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.