What's the difference between you and Dr House?
And in seriousness, House is fake whereas I am very real.
I imagine people die somewhat frequently under your care. Not that you're a bad doctor, just that the nature of ICU is that it's full of people who could die. How do you numb yourself to it? Does it ever get to you?
It only gets to me when it is a clearly preventable death, in someone who had plenty to live for. When it is an elderly person with countless end-stage medical problems, it is evident to all that something was going to take the guy out sooner or later. It was only a question of when, not whether. But when it is someone who was young and had no medical problems, and was healthy before, it rattles me. I still recall the 20 year old woman who died only of pneumonia, because her care was, let us say, delayed.
By the time I completed my training, I had already seen so many patients die that I was entirely accustomed to it. I have found that concentrating on the problems first, and the patient second, helps me be oblivious to the abject suffering that many patients are surely suffering. This way, I am separated from any emotional attachment, and can treat the patient objectively and decisively, rather than desperately.
How many patients are usually under your care at any given time?
Depends on the time of day or night. Usually it is the limit of the hospital's ICU beds, which is 24, but it can be greater than that if patients are waiting in other locations, such as the ER, the recovery room, or the general ward. That condition is best avoided, however, because it puts patient safety at risk when I try to be in too many places at once.
What's the darkest humour medical slang you've heard used?
You must realize that we use dark humor all the time, among ourselves, and not in front of patients. The list would be too long, and I can't remember all the now stale jokes I've told.
Ok, a recent one. "The management of that patient is ********." (The patient was mentally ********.)
Do people reveal strange things to do when they feel they may be near death?
No, because they are usually too moribund to even talk, or even be conscious. A deathbed confession is a Hollywood movie, not real life.
Do you think more about your own mortality because of what you do?
Only in that if I am to die, I would not want it prolonged needlessly, just for the sake of selfish family members. There are too many families that can't let go, and will torture the patient with needless medical procedures, ensuring that their deaths are more painful and violent than necessary.
Without mentioning your specific salary, how does the salary of your field compare to that of a GP? What's your schedule like?
Strictly speaking, there are no longer such things as GPs in the US. They now call everyone practicing internal medicine and family practice as "primary care." My salary is significantly higher than the incomes of most primary care, but since primary care is mostly outpatient offices, there may be all sorts of variations, depending on how well that office collects. Those offices are businesses, after all. I am a hospital employee so I collect a fixed salary, based on hours worked. I have always maintained that critical care is the best kept secret in medicine. Despite the intensity of practice, I only have to deal with my job while I am there. Once I leave, no one bothers me. I am not chained to my pager. I only work 40 hours a week, give or take, just like everyone else. But because my shifts are 12 hours long, I can usually knock that week out in 3.5 days. I have great flexibility in vacationing, and have 4 weeks off/year, plus time off for continuing education, much of which is reimbursed by the hospital.
What attracted you to critical care medicine over, let's say, being a family physician?
It was the immediate gratification of doing something that usually achieved immediate results. It was also my eventual displeasure at dealing with outpatient care. There, you have to deal with insurance claims, which are often denied under false pretenses, recalcitrant patients, and being chained to your pager. So you are never done working and yet are underpaid and underappreciated for it.
Wow, you sound like a TV show. I wonder if Denzel is busy next season?
He gets paid a lot more than I do.
There should never have been a TV show called "ER." That show so exaggerates what the ER is capable off that it doesn't deserve that kind of favorable image. Instead, there should been a series called "The Intensivists." I can see it now. You would have a team of intensivists, each of which have their particular specializations. One might be a trauma surgeon, another a medical intensivist, and another perhaps a pediatric intensivist. (I'm being someone obtuse for dramatic purposes, since all those guys wouldn't work in the same ICU.) Common premises on an episode might revolve around issues such as:
* intensivist contending with emergency physician over care of a patient, and how the ER never does anything, sending up the near-dead
* family issues of level of care on a patient, heightened to a dramatic extreme, such as keeping the brain dead on life support
* exotic illnesses presenting under seemingly innocuous circumstances
Here's what actually goes on more often in the ICU vs ER controversy.
http://www.youtube.com/watch?v=6AZm-eVz7c0
Nano,
Who is the most awesome economist you ever met?
My wife! She put out!
(She has a bachelor's in economics.)
How much leeway do you have to take "risks" with those on deaths door? Research shows doctors choose riskier options than they recommend for patients, so does being on death's door change that?
I've seen that study, and am not very surprised. I suspect it's because of doctors' moral ambivalence regarding care and responsibility for it. To put it bluntly, most doctors have no balls. They are afraid of making any false moves, and lack decisiveness. They are also ambivalent about their mortality, as well as patient mortality. The result is that they always hesitate. But where they never hesitate is with themselves, since they know that the responsibility will fall on them, and that they can only criticize themselves. With patients, they have to live with criticism from others.
Generally, intensivists, from what I've observed, are decisive. They deal with these issues all the time and don't shy away from them. I don't fear taking so many actions that others might call risks because I can handle them, but others may not be so decisive.
Unfortunately, teaching balls to people is a lot harder than teaching medicine.
Is Ischemic Postconditioning on its way to becoming a tool? The way I read it, it can be performed by a nurse using a blood-pressure cuff. The stats on it are pretty impressive.
Some of my work deals with the science of ischemic postconditioning, and I'm wondering if there's any traction.
Sounds like some weird kooky voodoo stuff to me.
What portion of your patients are in certain age brackets? Such as the elderly, children, young adults.
Please read the OP. I am not a pediatric intensivist. I only treat adults. About 3/4 of my patients are elderly, and the 1/4 that are young adults are nearly all admitted for drug overdoses. That's the usual break-down, because the elderly have disproportionately more medical problems.
Nanocyborgasm, how do you handle dealing with the families of your patients? Especially if one of your patients passes away? Do you ever become emotionally attached to your patients? Are their protocols or procedures that dissuade medical personnel from obtaining emotional attachments to their patients?
There are no such protocols.
I avoid getting involved emotionally with families. As far as I'm concerned, they are strangers to me, and I am their doctor, not their friend. I don't pretend to commiserate with them or empathize with them. I only act professionally and give them information and dispense opinion as necessary. I find that families respond favorably to that sort of treatment, rather than faking rapport. If rapport comes, it will be natural, not fake, born from repeated engagement. Most of the time, families just want information, and are very pleased to get it.
I've spent my fair share of time in hospitals and I can only help but that it would be not only physically draining, but emotionally exhaustive. I couldn't do it myself, but I'm interest to here what insight you have about this side of the job.
It's exaggerated. Once you've seen enough suffering, you become used to it. Only when it is far out of the ordinary do you take notice.
