Why I do Critical Care

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seinfeld

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The idea of doing Critical Care to some in the Anesthesia world is a nuisance. Some residents will dread the ICU months and in actuality for good reason. You get pummeled with scut work, long overnight calls and hours of pedantic rounding and re-rouding. You take care of patients transiently and never have ownership over the outcome.

Last week I had one of those cases that makes you glad to be a doctor, and for me, glad to be an Intensivist.

59 y/o WF with hx of breast CA and who is 4 wks s/p fibular fracture passes out at work. EMS brings her into the emergency and the ED docs promptly start heparin and send her to the CT scanner. I get a call from ED doc "Is this the ICU doc on call?" "Yes" i reply. "Well i have a lady down here with a saddle embolus on her CT scan and since she has returned from the study i have not been able to get BP, can you come help me?"

Long story short I get there she has a femoral pulse but CUFF not reading, I order TPA, Call interventional Cardiologist. I place a central line start some emperic norepi and dobutamine and then a left femoral ALine after failed attempts at radial even with U/S.

She goes PEA moments later. 2 rounds of EPI/Atropine, 40 of vaso she comes back. Off to cath lab where they do some mechanical clot busting.

Next morning I extubate her.

The most fulfilling part of all of this, was how grateful the family and the patient were. To her i was her doctor and i saved her life (something she and her husband tell me). Her husband probably thanked me 20 times over 2 days.

Today i followed up to see how she was doing now that she was out on the floor and I had some time b/w anesthetics. She looked great on a 2L NC. She thanked me once again.

Often in anesthesia we are the offensive lineman of surgery. We make it happen but never get the credit from the nurses or more importantly the patients. This was an opportunity to get to see how the quarterback feels.

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The idea of doing Critical Care to some in the Anesthesia world is a nuisance. Some residents will dread the ICU months and in actuality for good reason. You get pummeled with scut work, long overnight calls and hours of pedantic rounding and re-rouding. You take care of patients transiently and never have ownership over the outcome.

Last week I had one of those cases that makes you glad to be a doctor, and for me, glad to be an Intensivist.

59 y/o WF with hx of breast CA and who is 4 wks s/p fibular fracture passes out at work. EMS brings her into the emergency and the ED docs promptly start heparin and send her to the CT scanner. I get a call from ED doc "Is this the ICU doc on call?" "Yes" i reply. "Well i have a lady down here with a saddle embolus on her CT scan and since she has returned from the study i have not been able to get BP, can you come help me?"

Long story short I get there she has a femoral pulse but CUFF not reading, I order TPA, Call interventional Cardiologist. I place a central line start some emperic norepi and dobutamine and then a left femoral ALine after failed attempts at radial even with U/S.

She goes PEA moments later. 2 rounds of EPI/Atropine, 40 of vaso she comes back. Off to cath lab where they do some mechanical clot busting.

Next morning I extubate her.

The most fulfilling part of all of this, was how grateful the family and the patient were. To her i was her doctor and i saved her life (something she and her husband tell me). Her husband probably thanked me 20 times over 2 days.

Today i followed up to see how she was doing now that she was out on the floor and I had some time b/w anesthetics. She looked great on a 2L NC. She thanked me once again.

Often in anesthesia were are the offensive lineman of surgery. We make it happen but never get the credit from the nurses or more importantly the patients. This was an opportunity to get to see how the quarterback feels.

:thumbup::thumbup:
 
The idea of doing Critical Care to some in the Anesthesia world is a nuisance. Some residents will dread the ICU months and in actuality for good reason. You get pummeled with scut work, long overnight calls and hours of pedantic rounding and re-rouding. You take care of patients transiently and never have ownership over the outcome.

Last week I had one of those cases that makes you glad to be a doctor, and for me, glad to be an Intensivist.

59 y/o WF with hx of breast CA and who is 4 wks s/p fibular fracture passes out at work. EMS brings her into the emergency and the ED docs promptly start heparin and send her to the CT scanner. I get a call from ED doc "Is this the ICU doc on call?" "Yes" i reply. "Well i have a lady down here with a saddle embolus on her CT scan and since she has returned from the study i have not been able to get BP, can you come help me?"

Long story short I get there she has a femoral pulse but CUFF not reading, I order TPA, Call interventional Cardiologist. I place a central line start some emperic norepi and dobutamine and then a left femoral ALine after failed attempts at radial even with U/S.

She goes PEA moments later. 2 rounds of EPI/Atropine, 40 of vaso she comes back. Off to cath lab where they do some mechanical clot busting.

Next morning I extubate her.

The most fulfilling part of all of this, was how grateful the family and the patient were. To her i was her doctor and i saved her life (something she and her husband tell me). Her husband probably thanked me 20 times over 2 days.

Today i followed up to see how she was doing now that she was out on the floor and I had some time b/w anesthetics. She looked great on a 2L NC. She thanked me once again.

Often in anesthesia were are the offensive lineman of surgery. We make it happen but never get the credit from the nurses or more importantly the patients. This was an opportunity to get to see how the quarterback feels.
)

Yes - this is why I love EM and hope to start CCM soon.

