to best teach a particular trainee; inundate a newbie with too much information and they will be overwhelmed, but even a proficient proceduralist (including myself) has things to learn. For example, if someone has done a hundred lines, I still find things to teach. How do you do the line completely solo with no assistance? (How do you adjust the ultrasound knobs or place the probe cover when you're already sterile?) How can you maximize efficiency? How can you do the line without a drop of blood touching the patient's bed? My background as an anesthesiologist really helps me in this setting; I've had my share of pressure for efficiency in the OR and learned many tricks from placing regional nerve blocks.

The learning curve is steep at first and then plateaus. After doing a couple dozen lines, most physicians can handle straightforward central lines with ease. However, we occasionally have very high risk clinical situations, and that's when for patient safety, I do the lines myself. Trauma, obesity, prior lines and surgeries, altered anatomy, inability to tolerate usual positioning are all reasons a central line can be scary, but my most challenging line (and the one I'm most proud of) was for a dying liver patient.

The patient, who already had multiple neck central lines, needed emergent dialysis. He was extremely prone to bleeding from disseminated intravascular coagulation with an INR of 6. Cognizant of following my own advice, I set everything up carefully. Once I started, I had to move quickly because bleeding would start immediately, and a hematoma might make the procedure impossible. The patient's abdominal ascites from cirrhosis made femoral access difficult, but it was the best vein I had. With one quick stab into the femoral vein, the patient started oozing blood, even with a small 18 gauge finder needle (1.3mm diameter). With two quick dilations, I managed to slip the 12.5 French (4.2mm diameter) trialysis catheter into place. I was pretty sweaty as I did it. I am no surgeon, but sometimes I like that feeling when a challenge is presented and I use all my skills and experience to conquer it.

Image is in the public domain.

Families

One of the harder responsibilities as an ICU fellow is dealing with the frustrated, disgruntled, upset, or angry patient or family member. Fortunately, we don't encounter this too often, but it does happen, and those conversations and interactions are really tough. I really believe that emotions like these are understandable; I've never been hospitalized in the ICU or had a direct family member in that situation, but I can imagine how hard it must be. There is always room for more empathy, better communication, fewer complications, and improved support in the ICU. I think that most people who are upset are learning to cope with having a loved one in a critically ill condition.

I write this blog, though, to describe how challenging it is to be in this situation. Although sometimes, we get advance notice from a nurse that a family member is angry, we are often blindsided in this situations. Grievances sometimes involve things that I (or my team) was not involved in such as missed diagnoses at an outside hospital, delays in the emergency department, or the cost of parking. However, there are aspects of ICU medicine for which we are guilty such as poor communication with the family. I often view my role in these family meetings as explaining the clinical situation and allowing family members to vent. In the last few months, I've learned a lot about handling these situations. A quiet room, a calm demeanor, open ended questions, acknowledge a family member's sentiments, and when arguing will just get you into trouble all go a long way to improving relationships with families.

Ebola VI - What It Means for Me

As a critical care fellow, I'm likely to be one of the physicians taking care of patients with suspected or proven Ebola. It's a fascinating and crazy process. One of our first training sessions involved learning to put on and take off our personal protective equipment. It's a real process; the guide has 38 steps for donning the equipment and 27 steps for doffing it (which, by the way, is now one of my favorite words). We wear helmets with built-in fans normally sported by orthopedic surgeons to ventilate our suits while we work. We have three pairs of gloves, three layers of footwear. Walking feels strange, and placing an IV is a challenge. With three layers of gloves, I can barely palpate veins. Our body is protected by an impermeable suit and impervious surgical gown. I spent half an hour in the get-up, practicing intubating mannequins, placing IVs, and manipulating equipment, and by the end, under all those layers, I had worked up a sweat.

The real danger is taking off the equipment because that's when things are contaminated. There is a strict protocol and order in which everything is done including when we step out of the patient's room to the antechamber and when we're allowed to leave the antechamber. Currently, the way things are set up, there will always be a health care practitioner in the room, one in the antechamber to help, and two outside the room as well as a safety officer overseeing compliance with all of this.

Even though the diagnosis and treatment of Ebola virus disease is not necessarily complicated, as we plan for this potential threat, I'm learning how even for a relatively straightforward disease, we will have to implement new and complex protocols for physicians and other health care workers.

Image of an air-transportable isolation module is in the public domain, from Wikipedia.

Ebola V - What It Means for U.S. Hospitals

In the past few blogs, I've talked about Ebola in West Africa. Nevertheless, most of us aren't going to West Africa, even if we recognize how important that is. For the less daring, less courageous of us, we focus on preparations at home. Now that there are several cases of Ebola in the U.S., it is no longer a possibility or threat; it's real. Fortunately, we have the resources here to take care of it. What does this look like? What does this mean?

