The Hammer of God

[The Knife & Gun Club]

I’m incredibly proud of my EM training. As y’all know I’m now on the other side of the admit phone taking Critical Care admits at various sites. By and large the busiest days in trauma, surgical, medical ICU are a (complex, intellectually exciting) breeze compared to a shift in the pit.

But I’ve finally found a unit that’s got us beat. Transplant surgery ICU. Patients so medically fragile the wire from an IJ can put them into VTACH. Either immediately pre or post enormous surgical operations with such grievous injury that’s not even fathomable.

27 beds. We've got 4 multi-visceral transplants on the rack right now. Fresh out of the OR with a “total abdominal exenteration” and combined liver/spleen/pancreas/stomach, small, and large bowel transplant. Devastated immune systemss with sepsis from disseminated HSV. 3rd do over liver transplant on ecmo waiting for an organ, bleeding from every oriface and getting 10 units of product a day just to stay the course . Massive PE in the setting of active variceal GI bleed that the gi squad can’t control. I’ve got an aorta transplant (dual aortic circulation) where if one aorta starts to steal from the other due to hemodynamics and the transplanted vs native organs start to get ischemic.

All this is to say I’ve been in search for a long time for a gig that takes EM on face to face for acuity, high stakes, and volume. This may just be it.

One final story. A firefighter getting a liver/spleen/pancreas/stomach/intestine transplant for pancreatic benign mass encasing the IVC. VV ecmo running after the trip to the OR. Negative flow from the ecmo ripped apart the IVC anastomosis and had a suck down event with air entering the circuit. MTP of 144 PRBC, 110 FFP, 40 Cryo and 40 platelets. The donor pancreas and liver died. This guy is awake and talking. He tells me he can feel his organs dying and knows it won’t be long. We wait with the family, but they all know how this is likely the end for this 42 year old father of two. Give daddy a hug, he’s going in and out of vtach and he’s #3 on the list.

I’ve never seen anything like this and just wanted to share. It’s a world far insulated from EM or even medicine as a whole.

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[Franzd'Epinay]

 

[Radetzky]

3rd do over liver transplant on ecmo waiting for an organ, bleeding from every oriface and getting 10 units of product a day just to stay the course .

Sounds like a great use of an ECMO circuit and a donated organ.

 

[GonnaBeADoc2222]

I mean sounds like great physiology and procedures...but... What are the outcomes??

 

[watermanMD]

Buddy from residency told me about a place like this. Big name institution. They just keep these bodies “alive” for months on end to pad their numbers post-transplant and maintain funding, research $, etc. Said transplant surgeons captain the ship and they (CCM) put out fires and keep rocks alive.

 

[Rekt]

Sounds like futile care to me. Sometimes humans are meant to die.

 

[JacobMcCandles]

That's no way to live.

 

[ShockIndex]

I mean sounds like great physiology and procedures...but... What are the outcomes??

Like the OP, I started out in EM and then switched over to CCM thinking that I’d pretty much seen it all. Boy was I wrong. While intensivists at community ICUs take care of bread and butter sepsis and respiratory failure, working at a quaternary center for a multistate region involves a lot of peri-operative nightmares and re-do surgeries. One of the sickest patients that I’ve ever seen was a re-do lung transplant that came out of the OR on VA-ECMO and 2 Belmonts running continuous transfusions for “coagulopathic” bleeding. Before that night, I’d never seen someone get 50 units of product in a 12-hour shift…and I say that having seen plenty of people blown in half by IEDs in Iraq.

When I first started fellowship about 4 years ago, I had a hard time adjusting to the extremely aggressive care being offered to elderly and what I thought were terminally ill patients. My wife, who is not in medicine, pointed out that much of today’s routine care such as bypass surgery and heart transplants was high-risk, cutting edge stuff 50 years ago, and it takes elite centers and patients willing to push the envelope to make today’s high-risk tomorrow’s routine care. A similar conversation with one of our CT surgery fellows made it clear that all of these disaster cases are told of the risks going into the procedure, reminded that multiple other centers had declined them, and advised their life may be limited to a few extra months with a trach/peg in an LTAC. They all sign up for it.

