[Non CCM docs] just don't understand...the ICU

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BigRedBeta

BigRedBeta

Why am I in a handbasket?
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Per Will Smith and DJ Jazzy Jeff

So kinda like the threads in the Surgery forum about ridiculous consults and dismal pages, thought a thread about the ridiculous things other healthcare people just don't understand about the ICU could be fun.

I'll start:

Pediatric oncologists love to quote that mortality of intubated oncology patients is near 70% to us in the PICU as if somehow the intubation is what's killing them. I've had senior onc attendings when I was a fellow ask me NOT to intubate their patients because of that statistic despite the kid satting 82% on 40LPM and 100% O2... :smack:
 
Patient transferred from OSH with respiratory failure requiring the vent, subdural, metallic mitral valve on Coumadin INR 10 and was reversed with vitamin K and PCC. On day 2, INR is 1.2 and NSG orders 4 units of FFP. :bang:

Extubated a patient yesterday. He was hungry and pissed off. So we got him a diet but he refused to eat it. Claimed he was vegan and subsequently demanded eggs. :luck:
 
Two just the other night!

Referral for euDKA with a normal AG and ketones of 2.7. I gave the guy an apple juice and his ketones went away. Thank you for the most interesting consult.

Referral for a K of 2.6. "Needs a central line and monitored replacement." I got the lady some Chlorvescent K and basically said "Drink this every two hours, or I'm going to stick a big ass needle in your neck." Sorted by the morning.
 
lymphocyte said:
Two just the other night!

Referral for euDKA with a normal AG and ketones of 2.7. I gave the guy an apple juice and his ketones went away. Thank you for the most interesting consult.

Referral for a K of 2.6. "Needs a central line and monitored replacement." I got the lady some Chlorvescent K and basically said "Drink this every two hours, or I'm going to stick a big ass needle in your neck." Sorted by the morning.
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What was the pH of the first one? Because if normal they have 0/3 criteria for DKA.

Ketones of 2.7 is like coffee for breakfast and skipping lunch.
 
SpacemanSpifff said:
This is unfortunately a reality at my current institution - ophtho admits to an ICU bed, the patient is managed by a medicine floor team. Incredibly frustrating and a poor use of resources.
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To be fair, it's the same reason most DKA patients go to the unit. Any halfway decent medicine intern should be able to replete lytes and watch the gap, but you need the 2:1 nursing staff to get your hourly accuchecks.

What should be interesting to see is if CGMs ever get approved for in hospital use and see if insulin infusions can be moved to stepdown once the nursing workload is decreased.
 
SpacemanSpifff said:
This is unfortunately a reality at my current institution - ophtho admits to an ICU bed, the patient is managed by a medicine floor team. Incredibly frustrating and a poor use of resources.
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Optho should not have admitting privileges to the Unit. Cut that out and fix that problem.
Do they realize that those eye drops are gonna cost 10k a day?
 
Siggy said:
To be fair, it's the same reason most DKA patients go to the unit. Any halfway decent medicine intern should be able to replete lytes and watch the gap, but you need the 2:1 nursing staff to get your hourly accuchecks.

What should be interesting to see is if CGMs ever get approved for in hospital use and see if insulin infusions can be moved to stepdown once the nursing workload is decreased.
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Thankfully this unit was closed, talked to my charge and she and the floor charge decided the patient, being an adult, could give themselves eyedrops on the floor. We also do dka's on step down thank god, as long as they don't look like ass or meet pH criteria (7.1? if I remember right)
 
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BigRedBeta said:
Per Will Smith and DJ Jazzy Jeff

So kinda like the threads in the Surgery forum about ridiculous consults and dismal pages, thought a thread about the ridiculous things other healthcare people just don't understand about the ICU could be fun.

