Icu situations and burn out

[bingbongbink]

Let’s talk about some common situations that i’ve encountered working in the icu that contribute to burn out:

-pt is s/p Egd for gi bleed, remains inubated, pumped with 150 mcg of neo by anesthesia attending, signs out to no one and then pt dumped in the icu, bp promptly drops to 70-80s 5 mins after arrival to icu, anesthesia gone since its friday after 4 pm, pt stabilized icu

-pt came to ER, intubated, hypotensive after being put on sedation, pt is ignored for an hour, no workup done, no blood cultures, no abg, ER gives no meds and wants to admit to icu, after back n forth they agree to place access, pt is not sedated enough to place line, claim they are overwhelmed, we stop sedation, pressure holds, we gather pt to icu and stabilize there bc nothing is getting done in ER

-pt post op surgical procedures gets admitted for months on end, comes back w surgical complication, told non-operable and will die, pt on pressors so dumped on micu for conservative non-operative care, family mad with us the non surgeons that nothing is being done

— You get the idea here. It is the dumping ground for sick patients. This is the dark side of the icu. I naively thought maybe ppl in the hospital would do their job but it requires tons of confrontation, time and stress to address each issue and in each case i find it easier to take care of everything myself bc i cant rely on anyone else

Is this job not right for me? Overall volume is on the lower end so most of the docs don’t seem to care that much
I am salaried. Some productivity bonuses. Would an incentivized job make this all better? Maybe transition to private prac?
I wonder if the icu grind is not for me? Maybe im better off in the office, im not sure but covid has def brought out the worst and exacerbated the toxic work culture of my hospital. There are many other realms of bs occuring all over the hospital
Thanks for listening

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[DrMetal]

Let’s talk about some common situations that i’ve encountered working in the icu that contribute to burn out:

-pt is s/p Egd for gi bleed, remains inubated, pumped with 150 mcg of neo by anesthesia attending, signs out to no one and then pt dumped in the icu, bp promptly drops to 70-80s 5 mins after arrival to icu, anesthesia gone since its friday after 4 pm, pt stabilized icu

-pt came to ER, intubated, hypotensive after being put on sedation, pt is ignored for an hour, no workup done, no blood cultures, no abg, ER gives no meds and wants to admit to icu, after back n forth they agree to place access, pt is not sedated enough to place line, claim they are overwhelmed, we stop sedation, pressure holds, we gather pt to icu and stabilize there bc nothing is getting done in ER

-pt post op surgical procedures gets admitted for months on end, comes back w surgical complication, told non-operable and will die, pt on pressors so dumped on micu for conservative non-operative care, family mad with us the non surgeons that nothing is being done

— You get the idea here. It is the dumping ground for sick patients. This is the dark side of the icu. I naively thought maybe ppl in the hospital would do their job but it requires tons of confrontation, time and stress to address each issue and in each case i find it easier to take care of everything myself bc i cant rely on anyone else

Is this job not right for me? Overall volume is on the lower end so most of the docs don’t seem to care that much
I am salaried. Some productivity bonuses. Would an incentivized job make this all better? Maybe transition to private prac?
I wonder if the icu grind is not for me? Maybe im better off in the office, im not sure but covid has def brought out the worst and exacerbated the toxic work culture of my hospital. There are many other realms of bs occuring all over the hospital
Thanks for listening

What you're describing is basically the monotone, cyclic nature of any specialty.

What else are you trained in, are you Pulm CC, or just IM CC? I known some Pulm CC who left the ICU and do only strictly outpatient Pulm . . .definitely easier hours, but then you're on the other end of the spectrum (dealing a lot of BS consults, outpatient conundrums, etc).

 

[bingbongbink]

What you're describing is basically the monotone, cyclic nature of any specialty.

What else are you trained in, are you Pulm CC, or just IM CC? I known some Pulm CC who left the ICU and do only strictly outpatient Pulm . . .definitely easier hours, but then you're on the other end of the spectrum (dealing a lot of BS consults, outpatient conundrums, etc).

What do you mean by ‘any specialty’?