That being said, a lot of our ‘salvage’ procedures have expected mortality of 50-70%. My biggest concern now is the economics of it all. We are dumping millions into a single patient with no chance of ever returning to work or living independently (ie they’re 75). I jokingly tell my resident’s that many of these cases are why we have hospital administrators and insurers with MBAs to counter our MDs…they are often the only people willing to say, “no, we’re not going to pay for that ridiculous crap.”

 

[Mount Asclepius]

As someone who almost pursued a critical care fellowship in the past I jealously find these cases intellectually fascinating. Most of the EM that I actively practice now is pretty routine. Even the ‘complex’ cases in the ED.

I think the economic consideration is huge though. Our health care industry complex is unsustainable. We spend way too much money on end of life care. We (our country) can’t afford most of it. There is potentially a benefit to some of the cutting edge, but a lot of money spent on care for the dying results in increased health care expenses for the many. At some point we are going to reach a reckoning and need to make hard choices.

 

[EmergentMagician]

This is why I chose palliative fellowship (had previously entertained CC) - to be straight with patients and families. These problems are even worse on the pediatric side. That being said, there are a lot of politics at these institutions that drive behaviors. There are also some amazing CC docs out there who do great GOC conversations.

A simple statement (often times incredibly hard to actually say) of "you are coming to the end of your life" or "I worry that we are prolonging your dying and not your living" can go a long way. Frequently it takes a perceived impartial 3rd party (palliative) for the family to come around to the reality.
.

 

[skougess]

Buddy from residency told me about a place like this. Big name institution. They just keep these bodies “alive” for months on end to pad their numbers post-transplant and maintain funding, research $, etc. Said transplant surgeons captain the ship and they (CCM) put out fires and keep rocks alive.

This right here. And you will get in BIG time trouble if you initiate any sort of palliation conversation with the family before the one year post-op window is up.

 

[ShockIndex]

This is why I chose palliative fellowship (had previously entertained CC) - to be straight with patients and families. These problems are even worse on the pediatric side. That being said, there are a lot of politics at these institutions that drive behaviors. There are also some amazing CC docs out there who do great GOC conversations.

A simple statement (often times incredibly hard to actually say) of "you are coming to the end of your life" or "I worry that we are prolonging your dying and not your living" can go a long way. Frequently it takes a perceived impartial 3rd party (palliative) for the family to come around to the reality.
.

Since this thread has a quasi-spiritual connotation, I’m one of those rare “conservatives” who isn’t particularly religious or spiritual. I’m somewhere between Jeffersonian deist and agnostic with Judeo-Christian sympathies, but many Christians piss me off after a while. Having said that, I get the sense that the secularization of American society is driving a lot of this. People cling to the here and now, no matter how degrading, because they have no faith of anything better on the other side.

Despite this, I have no reservations telling families and patients that they are dying with no meaningful chance of discharge home. I’ll go on to say that the medical team can try and provide them a “blessing” of time by adding sand to the hourglass of life that is quickly running out. While I don’t know for certain how much time is left, experience leads me to believe that it will be measured in hours more than days. However, it’s certainly time that will be spent in an ICU bed and hooked up to machines. At some point, they may decide that the time is no longer a blessing and we can then stop trying to add more time, and focus on giving them a comfortable and dignified death.

I’m perfectly comfortable using terms like blessing almost in a secular sense with no real belief that anything resembling paradise or 50 virgins await.

 

[GonnaBeADoc2222]

This right here. And you will get in BIG time trouble if you initiate any sort of palliation conversation with the family before the one year post-op window is up.

