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

[alpinism]

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I'll echo the above and say that I go even farther and give 0.1 mg/kg right off the bat to patients. This means that an 80 kg patient gets 8 mg of Ativan. The way I'll explain it to the residents is that status epileptics causes excitotoxic brain damage similar to hypoxemic brain damage and you wouldn't slowly titrate oxygen upwards and wait for a response but instead give the full dose of oxygen immediately.

 

[leviathan]

Love the consults for BiPAP on the patient who has a high CO2 after getting a bunch of opioids.

 

[MoMoGesiologist]

Love the consults for BiPAP on the patient who has a high CO2 after getting a bunch of opioids.

At my place they will intubate or say they can’t do bipap because the pt is too sleepy. “OMG the CO2 is so high! We need to intubate!”

 

[BigRedBeta]

yeah, my complaint was more about the rush to intubation. Hit or miss on the dosing of benzos, but yes, certainly run into fretful dosing of benzos often. I don't get it. Was never a consideration in my peds residency to give an inappropriate dose. And I don't mind the intubation if ultimately that's what's really needed, but in a kid where this scenario as played out multiple times in the last 2 years, I don't understand why there was zero consideration of bipap...last time I had a toddler transfer from the floor with apnea due to benzos, I absolutely spent 90 minutes trying to get her on bipap before giving in.

Based on y'all's comments, it's clear - as per usual- only the ICU really demonstrates the ability to do proper assessments of the risks for the whole patient.

 

[Siggy]

At my place they will intubate or say they can’t do bipap because the pt is too sleepy. “OMG the CO2 is so high! We need to intubate!”

"OMG, the patient needs the ICU, the PaCO2 is 72!"

Um, did you realize that the pH is 7.32?

 

[MoMoGesiologist]

yeah, my complaint was more about the rush to intubation. Hit or miss on the dosing of benzos, but yes, certainly run into fretful dosing of benzos often. I don't get it. Was never a consideration in my peds residency to give an inappropriate dose. And I don't mind the intubation if ultimately that's what's really needed, but in a kid where this scenario as played out multiple times in the last 2 years, I don't understand why there was zero consideration of bipap...last time I had a toddler transfer from the floor with apnea due to benzos, I absolutely spent 90 minutes trying to get her on bipap before giving in.

Based on y'all's comments, it's clear - as per usual- only the ICU really demonstrates the ability to do proper assessments of the risks for the whole patient.

Good luck tryna get RT to bipap a pt who overdosed on narcotics at my place. “ZOMG they’re altered they need to be intubated!!” I used to think RTs were smart as a resident, maybe it was where I trained. A lot are *****s where I work now.

 

[deleted547339]

Good luck tryna get RT to bipap a pt who overdosed on narcotics at my place. “ZOMG they’re altered they need to be intubated!!” I used to think RTs were smart as a resident, maybe it was where I trained. A lot are *****s where I work now.

Haha. Yea. I had an RT tell me with a completely straight face that we (in the MICU) should run our vents like the trauma surgeons because fewer patients die in the trauma icu than in the MICU. At first I assumed she was joking, then tried to explain the difference in patient populations in the MICU vs. trauma ICU, then realized I was arguing with a fool and walked away.

 

[CCM-MD]

Case manager: Dr. C, we are ending up with too many trached patients. I think we need a ventilator weaning protocol to fix this problem.

Me: We have a ventilator weaning protocol.

Case manager: Then why do we have so many trached patients?

Me: Because a vent weaning protocol doesn't fix Mr. Bond's (mostly) dead brain.


He later went on to tell me that I should not tell patient families that such a thing as a tracheostomy exists.

 

[Siggy]

He later went on to tell me that I should not tell patient families that such a thing as a tracheostomy exists.

I mean... he's not wrong, but now we're talking DEATH PANELS (ooga booga). The trach doesn't do anything for the mostly brain dead turnip in ICU 15.

 

[CCM-MD]

I mean... he's not wrong, but now we're talking DEATH PANELS (ooga booga). The trach doesn't do anything for the mostly brain dead turnip in ICU 15.

The thought definitely comes from a good place. If lawyers didn't exist anymore, I would happily take the case manager's advice.

In my population of half brains, most need the trach for secretion management but don't necessarily need the vent. The trach is able to facilitate this and help with disposition. Doesn't do anything for the dead brain but definitely helps move them out.

 

[Siggy]

In my population of half brains, most need the trach for secretion management but don't necessarily need the vent. The trach is able to facilitate this and help with disposition. Doesn't do anything for the dead brain but definitely helps move them out.

Yep.... that's the nice thing about ICU... disposition is simple in most cases. Hospice, stepdown, or trach/peg/LTAC.

 

[deleted547339]

Yep.... that's the nice thing about ICU... disposition is simple in most cases. Hospice, stepdown, or trach/peg/LTAC.

Don’t forget the morgue.

 

[aafisahar]

Yep.... that's the nice thing about ICU... disposition is simple in most cases. Hospice, stepdown, or trach/peg/LTAC.

Discharge to the highest level of care

 

[MoMoGesiologist]

Until patients actually have to pay for grannies trach/peg, good luck not keeping these suffering souls around...

 

[Radetzky]

Until patients actually have to pay for grannies trach/peg, good luck not keeping these suffering souls around...

I’m interested because I don’t live in the states.. who pays?

