Can you broadly describe your place in the workflow (for lack of a better term) of the hospital? I'm just curious where your role in the ICU fits in with other doctors. Also, what does a typical day on the job involve for you?
Ask an Intensivist
- Thread starter Neonanocyborgasm
- Start date
SS-18 ICBM
Oscillator
Any particular protocols on the cutting edge of medical research? If not that advanced, then which one was the most recently updated?
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
I function as a mandatory consultant. Anyone who is admitted to the ICU has to be consulted by me or my fellow intensivists. This implicates me as the primary decision maker for all the patient's care while in the ICU, regardless of who else is involved in the patient's care.
A patient may be admitted directly to the ICU from the ER, the general ward of the hospital, or even the OR. Usually, this is after someone (even me) has recognized the patient's condition as critical enough to require such an action. Once in the ICU, I render whatever care I believe is necessary. There is some overlap with the actions of other physicians on the case, such as the primary physician and the consultants. Some are more proactive than others. Usually, there is little conflict but occasionally there may be disagreements in management. Other hospitals have dealt with this problem by "closing" their ICU, so that only intensivists may render care and that any other physicians must ask permission to do anything. I hope that one day, this will happen to every ICU.
There is always research going on, so protocols are constantly being developed and tried. One recent one is the hypothermia protocol, which is used when a patient has a cardiac arrest. The patient is cooled, using ice, cooling blankets, etc, to a lower than normal body temperature for about 36-48 hours. This preserves the brain and minimizes neurologic injury from impaired cerebral perfusion.
LucyDuke
staring at the clock
Is there any truth behind the tv cliché of doctors chilling in the lounge watching soap operas?
Quackers
The Frog
Have you ever accidentally killed somebody?
Have you ever gone to work drunk or been drinking the night before?
Have you ever gone to work drunk or been drinking the night before?
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
I'll tell you what's usually on in the lounge and you won't like it:
Fox News or CNBC. It's doctors either checking on their stock, or declaring everything "socialism."
It would be awfully complicated to explain the details of this particular case and why the encounter was so egregious. But I'll give it a shot. A patient was on mechanical ventilation with a ruptured heart valve. The usual treatment for that is open heart surgery. The patient refused the surgery (on a side note, the patient was an alcoholic, so this may explain the poor judgement). Without surgery, the patient would die. The cardiologist on the case asked me to wean the patient from the ventilator anyway and remove it, hoping that medical therapy would be good enough. When I suggested that that would be unlikely to work, he got angry and dismissed me from the case. "I'll just find somebody who will do it if you won't!" He consulted with a competing group of pulmonologists to do the same thing. A few days later, the patient died.
Not accidentally.
Yes, I've gone to work the morning after drinking. By then, I'm more than well sober and rested, like 99% of everyone else that's done it. I've never shown up to work drunk, though.
I do it all the time. The road blocks are usually from the deluded families, who imagine recovery from end-stage disease. You have to repeat the same script to them for weeks. It gets worse when there is conflict and disagreement within the family. Although we are only obligated to consider the wishes of the patient and the next of kin, the rest of the family may contend with them and poison their minds, often for ulterior motives.
SS-18 ICBM
Oscillator
What happened to the cardiologist? I'm curious as to what punitive actions are implemented following preventable patient deaths.
I agree. I want to know what happened in this case.
Although I suspect that because it's generally so hard to actually lay the blame on any person in cases like this he got away scot-free. Please tell me I'm wrong.
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
Nothing happened to the cardiologist.
LucyDuke
staring at the clock
I just wanted to know about the soap operas. TV is lying to me!
MikeL49NYVI
Warlord
I just saw this, and I am curious about one or two things:
My father ended up in a coma in ICU, after complications from open heart surgery. He physically recovered, but 16 hours on the operating table and being defibulated, about 90 times, to get his heart going again, was too much strain. And he could not come out of the coma.
The coma lasted two months, and my family struggled over this night and day. Your comments seem a bit callous concerning the decisions the families who have to go through this, and their emotional state. Maybe because you see it all the time, but to those to whom it is happening to it is a nightmare of indecision.
The doctors and nurses in the ICU were just wonderful towards us. And once they understood that my mother and two sisters-in-law are registered nurses, we got all the straight information and counsel that they could provide. Being the oldest of the children, I was very involved with all the decisions.
But I am curious to know if it just gets down to " just another patient" with you and your co-workers, or if at times you find yourselves getting more emotionally or sympathecially involved with a given situation. I do not mean this in a negative, or nasty way.