Criminal and unethical

 

[DrDrummer]

Despite this, I have no reservations telling families and patients that they are dying with no meaningful chance of discharge home. I’ll go on to say that the medical team can try and provide them a “blessing” of time by adding sand to the hourglass of life that is quickly running out. While I don’t know for certain how much time is left, experience leads me to believe that it will be measured in hours more than days. However, it’s certainly time that will be spent in an ICU bed and hooked up to machines. At some point, they may decide that the time is no longer a blessing and we can then stop trying to add more time, and focus on giving them a comfortable and dignified death.

This is an excellent and elegant metaphor, thank you for sharing it. I also liked the reference above to “prolonging your dying and not your living”, and myself have often tried to invoke the difference between doing things to people rather than for people when talking to families. Such hard conversations, and it often feels like patients and families have their minds made up already with respect to goals of care and no conversation will change that (if they’re on the side of maximal intervention), only experienced or witnessed suffering.

Transplant ICUs are very gnarly places and the cases you’re describing sound particularly crazy, sad and ethically complex. All the resource utilization you’re describing aside, is pretty amazing when you see someone who would frequently come into the ER with decompensated cirrhosis who now is doing well post-transplant and the immunologic aspects of transplant medicine are getting better all the time thanks to the work that centers like that one are doing. It’ll be real interesting to see how ECMO utilization evolves over the next decade as it becomes easier and more prevalent and moves out into community hospitals. Big money, bigger ethical conundrums.

 

[eefen]

I don't know.

I'm an intensivist - trained in EM and did CCM fellowship at big tertiary/quaternary care type places with transplant patients, BMT, mechanical support, ECMO, etc. Great training, fascinating physiology, fun procedures, and occasional amazing saves.

Now I'm working in a smaller community hospital. Still take care of sick patients (not the same population as above, obviously), but I think a really important part of our job is having realistic conversation with patients/families and creating realistic plans based on established goals of care. I don't begrudge not having access to endless quaternary care resources, because if the patient has a realistic ability to be salvaged I can transfer them, but if not, I find the family and patients are often much more at peace with an honest conversation and transition in goals of care if appropriate, or at least a clear time-limited trial of more advanced therapies that allows time to process and grieve.

From a purely moral injury standpoint, the most burnt out I've been so far has been when I've been watering/gardening hopeless cases on prolonged mechanical support and dealing with unrealistic families who have been fed false hope with no tempered expectations of reality - especially when forced by surgeons or proceduralists who only seem to really care when the patient is still within whatever "window" that the mortality will count against them (obviously not all of our surgical colleagues are like this, but I've got some stories).

On the other hand, having the time (smaller shop) to have these important conversations and establish relationships with families and care for them as they go through the that process is incredibly rewarding. Sure, aggressive care and savings lives is a big part of why a lot of us go into this, but equally important is helping patients and families understand the realities and limitations of medicine, and that everything we do has risks and benefits - and sorting out for them what is, understanding all of that, worth it in their minds. And if they decide on comfort measures, caring for families and patients and providing good and intensive comfort-focused care is just as important in my mind as lining/tubing/proceduring everyone else.

 

[HemorrhagicShock]

Criminal and unethical

Oh you mean Medicine as practiced in 2024?

 

[CoolDoc1729]

As someone who almost pursued a critical care fellowship in the past I jealously find these cases intellectually fascinating. Most of the EM that I actively practice now is pretty routine. Even the ‘complex’ cases in the ED.

I think the economic consideration is huge though. Our health care industry complex is unsustainable. We spend way too much money on end of life care. We (our country) can’t afford most of it. There is potentially a benefit to some of the cutting edge, but a lot of money spent on care for the dying results in increased health care expenses for the many. At some point we are going to reach a reckoning and need to make hard choices.

I don’t even know if the money is the biggest problem - we are basically dealing in Monopoly money at this point as far as the government goes - but for the first time in all of our lives, there are not essentially unlimited healthcare resources. Every day I see a couple 70 year olds that are shocked that they have to wait for anything ; then they’re really shocked when their mom’s nursing home has 24 patients per staff member or whatever. But the scarcity (of supplies, of organs, of blood products, of all sorts of staff from doctors to nurses to clerical to housekeeping) is all going to continue to escalate until the boomers die off. There’s too many of them, they don’t work for long enough, there aren’t enough of us, the math doesn’t math.

