Odd Thoughts at Night

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

Transfer Center II

This is a continuation of the post several days ago.

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

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

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

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

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

Gratitude

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

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

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

Transfer Center I

Before being a fellow, I was vaguely aware of the hospital's "transfer center." As an intern and resident, patients transferred from outside hospitals would magically appear, and I would have to leaf through packets of handwritten notes to try to figure out what the outside physician was thinking and determine the plan of action going forward. I knew there was an accepting attending and expected a transfer summary (though somewhat like unicorns, these were mostly fictional). But I was never privy to the process of how these patients got here.

Now as an ICU fellow, I have daily conversations with the transfer center. Staffed by well-seasoned nurses, the transfer center fields phone calls and inquiries from community physicians and other hospitals hoping to send their patients to Stanford. They triage patients and if a patient sounds like they have a medical ICU need, they give the ICU fellow a buzz.

For us, it feels a bit like a chore. We are busy with our mounting census, admitting patients from the emergency department, and responding to codes. Having a long phone conversation trying to tease out whether a patient needs to come over can be a bit of a burden. But I've realized in my interactions with the transfer center that they really help make things pain free.

A victim of a near-drowning has been in the intensive care unit at a large community hospital. The settings on his mechanical ventilation are pretty much maximized; he is requiring 100% oxygen and significant pressure to keep his lungs open. He developed acute respiratory distress syndrome, pneumonia, septic shock, liver failure, an ongoing gastrointestinal bleed, and kidney failure. He's on continuous renal replacement therapy, blood transfusions, and broad-spectrum antibiotics. The ICU doctor over there calls me because he does not know what else to do for this patient. Can he send the patient over for further management?

I declined the case. I felt that he was too tenuous to transport. With his ventilator settings and three vasopressors, I did not think he would survive a helicopter flight or ambulance ride. Furthermore, I couldn't think of any additional therapy we had that they hadn't tried. I talked to one of our cardiac surgeons to make sure ECMO (extracorporeal membrane oxygenation) was not an option, and then I told the outside physician that bringing him over would subject him to serious risk without a clear benefit.

A patient with alcoholic cirrhosis and known esophageal varices goes to a local emergency department because she is vomiting blood. Her blood pressures and hemoglobin are quite low and she's rehydrated, transfused, and started on some medication drips. Although that facility has an 8 bed ICU, they do not have a gastroenterology or interventional radiology consult service. After hearing about this, I took the patient. They needed a higher level of care which we could provide. When they arrived, I had our gastroenterologist scope her, place a few bands on a bleeding esophageal varix, and I sent her out of the ICU the following day.

Stay tuned - more stories to come.

Critical Care Crisis Nurses

As an ICU fellow, my best friends are our critical care crisis nurses. Whenever we respond to a code blue, rapid response, or crisis on the floor, they are right there, handing us supplies, coordinating care, and reminding us of things we missed. Especially as we get to know each other better, we become a fluid team, anticipating each other's next suggestions, bouncing thoughts off each other. When I've arrived at a crisis, I find my critical care crisis nurse taking vitals, placing IVs, getting an EKG, sticking on defibrillator pads. While these seem like simple and obvious steps, I've been to a lot of codes before the crisis nurse has arrived and found everyone panicked and frozen. When you arrive to a room of strangers in chaos, it's hard to get control of the situation. You end up spending all your time and energy on delegating simple tasks like palpating a pulse, pulling up labs, or getting a crash cart. Our job becomes so much easier when the crisis nurse magically makes all that happen. Furthermore, they've seen so many clinical emergencies that they know what I will want. By the time I ask for a medication, they've already procured it from the pharmacist. They know the ACLS algorithms as well as I do. And they chime in to remind me of steps I've forgotten in the heat of the moment.

Perhaps most importantly, critical care crisis nurses also act as triage for the ICU. I'm not sure how they find out, but they know about many of the decompensating or unstable floor patients. I've gotten several "heads-up" calls from them, and their clinical judgement is sound. In the same token, they've also helped prevent unnecessary ICU admissions by investigating patients that seem unstable but have a rational explanation for what's going on. A common example is the oncology patient undergoing chemotherapy; occasionally, someone will call a rapid response for tachycardia, but this may be expected given their medications. Our crisis nurses educate and advise bedside nurses, charge nurses, and primary teams to avoid these instances. They are our eyes and ears of the hospital, and they make my job so much easier.