I've been privy to some of the discussions and preparations at Stanford Hospital for managing new and emerging infectious diseases like Ebola. It is a process that involves a lot of people and departments. The physicians likely to encounter Ebola are emergency doctors, infectious disease specialists, and critical care physicians. But those at greatest risk will be those who have the most contact with Ebola patients, our nurses. We also have to involve administration, facilities management (how do you dispose of all the Ebola-contaminated gowns?), respiratory therapy, and the county public health office. We have to figure out our processes and policies. For example, what do you do if a potential Ebola patient has a cardiac arrest? If health care workers swarm into the room, they are likely to get exposed, even if they try to put on personal protective equipment. Do we send these patients to the MRI or CT scanner? How do we prevent potential infected persons from sitting in a waiting room? And though we all expect patients to enter the health care system through the emergency department or urgent care, it's entirely possible that they can show up to an unrelated clinic or satellite center.

Although these decisions are still undergoing review, we're using technology to our advantage. For example, to limit the health care workers directly in contact with a patient, we're considering putting cameras in patient rooms so physicians can talk to patients without going into the room. That way, specialists like infectious disease doctors can do most of their job without endangering themselves. We're coming up with the exact route a patient will take from the emergency department to the ICU room and how security will facilitate that transport. We're determining the appropriate number of nurses, the length of nursing shifts, and the appropriate level of evaluation - for example, with the biohazard suits, we cannot listen to the heart or lungs with a stethoscope. We have gotten chemicals that solidify waste to make it more manageable. Our office of emergency response and disasters has already put dozens of health care workers through the training for putting on the biohazard equipment.

Image of researcher in biosafety level 4 hazmat suit is in the public domain, from Wikipedia.

Ebola IV - Containment

So why don't we - the rich, privileged, and terrified - close off all contact with West Africa? Some politicians have advocated terminating flights to risky countries, but the CDC and other experts have resolutely opposed that. The first reason, I feel, is an ethical one. We have resources, volunteers, and an obligation to care for those who need aid. But even beyond moral obligation, the world is globally interconnected. There will be no way to quarantine a part of the world or a people, and attempting to do so will encourage illicit means of getting across borders. At least with airplanes, we can screen passengers for symptoms. If we shut airports down, the terrified and fleeing of West Africa will still make it out, but through means that are less traceable. Furthermore, the economies of West Africa are already being stressed by this epidemic; the cost of food has skyrocketed, and if trade were further suppressed, the economic damage to these countries - several of which have recently experienced civil war - may be irreparable.

Most importantly, though, containment of the disease in West Africa is what will prevent an epidemic or pandemic. Infectious diseases like this grow exponentially over time and if we try to isolate ourselves from the rest of the world, it will grow larger and larger until it overwhelms whatever barriers we throw up. If this gets out of control, the mortality will be unconscionable and the ability to get on top of the epidemic will be much more challenging. Now is the time to muster our resources, send health care workers to Africa, and put our minds together to limit the spread of disease. We cannot hide or ignore it.

First image is of an Ebola treatment unit; second image is of WHO health care workers putting on personal protective equipment. Both images shown under Creative Commons Attribution Share-Alike License.

Ebola III - The 2014 Outbreak

The 2014 outbreak in West Africa is the largest Ebola outbreak and the first one in West Africa. It is concentrated in Guinea, Sierra Leone, and Liberia, though there have been cases elsewhere including some in Europe and the United States. It has been going on for many months but only recently started getting media attention. Many infectious disease, public health, and other experts suggest that this is a critical point in the spread of the outbreak; without adequate resources to contain Ebola, it may become a worldwide epidemic or pandemic.

Understanding the disease requires understanding the culture, history, and people of West Africa. I know little about this, but it is really important. The behavior of the disease depends intimately on the sociocultural context where it exists. For example, burial customs in West Africa often involve touching, kissing, or bathing the deceased. Much of the early spread of Ebola happened at funerals with the death of an infected person. Furthermore, ongoing risk and spread occur when family members or patients lie about their disease or symptoms because they worry they will not get a funeral. Without proper education, the virus will continue to spread even as it kills its host. But this simple point - education - is a challenge if the people of West Africa don't believe authorities.

Suspicion of medical personnel and facilities also contributes to the problem. There have been instances of health care workers and hospitals being attacked because of a scared public that doesn't understand Ebola. The delivery of health care is impeded if patients refuse to seek care when they have symptoms. These countries are poor; they can't even handle those who do present for care. Fear of the disease may limit the treatment rendered; many patients are underresuscitated because of a fear to place an IV. Lack of protective health equipment for providers means that many providers have contracted and succumbed to the disease. There are so many barriers preventing effective control of this outbreak. In order to successfully contain the disease, we need to address not just the medical aspect, but also the social milieu in which it resides.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Ebola II - The Scare

Unlike other recent "epidemic" scares like avian flu and H1N1, Ebola is not spread by respiratory or airborne mechanisms. It is spread by contact with bodily fluids such as blood, vomit, and diarrhea. This tells us who will be at highest risk: healthcare workers. I don't suspect that the general public will be at great danger for getting Ebola, but practitioners doing invasive procedures or caring directly for sick patients will be vulnerable. In the study of epidemics, a variable called R0 describes how infective a disease is; that is, how many people each infected person is likely to further infect. Compared with other diseases like measles, Ebola's estimated R0 is quite low, somewhere between 1.5 and 2. We have to decrease this below 1 to ensure a disease will be eradicated.