I sympathize for the 42year old fireman who was provided as an example, and for his family, especially as the wife of a fireman, but how many people didn’t get organs so that guy could get half a dozen, and then they’re dumping in blood products like water to try to keep him alive?

I remember the talk when Obamacare was being put forward about rationing of care and about “death panels,” but it’s probably inevitable. I hope it never comes to that, but if it does, I hope there is some credence given to the opinions of the CC and palliative physicians who know what is futile better than everyone else.

 

[The Knife & Gun Club]

I don’t even know if the money is the biggest problem - we are basically dealing in Monopoly money at this point as far as the government goes - but for the first time in all of our lives, there are not essentially unlimited healthcare resources. Every day I see a couple 70 year olds that are shocked that they have to wait for anything ; then they’re really shocked when their mom’s nursing home has 24 patients per staff member or whatever. But the scarcity (of supplies, of organs, of blood products, of all sorts of staff from doctors to nurses to clerical to housekeeping) is all going to continue to escalate until the boomers die off. There’s too many of them, they don’t work for long enough, there aren’t enough of us, the math doesn’t math.

I sympathize for the 42year old fireman who was provided as an example, and for his family, especially as the wife of a fireman, but how many people didn’t get organs so that guy could get half a dozen, and then they’re dumping in blood products like water to try to keep him alive?

I remember the talk when Obamacare was being put forward about rationing of care and about “death panels,” but it’s probably inevitable. I hope it never comes to that, but if it does, I hope there is some credence given to the opinions of the CC and palliative physicians who know what is futile better than everyone else.

Yea the allocation of resources is really one of the biggest rubs in this case. The hospital pours an immense amount of resources into these patients, funded by tax payers to a large degree. You could argue the benefit to the community by having a cutting edge transplant center in your area comes back around in a way, but not 100%. In the 90s getting a liver transplant was a grievous, highly morbid surgery with abysmal survival rates and QOL.

Now we can put a liver in someone and they are walking POD 1, out of the ICU POD 2, and home with basically normal labs after being on deaths door within a week. You added 20 years to someone’s life, which is a pretty great ROI. There were a lot of “wasted resources” to get us to that place where single organ livers or kidneys can be uncomplicated and efficient.

But when I think about the people having stemis in triage waiting for hours, or the lady a coded on the floor of the waiting room during Covid because we were 200% of capacity - I just am not sure, honestly, where the greater return on investment would be. How many healthy living years could we provide our community if we staffed an ED, floor, rehab appropriately. Probably a lot.

And like @ShockIndex said - most of these quaternary center patients have been given a very earnest assessment of the very low likelihood of success in their cases. But I also wonder if they “understand” what it means to maybe have your life extended 6 months but that it will be in an ICU or LTACH maybe never getting to see the sun again. The patients are desperate, and looking for hope, so may not hear just how bleak a forecast they’re facing if the guy in the white coats still says “there’s a chance.”

 

[The Knife & Gun Club]

I sympathize for the 42year old fireman who was provided as an example, and for his family, especially as the wife of a fireman, but how many people didn’t get organs so that guy could get half a dozen, and then they’re dumping in blood products like water to try to keep him alive?

Actually not that many - outside of liver and kidney the rest of the abdominal organs are not particularly scarce or tough to come by.

Pancreas doesn’t tolerate transplant well alone so is reserved for special cases, and neither does the small Bowel/stomach/colon. Spleens are never transplanted alone.

So there’s not really a significant “waste” from an organ standpoint. It’s basically they’re doing a liver transplant but because the surgeons can’t effectively separate the donor liver from the mesentery/other abdominal contents they just remove the entire abdominal cavity en-bloc and replace it with a new one.