Im pulm.cc so i have considered escaping to the outpatient realm but felt it was too early in my career to give up CC

 

[DrMetal]

What do you mean by ‘any specialty’?

Im pulm.cc so i have considered escaping to the outpatient realm but felt it was too early in my career to give up CC

Every specialty has it's monotone, routineness. Is that what you're bother by, or the fact that you have to deal with the sickest patients? If the latter, no one can help you there, that is critical care.

I agree with you that it's probably too early to quit. Continue working it. You're in high demand. If you don't like where you're at, change jobs maybe. You're best asset are your feet.

 

[bingbongbink]

Every specialty has it's monotone, routineness. Is that what you're bother by, or the fact that you have to deal with the sickest patients? If the latter, no one can help you there, that is critical care.

I agree with you that it's probably too early to quit. Continue working it. You're in high demand. If you don't like where you're at, change jobs maybe. You're best asset are your feet.

Good advice. Thank you

 

[Radetzky]

Why did the pt with a non operable surgical complication end up on pressors in the micu in the first place?

 

[bingbongbink]

Why did the pt with a non operable surgical complication end up on pressors in the micu in the first place?

Post evar, graft got infected > septic shock > too sick to operate > comfort care

 

[chessknt]

Post evar, graft got infected > septic shock > too sick to operate > comfort care

That is actually a really satisfying outcome....

 

[bingbongbink]

That is actually a really satisfying outcome....

if you met the family, it was more relief than anything

 

[Tipsy McStagger]

What you're describing is basically the monotone, cyclic nature of any specialty.

Agree 100%. This is something that every specialty deals with in their own way. I don’t know what the answer is, it’s the reality of modern medicine.

I think it sometimes helps to look through the eyes of the person on the other end of the line. Which can be difficult because we only see a very small part of their workflow. It’s not perfect, but sometimes it helps me just shrug and say “meh, whatever I’ll just do it.”

 

[lymphocyte]

Let’s talk about some common situations that i’ve encountered working in the icu that contribute to burn out:

-pt is s/p Egd for gi bleed, remains inubated, pumped with 150 mcg of neo by anesthesia attending, signs out to no one and then pt dumped in the icu, bp promptly drops to 70-80s 5 mins after arrival to icu, anesthesia gone since its friday after 4 pm, pt stabilized icu

-pt came to ER, intubated, hypotensive after being put on sedation, pt is ignored for an hour, no workup done, no blood cultures, no abg, ER gives no meds and wants to admit to icu, after back n forth they agree to place access, pt is not sedated enough to place line, claim they are overwhelmed, we stop sedation, pressure holds, we gather pt to icu and stabilize there bc nothing is getting done in ER

-pt post op surgical procedures gets admitted for months on end, comes back w surgical complication, told non-operable and will die, pt on pressors so dumped on micu for conservative non-operative care, family mad with us the non surgeons that nothing is being done

— You get the idea here. It is the dumping ground for sick patients. This is the dark side of the icu. I naively thought maybe ppl in the hospital would do their job but it requires tons of confrontation, time and stress to address each issue and in each case i find it easier to take care of everything myself bc i cant rely on anyone else

Is this job not right for me? Overall volume is on the lower end so most of the docs don’t seem to care that much
I am salaried. Some productivity bonuses. Would an incentivized job make this all better? Maybe transition to private prac?
I wonder if the icu grind is not for me? Maybe im better off in the office, im not sure but covid has def brought out the worst and exacerbated the toxic work culture of my hospital. There are many other realms of bs occuring all over the hospital
Thanks for listening

I'm so sorry you're going through this. I've suffered and recovered from burnout, as have many of my colleagues. You are not alone.

There was a great post in the EM forum by @WilcoWorld about burnout that helped me tremendously, including the book recommendation "Medicine and Compassion." Ironically, the more I cared and let myself connect with my patients, the better I felt. Every encounter became an opportunity to help someone who was suffering beyond my comprehension. Every encounter gave me opportunity to express compassion and like a muscle it just grew and grew. That included compassion for my colleagues who were also probably overwhelmed and burnt out themselves.

