Tube and Lube

I just started my glorious new rotation of anesthesia/ultrasound.  My day consists of early awakenings and oh so early returns to the home base.  I still get up around 5:45am, which is not too dissimilar from my MICU mornings.  After some breakfast, reading email, and some highlights on the NYtimes, I drive to work around 6:30.  I'm only now getting into a routine in the anesthesiology department.  No one truly oversees you, which is good in the sense that you can make your day as long or short as you like.  However, there is most definitely the sense that you are a distraction to the regular flow of the OR.  I was recently told by a CRNA to go stand in the corner, which seemed entirely inappropriate given the nature of my rotation...to learn and act as part of the anesthesia team.  Clearly, this would be difficult to do with zero vantage point.  I dismissed it as a case of the Mondays (and perhaps a juvenile need to enforce authority over someone when you can get the chance) and got on with my day.  In the afternoons, I join the ultrasound team, which consists of our ultrasound director, ICU fellow, and another EM resident.  We scan away at any patient that is a potential appy, choley, AAA, pneumothorax, or any other interesting finding.  Ultrasound seems like an ingenious way to make procedures safer and give additional diagnostic information in little time.  In addition, to your potentially life-saving FAST exam for free fluid, there is the additional utility of a no radiation bedside tool.  It is another tool to make yourself independent of consultants that may delay the workup.  Of course at this stage I still feel like I couldn't grab the ultrasound on my own and make a definitive case for DVT or gallstones, but hopefully in a couple of weeks the skills will be sufficient.  For now, it is a laid back, enjoyable opportunity to learn without the responsibility of patient care as a distracter.

It has been odd not caring for my own patients during this rotation.  I feel liberated and yet surprisingly less purposeful.  It is almost as if by rendering away my patient care abilities, I've suddenly become more relaxed, but feel less good about my day.  However, it has helped me reconnect with family and my sense of humor.  I will not forget the drama of my last day in the MICU ending with the entirely appropriate comment by my fellow intern who I was orienting to her new rotation "What's wrong?  You look so upset."  It's hard not to be upset after witnessing a traumatic cric in a patient who was actually DNR/DNI and then getting the kickback by all the MICU nurses for allowing the patient to be admitted to our service despite a new (old) CMO decision made by the family.  What can I say!  I actually confronted the attending of this particular case today at conference immediately following a very a pro pos discussion on ethics and code decision making.  I got what seemed like a partial apology for my involvement in that case, but no admission on guilt in singlehandedly getting a patient to rebuke their code status when their situation was more than hopeless.  I suppose I need to learn to forgive and forget because there is no question I will be in the same situation some day soon.

MICU take home message

I just finished my last call in the MICU and I can say with certainty that I have found it both challenging, rewarding, and utterly exhausting emotionally and physically.  Challenging because I've done many procedures for the first time.  I did my first intubation on a nonparalyzed patient, I performed my first chest tube, I put in my first central line.  Also, given the resources that most ICUs have at their disposal your therapeutic options are virtually unlimited.  You can practice based on the most recent literature despite cost of drug therapy and because this is frequently a last measure, you can even make the argument for marginally experimental measures.  Xigris here I come.  I've learned how to put virtually everything in a drip - pressors, antibiotics, sedation, insulin, electrolytes.  The sky's the limit.  I enjoyed being the first responder to codes and knowing there was some sense of relief because the ICU team was there.  The team approach and daily rounding were enjoyable, which I can rarely say of any previous rounding experience.  I liked working closely with the families of the patient to explain what the options for management are and to discuss end of life care.

This was easily the most challenging aspect of the month.  The last patient that I declared dead was a metastatic esophageal cancer patient whose oncologist had not yet breached the topic of prognosis and end of life management.  As I navigated the family through the initial full code, to DNR, and eventually to do not escalate and comfort measures only, I realized that no other experience would rival this in complexity.  You need to read the situation for each individual family.  You need to assess whether it is appropriate to discuss the medical situation vaguely or whether a more technical narrative is desired.  You need to be sympathetic, but offer direction and you need to be certain at times when there is not much clarity about the actual events.  In this particular patient it was evident that there was a communication between the lungs and the gut (the NG tube was attached to a clean catch bag that filled with air in seconds), but it was unclear whether this was the cancer eroding the posterior esophagus or whether the friable surgical anastamosis site was coming undone.  What became clear to me throughout the conversation, however, was that the family did not need to know details and wanted to be allowed to mourn before making a CMO decision.  Eventually, they thanked me for everything we had done and I left with the feeling that even if there had been a medical error in his care - my chest tube had punctured the gut or the surgery had been botched, they would recognize that his end-of-life care was appropriate.  It's been difficult coming home from calls like these and moving on to my normal daily activities.

You most definitely bring your work home with you when you're in the ICU.  In the ED, I think it will be easier to walk away from these situations unscathed.  The low point was definitely a couple of days ago when I had been on this streak of all of my patients dying (some that I had carried for weeks) and was assigned a new patient that clearly would die on my shift.  I actually got tearful for a minute while rounding and had to pull myself together.  I'm happy to still have compassion and be able to feel these emotions for a patient, but at times I wish I could just get jaded already and at least be able to close the chapter with move on.

Here are some words of advice for the critical care rotations:
1. Know how to replete electrolytes - this will be an every day task and will eventually become reflexive - correct your Ca for low albumin and keep ventilated patient in the >2 Mg range
2. Love the ABG - you will do it over and over and over again
3. Sepsis is bread and butter ICU care - put in the line early, monitor CVP and SVO2 and transfuse away if needed
3. Do your research and you can make a case for most any treatment, if it is evidence based and your attending likes adventure
4. Communicate with families early, when you breach the topic of code status, it will be a lot easier
5. Pack an on-call bag with toiletries, snacks, water bottle, cell phone charger and ibuprofen - it's amazing what aches and pains will emerge when you're running around for 30 hours
6. Build a good relationship with your team - don't signout quick tasks and phone calls, give a good signout, and when you're on call get everyone else out on time
7. Never underestimate the value of the nursing evaluation - they have more experience with your patient and will help you preempt disasters if you listen well - have them get you when they turn your patient - you can auscultate and evaluate their decubs
8. Sleep when you can, I took melatonin at 5pm on my post call days and on 5pm the day after - it worked great
9. Try to keep some social obligations, you'll feel more in control of your schedule and you'll learn to love on call days for the prospect of post call lunches / breakfasts with friends and family
10. Learn what you can from your senior / fellow - you'll rarely get this much one on one time