I have had nearly identical cases twice before. The more satisfying of the two was a 45F PMHx unknown coagulopathy - off coumadin for unknown reasons who was in-n-out of PEA arrest (transient pllsVT) and ROSC with weak pulses...classic McConnell's when ROSC - tpa eventually successful - after a period of 2-3 hours of pressors and a bit of dobutamine, she was off all. Extubated the next day (following commands soon after last ROSC = no hypothermia) and only complaining of central chest pain (ttp) consistent with multiple rounds of aggressive chest compressions. Family and patients crazy grateful.

This was when I was a resident (have only been an attending for a little bit), but it is one of the reasons why I now push resus skills on our EM residents and why I think that peri-arrest CCM is so important for EM residents to learn (even though many still think this is stuff that CCM should do; it's rare for a place to have a doc like Seinfeld to show up in the ED during a resus or even within three hours of arrest).

HH
 
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great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it
 
most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

This is how i feel too, in CCM you'll get a couple of saves but the majority is what is stated above.

Congrats for the good work though.
 
great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

I agree....it's people like you who should NEVER do critical care.
 
great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

Although i agree that some of my time is spent being a palliative care doctor (which is frustrating since it is not what I trained for or intended to do for a career) its the humanity of doing critical care that keeps me going. It the conversation about how wonderful a mother or father they have been with their children, its seeing old pictures where the now middle ages children were knee high to a grasshopper that places the context of life in perspective. The reason i posted this case was that it was different, i helped some be with their family an unknown meaningful (key word) amount of time. Being a spouse and a dad, if i could have 1 more meaningful day with my loved ones I suffer to do so. This was not terminal cancer this was remission with low likelihood of recurrence.

Your post does contain truth but I fear you have lost sight of why we do what we do. I have been forced to do anesthetics on patients, ie hip fracture repairs on the demented and bed bound, so how different is that from keeping alive an 85 year 4 more days so the family came come to term with the eventuality of life?

Your arrogance and disregard for the frailty of the human condition is disheartening, especially since i am supposed to refer to you as a colleague. Why do you do acute medicine at all? Everything we do in the Anesthesia world except elective plastics is secondary to a slowly evolving process, vascular surgery is the most obvious example.

If comments like your become pervasive then we as Physicians will never have a place in the hearts of our patients and therefore will not be listened to when tough decision about the cost of healthcare have to be made. Your comment personifies the rich arrogant doctor who does not care about the humanity of our patients.
 
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great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

Maybe he did give this lady with metastatic breast cancer only six more months.
Maybe in those six months, she'll go to Europe and see the Louvre.
Maybe in those six months she will see a new grandchild born.
Maybe she'll have some more date nights with her husband where they'll get to recall why they love each other so much.

Don't discount an extra six months on the end of someone's life, especially when they still have their mental faculties remaining.

Maybe it was her time to go. But since Seinfeld was there, it wasn't.
 
great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

There's definitely some truth to this for a lot of cases in the SICU. Seinfeld's case IS NOT one of them. Get a clue.
 
Although i agree that some of my time is spent being a palliative care doctor (which is frustrating since it is not what I trained for or intended to do for a career) its the humanity of doing critical care that keeps me going.

Do you ever really spend time being a palliative care doctor in the ICU? From my experience, which is not much, it seems to be the exact opposite.

Not that it seems to be the case with this lady since you said she simply had a hx of breast CA and was sp fibular fracture but the SICU at my insitution seems to keep people alive just because they can, especially the transplant patients who can't even halt the aggressive care even if they want to. It seems that keeping some of the people alive for those six months that were discussed borders on torture. From what Ive seen, if someone is in the SICU for more than a couple of weeks, theyre either coming back to the unit soon or they are not leaving until God comes knocking. I mean no disrespect to what you do but I guess the question I'm coming to is are these patients just as prominent at private practice units as they are at academic institutions or is it that I am just seeing the sickest of the sick day in and day out?
 
I think it's easy to become callous about things in this career setting.

I've reflected on end of life issues recently and I think the will to live, even as we outsiders may perceive that life as being extremely poor quality, is extremely strong. It must be, because aside from the bed bound/vent-dependent patients we often see in the units, plenty of others deal with terminal illness in ways that shed light on the human will to survive. It's telling in some ways how perhaps the "instinct" to LIVE manifests itself every day. I think a lot of the time we become desensitized to it. I know I have in the past, and I need to remind myself of this.

Clearly, modern medicine is at a crossroads in many societies. People are living longer and technologies (albeit expensive ones) exist which does prolong life and even improves quality of life (or at least CAN). We all struggle with the issue of resource allocation, however, and these are problems that are coming our way as we become less of a "rich" nation. How will be pay for it all?
 
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Do you ever really spend time being a palliative care doctor in the ICU? From my experience, which is not much, it seems to be the exact opposite.

Not that it seems to be the case with this lady since you said she simply had a hx of breast CA and was sp fibular fracture but the SICU at my insitution seems to keep people alive just because they can, especially the transplant patients who can't even halt the aggressive care even if they want to. It seems that keeping some of the people alive for those six months that were discussed borders on torture. From what Ive seen, if someone is in the SICU for more than a couple of weeks, theyre either coming back to the unit soon or they are not leaving until God comes knocking. I mean no disrespect to what you do but I guess the question I'm coming to is are these patients just as prominent at private practice units as they are at academic institutions or is it that I am just seeing the sickest of the sick day in and day out?