Lastly, Ebola is scary for many reasons. Its current case-fatality rate (what I think of as mortality rate) is estimated somewhere between 60-90% meaning the vast majority of patients who got it have died. But this is in the context of a developing country with limited physicians and resources trying to deal with a disease that's incompletely characterized. I imagine that the case-fatality in a developed country with adequate provisions will be much lower. The treatment is supportive, like most of what we do in the intensive care unit; there are no proven antivirals or miracle drugs, so fluid hydration, blood pressure and oxygen support, and blood transfusions are the mainstay of therapy. The other reason Ebola scares people is its name; it is the stuff of outbreak horror movies. I have talked to many people who are panicked about Ebola but my prediction is that this outbreak will take far fewer lives than influenza will this winter season, but will get much more press.

Image of nurses caring for a patient with Ebola from a 1976 Zaire outbreak is in the public domain, from Wikipedia.

Ebola I - The Basics

I've been thinking about this topic for a while and procrastinating a bit to see where things go, but it's time to write this post. Ebola is coming. What it will look like, what it will mean, and whether it turns into the scare everyone's worried about remains to be seen, but there's no doubt about it, physicians and hospitals need to be prepared. I'm going to spend a few blogs writing about Ebola, not because it in itself is such a remarkable disease, but because its an outstanding case study in learning about the response to new and emerging infectious diseases, the globalization of health, the cultural context of disease, media and public response to threats, disaster preparation, and what it's like to be a physician for these patients.

First things first. Ebola was discovered in the mid-1970s so it's not a disease that's been around all that long. Its origins hint at where new diseases may come from: the transmission of viruses from animals to humans. Many recent infectious agents like HIV, swine flu, and avian flu have animal reservoirs, and perhaps this is what fascinates infectious disease and tropical medicine specialists. The exact host and viral life cycle are unknown so far, though evidence suggests a reservoir in bats. There have been over a dozen prior outbreaks, but each has been limited and has not caught global attention. In medical schools, Ebola and its related viruses are presented probably for five or ten minutes. After the 2014 outbreak, I am sure there will be more focus on it. This, also, is interesting; most physicians learn about Ebola by talking to the experts and reading the publications. I, certainly, was not well-versed in the disease, but when I found out I might be taking care of these patients, I started studying.

One challenge with Ebola is that its presentation is nonspecific; its symptoms could result from any number of diseases. Like most viral illnesses, it begins with fever, malaise, aches, and pains. Over the next few days, its symptoms move to the gastrointestinal tract with nausea, vomiting, and diarrhea. It kills patients due to severe dehydration and resulting metabolic disturbances and organ malperfusion. Diagnosing Ebola lies in the history: where has a patient traveled and who has he been in contact with? For now, while the outbreak remains in West Africa, screening patients is relatively easy, but if Ebola spreads to Europe or the United States, this will become a major problem.

Image is in the public domain, from Wikipedia.

Things We Don't Know

It's easy to diagnose, treat, manage, write about, and describe things we know well. The majority of clinical situations, cases, patients, and procedures described in this blog are ones I feel very familiar and comfortable with. But perhaps the point of training is to learn about and become better at those clinical situations, cases, patients, and procedures which intimidate us. As an anesthesiologist, I feel well-versed in many things, but one of the clinical scenarios that scares me most is the hematology patient.

One reason the Stanford medical ICU is much higher acuity than the other ICUs we rotate through is the high prevalence of patients with bone marrow transplants, graft versus host disease, acute leukemia, tumor lysis syndrome, and serious reactions to antineoplastic agents. These are disease states we almost never see in anesthesia, so I rely heavily on my medicine colleagues, my consultants, and my reading to give me guidance. These patients can be incredibly sick and though I can manage supportive care - the vasopressors, dialysis, mechanical ventilation, antibiotics, transfusions - I don't know the hematology very well. This makes it hard for me to estimate prognosis, talk at family meetings, decide on when to pursue chemotherapy, and identify side effects of antineoplastic agents. As a result, it'll be a personal focus the next few months for me to gain a better understanding of hematologic illness and disease courses.