You're right, ICU is where sick patients go. They need our help even when what they want isn't what they really need. They need our help even if they should have gotten better help before they needed us. They need our help, because we are the people who are the best trained to provide that help.

One thing that helped me was taking a break to do locum work. It let me travel, keep a flexible schedule, help out other departments, and see what was toxic about where I worked. What I realised is that the core of burnout is really moral injury, which is wanting to do good in a broken and toxic system. Maybe taking a break might help you too.

No matter what, I am wishing you all the very best. You are not alone.

 

[bingbongbink]

I'm so sorry you're going through this. I've suffered and recovered from burnout, as have many of my colleagues. You are not alone.

There was a great post in the EM forum by @WilcoWorld about burnout that helped me tremendously, including the book recommendation "Medicine and Compassion." Ironically, the more I cared and let myself connect with my patients, the better I felt. Every encounter became an opportunity to help someone who was suffering beyond my comprehension. Every encounter gave me opportunity to express compassion and like a muscle it just grew and grew. That included compassion for my colleagues who were also probably overwhelmed and burnt out themselves.

You're right, ICU is where sick patients go. They need our help, even when what they want isn't what they really need. They need our help, even if they should have gotten better help before they needed us. They need our help, because we are the people who are the best trained to provide that help.

One thing that helped me was taking a break to do locum work. It let me travel, keep a flexible schedule, help out other departments, and see what was toxic about where I worked. What I realised is the core of burnout is really moral injury, which is wanting to do good in a broken and toxic system. Maybe taking a break might help you.

No matter what, I am wishing you all the very best. You are not alone.

Thank you. This is very sound advice.

I have always thought that locums would be a nice escape.

I do enjoy the firefighting aspect and helping out other departments in need.

Happy New Year !!!

 

[Nephro critical care]

I have a recent case which may be going to trial. A patient with bowel ischemia is brought to ICU for profound shock. Surgeon does nothing for 24 hrs while pt gets worse and worse. Patient develops multiorgan failure. 24 hrs later surgeon takes pt to OR to resect lots of dead bowel. 6 month and multiple complications later pt gets DC.
Now I hear the patient is suing the hospital. Surgeon is blaming ICU saying we could have done a better job managing the shock / acidosis over first 24 hours while he was refusing to take pt to OR.

 

[The kitchen sink]

I have a recent case which may be going to trial. A patient with bowel ischemia is brought to ICU for profound shock. Surgeon does nothing for 24 hrs while pt gets worse and worse. Patient develops multiorgan failure. 24 hrs later surgeon takes pt to OR to resect lots of dead bowel. 6 month and multiple complications later pt gets DC.
Now I hear the patient is suing the hospital. Surgeon is blaming ICU saying we could have done a better job managing the shock / acidosis over first 24 hours while he was refusing to take pt to OR.

documentation will be key here
i notice surgeons typically whip out their calculators that say mortality is >80% and usually try not to operate esp if multiorgan failure
But if he wasnt in multiorgan failure when he came in there may have been a window to operate
It’s a he said she said issue now

 

[Tipsy McStagger]

It's ridiculous to think you can manage anything very well without treating the underlying cause. No matter what you do, the patient will get worse in time, it's just a matter of how quickly.

 

[The kitchen sink]

It's ridiculous to think you can manage anything very well without treating the underlying cause. No matter what you do, the patient will get worse in time, it's just a matter of how quickly.

Exactly, the cognitive dissonance is off the charts

 

[chessknt]

I have a recent case which may be going to trial. A patient with bowel ischemia is brought to ICU for profound shock. Surgeon does nothing for 24 hrs while pt gets worse and worse. Patient develops multiorgan failure. 24 hrs later surgeon takes pt to OR to resect lots of dead bowel. 6 month and multiple complications later pt gets DC.
Now I hear the patient is suing the hospital. Surgeon is blaming ICU saying we could have done a better job managing the shock / acidosis over first 24 hours while he was refusing to take pt to OR.

In this case a 'better' job would have been to let the patient die before the surgery so nobody would be getting sued instead of investing limitless resources in their survival just to get slapped with a lawsuit for not doing a good enough job. God bless america.