Much of my experience in training is as you describe.My SICU tends to still have this element but i have found PP surgeons are more realistic about outcomes once they see downward spiral. When i started in private practice I decided I would discuss openly with patients families the perception of recovery. But that discussion comes at the appropriate time. I dont discuss end of life care with first time intubated COPDs but when they get extubated I do inform them of the natural progression of the disease and how they will likely be back. If its the 3rd time in 6 months intubated then I have frank and open discussions about the prospect of meaningful recovery and how they will likely die in a chronic vent facility, but i still provide all the therapy i possible can to get them extubated. Once they fail therapy i sit down with the family and ask "what was your Dad like?, what would he have wanted? " My most used line is "I believe that it is be time to change the focus of hope. We have been hoping for recovery but there is nothing more i can do, I dont want your "dad" to suffer at the hand of my treatments, its time to ensure for a peaceful passing". Interesting a palliative care study found that patient who opt for palliative care at the end of life tend to live an average of 3 months longer. Surgeons have a tough time addressing theses issues because they, in most cases, created the situation. If you perforated the Common Bile duct during a Lap Chole and the patient got septic you too would be hoping that the patient doesnt die.

The media continues to perpetuate they idea that medicine can cure. In reality there is very little we ever cure, we provide the body with support so it can heal.

I too believe that real question the politicians should be asking is how can we cut the cost of care without addressing the benefit of care at the end of life. For us physicians liability reform is key. We need more support in saying no.

In the case i described, she was actually a young patient with a good life expectancy, I would give it my all everytime.
 
Much of my experience in training is as you describe.My SICU tends to still have this element but i have found PP surgeons are more realistic about outcomes once they see downward spiral. When i started in private practice I decided I would discuss openly with patients families the perception of recovery. But that discussion comes at the appropriate time. I dont discuss end of life care with first time intubated COPDs but when they get extubated I do inform them of the natural progression of the disease and how they will likely be back. If its the 3rd time in 6 months intubated then I have frank and open discussions about the prospect of meaningful recovery and how they will likely die in a chronic vent facility, but i still provide all the therapy i possible can to get them extubated. Once they fail therapy i sit down with the family and ask "what was your Dad like?, what would he have wanted? " My most used line is "I believe that it is be time to change the focus of hope. We have been hoping for recovery but there is nothing more i can do, I dont want your "dad" to suffer at the hand of my treatments, its time to ensure for a peaceful passing". Interesting a palliative care study found that patient who opt for palliative care at the end of life tend to live an average of 3 months longer. Surgeons have a tough time addressing theses issues because they, in most cases, created the situation. If you perforated the Common Bile duct during a Lap Chole and the patient got septic you too would be hoping that the patient doesnt die.

The media continues to perpetuate they idea that medicine can cure. In reality there is very little we ever cure, we provide the body with support so it can heal.

I too believe that real question the politicians should be asking is how can we cut the cost of care without addressing the benefit of care at the end of life. For us physicians liability reform is key. We need more support in saying no.

In the case i described, she was actually a young patient with a good life expectancy, I would give it my all everytime.

Yeah, this is true. Also, I've seen surgeons take a personal stake in a case that WAS going well via their interventions but then take a turn for the worse for any number of reasons. I think we tend to forget this dynamic sometimes and surgeons aren't generally going to communicate that.
 
Congratulations to all for not turning this into a heated back-and-forth with the hostile poster above.

There's no doubt that critical care is expensive and that the lion's share of the money is spent on people at the very beginning of a life that started too early and at the very end of a life that's gone on too long. As much as we all acknowledge that this is wasteful, I have to admit, it's hard, and probably inappropriate or unethical, to incorporate those feelings/considerations into an individual patient encounter. The day will come, I suppose, when physicians will be incentivized to ration (payments will be capitated, or there will be quality bonuses that favor not providing such care), but I hope I'm wrong. These considerations need to take place at a societal level.

What is the elderly patient's last month worth to SOCIETY? And should that even be the bar? Do the taxpayers care if some old guy has an extra month to spend with his family? Are they the arbiter just because it's their tax dollars that fund such care? We have the QALY as a unit of cost-effectiveness; should we just not do stuff that has a dollar-per-QALY ratio above some level? Should that become society's expectation? Are people really able to put themselves in their neighbors' shoes, or think long-term enough to consider that, one day, it's THEIR father on the block? I think about these things a lot and don't have any good answers.
 
Your arrogance and disregard for the frailty of the human condition is disheartening, especially since i am supposed to refer to you as a colleague. Why do you do acute medicine at all?

Well said. People like this are an embarrassment to the institution of Medicine - and Anesthesiology. My father was saved from a PE and a year later passed away peacefully in hospice from NSCLC. We cherished every day between the two events as did he. He saw his last grandchild and namesake born and experienced many joyful occasions in that year. I hope you really think about what you wrote and if you mean it and aren't embarrassed after re-reading it please reconsider your career choice. I feel sorry for any patient unlucky enough to have you as a "Dr".
 
Congratulations to all for not turning this into a heated back-and-forth with the hostile poster above.