Image of acute myelogenous leukemia blood smear shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Why Anesthesiologists Matter

A middle aged man is brought to the emergency department for a fall and loss of consciousness. A stat CT scan of the brain shows a severe brain bleed, probably from uncontrolled high blood pressure. His neurologic exam is deteriorating; he doesn't wake up to voice or touch, and he cannot protect his windpipe, so the emergency physician determines that a breathing tube is necessary. As they make this determination, they call me as the ICU fellow and say they are going to admit the patient to my service.

Even though the emergency physicians have formulated an appropriate plan, I rush down because this will be my patient. When I arrive, the medications to ensure the patient is asleep for intubation have already been given. The ED physicians have used their standard agents for intubation, but they are absolutely not the ones I would choose. The medications they use are ideal for overwhelming infection, trauma, and massive bleeding because they maintain the blood pressure. But this person was bleeding into his head; as an anesthesiologist, I would have chosen medications that prevented a hypertensive crisis. Unfortunately, I arrived moments before I could give them feedback.

In this situation, everyone in the room was tense and stressed about getting the breathing tube in. But as an anesthesiologist, when I glanced at the patient, I was fairly confident I could do it without trouble. I kept my focus on the main thing that would kill this patient: his blood pressure, especially with the forceful ED laryngoscopy, would go through the roof, and this would dramatically worsen the bleeding. I grabbed propofol and labetalol, two agents to lower the blood pressure, but it took me several minutes to get the blood pressure into an acceptable range. I was the only one focused on those vital signs, and if I had not been there, critical time would have been lost. Here is a situation where an anesthesiologist matters.

Many people can put in breathing tubes. Emergency doctors, intensive care physicians, neonatologists, even emergency medical technicians can do the physical action. But I spent three years learning the nuances: how to minimize trauma, what medications to choose, what complications to expect, how to manage the whole patient while focused on one small task. No matter how good a non-anesthesiologist is, his training is simply not as focused on these critical few minutes, sending a patient to sleep and securing the windpipe. In this case, I think it mattered. I have a lot of respect for other specialties because they do things I know little about. I write this blog not to criticize them, but to say that as an anesthesia-trained ICU fellow, there are situations, procedures, and medical decisions I feel very confident about, and I hope we are recognized for those instances of expertise.

Real Work Again

The month in the VA gave me a taste of perhaps what community ICU could be like. With only fifteen beds, patients and diseases that by ICU standards weren't too severe, and lots of teaching opportunities, it was the easy life. I thoroughly enjoyed introducing third month interns to the world of medicine, challenging my residents and mid-levels, and learning how to act an attending. VA calls were home calls, so I'd go home late in the evening and only occasionally be called back for admissions. I spent time not only studying and learning, but also taking care of myself and enjoying life.

Alas, such things cannot last. After the VA, I've been at the Stanford medical ICU, the paragon of medicine and one of the most exhausting rotations this year. When I started, I ran a team that had nearly twenty patients, and no matter how many we sent to the floor, we'd reaccumulate nigh instantly. As a fellow in the MICU, we have are own defined roles and don't take on as many attending responsibilities. I scurried about to multidisciplinary rounds, family meetings, and lectures. I occupied myself with supervising procedures, running codes, and admitting patients. The acuity these past few weeks has been quite high, and I've gathered a few interesting stories to blog about this week.

Difficult Airway in the ICU

I've had my share of difficult airways in residency, but the difference now is that I ought to be fully independent with airway management. Of course there is an ICU attending, but that attending isn't always an anesthesiologist, and in those circumstances, I am the go-to airway person in the ICU.

The Palo Alto VA has a pretty amazing spinal cord unit; we have patients transferred from all over to get our expertise in management of spinal injuries. A middle-aged vet with a longstanding cervical spine injury and fusion has subacute respiratory failure. His mouth opening is poor and his large face and prominent beard would make mask delivery of oxygen challenging. After talking it over with the patient and his sister, we decide to intubate him to get him through his pneumonia. How do I proceed?

Normally, I would come up with a plan and then discuss it with my anesthesia attending, but here, I had the role of "airway." Most of my co-residents who are now attendings talk about becoming a little more conservative now that they are on their own. I did the same. With the difficult airway cart in place, I decided to induce anesthesia, put in a laryngeal mask airway, and ventilate through the airway. After I knew I could deliver oxygen, I proceeded to use a fiberoptic bronchoscope, visualize the vocal cords and windpipe, put a catheter there, and then use the catheter as a guide to place an endotracheal tube. I was sweating a little bit, but it went easily, and his lowest oxygen saturation was 99%.

