Why I do Critical Care

[michigangirl]

This is from my "why doctor's die thread" because DHB referred to this thread when posting.

Oh please, it's just ridiculous imo to be so conservative with the drugs you are giving to someone you've sentenced to death by stopping dialysis/vent/other life maintaining therapies.
Load them up, quick exit, everybody's happy.

So you agree your goal is a quick exit. I work with kids. I had a dad tell me point blank (he was a vet, so very interesting perspective))--"I don't want to kill him with morphine"-- so we pulled the tube and gave a touch of the stuff and let things ride their course. Not everyone wants a quick exit. And my opioid dose should not be the cause of death. Many of my parents want the interventions stopped, drugs given, monitors off, and time-- be it minutes-hours to spend with their children while they still have a sign of life-- as long as they seem comfortable. Some of these parents ask to sleep in bed with their child in their last moments, or just hold them. And that's my job. It's ridiculous to say the ICU and palliative medicine don't go hand in hand. I realize the adult world might be different. But it's not THAT different. If you decide ICU is your thing-- you should be prepared to deal with the vast ethical and emotional aspects of palliative medicine-- and doing it well. There's no room for wham bam thank you m'aam.

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[Doctor4Life1769]

I've noticed a variety of personalities. From the cowboy types to the meek.

I like it. It's acute medicine. Stable becomes unstable and vice versa. You're appreciated for your services.

Also, there is a huge palliative aspect as stated previously. Everyday we make tough medico-ethico-legal decisions regarding code status, CMO, etc. It takes really knowing your stuff and being able to effectively communicate what you know to your patient's families so they can make the best decisions for their loved ones. Often times, it's that inability to convey info (and understand it) that makes these situations tough.

Pain and sedation are also huge.

At this point in time, I gotta see how my time in the OR goes next year. I like the little people population and am considering pediatrics for a fellowship. However, a close 2nd is CCM. I just don't want to do a peds residency to do a fellowship in NICU/PICU.

 

[dhb]

And my opioid dose should not be the cause of death.

The PICU is a different beast, all my comments are directed at adult CCM since i've never been in the PICU.

However morphine has never killed anyone (bar criminal acts) in the ICU. People die because they're sick as **** not because they receive a small or large dose of medication.

 

[Arch Guillotti]

I've seen a sick patient get too much morphine (which was a small dose) in the ICU and then spiral irreversibly downward.

 

[dhb]

I've seen a sick patient get too much morphine (which was a small dose) in the ICU and then spiral irreversibly downward.

My point exactly

 

[Idiopathic]

10mg of morphine is essentially equivalent to 100mcg of fentanyl, so I think most everyone here would give that.

 

[Idiopathic]

[/B]

Exactly. 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!

i wholeheartedly disagree with this. 10mg of morphine is not ridiculous overdosing, in fact its a reasonable postoperative pain dose, as well as an ICU pain dose. I hardly ever give it, however, since fentanyl is easier and has fewer side effects, but if someone is in pain, 10mg is a defensible dose.

 

[michigangirl]

You are missing the point. We are not talking post-op pain. We are not even talking ICU pain. We are talking subjective assessment of air hunger after withdrawal of care in critically ill patients to ease the transition from elective extubation. Would you like to write an algorithm for palliative care that includes 10mg of morphine as the standard air hunger dose for ALL patients being extubated for care withdrawal? I'm not saying many patients won't do fine with that or need that or more. My argument is its silly to AUTOMATICALLY give this to EVERYONE.

i wholeheartedly disagree with this. 10mg of morphine is not ridiculous overdosing, in fact its a reasonable postoperative pain dose, as well as an ICU pain dose. I hardly ever give it, however, since fentanyl is easier and has fewer side effects, but if someone is in pain, 10mg is a defensible dose.

 

[yappy]

anyone ever give a little narcan to see what happens with an elective extubation in the ICU?

 

[nitroglycerine]

)

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

Respectfully, what is ROSC? We foreigners do not always know the specific slang. Thanks.

 

[Orin]

Respectfully, what is ROSC? We foreigners do not always know the specific slang. Thanks.

http://lmgtfy.com/?q=ROSC&l=1

Return of spontaneous circulation (ROSC)

 

[nitroglycerine]

How do you guys feel about pushing 10 of morphine prior to a terminal wean?

I would personally like 100 for myself in that situation. If only I could carry a release of liability letter in my wallet for the doctor with the guts and kind enough to do it for me. I would even pay for 20 of Nimbex to go along with it. Seriously, guys.

 

[nitroglycerine]

http://lmgtfy.com/?q=ROSC&l=1

Return of spontaneous circulation (ROSC)

Many thanks.

 

[NotAMD]

I would personally like 100 for myself in that situation. If only I could carry a release of liability letter in my wallet for the doctor with the guts and kind enough to do it for me. I would even pay for 20 of Nimbex to go along with it. Seriously, guys.

i absolutely agree, and give me 200 of propofol as well - see ya

 

[epidural man]

pedantic rounding and re-rouding.

Well said...

and i love the word pedantic.

I enjoyed your words by the way.