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
What you're describing is not at all the usual situation. The usual situation for palliative and hospice care is someone with an end-stage disease, like metastatic cancer, or end-stage heart failure, or end-stage COPD. Those disease states have no effective treatment, so there is no doubt about where they will lead. There is no doubt except to the families, who ignore advice from medical professionals, and instead imagine their own brand of medicine. There was a recent study that discovered that families, in fact, largely ignore advice from physicians and instead base their end-of-life decisions on what amounts to their private imaginations. They take into consideration a patient's "will to live." (There is no such thing as simply willing oneself to live. You will live or die according to biology.) Or they selectively consider religious issues, such as claiming that only god can claim a life. (Which, if true, does not explain why they so eagerly prevent him from doing so through life-sustaining technology.) They also grapple with their own internal psychological conflicts. Most often this may involve regret over how they treated the patient during their life, or their own ambivalence in dealing with death in general. My sympathy is decidedly short with these families because patients with chronic end-stage diseases have usually had them for a long time -- sometimes years -- and that's plenty of time for anyone to consider the matter. Quite often, however, they deny the issue entirely, and pretend all sorts of outraged denial when physicians inform them of the prognosis. So it often becomes that personal matters which should've been settled months or even years ago have to be pressed within a short time frame of hospitalization. That's not an ideal situation. I may have, at any time, up to 24 critically ill patients, most of whom will survive their ordeal. I do not have time to become a psychiatrist and counselor to dysfunctional families while I struggle to prevent death for those who actually have a fighting chance.
If there is any callousness here, it is from the families who insist on submitting their loved ones to painful and uncomfortable medical procedures, only to assuage their own guilt and to have no actual regard for the anguish of the patient, despite claiming to the contrary. (In some of my speeches, I will often preface "...so the only compassionate action is...". No family can deny it because that would imply lack of compassion on their part.) Many of these patients have advanced directives, which are essentially living wills that indicate what they would want done in the event they are faced with a terminal condition. Families will often violate these advanced directives for their own selfish interests. I have seen some families even hide the advanced directive so that they can continue to make demands without the encumbrance those directives would be to them. So I say again, if there is any callousness, it is in these families, who willfully violate their own loved one's final wishes, for their own selfish motives.
I have also observed other disturbing social trends that indicate to me that families have become increasingly selfish and dishonorable to their loved ones. One I noticed is that when a patient is admitted with a terminal condition, the families will demand that the patient be "kept alive" on life support until the entire extended family arrive to "say goodbye", upon which life support will be withdrawn, and the patient will die on a schedule. This disturbs me for several reasons. Why would you want to remember your relative's moment of death? Do you want to have the ghostly haggard image of the death of your mother or father burned into your brain for all eternity? Do you want to remember the smell of decay? Wouldn't you prefer to remember them in life, at their best and finest? Another that disturbs me is this whole notion of calling every relative in from all over the country, and sometimes the world, and meanwhile demanding the patient be kept alive for THEIR sake. What about for the patient's sake? Maybe it was his time to go, and instead you prolong the agony entirely needlessly, and, in my opinion, selfishly.
So you really don't have a clue what you're talking about, when you criticize my approach to palliation. You don't know what disturbing things I have to tolerate from all manner of family dysfunctions. Most of all, you know nothing of medicine, and so are not at all qualified to understand when palliation is called for. You did not even describe your father's situation accurately. Patients who undergo open heart surgery may be placed on cardiopulmonary bypass, where a pump-oxygenator functions as a heart. The native heart is arrested during the case. (There is a version of this surgery where the heart continues to beat and is operated on while beating, but this can always be changed during the surgery.) So your father could've had cardiac "arrest" 90 million times and it would make no difference. His blood would still have been circulating the whole time using a cardiopulmonary bypass. Having a cardiac arrest during heart surgery is not a "game over" moment for that patient, and is not necessarily a matter of end-stage disease.
holy king
Deity
relatives finding it tough to let go are indeed a problem, but telling them they know nothing about medicine certainly isnt going to help anyone.
Quackers
The Frog
That is a disturbing lack of compassion from a Doctor IMO.
holy king
Deity
well, to be fair, it isnt his job to be compassionate, but to keep human bodies running.
just dont let him speak to any relatives in between.
just dont let him speak to any relatives in between.
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
Actually, if I notice a dysfunctional family like that, I will simply not talk to them. It's very obvious that they have their minds made up and I will have no power to convince them of anything. Trying will only frustrate me and anyone else in the room.
When I do talk to families, I know how to put on the right face, so no family believes I lack compassion. But these are my private thoughts and this is what you get. Having gone through trials like these with my own family members, I am not sympathetic to their inability to let go.
People today have this unfounded notion as if death doesn't exist except in some anonymous fashion. They think medicine can pull off any trick. They also lack an understanding between quantity of life and quality of life. When a patient is technically alive on a mechanical ventilator, but is a vegetable, that's not life.