There's no doubt that critical care is expensive and that the lion's share of the money is spent on people at the very beginning of a life that started too early and at the very end of a life that's gone on too long. As much as we all acknowledge that this is wasteful, I have to admit, it's hard, and probably inappropriate or unethical, to incorporate those feelings/considerations into an individual patient encounter. The day will come, I suppose, when physicians will be incentivized to ration (payments will be capitated, or there will be quality bonuses that favor not providing such care), but I hope I'm wrong. These considerations need to take place at a societal level.

What is the elderly patient's last month worth to SOCIETY? And should that even be the bar? Do the taxpayers care if some old guy has an extra month to spend with his family? Are they the arbiter just because it's their tax dollars that fund such care? We have the QALY as a unit of cost-effectiveness; should we just not do stuff that has a dollar-per-QALY ratio above some level? Should that become society's expectation? Are people really able to put themselves in their neighbors' shoes, or think long-term enough to consider that, one day, it's THEIR father on the block? I think about these things a lot and don't have any good answers.

I think as a society we really need to have this "discussion". No easy feat, I agree completely. This will become hugely political if we see any such "rationing".

I don't know, though, if we'll see incentives as such but rather the large payers will simply set guidelines for qualifying for an intervention. If you don't meet the criteria, then you'll be out. After all, not everyone with liver disease qualifies for a transplant. Sadly, any "committees" or working groups/consultants will be called "Death Panels" by a lot of people.

For starters we could save a lot of money by utilizing EBM for god's sake. That alone would save billions per year.
 
For starters we could save a lot of money by utilizing EBM for god's sake. That alone would save billions per year.

Sure, but whose "E" are we going to use? Remember when we thought it was a good idea to give hormone replacement to women during menopause, and how now we think it kills them? Or when the evidence suggesting to give steroids to septic patients? Or Beta-Blockers to people having surgery (anyone see Don Poldermans was fired for academic dishonesty)? I don't want to hijack the thread, but I'm starting to think EBM is a myth, and I certainly think that tying incentives or payments to adherence to whatever passes as EBM in any given year has the potential to do as much harm as good, inasmuch as EBM seems often to miss the mark of what actually saves patients' lives.
 
Listen slim everyone gets bitter and jaded in residency. Don't let it consume you though. We have all seen our fair share or futile care and gomers wasting away in the ICU. Personally, I enjoyed reading the OP's post.

great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it
 
One of the central issues I have with the whole concept of EBM is that "expert opinion" is just about as low as you can go on the evidence pole, but who decides which studies are incorporated into the meta-analyses and the medical society guidelines (eg the AHA, ACC, ACP etc), but so-called experts. Granted, I think that it's all we have to go with, in addition to reading and deciding for yourself, but it's far from the beacon of purest intellectual expression that's its sometimes touted to be.
 
"Why I do Anesthesia" Yesterday I had a difficult airway in the ER that I was able to fiberoptically intubate and saved the guys life!! yay!! - this is essentially the OPs post ..

I dont thnk its fair to pick through the 99% of the mundane activities that you actually do day to day, and focus on the random outliar that happens 1-2x/year and say THIS is the reason to do this specialty.. would make for a pretty miserable profession if i felt like this ..

Take a look at the other 99% of the time when you are unable to intubate/do a procecure, dealing with less exciting cases, dealing with production pressure/surgeons etc... then tell me you like anesthesia once you can deal with these things and ill buy it

I was trying to offer a more real perspective on the 99% of time youll spend in the unit. I personally wouldnt go into the ICU expecting to save many functional peoples lives.

And I dont know why im taking such flac for being arrogant or not caring, it is the fact that I AM caring about the misery/unnecessary suffering of these terribly sick people that i DONT want them intubated, ventilated, poked for labs, line changes, medicated, etc... let them die with some peace and some dignity - regardless of cost, no one is talking about rationing or death squads.. just use your common sense and do what is right by people - and I think our ICUs do a terrible job at this right now and if your not part of the solution as a unit attending you are part of the problem

here a personal story ....

my grandfather was 87, recently put on coumadin for a stent in his leg for developing PVD, fell at church (literally) and had a massive SDH and stays down, he was also on plavix, aspirin, nsaids...

i am a college senior, neurosurg doc talks to my uncle and I over phone, basically says craniotomy is his only hope of survival, of course we say proceed, "its his only hope of survival" anyway, the evacuation went well, and all the numbers/scans looked good but he rebled, he never woke up or came off the vent and on POD 2 when we all were able to make it to town we had the pleasure of seeing him terminally extubated and subsequently gasp violently for air for ~20-30 minutes before his resp. muscles got tired and he gave up and my whole family was traumatized .. thanks ICU .. they should have told us from the start he has low chance of survival, and not advised the operation, I KNOW this all still goes on today in the unit - no one tells it to the families like it is.. its not the "crazy" family its the disconnected doctor most of the time and i dont want to be a part of this broken system
 
I KNOW this all still goes on today in the unit - no one tells it to the families like it is.. its not the "crazy" family its the disconnected doctor most of the time and i dont want to be a part of this broken system

It sounds like you had a bad experience, but this is not exactly the OP's scenario, and that's not how I dealt with those scenarios as a resident. For each story about a patient whom I thought we shouldn't be advancing our care, I have another story about a family who was unnecessarily extending the life of a loved one, against the suggestions of physicians.