 

[Gastrapathy]

It makes me happy that a thread that was supposed to be about how the rest of us just don’t understand devolved into an argument between intensivists about 30 year old patients. Seems right somehow.

and yes, that patient was too unstable for endoscopy earlier but now you’ve done such a great job that he is safe to wait until morning. Thanks! Love you guys!

 

[chocomorsel]

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.

The neurologists don’t know the doses for meds for Status?

 

[chocomorsel]

I’m interested because I don’t live in the states.. who pays?

The insurance companies or the government. For grandma/old it’s the government through us taxpayers like the rest of the world.
But talking about rationing healthcare in this country is interpreted as talking about “death squads” you know, like the Europeans have.
So every dying old person gets whatever the family wants regardless of what is best for them and whether or not it’s a total waste of resources. We waste a lot of resources at the end of life here.

 

[Siggy]

The neurologists don’t know the doses for meds for Status?

At a minimum, they actively choose not to when loading patients with status. For benzos, everyone is too afraid of snowing the patient to the point where they need to be intubated.

 

[SurfingDoctor]

The insurance companies or the government. For grandma/old it’s the government through us taxpayers like the rest of the world.
But talking about rationing healthcare in this country is interpreted as talking about “death squads” you know, like the Europeans have.
So every dying old person gets whatever the family wants regardless of what is best for them and whether or not it’s a total waste of resources. We waste a lot of resources at the end of life here.

I don’t know a better way to get the chemo to the cancerous cells than external, directed cardiac massage.

 

[chocomorsel]

I don’t know a better way to get the chemo to the cancerous cells than external, directed cardiac massage.

 

[lymphocyte]

All things trache.

This week featured a Yahtzee of both 1) trying to oxygenate via a blocked cannula and 2) trying to oxygenate via mouth a total laryngectomy.

 

[aafisahar]

At a minimum, they actively choose not to when loading patients with status. For benzos, everyone is too afraid of snowing the patient to the point where they need to be intubated.

Yea I'm more afraid of them melting their goddamn brains

 

[lymphocyte]

Source control. Now please.

And nec fasc is a surgical diagnosis. It's not clinical. It's not radiographic. It's surgical! If they're super sick, "cellulitis" is a diagnosis of exclusion -- just please take them to theatre. We've had 2 misses and 3 near misses in the last year with delayed operations, including 2 young people... Drives me nuts.

 

[jw3600]

Source control. Now please.

And nec fasc is a surgical diagnosis. It's not clinical. It's not radiographic. It's surgical! If they're super sick, "cellulitis" is a diagnosis of exclusion -- just please take them to theatre. We've had 2 misses and 3 near misses in the last year with delayed operations, including 2 young people... Drives me nuts.

By surgical diagnosis you mean can only be truly excluded in the OR?

 

[lymphocyte]

By surgical diagnosis you mean can only be truly excluded in the OR?

It's actually based on the first six words of my favourite review article on necrotising soft tissue infections by Stevens from University of Washington.

I think perhaps there's grey area, and I think there's a role for experience and very timely imaging with, for example, MRI... But I also think if they're on three vasoactive agents by the morning with gas in the tissue, it's a little less grey.

I also think if they're truely unwell with "cellulitis," everybody can sleep easier at night knowing what it isn't, rather than wondering what it might be and waiting too long.

Would you agree? Do you have a different approach?

https://www.nejm.org/doi/10.1056/NEJMra1600673

 

[jw3600]

It's actually based on the first six words of my favourite review article on necrotising soft tissue infections by Stevens from University of Washington.

I think perhaps there's grey area, and I think there's a role for experience and very timely imaging with, for example, MRI... But I also think if they're on three vasoactive agents by the morning with gas in the tissue, it's a little less grey.

I also think if they're truely unwell with "cellulitis," everybody can sleep easier at night knowing what it isn't, rather than wondering what it might be and waiting too long.

Would you agree? Do you have a different approach?

https://www.nejm.org/doi/10.1056/NEJMra1600673

Sure. Seems totally reasonable.

I am EM, so our practice environments are a little different but in general a sick "cellulitis" is concerning.

If I have a patient that has an obvious soft tissue infection that is in any way sick e.g, significant tachycardia, hypotension, vasoactives, lactate > 4, I am obtaining a stat surgical consult. The CT might be ordered but I would not want imaging to delay definitive treatment because as you alluded it's not necessary. If the surgical team evaluates and says "this is just cellulitis, medical management, no acute surgical interventions" I am documenting name of said surgeon and time in chart. If I have ANY imaging showing gas in the tissue in the above patient.....I am turning on my body cam to document this interaction.

 

[Radetzky]

It's actually based on the first six words of my favourite review article on necrotising soft tissue infections by Stevens from University of Washington.

I think perhaps there's grey area, and I think there's a role for experience and very timely imaging with, for example, MRI... But I also think if they're on three vasoactive agents by the morning with gas in the tissue, it's a little less grey.

I also think if they're truely unwell with "cellulitis," everybody can sleep easier at night knowing what it isn't, rather than wondering what it might be and waiting too long.

Would you agree? Do you have a different approach?

https://www.nejm.org/doi/10.1056/NEJMra1600673

Agree entirely, “cellulitis” plus sick enough to need vasoactives mandates surgical look in my opinion. The morbidity from a negative look is minimal, other than the surgeons perceived morbidity of having to get out of bed. Gas is great if present on imaging but often isn’t.