When I do talk to families, I know how to put on the right face, so no family believes I lack compassion. But these are my private thoughts and this is what you get. Having gone through trials like these with my own family members, I am not sympathetic to their inability to let go.
People today have this unfounded notion as if death doesn't exist except in some anonymous fashion. They think medicine can pull off any trick. They also lack an understanding between quantity of life and quality of life. When a patient is technically alive on a mechanical ventilator, but is a vegetable, that's not life.
MikeL49NYVI
Warlord
Please take another look at my questions. I was in no way trying to be critical, and wrote my last two paragraphs with the intention to make that point. And since the incident with my father happened 18 years ago, and I wrote a very abbreviated account; not everything is in there.
As a family we knew exactly what was going on. My mother and two of my sisters-in-law are registered nurses. And one of my brothers is a social worker helping familes who have a loved one in Hospice. At first we were treated like we wern't able to understand what was being said. But once the doctors and nurses knew who they were dealing with, they became much more amiable and polite towards us.
What happened was; they preformed a triple by-pass on my dad, everything went fine, they closed him up, and could not get his heart going back on it's own. Eventually they had to open him up again, and do another by-pass. They said there was more damage than what was originally indicated in all the tests. Like I just said it was 18 years ago, and I do not have the complete story at hand. But the agony we went through, as a family, was real enough, and I'll never forget what that was like. (Including our concern for what my dad was going through)
And although my father never did come out of the coma, his body healed, and he was taken off the respirator, and put into a regular room, and eventually into a nursing home. When it became very clear that he was not going to come out of the coma, we put a DNR order in. But we left the feeding tube in place. This was while he was still in the ICU. Everything we did was in consulation with the doctors. And like I said, they were very helpful and supportive. One or two of us at a time were allowed to go in and sit with him regardless of visiting hours, including all night. They trusted us that much; we were not an irrational, hysterical bunch.
Again, I am not going into all the details of the family conversations, and the decisions. We all hatred seeing my father in that condition, and we all knew he would have hated it himself. So, we do not fit into any of the descriptions of the families you mention.
You jumped to conclusions with me, all I was asking was that with all the patients and families, and situations you have seen has it become "just one more"? Or are there times you are moved to emotion or sympathy by what you see happening?
I appreciate that you have seen and had to deal with many families, and all types of experiences. Stuff that I cannot even begin to imagine, I'll bet. And there is no way any reasonable person can be critical of you or anyone in your profession, unless they do it themselves. I am only asking as some one who has been on the other side of this, with two grandparents, a father and an uncle, and a very close friend. So I am not without some experience from the family side of it.
Neonanocyborgasm
Deity
- Joined
- Apr 21, 2004
- Messages
- 4,695
The story still sounds incomplete. 20 years ago, nearly all the CABGs were on-pump. A situation in which the heart could not be resuscitated this way would just lead to death on the operating room table, not coma.
Those in which the patient suffers from an end-stage chronic disease all play out the script identically. Your father's incident of surgery gone wrong is not a chronic end-stage disease. The script goes something like this:
* patient with a chronic ailment, who is often languishing in a nursing home, is admitted to the ICU for some acute illness, such as pneumonia
* physician realizes patient has a chronic, debilitating, and ultimately terminal illness for which there is no treatment
* physician tells family of the chronic illness (ie. metastatic cancer) and suggests palliation may be warranted
* family reacts indignantly as if they believed that chronic illness was curable
* physician relents. patient spends another 2 weeks in the ICU with one problem or another surfacing (which means they were there all along) that prevents patient from being discharged
* family then begins to see that patient is not getting any better and produces a written advanced directive where the patient indicated refusal of life-sustaining measures. [some variation here... maybe advanced directive is produced earlier but ignored, for example]
* patient is made DNR, and life-sustaining measures withdrawn on a schedule the family agrees (usually after every relative and friend is summoned to watch death unfold), and patient dies usually seconds to minutes later
By the time the patient had died, he hadn't been conscious for months to years, and his body had atrophied to the point where he was a skeleton. Yet, the family insisted he was "ok." He had, effectively, been dead all that time, and there had only been the illusion of life. ("Illusion of life" is another phrase I may utter to families in this position.)
I hope you understand my point of view, here. I don't begrudge families who had a young person with an acute catastrophic injury or illness. That's not the same as the family who plunged their heads into the sand while a family member degenerated and shriveled up over months to years, and they couldn't accept it, even after years, and instead devolved to family in-fighting.
I used to believe that I was seeing on a small segment of the population do this, but studies have shown that 90% of a person's wealth is spent in the last 6 months of life. That means that this happens with almost everyone.
Similar threads