 

[Radetzky]

Sometimes in these situations you just have to threaten a complaint to their department chair to get them to come in and operate.

 

[Katheudontas parateroumen]

In this case a 'better' job would have been to let the patient die before the surgery so nobody would be getting sued instead of investing limitless resources in their survival just to get slapped with a lawsuit for not doing a good enough job. God bless america.

So true and that’s sickening. Can’t have it anyway

 

[NontradICUdoc]

The ones that get me to the point of burnout are the overdose cardiac arrests that are between 20 and 40 years old. Not only are their families devastated but they tend to have young kids. Almost broke down crying one day when I had to do a brain death on my 3rd patient <30 in 2 weeks for this.

 

[chessknt]

The ones that get me to the point of burnout are the overdose cardiac arrests that are between 20 and 40 years old. Not only are their families devastated but they tend to have young kids. Almost broke down crying one day when I had to do a brain death on my 3rd patient <30 in 2 weeks for this.

Hang in there man it comes and goes in waves, especially if there is a bad batch out. Most of the time the kids are with someone else in the family and while they get dealt a rotten hand in life to be sure there is at least certainty in being dead as opposed to the purgatory some people elect for in the trach/PEG farm.

 

[TeddyBoomBoom]

Let’s talk about some common situations that i’ve encountered working in the icu that contribute to burn out:


-pt came to ER, intubated, hypotensive after being put on sedation, pt is ignored for an hour, no workup done, no blood cultures, no abg, ER gives no meds and wants to admit to icu, after back n forth they agree to place access, pt is not sedated enough to place line, claim they are overwhelmed, we stop sedation, pressure holds, we gather pt to icu and stabilize there bc nothing is getting done in ER

Full disclosure, I only quoted part of the OPs post here since I’m an ER doc and can only speak of ED things.

First and foremost, I agree that the no-workup admit to the unit is 🐄 💩. I have literally never called the ICU without X-rays, imaging, blood gasses, cultures, etc at the very least ordered to be done in the ED before leaving for the unit.

Also, I think it is totally within my obligation to
get the pt a central line if they need it. Or a chest tube. I would never pawn off a procedure on a critically ill pt to the unit.

However, past that… my nurses are on a 4:1 ratio on a good day, which is verrrry different than the unit. I’ve heard the frustrations from the IP/ICU attendings about orders/labs/meds/etc just grinding to a halt in the ED. An ICU pt boarding in my ED has a nurse that has about 12-14 min/hr to devote to that patient, and I’m fortunate to work at a place that has, for the most part, exceptional nurses.

I get the frustration, but wanted to give my perspective. I love my critical care peeps but it’s a totally different world. But like I said, I do think that the ED should be responsible for getting CVL access, and an appropriate work pending.

Anyways. I can totally empathize about the burn out, and try to give you CC folks the best workup I can from the ED 🤷‍♀️

 

[jdh71]

Full disclosure, I only quoted part of the OPs post here since I’m an ER doc and can only speak of ED things.

First and foremost, I agree that the no-workup admit to the unit is 🐄 💩. I have literally never called the ICU without X-rays, imaging, blood gasses, cultures, etc at the very least ordered to be done in the ED before leaving for the unit.

Also, I think it is totally within my obligation to
get the pt a central line if they need it. Or a chest tube. I would never pawn off a procedure on a critically ill pt to the unit.

However, past that… my nurses are on a 4:1 ratio on a good day, which is verrrry different than the unit. I’ve heard the frustrations from the IP/ICU attendings about orders/labs/meds/etc just grinding to a halt in the ED. An ICU pt boarding in my ED has a nurse that has about 12-14 min/hr to devote to that patient, and I’m fortunate to work at a place that has, for the most part, exceptional nurses.

I get the frustration, but wanted to give my perspective. I love my critical care peeps but it’s a totally different world. But like I said, I do think that the ED should be responsible for getting CVL access, and an appropriate work pending.

Anyways. I can totally empathize about the burn out, and try to give you CC folks the best workup I can from the ED 🤷‍♀️

I'm always happy to see a central in place when a patient comes up. I think at some point in everyone's career you are more than happy to not have to be the one to take the time to place them. And then you often really don't need them either, and it doesn't bother me if a patient comes up without a central line either. I can always put one in later. Often depending on how busy me and the ED are we will discuss who will put it in during the admitting call.

