Back in the CVICU

Although one of my last rotations as a resident was in the cardiovascular intensive care unit, I was not gone for long as it was one of my earliest rotations as a fellow. The role of the resident and fellow is pretty much the same, and although the second time on the rotation was a little bit easier and made more sense, it was just as exhausting.

The thing about the CVICU is that the patient acuity is higher than anywhere else in the hospital. Our surgeons offer surgery to patients who have been deemed too high risk elsewhere. We take transfers of patients from all over Northern California and have expanded the procedures we perform. On "TAVR Tuesdays," the day where our surgeons and cardiologists perform minimally invasive aortic valve replacements (TAVR stands for transcatheter aortic valve replacement), we routinely get patients in their 80s and 90s.

All of these factors make post-op management incredibly challenging. I've had patients on six or seven inotrope, vasopressor, or pulmonary hypertension agents: epinephrine, norepinephrine, vasopressin, phenylephrine, methylene blue, inhaled nitric oxide, and epoprostenol. We struggle not only with complex cardiopulmonary physiology - I've seen pulmonary artery pressures 110/50 - but also with sepsis, gastrointestinal bleed, and anuric renal failure. Balloon pumps, ventricular assist devices, and transplants make up half our service. Compared to my previous month, we only had a few patients on ECMO, but the overall service was sick. I had to perform emergency trans-esophageal echocardiograms several times, rush patients back to the OR, and manage rocky intubations and extubations.

On some level, I loved it. I picked ICU medicine and anesthesia for the moments where someone's life depended on a thoughtful but immediate synthesis of an array of complex data. I like the adrenaline, the fear, and the thrill of seeing patients on death's door get better. But overall, the month sapped me. We had some staffing problems which put a lot of strain on the residents and fellows that month, and I really appreciated my colleagues who all put in more time than expected to care for our patients. There was a time when I could fill my life with work, food, sleep, and exhaustion, but when I think of a job in the future, I think I'll want something with less craziness.