A week later, we tried to extubate him, but unfortunately, he failed to maintain his airway on his own. I had to put the breathing tube back in. This time, though, I had a resident. I knew what worked for me last time and I was confident I could reintubate him if necessary, so I asked the resident what she wanted to do to put the breathing tube in. She decided to go with a throwback to the 1990s with a Patil-Syracuse mask. I had only used this once or twice, but I trusted her judgment. The seldom-used Patil mask is designed to allow delivery of positive pressure ventilation while the anesthesiologists secure the airway with a fiberoptic scope. We used it with our BIPAP machine and ensured that it had adequate oxygen delivery and ventilation prior to putting the patient to sleep. Since we could continuously breathe for the patient while guiding the flexible camera into the windpipe, we had all the time we needed. The anesthesia resident, one of the best ones I've ever worked with, did everything independently. This taught me a lot as an attending, to trust my resident's skills, to appreciate judgement decisions, and to have confidence that I could rescue the patient if things went wrong. Now that I'm an ICU fellow, I don't intubate all that much, but occasions like these are ever so exciting.

Defying Augury

Although the acuity of the VA ICU patients is not as high as those in the "big house," we do occasionally get quite challenging medical mysteries. A patient with proven adrenal insufficiency by cortisol stim test simply cannot wean off stress dose steroids. In his month-long stay in the ICU, he kept on having recurring episodes of "sepsis." He has cyclic spikes in his temperature, drops in his blood pressure, and increases in his white count. He has multiple sources of infection including multiple indwelling lines, aspiration events, urinary infections, joint effusions, intraabdominal sources, and skin infections. Every time this happens, we increase his pressors, broaden his antibiotics, and put him on stress dose steroids. He gets better and after we get him off pressors, we start slowly inching back on his stress dose steroids and antibiotics. Soon thereafter, another episode happens and the cycle recurs again. It's frustrating because each bout of sepsis sets him back more and more, limiting his nutrition, accumulating insults to his organ systems. But we cannot keep him on high dose catabolic steroids and ultra-broad-spectrum antibiotics forever. His muscle mass has already wasted away and he's already had Clostridium dificile infections. We've consulted every service in the hospital and performed tests I rarely order like WBC scans. Yet he defies augury, and we simply cannot get him better. It's a sad story, and unfortunately, not an uncommon one in the ICU. It reminds me that modern medicine has its limitations.

General Surgery and the ICU

At the VA, we had a considerable number of general surgery patients on our ICU service. As an anesthesiologist, the post-operative care of surgical patients feels fairly manageable. But there were a number of remarkable critically ill general surgery patients who we treated on my month at the VA. Some were long-term players. One patient with multiple abdominal surgeries developed a persistent, severe hematuria - he was bleeding into his urine. For a week, our urologists worked to find the area of bleeding, but when one source was controlled, another became problematic. I don't usually think of hematuria as an ICU problem, but for this gentleman, nothing was a magic bullet. We put in nephrostomy tubes, used specialized urinary catheters, did continuous bladder irrigation, sent him to IR. Eventually, we achieved tenuous control of it and sent him to the floor. Another patient who refused to see a doctor came in with a perforated colon from metastatic colon cancer. As part of our ICU care, we had to involve the oncologists and palliative care doctors because adjusting to this new disease was going to be a big psychological shift and coping challenge. A separate vet with a perforated bowel had blueberries free-floating in his abdomen. The infectious and inflammatory response was so severe I had him on four vasopressors at one time, but we managed to tide him through. Another vet with a similar disease had breakdown of his abdominal wall so he had an open abdomen. His wound healing was so poor that the surgeons felt it would be months before they could close up his abdomen. 

Most of my year is focused on the medical intensive care unit and we simply do not see patients like this on that service. This month at the VA reminded me that a critical care physician must be well-rounded and prepared to take care of many, many different disease states and conditions.

The Next Generation of Health Care Professionals

Along with a few other writers from The American Resident Project, I participated in a panel at the 12th annual UC Davis Pre-Medical and Pre-Health Professions National Conference. Sponsored by The American Resident Project, we got to meet premeds and recent graduates interested in going to medical school. The panel was chaired by Dr. Sam Nussbaum, and I really enjoyed the lively discussion we had. We covered topics like work-life balance, 30-hour calls, building patient-physician relationships, and challenges in residency. Over lunch, the panelists, Dr Nussbaum, and I mulled over some of the changes happening in health care, problems with our current delivery system, and possible innovations to meet our dynamic health care needs. The thought provoking day reminded me we cannot be complacent or passive; as physicians, we have an imperative to become leaders, tackle system problems, educate and inspire the next generation of physicians, and engage our communities. Although participating in a panel like this takes away one of those coveted days off, it is such an opportunity for me to ponder the bigger questions of health care with brilliant people.

Paresthesias

Sometimes patients complain of painful paresthesias. We often think of paresthesias as pins and needles or numbness and tingling. But,I wonder, how bad could numbness and tingling be? How could it be so severe that patients go into the emergency department or pain clinic requesting opioids?

