Happy Leap Day!

Jump, hop, skip, dance. There may be a lot of heartbreak, sadness, illness, fear, and worry in the world, but there is also joy, brilliance, happiness, light, and love as well. In my work and in my personal life, I have begun to recognize in finer detail and deeper facets the textures of emotion we encounter in daily life. A patient gets worse. A patient gets better. A relationship sours. A relationship strengthens. We feel the rumble of emotions, we reflect, we adapt, we grow. I've learned there are so many things I cannot change: missteps made in the past, the disease that grows too rampant, the emotions of others. I am only accountable for my words and my behaviors. So: I jump, hop, skip, dance. It is leap day, after all.

ICU This Week

I'm attending in the critical care unit this week, which effectively means I'm not going to blog much. This week usually ends up exhausting me because I think to do it right for the patients, I have to devote my attention completely to the unit. When I was an intern, I was one of those who had to settle everything in before getting to my notes, and now as an attending I'm not much different. By the time I admitted two patients, rounded on fifteen others, talked to consultants, intubated, placed three lines, and squared away orders, it was time for sign out. I wrote all my notes after I should go home. It might be like that all week. On the other hand, I love this role and it makes me feel like a "real doctor" more than almost anything else. So I enjoy it and I'm present and I won't have much time for this blog.

Craig

Here for the Patients

I am about to leave the hospital when I get a call from the nursing supervisor. A rapid response is called on a patient with no IV access who is hypotensive. Apparently, he has dialysis fistulas in both upper arms and has amputations of both legs. Yikes. No one can get access on him, and though he's talking with a pressure of 70/30, we're all worried he's going to code. Normally, floor patients have central lines placed by the emergency department or interventional radiology, but both of them decline. The ER is completely full and IR is not returning calls. The intensive care physician is at home. So someone thinks of me and calls the on call anesthesiologist.

I happen to really enjoy line placement, but when I arrive, I know this may be a nightmare. The patient has had multiple vascular accesses, from pacemakers to cardiac catheterizations to vascular bypasses to several dialysis fistulae. But as the only one who shows up who can place a central line, I gather my supplies. It takes me longer than any line I've ever placed. Even when I supervised residents and medical students placing lines, I don't think it ever took that long. I can get into the internal jugular veins, but due to stenosis or scarring or something else, I cannot pass a wire deep into the vessel. Ultimately, I go for a femoral approach, my least favorite (and in an amputee), but I am out of options.

Going home, I get a call from the hospital. I'm worried its an add-on that will bring me back to work, but instead it is the nursing supervisor thanking me. I say, "No problem, I'm here for the patients." The rest of the way home, it sinks in. The real incentive for me to go out of my way and place a line on the floor is the doctor's obligation and caring for the patient. I'm not expected to do this, I'm certainly not paid for it, and I incur risk in doing it. But the reason I obliged and never thought about turning my back is because I'm here to care for people.

Electronic Medical Record

In the past few months, we made a huge switch from one electronic medical record to another. I am not privy to all the reasons behind the switch, but I think it's a good thing. We used to use a hybrid electronic and paper system with some things on the computer (electronic ordering, for example) and other things on paper (notes, documentation). This became unwieldy and cumbersome; it was hard to find some information or even know if it was available. There was duplication of work and tests, and the whole system felt as though it had been constructed piecemeal. We switched over to Epic, which I had used in training. It's still a very clunky platform, but at least five years of using it in residency taught me its ins and outs. I've come to realize it can be a fairly powerful tool, but its simply not designed for most clinicians in mind. I think for some of us, who grew up programming on C++ and BASIC, who took computer science classes in college, who tinker with our computers and apps to personalize them, there's some desire to get EPIC to work better. But for most, it's just another frustrating thing we have to wrangle with.

In any case, the transition was interesting for me because I pretty much went through the same thing in residency. There were some required classes, then a few weeks of "shadow charting" where we practiced on the new system while documenting on the old system, then a "go-live" period. From my end, it went pretty smoothly since I already knew how to use the software. The hospital poured significant resources into smoothing the transition, and I think they did pretty well in making it happen. Preparation really prevented any large IT disasters, and now that we've been with the new system for several months, it almost feels hard to remember what the old one was like.

Laryngoscopes and the Environment

There exists an odd debate regarding laryngoscopes. The Joint Commission which regulates hospitals regulates the sterility of laryngoscopes. The traditional scopes and blades have to be sent down for processing, which apparently involves multiple chemical baths. In response, some companies have designed single use disposable laryngoscopes which circumvents the regulations on sterile processing. They claim that throwing away these laryngoscopes - which have a light source, batteries, and a good amount of plastic - is better for the environment than multiple chemical baths. Maybe this is true, but I am shocked that this is considered a "good" solution. We go through so much equipment in the hospital; there must be some way we can avoid massive amounts of chemicals or tossing every instrument as if it were single use. This is not a sustainable solution, and the Joint Commission needs to recognize the harms it causes with its regulations.

Zika

The outbreak of Zika virus, along with all the other recent global outbreaks - Ebola, Avian flu, swine flu, Chikungunya, Middle Eastern respiratory syndrome coronavirus, etc. - remind me of the global nature of infectious disease and public health. Each individual disease will come and go, but the problem will not go away. The globalization of the world, the ease of travel, the disparities in living conditions and health care, and environmental changes with global warming will make global infectious disease a recurring threat. I recently reread Margaret Atwood's Oryx and Crake, and it really strikes home. If we do not work on improving global health conditions and reducing health disparities, if we do not start studying and focusing on what global warming means, if we do not create the resources to tackle emerging diseases, one of these microbes will get out of hand.

Zika Virus electron micrograph is in the public domain, from phil.cdc.gov.

Super Bowl 50

Apparently, with Super Bowl weekend coming up, the area expects an influx of over a million visitors. That really surprised me! All the local hospitals (including the one I am at) have put into place plans for increasing capacity, triaging patients, and responding to a mass emergency. It makes me think of the system strains that occur with large events like the Olympics, presidential debates, and big conferences.I suppose preparation and planning are key. Hopefully I won't need to rush in this weekend.

Sleep and Dreams

Sometimes, when I am feverish or sick, I have bizarre dreams with flights of ideas. My mind fixates on the strangest things (including work things) and no matter how much I try, no matter what meditation techniques I employ, I can't get these strange thoughts and images out of my head. I wonder whether that is what patients with delirium experience. Delirium is a really common hospital problem where a patient waxes and wanes in their attention and orientation. If you take a perfectly normal high functioning executive and give her an infection, treat her with antibiotics, stick her in the intensive care unit where she is awoken every hour, exchange her clothes for a gown, place tubes and lines that tangle her up, she will get confused. It's easy to imagine how she might not remember where she is, how she might become paranoid, how she might even have hallucinations or delusions.

We underestimate how tough it is to be an inpatient, especially in the intensive care unit. These days, I am at most in the hospital for a twenty-four hour stretch, and even that is enough to drive me crazy. I cannot begin to fathom being elderly or sick or alone for days or weeks in the hospital. I know there are a lot of initiatives to improve hospital life, and I make a big point of it by identifying patients that don't need to be woken up through the night, but it's still not pleasant.

Families also underestimate this problem. In the intensive care unit, I see patients at the end of life. Families recognize this but also want us to "just keep doing what we're doing" whether for more time or for a miracle or because they cannot stand to stop. Even though I can treat pain and anxiety and constipation and nausea and a dozen other symptoms, I cannot eliminate all suffering. The hospital is not a dignified place. It is not a comfortable place. It is a necessary place that comes with risks, benefits, and alternatives, just like everything else.