More importantly, you can't let that one personal experience color every future clinical interaction with patients. Your story has very little to do with the OP's post, aside from the fact that they both occurred in an ICU. Every 59 y/o with a hx of breast cancer is not "terminal", and they don't all have mets. By suggesting we let basically everyone with a critical injury die, you are playing god as much as the most aggressively life-sustaining ICU doctor, you are just looking for a different outcome.

I have a similar story to yours. Someone very, very close to me had a VFib arrest a year ago. Resuscitated, he was transported to the ICU and awaited a CABG. He had been adjusting his coumadin dosein the weeks leading up to this event to help with some bleeding difficulties, and while in the ICU, in front of my eyes, stroked. Never got his CABG scheduled for the next day, instead got an emergent hemicraniectomy. Although I wasn't told this, I can imagine absolutely no one expected him to survive. Within 3 days of this event, on my way back home, with half his calvaria in a freezer and an ET tube down his throat, he reached for my head to hug, then managed to scribble on a piece of paper and ask me if I would be flying back first class. At that exact moment, I knew that whatever may become of his body, his personality, and the father I knew, would be just fine.

It's been a rough year since then, full of adjustments for everyone, but he has enjoyed watching me advance in my profession, and has enjoyed seeing his grandchildren grow up on the computer and in person. Even after he made it out of the hospital. I never that he would make it another year. It's been 14 months now., and he continues to steadily improve, but more importantly, I am glad that I have had this time with him, and that he will now be more than just a man in pictures to my children.

So yeah, everyone who reads this forum understands that our job is mostly boring, and that we lose as many people as we save, and that medicine as it currently stands in this country needs to be fixed on many levels. But the OP was proud of one moment in his career where he was presented with an opportunity to save a woman's life, and performed remarkably well to do just that. That would have been enough, but the gratitude of the family for his efforts was the icing on the cake. It is the rare moments like this that keep many of us working the other 99% of the time. Do you think Aaron Rodgers chose to become a football player because he enjoys practice? Hell no. He wanted to win the Super Bowl. Those 60 minutes of his football career probably represent .0001% of his time in football, but I bet he would tell you that's exactly why he chose to play football.

~sorry for the long post.
 
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The media continues to perpetuate they idea that medicine can cure. In reality there is very little we ever cure, we provide the body with support so it can heal.

This is very true but it's not just "the media" i think a lot of doctors like to think that they cure/save people.
 
Last week I had one of those cases that makes you glad to be a doctor, and for me, glad to be an Intensivist.

Great story, one of the reasons that I'm drawn to CCM. I've been a small part of a lot of similar stories (as an RT), but I want to play a bigger role in them.

There's no doubt that critical care is expensive and that the lion's share of the money is spent on people at the very beginning of a life that started too early and at the very end of a life that's gone on too long.

I like the way you worded that... I might have to steal it as my own! :D

Listen slim everyone gets bitter and jaded in residency. Don't let it consume you though. We have all seen our fair share or futile care and gomers wasting away in the ICU. Personally, I enjoyed reading the OP's post.

Arch, are you funneling your inner Jet? :laugh:
 
It sounds like you had a bad experience, but this is not exactly the OP's scenario, and that's not how I dealt with those scenarios as a resident. For each story about a patient whom I thought we shouldn't be advancing our care, I have another story about a family who was unnecessarily extending the life of a loved one, against the suggestions of physicians.

More importantly, you can't let that one personal experience color every future clinical interaction with patients. Your story has very little to do with the OP's post, aside from the fact that they both occurred in an ICU. Every 59 y/o with a hx of breast cancer is not "terminal", and they don't all have mets. By suggesting we let basically everyone with a critical injury die, you are playing god as much as the most aggressively life-sustaining ICU doctor, you are just looking for a different outcome.

I have a similar story to yours. Someone very, very close to me had a VFib arrest a year ago. Resuscitated, he was transported to the ICU and awaited a CABG. He had been adjusting his coumadin dosein the weeks leading up to this event to help with some bleeding difficulties, and while in the ICU, in front of my eyes, stroked. Never got his CABG scheduled for the next day, instead got an emergent hemicraniectomy. Although I wasn't told this, I can imagine absolutely no one expected him to survive. Within 3 days of this event, on my way back home, with half his calvaria in a freezer and an ET tube down his throat, he reached for my head to hug, then managed to scribble on a piece of paper and ask me if I would be flying back first class. At that exact moment, I knew that whatever may become of his body, his personality, and the father I knew, would be just fine.

It's been a rough year since then, full of adjustments for everyone, but he has enjoyed watching me advance in my profession, and has enjoyed seeing his grandchildren grow up on the computer and in person. Even after he made it out of the hospital. I never that he would make it another year. It's been 14 months now., and he continues to steadily improve, but more importantly, I am glad that I have had this time with him, and that he will now be more than just a man in pictures to my children.

So yeah, everyone who reads this forum understands that our job is mostly boring, and that we lose as many people as we save, and that medicine as it currently stands in this country needs to be fixed on many levels. But the OP was proud of one moment in his career where he was presented with an opportunity to save a woman's life, and performed remarkably well to do just that. That would have been enough, but the gratitude of the family for his efforts was the icing on the cake. It is the rare moments like this that keep many of us working the other 99% of the time. Do you think Aaron Rodgers chose to become a football player because he enjoys practice? Hell no. He wanted to win the Super Bowl. Those 60 minutes of his football career probably represent .0001% of his time in football, but I bet he would tell you that's exactly why he chose to play football.