I like a bit of work-up to start down there but don't expect it to be exhaustive, and it's mostly CT that I want done before a patient comes up. I like initial labs there so I can get sense of "how sick" but it's not always necessary, but I hate having to send a patient to CT when they've already made it to the unit. I mean being intubated is "check mate" and I will be taking them, but that's the only thing that grinds my gears is asking for admit simply because they are intubated and nothing is done - this usually only happens with the "new kids" and only once.

 

[The kitchen sink]

The central line thing can be a headache- some places have CC PAs or willing/certified residents that just drop them in. Some places are moving towards peripheral pressors, slowly. But if you have a culture of ER asking to admit everyone immediately post-intubation, without any attempt initiating a work-up (put the orders in the computer, and discuss with admitting team if anything else needs to be added) or further stabilization (central line if on pressors or hypotensive, or peripheral pressors if your hospital policy allows), then I see a problem. That kind of situation needs to get bumped up. It’s really not a you against us situation, it should be discussed based on how busy the services are. But ultimately, if the ER is not willing to stabilize a sick patient, then what is the role of the ER here? Happy to hear the ER folks thoughts.

That being said, what are all your hospitals policies on pressors and access? I recently worked in a different ICU where peripheral pressors were common, and within hospital policy. It was stunning to see the level of comfort around it. They did have some criteria, usually an IV in the upper arm (brachial, basilic or cephalic veins, I assume).

 

[jdh71]

The central line thing can be a headache- some places have CC PAs or willing/certified residents that just drop them in. Some places are moving towards peripheral pressors, slowly. But if you have a culture of ER asking to admit everyone immediately post-intubation, without any attempt initiating a work-up (put the orders in the computer, and discuss with admitting team if anything else needs to be added) or further stabilization (central line if on pressors or hypotensive, or peripheral pressors if your hospital policy allows), then I see a problem. That kind of situation needs to get bumped up. It’s really not a you against us situation, it should be discussed based on how busy the services are. But ultimately, if the ER is not willing to stabilize a sick patient, then what is the role of the ER here? Happy to hear the ER folks thoughts.

That being said, what are all your hospitals policies on pressors and access? I recently worked in a different ICU where peripheral pressors were common, and within hospital policy. It was stunning to see the level of comfort around it. They did have some criteria, usually an IV in the upper arm (brachial, basilic or cephalic veins, I assume).

We run peripheral pressors often. No official policy which I think is good because the second you make a rule, a 100 patients come along and break it. We tend to place a central line if the pressors seem to be escalating quickly and to higher doses and your sense is it will be a long slog. Often, these patients just run out of "access" with all the stuff we are putting in that can't be run in through the same place too. The peripheral IV needs to be decent sized, so no 22g hand IVs or something like that.

 

[jdh71]

But if you've some some little old lady in from the nursing home with a UTI who needs a bit of pressor and abx and is otherwise stable and has a decent IV . . . I'm not putting a central line in that patient.

 

[The kitchen sink]

But if you've some some little old lady in from the nursing home with a UTI who needs a bit of pressor and abx and is otherwise stable and has a decent IV . . . I'm not putting a central line in that patient.

Makes sense.

 

[SurfingDoctor]

We will run "low-dose" pressors peripherally. There's no set number but if you are going above 0.1 mcg/kgmin or on more than 1 at any dose, you generally get a CVL. There was actually a recent greater push to give children CVLs with any pressor because the IVs were infiltrating, which I partly understand due to size and patient movement but also partly attribute to high nursing turnover rates and senior nurses leaving and being replaced by people of barely drinking age and poor nurse to patient ratios.

We also don't typically have the ER try any central access due to a series of sentinel events in the past when it was attempted. That was true for my prior institution as well, but this is pediatrics mind you.