Some friends of ours gave us peppers that they grew in their garden. They didn't know what kind of peppers they were, but they warned us, "they're pretty spicy." Being me, I took huge raw bite of one. It was hot. It turns out the peppers were Rocoto peppers, shown above. On the Scoville scale, a measurement of the spicy heat of peppers, it is high up there, along with habaneros and the scotch bonnet. It's spicy enough that I don't know what to do with our bag of peppers; I've tried adding it to various dishes but the kick is pretty impressive. In any case, that day I ate the raw pepper, my mouth and fingers were burning for hours, and it was painful. Sometimes it's important to know what a patient experiences, and after this run-in with the Rocoto, I can believe that neuropathic pain and paresthesias can be near unbearable.

Of course, this hasn't dissuaded me from taking more raw bites of the pepper. I'm not sure why I do it, but perhaps it's the same reason I keep signing up for more years of training.

Image shown under Creative Commons Attribution Share-Alike License.

That One Last Thing

Part of critical care fellowship is learning how to handle the extremes of a disease. When someone's oxygenation is so bad that you've maximized your ventilator, what do you do? When someone's blood pressure is refractory to every drip you can think of, what do you order? When a patient's on every antibiotic you can think of but you still think they have an infection, what do you add?

On my VA rotation, a patient was transferred from another hospital for consideration of heart transplant. He had advanced end stage heart failure and received continuous inotropic infusions as an outpatient to support his heart. His weak heart was dependent on constant medications to give it enough squeeze to keep him alive. When he arrived at our facility, his numbers looked awful. His liver and kidneys were starting to be injured. We put in a pulmonary artery catheter to figure out his cardiac output and systemic vascular resistance. No matter how carefully we titrated his dobutamine and milrinone, we could not find the sweet spot where his heart and all his other organs could be supported. While everyone perseverated on his medications - whether to add epinephrine or vasopressin, whether diuresis would help or not - I knew that no drug could fix this problem. I called the cardiac surgeon and had them come over to place an intra-aortic balloon pump. This mechanical device didn't have the side effects of blood pressure medications and could keep his kidneys, liver, and brain perfused by mechanically assisting the heart. It was that one last thing that could keep him alive while we waited for a heart transplant.

Yesterday, in the medical ICU, I had a patient with life-threatening acute respiratory distress syndrome - a widespread inflammation of the lungs. I was on maximum ventilator settings with delivered oxygen of 100% and an end-expiratory pressure of 14. There was very little I could do with the breathing to machine to deliver more oxygen to the patient. As a resident, we are taught to adjust the delivered oxygen and end-expiratory pressure, but what do you do when you have nowhere to go? I added inhaled epoprostenol, a medication that dilated pulmonary blood vessels, and paralyzed the patient to prevent disharmony with the ventilator. It only helped marginally, but it's that one last thing, the thing few people recognize, that might make the difference.

Cardiac Surgery

The management of post-operative cardiac surgery patients at the VA is very different than that at Stanford, a difference that is especially noticeable as I moved from my CVICU rotation to VAICU. At the VA, mostly because it's the "way things have always been done," the goals are quite different. While we usually try to wake cardiac surgery patients up and extubate them within six hours, at the VA, we keep them deeply sedated overnight. The surgeons tend to be quite conservative, keeping pulmonary artery catheters in longer, titrating drips more slowly, and keeping patients in the ICU more time. If a complication like atrial fibrillation brings a patient back to the ICU, they become even more cautious about having that patient leave. As a result, I get a little frustrated and worried that we are exposing patients to risks of the ICU and aren't allocating resources appropriately. In many ways, the VA is a health care bubble that is isolated from the pressures of the private practice environment. The VA doesn't have external pressures from insurance companies to cut costs and meet outside quality standards. This is not to say that the care at the VA is inappropriate; in fact, our cardiac surgery patient outcomes are solid. But there are many ways of delivering health care, and tailoring care to a particular system or patient population is important.

Soft Calls

As an ICU fellow, I often get consulted to see a patient in the emergency department or floor who is in the gray zone of whether they need to come to the ICU. Perhaps the primary team feels like they have things under control but want another set of eyes. Maybe they could get worse, but it's pretty unlikely. Occasionally, the diagnosis is unclear so no one knows how sick they might become. We deal with this all the time: a patient who is septic from a urinary source but has no end-organ damage, a normal blood pressure, and normal lactate; a patient with hypoxia requiring noninvasive positive pressure ventilation that might just be turning around; a patient with diabetic ketoacidosis whose anion gap is on the way to closing.

In the vast majority of these cases, the patient would do fine in a step-down or monitored bed. Sometimes, while waiting for a bed, they get better in the emergency department. If they come to the ICU, they quickly leave once they are better.