I'll start:

Pediatric oncologists love to quote that mortality of intubated oncology patients is near 70% to us in the PICU as if somehow the intubation is what's killing them. I've had senior onc attendings when I was a fellow ask me NOT to intubate their patients because of that statistic despite the kid satting 82% on 40LPM and 100% O2... :smack:
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Stem cell marched up in a heat to the unit one evening that we were talking with the patient's family about withdrawal of care. Patient hadn't engrafted, was tubed with a plateau in the 30s, and had a map sitting in the 30's on 4 vasoactive gtts, mottled and cold, anuric. Adult onc and realistic goals of care discussions seem to be incompatible
 
WheezyBaby said:
Stem cell marched up in a heat to the unit one evening that we were talking with the patient's family about withdrawal of care. Patient hadn't engrafted, was tubed with a plateau in the 30s, and had a map sitting in the 30's on 4 vasoactive gtts, mottled and cold, anuric. Adult onc and realistic goals of care discussions seem to be incompatible
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There's the old joke about why they put nails in the coffins of cancer patients?

It keeps the oncologist from doing another round of chemo.
 
WheezyBaby said:
q1 nursing care 🙂
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Yep. I’ve actually seen this happen. q1 gtts or q2 IOP measurements went to the ICU due to the demands on nursing care. To be fair, these were generally vision threatening diagnosis.
 
WheezyBaby said:
Thankfully this unit was closed, talked to my charge and she and the floor charge decided the patient, being an adult, could give themselves eyedrops on the floor. We also do dka's on step down thank god, as long as they don't look like ass or meet pH criteria (7.1? if I remember right)
Click to expand...

my father is an ophthalmologist and hasn’t admitted a patient (or rather asked the hospitalist) to admit a patient in over a decade. His experience has been if you explain to a patient they need these drops every hour or they will go blind this is strong motivation and they always get it done. Most people don’t want to be in a hospital anyway.

But the real reason the ICU exists is because of nursing. So q1 patients actually make sense in the ICU. But clearly there is no reason to involve critical care in some of these cases.

The cases I find really irritating are the strokes post tPA. I don’t know if it’s a national guideline recommendation or if it’s just the way things go where I work but seems like overkill from even a nursing perspective.
 
jdh71 said:
my father is an ophthalmologist and hasn’t admitted a patient (or rather asked the hospitalist) to admit a patient in over a decade. His experience has been if you explain to a patient they need these drops every hour or they will go blind this is strong motivation and they always get it done. Most people don’t want to be in a hospital anyway.

But the real reason the ICU exists is because of nursing. So q1 patients actually make sense in the ICU. But clearly there is no reason to involve critical care in some of these cases.

The cases I find really irritating are the strokes post tPA. I don’t know if it’s a national guideline recommendation or if it’s just the way things go where I work but seems like overkill from even a nursing perspective.
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All the hospitals I have worked at have had this same thing. Any stroke post-tPA comes to the ICU for 24h.
 
lymphocyte said:
We have this too! It drivers me nuts!!

There was a 82 year old high level care nursing home resident with dementia NIHSS 25 -- deemed not to be any kind of neurosurgical candidate and NFR/NFI -- who was gobsmackingly thrombolysed. Normotensive. "What if he bleeds"?

View attachment 294776
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I had a >90 year old recently who got EVT. He was a "good" 90+ year old though. I believe he did well.
 
SurfingDoctor said:
Well, adult congenital is a whole different beast.
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More seriously, I don't know the details of the specific patient you're referencing obviously, but I think theres a population that's just going to get better care in the picu than micu even if they're 35 between issues they may run into with weight based dosing, familiarity with the pathology, familiarity with the relationship that exists between those who have never had decision making ability and their caregivers, etc. At least at the current time. When transitions of care are happening more seamlessly in the US I may change my stance
 
WheezyBaby said:
More seriously, I don't know the details of the specific patient you're referencing obviously, but I think theres a population that's just going to get better care in the picu than micu even if they're 35 between issues they may run into with weight based dosing, familiarity with the pathology, familiarity with the relationship that exists between those who have never had decision making ability and their caregivers, etc. At least at the current time. When transitions of care are happening more seamlessly in the US I may change my stance
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There’s no familiarity for congenital diseases that were terminal 3 decades ago but that technology and modern medicine have usurped the natural history and have allowed them to become adults... PICU or otherwise
 