~sorry for the long post.

:thumbup:
 
Great story, one of the reasons that I'm drawn to CCM. I've been a small part of a lot of similar stories (as an RT), but I want to play a bigger role in them.



I like the way you worded that... I might have to steal it as my own! :D



Arch, are you funneling your inner Jet? :laugh:

I was thinking the SAME thing!:laugh::laugh::laugh:
 
A bit of a deviation from the OP, but not entirely.... Just last year, as an intern on call in the SICU by myself, mind you, this family who's son, brother, and husband had a massive stroke status post CABG/Maze decided to have a "weaning" discussion WITH ME, and (I kid you not) at 2 a.m. (we don't have visitation limitations or hours at the place I work much to our dismay and surely the nurses)

The reason they had been there so late was because they had been "thinking" about weaning for days, and that day was SUPPOSED to be the day... This guy was 54......

I took care of this guy for about 2 1/2 weeks straight after he came to the unit. The stroke was discovered something like POD1 because, well, he just wasn't responding. His GCS was like a 5t. Imaging showed evidence of massive ischemic infarct (forgot the exact anatomy). So, s/p multiple neuro "consults", repeat imaging, EEG.... Repeated discussions regarding extremely poor prognosis and permament vent dependence...

So, again, I'm the dude who's seeing this guy day in and day out. CV surgeon rarely around at this point. Rounding intensivists that month were rotating probably more than usual so not as much continuity there. I get to know the guys whole family. Great people. Kind of simple folks but good peeps. You know the type. Wife keeps saying how she KNOWS her husband wouldn't want to go on like this, but family (I got the impression rather religious but not to knock religion I think they were also just overly "hopeful"). So, they were making (as truly nices as they all were) the wife look like the Grim Reaper. I'm sure you've all seen this before. So, the wife keeps delaying terminal wean each day. Days go on and on......

Now it's 2 a.m. and they as the Doc (this is August of intern year) to chat in the conference room......... Oh ****, I'm thinking. Again, they trusted me the most since, hell, I was the dude with Dr. on my badge that they saw the most.... Not even sure they fully realized what a resident is, though I know I did tell them I was a resident.

So, the dudes sister is bauling her eyes out. Dad has this look of despair in his watery eyes that I almost couldn't even look at. Mom, the same. Brother is keeping it somewhat together. Wife looks as distraught as a person can be...... Again, you've all seen this, but it was new to me at the time...

I ALMOST lost it, it was so f.cking sad. Worst of all they asked me "how he would die"... Incidentally, I think just on my previous call, I had to pronounce a dude dead, and we terminally weaned while I watched right there (only took about 10 min, thankfully). So, I knew how someone often will die.

They wanted to know if they could/should be there when we wean him off the vent. I explain (holding back serious emotions, likely greatly exacerbated by a lack of sleep) that he wouldn't feel any pain but that it's not always a comfortable thing to watch (and they pressed, so I HAD to explain the breathing issue...). It was a nightmare.

Worse is the fact that they had told me about everything about this guy whom I had only seen as a vent-dependent "vegetable". Apparently he was a great guy. Big heart. Huge animal lover. Loved at work.... etc etc. The big heart/will do anything for someone in need part really "took".

Wow. That was a tough one. Ultimately, my month was over, dude still on a vent but ultmately he was terminally weaned about 2 weeks later......

Point? Not sure I have one other than it's easy to see how a couple days turns into a couple weeks and then a few months or more in some cases.

I do think it's important, though, for an attending (surgeon or intensivist) to have a FRANK discussion with families about prognosis. AND, even a discussion amongst the myriad of consultants should have taken place so that they were speaking with as much of a unified voice as possible.
 
I would like to thank everyone for the great thread.

Seinfeld, Did you have any problems finding the job you were looking for? Do you work with pulm/cc or no? What are your thoughts about the anesthesia/ CC doctor in PP?
 
Long story short I get there she has a femoral pulse but CUFF not reading, I order TPA, Call interventional Cardiologist. I place a central line start some emperic norepi and dobutamine and then a left femoral ALine after failed attempts at radial even with U/S.

She goes PEA moments later.

Is it possible you pushed more clot in while doing the lines? Pushed a little something while doing the a line? Was it a femoral central line also? Was it in the neck? If so, could trendelenburg make a clot migrate? If no trendelenberg, did you expose the patient to air emboli?
 
Maybe in those six months, she'll go to Europe and see the Louvre.
Maybe in those six months she will see a new grandchild born.
Maybe she'll have some more date nights with her husband where they'll get to recall why they love each other so much.

Worlds resources are limited. When some gets something, another is deprived of it.

Maybe her son will never be able to see the Louvre because mom squandered his inheritance during her vacation to Europe.
Maybe in 6 months she gets to see her new grandchild die.
Maybe she will have more nights to regret marrying her husband while she goes thru a bitter divorce.

You see, you can play the same cards in reverse. Not that it really matters but it makes your arguments pointless.
 
Worlds resources are limited. When some gets something, another is deprived of it.

Maybe her son will never be able to see the Louvre because mom squandered his inheritance during her vacation to Europe.
Maybe in 6 months she gets to see her new grandchild die.
Maybe she will have more nights to regret marrying her husband while she goes thru a bitter divorce.