 

[sylvanthus]

We run peripheral pressors often. No official policy which I think is good because the second you make a rule, a 100 patients come along and break it. We tend to place a central line if the pressors seem to be escalating quickly and to higher doses and your sense is it will be a long slog. Often, these patients just run out of "access" with all the stuff we are putting in that can't be run in through the same place too. The peripheral IV needs to be decent sized, so no 22g hand IVs or something like that.

My favorite is the surgical pt who “was totally fine” no need for central line in OR, as the anesthesiokogist is actively pushing neo when the pt gets into the unit. Inevitable ends up on 3 pressors and needs a line asap.

Happens all the damn time.

 

[The kitchen sink]

My favorite is the surgical pt who “was totally fine” no need for central line in OR, as the anesthesiokogist is actively pushing neo when the pt gets into the unit. Inevitable ends up on 3 pressors and needs a line asap.

Happens all the damn time.

150 mcg of neo en route to ICU will do the trick 🤣

 

[grt398]

So based on the following study and various discussions with nursing/pharmacy

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shmpublications.onlinelibrary.wiley.com

My residency program would run peripheral levo/epi up to 72 hours, and up to something like 0.2 or so mcg/kg/min.

 

[Siggy]

150 mcg of neo en route to ICU will do the trick 🤣

Don't forget about the undocumented push of roc... so the patient can be transported.

1. Then you get to play the fun "stroke or paralyzed" game.

2. Imagine if the ICU worked like that and every time a vented patient left the floor you hit them with paralytics.

3. There's never any sedation running.

 

[jdh71]

My favorite is the surgical pt who “was totally fine” no need for central line in OR, as the anesthesiokogist is actively pushing neo when the pt gets into the unit. Inevitable ends up on 3 pressors and needs a line asap.

Happens all the damn time.

To be fair sometimes the septic abdomen or kidney gets the patient all stirred up once surgically intervened upon. Pressors may have been doing okish in the OR and escalate after. But yeah. Sometimes I’m cynical too. Those late in the day cases that need to come to the unit because they “can’t be extubated”?

 

[The kitchen sink]

To be fair sometimes the septic abdomen or kidney gets the patient all stirred up once surgically intervened upon. Pressors may have been doing okish in the OR and escalate after. But yeah. Sometimes I’m cynical too. Those late in the day cases that need to come to the unit because they “can’t be extubated”?

Can’t be extubated bc it’s 430 pm 🤨 lmao

 

[jdh71]

Can’t be extubated bc it’s 430 pm 🤨 lmao

Exactly.

 

[lymphocyte]

Relevant to this thread.

 

[grt398]

Don't forget these two:

 

[TeddyBoomBoom]

The central line thing can be a headache- some places have CC PAs or willing/certified residents that just drop them in. Some places are moving towards peripheral pressors, slowly. But if you have a culture of ER asking to admit everyone immediately post-intubation, without any attempt initiating a work-up (put the orders in the computer, and discuss with admitting team if anything else needs to be added) or further stabilization (central line if on pressors or hypotensive, or peripheral pressors if your hospital policy allows), then I see a problem. That kind of situation needs to get bumped up. It’s really not a you against us situation, it should be discussed based on how busy the services are. But ultimately, if the ER is not willing to stabilize a sick patient, then what is the role of the ER here? Happy to hear the ER folks thoughts.

That being said, what are all your hospitals policies on pressors and access? I recently worked in a different ICU where peripheral pressors were common, and within hospital policy. It was stunning to see the level of comfort around it. They did have some criteria, usually an IV in the upper arm (brachial, basilic or cephalic veins, I assume).

I’m a new ER attending. I remember one time as a resident (ONE!) where I admitted a pt to the unit who was hypotensive, and then the CC care team ended up doing a line in the ED. I’m still embarrassed about that. It’s the definition of under resuscitation prior to admission.

I totally get that you can run pressers low dose peripherally. And I get that central access has risks. But I’m also a cautious person as an ER doc. I have no idea what is going to happen. Is the patient going to crash? Is the pt going to board in the ER? In the patient going to board in the ER and then crash? 🤷

If an admitted and bedded ICU pt wants to be trialed on low dose peripheral pressers in the unit I think that’s fine. But if I’m in the ER and starting pressers after fluids, I do a central line prior to leaving the ED. I wouldn’t feel right driving home with my ER pt on peripheral pressers prior to admission.