SurfingDoctor said:
There’s no familiarity for congenital diseases that were terminal 3 decades ago but that technology and modern medicine have usurped the natural history and have allowed them to become adults... PICU or otherwise
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I think even something relatively common like a patient with quadriplegic CP, intellectual disability, malnourishment, and a mace/Monti/gtube are better suited in the picu, generally speaking. I agree with what you're getting at, but PICU is still more familiar with the umbrella of "extremely rare previously terminal multisystem genetic / metabolic disorder no one knows about", and there's an approach to that type of encounter, even if not necessarily a familiarity with the condition itself. Obviously these opinions aren't data driven, just anecdotal/experiential. I think medicine has a much higher likelihood of floundering with these patients
 
WheezyBaby said:
I think even something relatively common like a patient with quadriplegic CP, intellectual disability, malnourishment, and a mace/Monti/gtube are better suited in the picu, generally speaking. I agree with what you're getting at, but PICU is still more familiar with the umbrella of "extremely rare previously terminal multisystem genetic / metabolic disorder no one knows about", and there's an approach to that type of encounter, even if not necessarily a familiarity with the condition itself. Obviously these opinions aren't data driven, just anecdotal/experiential. I think medicine has a much higher likelihood of floundering with these patients
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I know what families prefer due to familiarity and where they are more comfortable, especially when they get to go to the adult side, but just cause the family wants it doesn’t make it right nor appropriate.
 
SurfingDoctor said:
Okay. I disagree that is anything familiar about a 30 year old patient whose disease was terminal 30 years ago.
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then you are wrong

pediatricians seems still more familiar with these diseases than adult Intensivists.

the fact that these patients are just bigger now isn’t terribly relevant

but who actually wants to do what is correct for a patient?! Amirite?!? lol
 
jdh71 said:
then you are wrong

pediatricians seems still more familiar with these diseases than adult Intensivists.

the fact that these patients are just bigger now isn’t terribly relevant

but who actually wants to do what is correct for a patient?! Amirite?!? lol
Click to expand...
Taking care of 30 year olds in a pediatric hospital isnt “correct” by many people who work in pediatric hospitals. No more than taking care of 3 year old would be in an adult hospital
 
SurfingDoctor said:
Taking care of 30 year olds in a pediatric hospital isnt “correct” by many people who work in pediatric hospitals. No more than taking care of 3 year old would be in an adult hospital
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Except when they have a pediatric disease that isn’t seen in adults. Just being a certain age doesn’t change the expertise.

What is it about a 30 year old you would have so much trouble with?
 
jdh71 said:
Except when they have a pediatric disease that isn’t seen in adults. Just being a certain age doesn’t change the expertise.

What is it about a 30 year old you would have so much trouble with?
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Oh, I can manage it because other's refuse or uncomfortable or whatever, but that's not really the point. There's nothing really pediatric about congenital diseases. That's pretty arbitrary. Are you suggesting any adult with Hirschsprung's disease should be at a pediatric hospital because they have a birth defect?

There's also nothing pediatric specific about trachs and gtubes, but if people are unable to manage that... so be it I guess.
 
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SurfingDoctor said:
Oh, I can manage it because other's refuse or uncomfortable or whatever, but that's not really the point. There's nothing really pediatric about congenital diseases. That's pretty arbitrary. Are you suggesting any adult with Hirschsprung's disease should be at a pediatric hospital because they have a birth defect?

There's also nothing pediatric specific about trachs and gtubes, but if people are unable to manage that... so be it I guess.
Click to expand...

there are some diseases where pediatricians simply have the most experience

hell I’ve never seen a adult with Hirschsprung’s disease. I had to look it up. Which is kind of making my point.

if all I’m dealing with is a patient whose colon doesn’t work but is in for whatever else any of us in here can take care of that patient

I’m not sure off the top of my head even what would be a good example but an exacerbation or decompensation of a disease known really only to pediatricians only and it’s that exacerbation or decompensation that has the patient in the ICU in the first place. Especially if the partient is still being seen by a pediatrician for this disease. It’s not the same as just admitting some rando 30 year old to the picu which wouldn’t be appropriate

I know doing what is best for a patient is occasionally really inconvenient.
 
SurfingDoctor said:
Oh, I can manage it because other's refuse or uncomfortable or whatever, but that's not really the point. There's nothing really pediatric about congenital diseases. That's pretty arbitrary. Are you suggesting any adult with Hirschsprung's disease should be at a pediatric hospital because they have a birth defect?

There's also nothing pediatric specific about trachs and gtubes, but if people are unable to manage that... so be it I guess.
Click to expand...