Yet I take a large number of these patients to the ICU. Some of it is just uncertainty; if I am putting my name down as the responsible physician, I tend to be conservative and not risk sending them inappropriately to a lower level of care. Most of the time, I just want to play it safe. But there are a lot of arguments that this is the right way of using the ICU. Most patients with a dynamically changing disease process will either get worse or turn around within the first day of being in the hospital. This is the time period, the "golden hour," where our interventions matter. If we get them to the ICU and stabilize them, that's far more effective than having them get worse in a regular bed and bringing them up emergently. In that situation, we will have lost time, fumbled with transitions of care, and done the patient a disservice. In some eyes, the ICU is designed for the purpose of getting those critically ill patients better within the first day or two of presentation and then sending them to the floor. It's not designed for the chronically ill patients who stay for weeks on end.

I get a lot of criticism for this decision making though. My residents feel like they are getting extra work for a patient who is "not all that sick." Nurses and administrators may feel that I am not using resources appropriately. It's a strategy that doesn't really contain costs. This year as a fellow, I am sure I will become a little more nuanced with determining the disposition of those "soft call" patients in the gray zone.

Letting Go

Sometimes, death is easier for the patient than for the clinician. I met a wonderful 90 year old vet with a turn-of-the-century name (omitted for privacy reasons) who had metastatic end-stage cancer. He was receiving palliative care, but because of worsening pain, he decided to undergo a palliative surgical procedure. Although we sometimes think surgery is at odds with palliative care, there are times when the intent of surgery is not curative, but simply to make a patient more comfortable at the end of his life. This of course must be weighed against the risks and costs of a surgery so it's a rare event but certainly an appropriate one in some circumstances.

I met the gentleman in the ICU after the case. He was fairly hypotensive and so we resuscitated him, supported his blood pressure, and extubated him from mechanical ventilation. Boy, did he have a personality. He learned all our names (insisting on examining our badges), gave us sage advice ("To get to 90, have a glass of wine every day), and told us delightful stories from his nine decades of life. We grew pretty attached to him. When we talked to him about his "code status," he was quite clear - no heroic measures to resuscitate his heart and he didn't want us to "put that stick down his throat again." His daughter agreed wholly with his wishes. He told us he wished to have his body donated to a medical school. He had lived a wonderful life and made plans for his death. But day after day, he seemed to turn around, requiring fewer blood pressure medications and recovering from surgery slowly.

Unfortunately, at 90 with metastatic cancer, recent surgery, and a host of other factors, he had many reasons to have sudden decompensation. Twice, he had an arrhythmia that dropped his blood pressures and rendered him unconscious. The first time, medications brought him back. He returned to his usual personality, playfully bossing the nurses around. The second time, a completely unexpected cardiac arrest, was not reversible.

Surprisingly, this death affected he medical team more than anyone else. The daughter understood completely and accepted his passing. We, on the other hand, wondered what we could have done differently. Was there a medication we could have started earlier? A test we could have done? A quicker response to his arrhythmia? We wanted so much to have saved him because his personality was so endearing. He was so human to us, the epitome of happiness at age 90, and his death was a blow to ideals.

We had to remind ourselves that this was what he wanted, what was best for him. Instead of a prolonged death of suffering, he simply lost consciousness and passed. His wishes were upheld; he didn't have painful chest compressions or an undignified breath tube shoved in. He spent the last of his days joking with his daughter, telling me about his hobbies (he spent several hours a day on the computer corresponding), and assuring us he was happy and comfortable. Then, within minutes, he simply crossed the bar. In modern medicine, this was probably the most dignified, wholly appropriate, and somewhat rare kind of death.

Knowing Your Environment

Every hospital is different, and getting to know your hospital is a big part of being an ICU fellow. When we make decisions about a patient's "disposition" - that is, what level of care a patient needs - we have to be aware of our hospital's capability. I mention this because the VA is quite different than Stanford. The ICU at the VA often has patients whose acuity isn't all that high simply because they have specific nursing needs that only the ICU delivers such as hourly vascular checks. Patients that may go to the floor at other hospitals come to the unit at the VA. This also occasionally happens because the floor's ability to take care of sick patients is quite limited at the VA. I've often taken patient's to the ICU who might have stayed on the floor at a different hospital. This has a lot of implications, including cost considerations; an ICU bed uses a lot of resources and costs quite a bit, so having a system where a nonacute patient may take up slots might not be the most efficient. But it can also create an odd mix of patients in the unit. A patient may be moribund, on multiple intravenous pressors, mechanical ventilation, and dialysis, while his neighbor might be chatting, reading the morning newspaper, having breakfast, and simply having his pulses checked hourly. It's an odd unit in that respect. At times, I feel like I'm running a medicine ward service.

The other aspect of the VA is that it runs pretty close to capacity all the time. When patients come into the emergency department, I occasionally struggle to find them a bed. We wait for days to transfer patients out of the ICU. This, too, increases the cost of health care; we have patients who are appropriate for the floor taking up ICU resources simply because no other bed is available. Perhaps because the VA is not a profit-focused hospital, this is less important. However, considering our overall national expenditure on health care, we have to keep such things in mind.