I’m not saying others are wrong, but my practice is to get central access if needing pressers prior to leaving my care.

 

[The kitchen sink]

I’m a new ER attending. I remember one time as a resident (ONE!) where I admitted a pt to the unit who was hypotensive, and then the CC care team ended up doing a line in the ED. I’m still embarrassed about that. It’s the definition of under resuscitation prior to admission.

I totally get that you can run pressers low dose peripherally. And I get that central access has risks. But I’m also a cautious person as an ER doc. I have no idea what is going to happen. Is the patient going to crash? Is the pt going to board in the ER? In the patient going to board in the ER and then crash? 🤷

If an admitted and bedded ICU pt wants to be trialed on low dose peripheral pressers in the unit I think that’s fine. But if I’m in the ER and starting pressers after fluids, I do a central line prior to leaving the ED. I wouldn’t feel right driving home with my ER pt on peripheral pressers prior to admission.

I’m not saying others are wrong, but my practice is to get central access if needing pressers prior to leaving my care.

Thanks for chiming in. I’m the same way with my unit. If they are borderline hypotense, i’m not leaving without them being lined up.

 

[turkeyjerky]

The central line thing can be a headache- some places have CC PAs or willing/certified residents that just drop them in. Some places are moving towards peripheral pressors, slowly. But if you have a culture of ER asking to admit everyone immediately post-intubation, without any attempt initiating a work-up (put the orders in the computer, and discuss with admitting team if anything else needs to be added) or further stabilization (central line if on pressors or hypotensive, or peripheral pressors if your hospital policy allows), then I see a problem. That kind of situation needs to get bumped up. It’s really not a you against us situation, it should be discussed based on how busy the services are. But ultimately, if the ER is not willing to stabilize a sick patient, then what is the role of the ER here? Happy to hear the ER folks thoughts.

That being said, what are all your hospitals policies on pressors and access? I recently worked in a different ICU where peripheral pressors were common, and within hospital policy. It was stunning to see the level of comfort around it. They did have some criteria, usually an IV in the upper arm (brachial, basilic or cephalic veins, I assume).

I think the culture at some training programs is to transfer care asap to the critical care team. Usually efficient shops w/ ample bed availability and/or in-house ICU fellows. Last year I was working at one of these places (I'm EM) and I was frankly unimpressed with the resus skills/knowledge of most the other EM attendings and quality of training for the residents. They were really big on peripheral pressors and you would often get pushback from nurses when trying to put a line in. My own major worry about peripheral pressors is not whether or not they're safe to infuse (I believe the evidence is strong enough that they are), it's whether or not the patient will be okay if/when the line gets lost.

I think some of this can be helped w/ a simple FYI message to the ED medical director that you would prefer that patients be lined up in the ED.

 

[chessknt]

I’m a new ER attending. I remember one time as a resident (ONE!) where I admitted a pt to the unit who was hypotensive, and then the CC care team ended up doing a line in the ED. I’m still embarrassed about that. It’s the definition of under resuscitation prior to admission.

I totally get that you can run pressers low dose peripherally. And I get that central access has risks. But I’m also a cautious person as an ER doc. I have no idea what is going to happen. Is the patient going to crash? Is the pt going to board in the ER? In the patient going to board in the ER and then crash? 🤷

If an admitted and bedded ICU pt wants to be trialed on low dose peripheral pressers in the unit I think that’s fine. But if I’m in the ER and starting pressers after fluids, I do a central line prior to leaving the ED. I wouldn’t feel right driving home with my ER pt on peripheral pressers prior to admission.

I’m not saying others are wrong, but my practice is to get central access if needing pressers prior to leaving my care.

I guess it depends on how busy you are. One of the hospitals where I work the ER docs are churning 2-3 pph waiting room is 10-20 people deep minimum even in the middle of the night. They dispo people to ICU 20-30 minutes after admit without labs back. I dont really care as long as they get CT scans and ideally necessary consults called in the ED so all that **** is in progress so I can throw orders at them until I get a chance to actually see them.