There's nothing really adult about type 2 diabetes, but the familiarity of any given internist with the condition and what's appropriate modification of outpatient management during a hospitalization compared to a pediatrician dramatic. If you put a sick metabolic "adult" in a MICU they are not going to do well. The goal will be to successfully transition these patients to adult care as they live longer and their prevalence as adults increases but we are so not all the way there.
 
jdh71 said:
there are some diseases where pediatricians simply have the most experience

hell I’ve never seen a adult with Hirschsprung’s disease. I had to look it up. Which is kind of making my point.

if all I’m dealing with is a patient whose colon doesn’t work but is in for whatever else any of us in here can take care of that patient

I’m not sure off the top of my head even what would be a good example but an exacerbation or decompensation of a disease known really only to pediatricians only and it’s that exacerbation or decompensation that has the patient in the ICU in the first place. Especially if the partient is still being seen by a pediatrician for this disease. It’s not the same as just admitting some rando 30 year old to the picu which wouldn’t be appropriate

I know doing what is best for a patient is occasionally really inconvenient.
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I have, my last call. But he was admitted to the PICU for CAP, completely unrelated to his Hirschsprung's. It really doesn't matter that much to me cause I'm still going to do my best to take care of the patient, but it still is in line with the topic of the thread.
 
WheezyBaby said:
There's nothing really adult about type 2 diabetes, but the familiarity of any given internist with the condition and what's appropriate modification of outpatient management during a hospitalization compared to a pediatrician dramatic. If you put a sick metabolic "adult" in a MICU they are not going to do well. The goal will be to successfully transition these patients to adult care as they live longer and their prevalence as adults increases but we are so not all the way there.
Click to expand...
This was exactly my point... but people wanted to argue against it. Whatever. I feel like this whole discussion has been circular.
 
SurfingDoctor said:
I have, my last call. But he was admitted to the PICU for CAP, completely unrelated to his Hirschsprung's. It really doesn't matter that much to me cause I'm still going to do my best to take care of the patient, but it still is in line with the topic of the thread.
Click to expand...

good for you I guess?

Id have no problem treating pneumonia in that patient. Even having look up hirschsprung after all these years.

sometimes the patient is still going to be best served in the picu - your example is NOT an argument against my point
 
SurfingDoctor said:
This was exactly my point... but people wanted to argue against it. Whatever. I feel like this whole discussion has been circular.
Click to expand...

I'm not arguing at all against a grand plan to transition, but there is minimal to no financial incentive to do so and the work involved is substantial, we're years and years away from getting there. In the interim, there are going to be legal adults who are best served in a pediatric center. I appreciate help from the adult side as well for matters that are poorly addressed at most peds centers, e.g. interventional pulm, neuroIR, ERCP, etc.
 
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WheezyBaby said:
I'm not arguing at all against a grand plan to transition, but there is minimal to no financial incentive to do so and the work involved is substantial, we're years and years away from getting there. In the interim, there are going to be legal adults who are best served in a pediatric center. I appreciate help from the adult side as well for matters that are poorly addressed at most peds centers, e.g. interventional pulm, neuroIR, etc.
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I guarantee you, that is a minority position among people who work in children's ICU. I'm not saying they refuse care (they don't), but it contributes to problems within units and for patients. But I also agree, there is little drive to fix the issue, so there it is.
 
SurfingDoctor said:
I guarantee you, that is a minority position among people who work in children's ICU. I'm not saying they refuse care (they don't), but it contributes to problems within units and for patients. But I also agree, there is little drive to fix the issue, so there it is.
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Numerous subspecialists at my center DO refuse to see patients above a certain age. I agree it's a major problem.
 
WheezyBaby said:
Numerous subspecialists at my center DO refuse to see patients above a certain age. I agree it's a major problem.
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In the PICU? Having done this for a decade, I’ve personally never seen it (unless it was a staffing issue).

Consulting services on the other hand whip out the “I am not credentialed” more times then I’d like to admit.
 