You see, you can play the same cards in reverse. Not that it really matters but it makes your arguments pointless.

:laugh::laugh:
 
"Why I do Anesthesia" Yesterday I had a difficult airway in the ER that I was able to fiberoptically intubate and saved the guys life!! yay!! - this is essentially the OPs post ..

I dont thnk its fair to pick through the 99% of the mundane activities that you actually do day to day, and focus on the random outliar that happens 1-2x/year and say THIS is the reason to do this specialty.. would make for a pretty miserable profession if i felt like this ..

Take a look at the other 99% of the time when you are unable to intubate/do a procecure, dealing with less exciting cases, dealing with production pressure/surgeons etc... then tell me you like anesthesia once you can deal with these things and ill buy it

I was trying to offer a more real perspective on the 99% of time youll spend in the unit. I personally wouldnt go into the ICU expecting to save many functional peoples lives.

And I dont know why im taking such flac for being arrogant or not caring, it is the fact that I AM caring about the misery/unnecessary suffering of these terribly sick people that i DONT want them intubated, ventilated, poked for labs, line changes, medicated, etc... let them die with some peace and some dignity - regardless of cost, no one is talking about rationing or death squads.. just use your common sense and do what is right by people - and I think our ICUs do a terrible job at this right now and if your not part of the solution as a unit attending you are part of the problem

here a personal story ....

my grandfather was 87, recently put on coumadin for a stent in his leg for developing PVD, fell at church (literally) and had a massive SDH and stays down, he was also on plavix, aspirin, nsaids...

i am a college senior, neurosurg doc talks to my uncle and I over phone, basically says craniotomy is his only hope of survival, of course we say proceed, "its his only hope of survival" anyway, the evacuation went well, and all the numbers/scans looked good but he rebled, he never woke up or came off the vent and on POD 2 when we all were able to make it to town we had the pleasure of seeing him terminally extubated and subsequently gasp violently for air for ~20-30 minutes before his resp. muscles got tired and he gave up and my whole family was traumatized .. thanks ICU .. they should have told us from the start he has low chance of survival, and not advised the operation, I KNOW this all still goes on today in the unit - no one tells it to the families like it is.. its not the "crazy" family its the disconnected doctor most of the time and i dont want to be a part of this broken system

I'm going to stay out of the debates/discussion here since my focus is kids in the ICU and that's another ball game, but notanMD, I am sorrowed by your description of your grandfather's death-- noone should die in a hospital gasping violently for breath when care is being withdrawn. Part of compassionate care, when the decision is made to withdraw, is the keep the patient comfortable. I am sorry this did not happen in his case. Withdrawal is part of an ICU physician's "skill" set, in that, our job is to make the withdrawal as peaceful and comfortable for the patient and family as much as humanly and medically possible without crossing the line of euthanasia. Air hunger is unacceptable in the ICU, unless a family member vehemently rejects medication (i.e. opioids)-- even then, this deserves intensive discussion as to why they are requesting this. The system your grandfather died in seemed to be broken, or at the least an ICU physician and/or nurse missed the boat.
 
How do you guys feel about pushing 10 of morphine prior to a terminal wean?

That's what we do in our ICU, sometimes give ativan or versed too. I think that suppressing the agonal breaths helps the family avoid the emotional trauma alluded to earlier re: agonal struggling.
 
It's all about titration to comfort. I wouldn't push 10. 2-4 at a time depending on how sensitive he/she is. Enough to suppress obvious signs of air hunger.

I wonder if any states consider this assisted suicide from a legal perspective. I never, frankly though of that, but boy would it be useful to use some opioid and/or versed.....
 
How do you guys feel about pushing 10 of morphine prior to a terminal wean?

Push 10 just for the hell of it? No.

I like fentanyl for end of life comfort, mostly because patients are usually already on it.

I write the initial order for 100mcg/hr above what the patient is currently getting to be titrated UP every 30 minutes by 100mcg/hr for any signs of pain, anxiety, or dyspnea. On top of that I write a 50-200mcg IV bolus Q5-10 minutes PRN signs of pain, anxiety, or dyspnea.

As proman already brought up, it's the double effect. As long as you are treating real symptoms, you're not "killing" anyone. Interestingly enough when they actually look at this in the palliative literature, patients don't die faster simply because we give them the comfort care they require.
 
Push 10 just for the hell of it? No.

I like fentanyl for end of life comfort, mostly because patients are usually already on it.

I write the initial order for 100mcg/hr above what the patient is currently getting to be titrated UP every 30 minutes by 100mcg/hr for any signs of pain, anxiety, or dyspnea. On top of that I write a 50-200mcg IV bolus Q5-10 minutes PRN signs of pain, anxiety, or dyspnea.

As proman already brought up, it's the double effect. As long as you are treating real symptoms, you're not "killing" anyone. Interestingly enough when they actually look at this in the palliative literature, patients don't die faster simply because we give them the comfort care they require.