The VA ICU

The VA ICU is a special place for me for lots of reasons. It is where I started the very beginning of internship year, when my white coat was clean and pressed, when my transfer summaries were gregarious novels, when I was bright-eyed and bushy-tailed. Surprisingly (or perhaps not), it hasn't changed too much. This time returning, I recognized many of the same nurses, argued with the same surgeons, dealt with the same frustrations. But there is a small feeling of recognition, as if returning home.

When I started internship year, I had no sense of perspective, and the VA in Palo Alto felt like a large and intimidating place. As I was sent out to find the spinal cord unit, the preoperative clinic, the emergency department, I marveled at how large the campus was. Now it seems like a tiny microcosm. I used to find the 15 bed ICU intimidating, but now, it's a breeze. I've figured out all the processes, realized how I fit in. And I've seen my peers go through this process too. One of my cointerns is now a medicine attending at the VA and we shared a couple patients together.

With only 15 beds, it is good training grounds for interns. Some days, I am frustrated by how long rounds take, but I remember that I was there once, that this is hard, and that interns have a steep learning curve to surmount. But it also gives me great opportunities for teaching, and it's so refreshing to have time to explain my thought process, discuss our patients, challenge misconceptions. We also have residents and nurse practitioners who help supervise the interns, and they are ever a source of learning, amusement, and assistance. My job was made so much easier by my brilliant residents who kept the interns in line, taught them so much, made sure all the checkboxes in patient care were completed. This structure with interns and mid-levels gave me the opportunity to play junior attending, running rounds, making decisions, and overseeing big picture plans. Having this leadership role was really important for me to gain confidence and nudge me out of my normally introverted personality. After CVICU where I played a resident role, this was refreshing change.

Finishing Up Round Two in the CVICU

As I reflect on my last few days on the cardiovascular ICU, I remember great relief and also strangely, a little longing. It is the feeling of being forced to do something I wasn't sure I could handle, and then coming out intact at the end. There was a period of time in there where I worked 17 days in a row that I had this inexplicable mix of exhaustion and accomplishment. Each day we spent 12-16 hours in the hospital, and after two and a half weeks of that, I knew every single detail about every single patient. I understood their hearts so intimately, could tell you how the patients responded to each hemodynamic change, could recount the story of recovery after surgery. This is medicine as was practiced generations ago, when the word "housestaff" and "resident" were literally true. The hospital was my home, the patients, nurses, surgeons my family. I learned so much and felt invincible. I took the best parking spot when I arrived at 4AM, learned the quickest routes to the cafeteria, found stashes of snacks for ailing residents and fellows. I got to know which family members slept in their loved ones' rooms, which nurses took extra night shifts, which anesthesia techs staffed the graveyard shifts. I loved that feeling.

But it was also a month where I seldom saw my wife, abandoned my blogs, forgot about cooking, became derelict in emails, became lost to follow-up to my friends and family. One of my friends' parents refers to her OBGYN residency as the "dark ages," a gap of four years where she knows nothing of current events, movies, books, pop stars, friends' life events, elections, politics. It is a sacrifice physicians generations ago made, and something we seldom do now. After going through this month, I understand why such a period of clinical immersion is so transformative but also how it can wreak havoc on any identity outside being a physician. I am glad I went through my CVICU month. I am glad it is done.

Root Cause Analysis

When a really bad outcome happens, the hospital undergoes a process called root cause analysis to figure out what went wrong. It's easy to point fingers at superficial or proximal elements that led to the incident, but this formal method of evaluation assures us that all contributions to a clinical event are identified.

When a root cause analysis happens, it's a big deal, committees upon committees. In this instance, a patient passed away within days of receiving a transplant. Why did this happen? Could we have avoided it? Were there misses with the pre-operative medical management, the surgical technique, or the anesthetic? What could we have done post-operatively to prevent this devastating outcome? With the scarcity of organs and donors, this was the kind of incident that really forced us to review our processes. With all the stakeholders involved - the medical transplant team, the surgeons, the medical intensive care team, the cardiothoracic critical care team, the nurses, the operating room staff, the transplant coordinators - we really probed into every possible contributor to the patient's death. I hope that this ultimately makes future transplants safer for patients.

We do a lot of transplant surgeries, and I've been in the operating room on the anesthesia side, in the pre-operative evaluation on the medical ICU side, and in the post-operative management on the CVICU side. We have so many successes; patients who have been living on home oxygen or home infusion pumps for years who walk out of the hospital. But it is the sadder, less successful outcomes that help us improve our clinical care. I wish that every patient had a perfect transplant course, but when it doesn't happen, it is our responsibility to scrutinize and fix things. I write this blog not to point out our deficiencies, but to emphasize our constant, ongoing commitment to improving patient care. Every institution has incidents like these, but I think it is important for me to be open and talk about all our stakeholders are committed to processes like root cause analysis.

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.

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.

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.

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.