Changing Landscape of Critical Care

What's fascinating to me is that ICU care has changed dramatically even in a short span of time. When I did my critical care month as a medical student a little over five years ago, I saw vastly different approaches. For example, back then, we sedated nearly all our intubated patients with midazolam and fentanyl infusions. Now less than 1% of our patients have that combination; we've gone to hydromorphone and dexmedetomidine drips. Back then, we had dexmedetomidine but it was exorbitant and we didn't fully appreciate the delirogenic effects of benzodiazepines and the accumulation that would occur over time. Similarly, I saw a lot less continuous renal replacement therapy then than I do now. Not all the changes are good; our bugs are more resistant, and so our antibiotics have evolved as well. Many practices we take for granted such as sedation vacations, nutrition management, and glucose goals were fairly novel when I started as a medical student; back then, we'd discuss these "exciting" papers and now we frown upon anyone who doesn't know about them.

To me, this emphasizes the importance of specially trained critical care physicians. In the past (and in other hospitals), the ICU is managed by doctors who aren't ICU trained. But the landscape changes so incredibly quickly, and unless those physicians keep up with the latest literature, they could be practicing obsolete medicine. In the same vein, ICU doctors need to keep up with the latest research and opinions on controversial topics and new advances in order to stay at the edge of medicine. I am sure that many of the things I learn now as a fellow will be old news in a few years. Part of our learning is understanding how to learn, how to keep up with the literature, and how to evaluate and interpret data to make the right decisions for our patients.

MDAWARE

One of the more common responses of the medical intern or resident is "MD aware." Whether the laboratory calling us about a critically abnormal sodium level, the pharmacy informing us of a drug-drug interaction, or a nurse relaying a patient's complaints, we often respond, "Thanks, we know about it." In fact, when our electronic medical record flags a potential duplicate order or medication interaction, a pop-up box comes up, and I always click "MD aware - will monitor." One of our recently graduated cardiac surgery chief residents had the best license plate I've seen in a while - "MDAWARE." I wish I thought of it.

Sleep in the ICU

Nobody in the ICU sleeps. As I walk through the hallways at 2 in the morning, nurses are bustling around getting medications, respiratory therapists administer nebulizers, the front desk phone rings with new admissions. My residents are hard at work checking labs, putting in lines, writing notes. My phone never stops ringing and I am on my feet all day, from one end of the hospital to the other. But most importantly, our patients can't get much rest. With alarms ringing, X-rays machines rolling around, vital sign checks, it's no surprise that nobody sleeps in the unit. Even the family member with a chair pulled up, blanket wrapped around the neck awakes anxiously with every little sound.

The Phone and Consults

On the medical ICU, one of the fellows is always carrying the "phone," which is a bit like a hot potato. The fellow carrying the phone is the main gateway for patients to be admitted to the ICU. The emergency department calls us with new patients who have medical critical care needs, from sepsis and hypotension to respiratory failure to neurologic catastrophe. In fact, the phone fellow often spends his time hovering between rooms in the ED, stabilizing patients and determining whether they need to come to the unit or not. We also get a good number of floor consults for inpatients who are looking a little sicker. These consults require a lot of clinical intuition and judgment. From a resource-management standpoint, I can't take every patient into the ICU so I have to tease out those who can be managed on the floor and those who cannot. Often, I will make several interventions to figure out the safest disposition for a patient. Sometimes, I will round on them hourly to get a sense of where things are going. Occasionally, this means that I get into arguments with the emergency department or primary team about what is appropriate, but I try to be reasonable in determining how to allocate our limited beds. Surprisingly, gut feeling and instinct plays a lot into it. I've written before about the clinical gestalt when physicians see a patient. Some people just "look sick." They appear frail, tenuous, or fragile. Others may have vital sign or lab abnormalities but look "stable." You have to take these clinical impressions with a grain of salt, but sometimes, they turn out to be the right decision. When I decide someone needs to come up to the ICU, I work closely with our nursing supervisor and bed control to get them upstairs as soon as possible.

The Lag in Blogs, and What Fellowship is Like

As you progress through the medical training, you gain more and more responsibility. You realize what it means to be truly invested in a patient's care and wellbeing. As a fellow, I am feeling that a lot. The buck stops with me; as a medical student or intern or resident, you can pass decision-making and responsibility on, but as a fellow, I have to call the shots or call my attending. And I take that seriously. This last month or so has been exhausting because I stay late, spend a lot my time and energy trying to figure out the big picture decisions for my patients. It's really hard, and I'm learning a lot as I see the outcomes of the choices I make. I am reluctant to hand over care of my patients, and I check in to follow up with what happens to them. Although I don't have to deal with as much detail-oriented "scutwork," I also feel a lot more responsibility for those in my care. I think this is all part of growing up, and the growing pains mean that my blogs are little less frequent.