Exactly. :thumbup: There are multiple ways to do this. But pushing 10mg straight up is crossing an invisible line. Our job as ICU docs is treat pain and discomfort. And as this OP states, they don't die faster with comfort care. UNLESS you push 10 mg straight up in a relatively narcotic naive and sensitive patient!
 
great so you have prolonged this cancer patients life until she deteriorates more slowly, gets a brain met, speech becomes incomprehensible, family has to watch her slowly decline, and then they would be praying for the PE that would take her life all at once peacefully ... and THIS is why i would never do CCM, i dont really declare victory for saving people from the acute situation when the real illness they have will still kill them or make there life miserable within 6 months to 1 year.. this might have been this ladys time to go, like to 85 yeard olds sp sdh evacuation in the unit.. maybe this lady had beat cancer (but still clotting?) and had a great future but most of the patients i have seen in the unit (pgy4) have a hopeless longterm prognosis that no one wants to openly discuss, and yet will do these ridiculous things and pat themselves on the back for it

Wow! Long night on call?
 
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Exactly. :thumbup: There are multiple ways to do this. But pushing 10mg straight up is crossing an invisible line. Our job as ICU docs is treat pain and discomfort. And as this OP states, they don't die faster with comfort care. UNLESS you push 10 mg straight up in a relatively narcotic naive and sensitive patient!

Really? 10mg of morphine IVP does not seem like that much to me for an average sized adult. And I have done it many times for "air hunger"/"agonal breathing" for patients extubated and receiving comfort measures only.

I must have missed a post or something. What am I missing? Were we talking 10mg of fentanyl!?

HH
 
No, you didn't miss anything. It's all relative. If your patient is already on the equivalent of 30 mg/hour of morphine and is breathing spontaneously, then a 10 mg IV push probably won't be a big deal. But in my experience, most withdrawals are in critically ill patients who may be on pressors, may be narcotic sensitive, etc. You have to take the whole clinical picture and each case individually. One of the withdrawals I did with an 8 year old a boy with metastatic CA, we titrated 5 mg of morphine at a time and ended up giving him 50mg in a span of 10 minutes to decrease the obvious signs of air hunger. So clearly there are patients who have been on lots of opioids, very tolerant, who will need a lot. But to answer the OP's question about what I think about pushing 10 mg IV Morphine-- the answer is don't do it just because 10 mg sounds good. These patients are complex and all respond differently. So you need to make a comprehensive assessment.
 
I originally entered anesthesia fully intending to go into CCM, but the things I saw in the SICU completely changed my mind. I always felt I would be able to be honest with my patients and their families, but unfortunitely in many large institutions there are strong personalities with their own interests who dominate the scene. Just some examples. Bringing a 57yo F smoker with a massive intracranial bleed from an undiagnosed brainstem/pontine mass who already coded twice en route, fixed and dilated, and on max pressor support to the OR for evacuation. Pt died within an hour of arrival to ICU. WTF? Seriuosly, this is where my energy should be spent? 60 yo F w/met pancreatic CA s/p multiple procedures (whipple, debulking, LOA) who presented with an SBO, became septic, max pressor support, taken to OR for another procedure and died within an hour of arrival to the ICU. 70 yo F w/ multiple medical problems (CAD, DM, ESRD, anoxic brain injury) who we kept alive in the ICU because her family had financial motivations to do so. The surgeons are not honest with the families and the families sometimes have horrible motivations for keeping their family members alive.

I have alot of respect for those like Seinfeld who are in it for the right reasons and from his posts seem to know when to draw the line. I have no respect for the surgeon who uses patients are teaching cases for junior residents and I have witnessed this. I have no respect for the surgeon who takes their patient to the OR repeatedly or keeps them alive in the ICU to cover for their mistake. I decided that until this country has an honest discussion about and acceptance of death then my life's work would be wasted and I would simply be frustrated trying to change a dysfunctional system.
 
By trying to eliminate sign of air hunger arent we just reactively trying to narcotize the pt well enough to make them apneic?
 
The idea that palliative care is the antithesis of CCM was referenced above.

However, I feel that aggressive - dare I say 'critical' - palliative care should be or already is a large part of CCM.

Although many folks interested in CCM may not be interested in this, I, for at least one, am interested in pain control and limiting the potential waste and tortur ofe inappropriately aggressive supportive therapy (costs included).

I don't think palliative care and CCM are opposites...all in the best interests of the patient...when the patient is an ICU patient, palliative care is well within the scope of CCM docs (esp in smaller centers where palliative docs are not available; and esp when surgeons or primary docs are not considering all aspects of CCM and proper end-of-life care).

HH

...and that's why I think this new discussion of the 'doctrine of double effect' and 10mg morphine are particularly useful...this really is CCM.

HH
 
The idea that palliative care is the antithesis of CCM was referenced above.

However, I feel that aggressive - dare I say 'critical' - palliative care should be or already is a large part of CCM.

Although many folks interested in CCM may not be interested in this, I, for at least one, am interested in pain control and limiting the potential waste and tortur ofe inappropriately aggressive supportive therapy (costs included).

I don't think palliative care and CCM are opposites...all in the best interests of the patient...when the patient is an ICU patient, palliative care is well within the scope of CCM docs (esp in smaller centers where palliative docs are not available; and esp when surgeons or primary docs are not considering all aspects of CCM and proper end-of-life care).

HH

...and that's why I think this new discussion of the 'doctrine of double effect' and 10mg morphine are particularly useful...this really is CCM.

HH

I definitely believe that Anesthesia/CCM/Palliative/Pain are all part of the same spectrum and something we should be involved in...especially in academic settings.
 
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