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.