HIV - An End in Sight?

One of the amazing things proposed by HIV scientists, organizations, and advocates is the possibility of quelling the spread of disease. The widespread availability of antiretrovirals and recent research about ways to reduce transmission of disease with peripartum medications, circumcisions, and other interventions hold promise that within the next decade and a half, we may reach a tipping point in the AIDS epidemic. I've read a few articles that by 2030, we might reach a point where each patient with HIV infects fewer than one patient with HIV. This means that with each generation, fewer and fewer people will have the disease. Although cure remains remote (there is a widely publicized study of cure with a bone marrow transplant for concurrent leukemia), prevention may be the key to controlling this disease. If this is the case, then we will have witnessed an amazing era for infectious disease. What a time to be in medicine! I remember reading books about the first cases in the 80s, seeing acute HIV infection as a medical student, memorizing the early antiretrovirals as an intern, and now perusing the HIV issue of JAMA. Although this is not my area of expertise, I am awed by the changes in our approach to AIDS. I remember the debate about starting antiretrovirals early versus later, the opportunistic infections I'd admit every call day, the complex regimens of medications. Now we start ARVs early (we don't even necessarily call it HAART anymore!), I haven't seen an opportunistic infection in a long time (probably related to being in anesthesia and seeing patients in Palo Alto), and we have combination pills. It's fun seeing medical history unfolding even in my short period of training.

The Problem with Standardized Testing

I am not a big fan of how the standardized testing industry has invaded medicine. My biggest issue is that it is hugely expensive, both in time and money, and its benefits are unclear to me. I've probably put $5000 into testing registration and fees, and missed a week of work. This doesn't seem like a lot, but when you consider that every physician finishing training undergoes this, that's a significant economic cost. If this conferred a reasonable benefit, I'd be all for it. But I'm not sure it does.

We want all our physicians to meet a standard - perhaps "Board certification" - because presumably, it identifies well-trained, competent, and professional doctors and excludes those who are irresponsible, incompetent, or unethical. But do we know this? I've never seen any studies that show that those who fail the Boards harm patients or that those who don't are safer. How do we know where to set the bar? Is it an arbitrary cutoff that some committee decides?

For every medical test I order, I have some sense of its sensitivity and specificity; how likely it will catch a disease if someone has it and how likely someone without the disease will have a negative test. What is the sensitivity and specificity of our standardized tests? Is it worth the economic burden we impose on our physicians to take them?

Finally Back! With Commentary on Standardized Testing

I apologize for the long hiatus! The primary board certification exam was quite the hurdle and I'm quite relieved to be through with it. The testing center was filled exclusively with anesthesia residents and recent graduates; overhearing conversations, I realized there was a big contingent from UCSF as well. As a five hour test, it wasn't all that bad. Graduate medical education has really gotten into standardized testing, so much that a half day test seems like nothing. The exam itself was pretty much all querying fund of knowledge. But the fund of knowledge required for an anesthesiologist is really broad. Questions ranged from newborn blood gases to geriatric anesthesia, from ICU management of nutrition to mechanisms of action of neuropathic pain medications. There was a lot of subspecialty anesthesia probing complicated neurologic physiology, obstetric disease states, pediatric emergencies, and echocardiography. While all anesthesiologists should be well-versed in such broad topics, the truth is, there are few jobs that engage everything. Ultimately, we only use a subset of our training, but that's probably true in all aspects of medicine. I do think that board certification should mean that an anesthesiologist is competent in all domains of our field, but it's important to recognize that we are testing a broad fund of knowledge which is not necessary for most jobs.

Furthermore, fund of knowledge is not all that important. On tests, it's easy to ask questions about facts. Some questions give a list of congenital anomalies and ask about the syndrome. But for the most part, this is not an important thing to memorize. I can always look it up. It's more important for me to recognize when congenital anomalies might constitute a syndrome so I do look it up. Likewise, in clinical medicine, I rarely need to know the mechanism of action of a drug, and if I did, I'd simply do an Internet search. Instead, board certification should be about testing things which are not easily Googled, where diagnosis or patient management depends on a practitioner's clinical acumen. For example, the signs of malignant hyperthermia, an anesthetic emergency, is a reasonable question because recognizing MH can be challenging, and knowing the manifestations and treatment immediately can lead to quicker patient care. If I ever saw MH, I'd act first, then confirm my decisions by looking it up. It's difficult for a multiple choice test to test clinical judgement, and much of anesthesia is practical, applied, and nuanced. Most decisions I make during a day are not clear-cut or black-and-white. I suppose this is why there is an oral part to the certification exam as well.