 

[Birdstrike]

I’m incredibly proud of my EM training. As y’all know I’m now on the other side of the admit phone taking Critical Care admits at various sites. By and large the busiest days in trauma, surgical, medical ICU are a (complex, intellectually exciting) breeze compared to a shift in the pit.

But I’ve finally found a unit that’s got us beat. Transplant surgery ICU. Patients so medically fragile the wire from an IJ can put them into VTACH. Either immediately pre or post enormous surgical operations with such grievous injury that’s not even fathomable.

27 beds. We've got 4 multi-visceral transplants on the rack right now. Fresh out of the OR with a “total abdominal exenteration” and combined liver/spleen/pancreas/stomach, small, and large bowel transplant. Devastated immune systemss with sepsis from disseminated HSV. 3rd do over liver transplant on ecmo waiting for an organ, bleeding from every oriface and getting 10 units of product a day just to stay the course . Massive PE in the setting of active variceal GI bleed that the gi squad can’t control. I’ve got an aorta transplant (dual aortic circulation) where if one aorta starts to steal from the other due to hemodynamics and the transplanted vs native organs start to get ischemic.

All this is to say I’ve been in search for a long time for a gig that takes EM on face to face for acuity, high stakes, and volume. This may just be it.

One final story. A firefighter getting a liver/spleen/pancreas/stomach/intestine transplant for pancreatic benign mass encasing the IVC. VV ecmo running after the trip to the OR. Negative flow from the ecmo ripped apart the IVC anastomosis and had a suck down event with air entering the circuit. MTP of 144 PRBC, 110 FFP, 40 Cryo and 40 platelets. The donor pancreas and liver died. This guy is awake and talking. He tells me he can feel his organs dying and knows it won’t be long. We wait with the family, but they all know how this is likely the end for this 42 year old father of two. Give daddy a hug, he’s going in and out of vtach and he’s #3 on the list.

I’ve never seen anything like this and just wanted to share. It’s a world far insulated from EM or even medicine as a whole.

Do you enjoy this work?

 

[Groove]

The only thing I envy after reading OP's post is that level of resident/fellow/new attending hypomanic excitement. I'm sure I had that at one time but damn....I get tired just trying to remember how I tapped into that, lol.

Echmo and over ~300 blood products on a dude who is likely middle class income and spotty health insurance? Yikes. Man, let me go already. Palliative Care consult and save all that stuff for someone else with better odds. Who pays for all of that? There's no way his estate will cover it after he dies. God forbid his spouse gets sent any of the bills.

Man, I'm so glad I didn't do CCM. I'm glad you guys are enjoying it though. To each their own. It can't be all chocolates and roses though because you guys are only 10% below us on that physician burnout report with a solid 55%.

 

[ProReduction]

Since this thread has a quasi-spiritual connotation, I’m one of those rare “conservatives” who isn’t particularly religious or spiritual. I’m somewhere between Jeffersonian deist and agnostic with Judeo-Christian sympathies, but many Christians piss me off after a while. Having said that, I get the sense that the secularization of American society is driving a lot of this. People cling to the here and now, no matter how degrading, because they have no faith of anything better on the other side.

Despite this, I have no reservations telling families and patients that they are dying with no meaningful chance of discharge home. I’ll go on to say that the medical team can try and provide them a “blessing” of time by adding sand to the hourglass of life that is quickly running out. While I don’t know for certain how much time is left, experience leads me to believe that it will be measured in hours more than days. However, it’s certainly time that will be spent in an ICU bed and hooked up to machines. At some point, they may decide that the time is no longer a blessing and we can then stop trying to add more time, and focus on giving them a comfortable and dignified death.

I’m perfectly comfortable using terms like blessing almost in a secular sense with no real belief that anything resembling paradise or 50 virgins await.

I've had the total opposite experience in critical care. I've found that secular/atheist/humanist (usually skew more educated) families are much more comfortable with death than hyper-religious families. Hyper-religious families will frequently cling to "God can still save him", whereas secular families had to deal with the fragility and finite nature of life (in the non metaphysical sense) long ago.