SurfingDoctor said:
In the PICU? Haven’t done this for a decade, I’ve personally never seen it (unless it was a staffing issue).
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Not the intensivists, but there are services that decline to consult on adult patients. Exceptions would be on a case by case basis, e.g. critically ill accepted to the PICU. Also not painting this as one-sided. I think its much more common for internists/IM subspecialists to decline to treat a minor. Scope of practice and liability concerns
 
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In the spirit of the original theme

- regarding non invasive ventilation as a blanket treatment for hypoxia of any cause

- thinking that fluid will affect the integrity of the surgical anastamosis but a butload of Levo won’t

- asking if the patient can have zero PEEP in order to avoid a pneumothorax

- just generally not understanding the principle of ‘swimming like a shark’ in the icu.
 
Teenager with epilepsy, multiple ICU admissions due to getting apneic with benzos resulting in intubations. You'd think the ED would recognize the pattern and limp along with bipap and avoid the risk. Tempted to tell the parents they should push for a DNI.

Then again, it's not like I can get the ED to remember that seizures result in elevated PCO2 and it's a terrible idea to draw a gas in the immediate post-ictal phase...so maybe I'm expecting too much
 
BigRedBeta said:
Teenager with epilepsy, multiple ICU admissions due to getting apneic with benzos resulting in intubations. You'd think the ED would recognize the pattern and limp along with bipap and avoid the risk. Tempted to tell the parents they should push for a DNI.

Then again, it's not like I can get the ED to remember that seizures result in elevated PCO2 and it's a terrible idea to draw a gas in the immediate post-ictal phase...so maybe I'm expecting too much
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Remember selection bias. For every time this happens, theres 10 others that they sit on and ultimately admit to the floor.

We have this guy who comes in every day. I mean every day. Sometimes 3 times a day. He finally had to be admitted. The hospitalist was shocked. They were like “whoa, this guy had been to the ER hundreds, maybe thousands of times - and you’ve never admitted him. I just thought y’all admitted everybody.”
 
BigRedBeta said:
Teenager with epilepsy, multiple ICU admissions due to getting apneic with benzos resulting in intubations. You'd think the ED would recognize the pattern and limp along with bipap and avoid the risk. Tempted to tell the parents they should push for a DNI.

Then again, it's not like I can get the ED to remember that seizures result in elevated PCO2 and it's a terrible idea to draw a gas in the immediate post-ictal phase...so maybe I'm expecting too much
Click to expand...
I'm all for complaining about the ED, but assuming that these are real seizures, I'm having a hard time faulting the ED with giving the first line treatment for status (of which, they're probably underdosing anyways).
 
Siggy said:
I'm all for complaining about the ED, but assuming that these are real seizures, I'm having a hard time faulting the ED with giving the first line treatment for status (of which, they're probably underdosing anyways).
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Benzos are crazily under-dosed. All the ancillary data from the big ESETT trial last are eye-opening. Only 30% got the minimum effective benzo dose as initial treatment in ED. 12% of patients had to be outright excluded because they never got the minimum effective dose. This was in a trial, at academic centres. The retrospective data are worse.

The risk of cardiorespiratory depression is higher in under-treated status than it is with receiving adequate doses of benzodiazapines. ED under-dosing of benzodiazapines is one of my biggest pet peeves.

Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients with Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019.
 
lymphocyte said:
Benzos are crazily under-dosed. All the ancillary data from the big ESETT trial last are eye-opening. Only 30% got the minimum effective benzo dose as initial treatment in ED. 12% of patients had to be outright excluded because they never got the minimum effective dose. This was in a trial, at academic centres. The retrospective data are worse.

The risk of cardiorespiratory depression is higher in under-treated status than it is with receiving adequate doses of benzodiazapines. ED under-dosing of benzodiazapines is one of my biggest pet peeves.

Sathe AG, Tillman H, Coles LD, et al. Underdosing of Benzodiazepines in Patients with Status Epilepticus Enrolled in Established Status Epilepticus Treatment Trial. Acad Emerg Med. 2019.
Click to expand...


Everyone at my hospital is shocked (SHOCKED) when I order Ativan 4 mg (AES guidelines: 0.1mg/kg up to 4, option to repeat once). Similarly with the 4.5 grams of Keppra (AES guidelines 60 mg/kG up to 4.5 grams). If I have to intubate someone because of 4mg of ativan, I'm just as likely going to need to intubate them for the status anyways. Neuro is just as bad.
 
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