 

[The Knife & Gun Club]

Do you enjoy this work?

I like ICU, and really love normal Surigcal ICU type of work. Unlike the ED, surgical ICU Pts come in with a defined problem, a semi-planned large physiologic insult, and you know what baseline you are trying to get them back to.

There’s no pressure to dispo, social issues, malignerers, or people putting on a show. You know their major problem upfront, and the skill set which we have as EM docs pairs very well for recognizing when things are going wrong vs expected course.

I personally couldn’t do the transplants forever - it’s fascinating but the moral injury is quite significant

 

[The Knife & Gun Club]

The only thing I envy after reading OP's post is that level of resident/fellow/new attending hypomanic excitement. I'm sure I had that at one time but damn....I get tired just trying to remember how I tapped into that, lol.

Echmo and over ~300 blood products on a dude who is likely middle class income and spotty health insurance? Yikes. Man, let me go already. Palliative Care consult and save all that stuff for someone else with better odds. Who pays for all of that? There's no way his estate will cover it after he dies. God forbid his spouse gets sent any of the bills.

Man, I'm so glad I didn't do CCM. I'm glad you guys are enjoying it though. To each their own. It can't be all chocolates and roses though because you guys are only 10% below us on that physician burnout report with a solid 55%.

Very true words. I often fear I’m out here chasing that fleeting rush of the first intubation/resus that we can’t really ever get back.

I’ve got an old selfie saved on my phone from the day I decided to do EM as a little MS2. Hair all messed up, eyes wide after a 12 hr shift doing what I’m sure was useless nonsense but at the time was my best day in medicine.

That fire always fades and I did CCM to try and find a more stable semi normal “job” so that I can do EM as a side passion. I’m happy with my setup at least for now as a CCM fellow with some ED attending shifts sprinkled in. But who knows what the job market holds 🤞

 

[Dr Mantis Toboggan]

I've had the total opposite experience in critical care. I've found that secular/atheist/humanist (usually skew more educated) families are much more comfortable with death than hyper-religious families. Hyper-religious families will frequently cling to "God can still save him", whereas secular families had to deal with the fragility and finite nature of life (in the non metaphysical sense) long ago.

My old boss had a great line for the hyper-religious, delusional about their loved ones prognosis types:
“God doesn’t need machines to work miracles.”

 

[Apollyon]

I've had the total opposite experience in critical care. I've found that secular/atheist/humanist (usually skew more educated) families are much more comfortable with death than hyper-religious families. Hyper-religious families will frequently cling to "God can still save him", whereas secular families had to deal with the fragility and finite nature of life (in the non metaphysical sense) long ago.

I knew a guy in SC over 30 years ago who wouldn't wear a seatbelt, because, he said, "God will save me". I asked him, "Then why did God let someone invent them?" He didn't have an answer.

He's dead now. (Natural causes, not MVC)

 

[RustedFox]

My old boss had a great line for the hyper-religious, delusional about their loved ones prognosis types:
“God doesn’t need machines to work miracles.”

But God works in mysterious ways.

 

[dozitgetchahi]

Buddy from residency told me about a place like this. Big name institution. They just keep these bodies “alive” for months on end to pad their numbers post-transplant and maintain funding, research $, etc. Said transplant surgeons captain the ship and they (CCM) put out fires and keep rocks alive.

Totally agree.

One of the hospitals we covered as a resident had a very active liver and kidney transplant program. When I rounded on other services in that hospital, I grew to resent the fact that the transplant teams basically seemed to see every other service in that hospital as existing to keep their “Frankensteins” alive until the end of whatever window they had to get them…I can remember doing a Heme consult on some unfortunate liver tx disaster who had been continuously hospitalized for something like 11 months, and then one of the days we went to go see the patient we were told that the pt had just gone on hospice…the “window” had closed the day before, and the transplant surgeons had lost interest at that point…

 

[CajunMedic]

But God works in mysterious ways.