Most of the patients are admitted for trauma or transferred after a brain injury. The patients on other services, e.g., colorectal, bariatrics, or surgical oncology, are here because something went seriously wrong. I’m on the “ICU Team,” but enjoy listening in on the other surgical services during their rounds before their 7:00 am OR start. I run into Device Denise, doing her “acting internship” (fourth-year medical student taking over the role of a first-year resident for one month) on the acute care surgery (ACS) service. Has she seen anything crazy? “Mostly a lot of butt abscesses and scrotal nec fasc in fat people,” she responds.
Every week we have a new ICU attending. This week it is the chief of trauma surgery. “The most important role of an attending is humor. If my residents don’t laugh at least once per day, I have failed.” He lets the PGY3 lead rounds: “If I cannot trust you to manage the basic stuff, we have a lot bigger problems.” The PGY3, a holdover from the previous week, is a rockstar, so rounds go smoothly. We order a CT scan with IV contrast to look for any undrained fluid collection that could explain my patient’s persistent pressor requirement. We place several arterial and central venous lines on patients. On Tuesday, the attending leaves midway to appear in court regarding a murder case in which the victim perished in our hospital.
A common ICU topic on rounds is optimizing ventilator sedation. “We don’t want the patient snowed [overly sedated],” the PGY3 explains regarding a brain bleed patient who has been in the ICU for 20 days. “Wean her sedation,” he continues. “The nurses won’t like us but we need the family to make a decision regarding goals of care.” Are we withdrawing care; or are we progressing to “trach and peg”? (Tracheotomy, a more permanent airway through the neck and a percutaneous endoscopic gastrostomy tube for long-term feeding.)
We often struggle to communicate with a patient’s family. A 50-year-old African-American male is suffering from lung cancer with metastasis to the lungs, liver, and brain. If he had never had any complications from surgery and if could be a candidate for palliative chemoradiation (e.g., recover enough strength to be able to walk), he would live for six more months. However, he has had two craniotomies due to brain swelling and is severely debilitated: unable to walk, unable to control his secretions, unable to speak or understand language. His aunt comes to see him every day, but his mother lives 500 miles away and is the one with medical power of attorney. Whenever we call her, she responds with “Just do everything,” despite our cautions regarding quality of life. The aunt explained that the mother and son were never close, that she did not raise him, and that they have not seen each other in at least a decade. “She was not in his life at all,” says the aunt. The nurses are distraught over this patient’s condition, but the Ethics team tells us that there is no realistic way to overrule the absent mother, regardless of our notes that all care is futile.
[Editor: If Medicaid were not paying the $10,000+/day cost, the mother might be less enthusiastic about heroic measures.]
Our PGY3 explains his second Ethics consult of the week, regarding a 55-year-old male who had a log roll over him crushing his thorax and abdomen. “In addition to several rib fractures, he has a burst fracture of his 5th lumbar vertebrae. Unless he gets emergent fixation of the vertebral body, he will become permanently disabled. The patient has significant intellectual disability, operating at the mental capacity of a 7th grader. We learn that he is a vagrant, and was found living in a farm shed. The family adopted him, allowing him to live in the shed and help on the farm, but they can’t approve the necessary surgery, which the patient refuses, saying that it is only a “bruise.” He alludes to family living 200 miles away and the single trauma case manager spends a whole day unsuccessfully attempting to contact any relative. We therefore request a judicial authorization for surgery.
The morning after the paperwork went in, the judge, our institution’s head attorney, and a public defender crowd into the ICU room. We are joined by the ICU attending, my PGY3, and a PGY4 neurosurgery resident. The attorney presents witnesses to the judge. They explain the medical context and likely outcomes. The neurosurgery resident explains, “If he does not receive this operation, he will become paralyzed from the waist down, develop urinary and fecal incontinence.” The judge asks whether there are any less invasive procedures. “The alternative would be bed rest for six months in hopes that the fracture will heal on its own.” The attorney asks the ICU attending regarding his experience and the implication for being bed-bound for six months. She then rests her case. The judge asks the patient if he understands the situation. The patient responds that he is not seriously ill, and can heal the bruise himself. The judge rules authorizes the operation over the patient’s continued objections.
(The patient was not on Medicaid, but the hospital is usually successful at getting patients signed up and obtaining payment for services performed within the preceding three months. Medicaid, however, won’t pay for the case manager’s time or the staff time spent with the judge. Rates for ICU care for privately insured patients need to be high enough to cover all of these losses.)
My 70-year-old trauma patient has not improved. I check in with him every hour or so and enjoy chatting with the hard-working son and daughter-in-law, a former respiratory therapist. I want this to be my first example of a trauma patient who completely recovers and regains a normal level of quality of life. We are trying to wean him off the ventilator, but he continues to breath at almost 15 L per minute (normal “minute ventilation” is 5 L). Although he has a colostomy, he has the potential to get this reversed if we can get source control and get his kidneys to recover. On the first day the 70yo patient after his operation, my PGY3 resident presciently warned the family and the patient hat we always worry about kidneys. He has developed renal failure, requiring continuous dialysis (CRRT). The full ICU team, consisting of the attending, two nurse practitioners, the PGY3, two critical care fellows, and myself, discuss with the family taking the patient off the ventilator. The attending jumps in, “You know a great way to see if a patient is ready to be extubated… Ask him.” He asks him. The patient doesn’t answer for a few seconds, then sadly responds that he needs it.
(I follow the patient for the next two weeks. After a three-week stay in the ICU, he is transferred to the step-down unit. He is off the ventilator (tracheostomy tube removed), but his kidneys never recovered. He is alive, neurologically and functionally intact, but will be on dialysis for the rest of his life. He has the potential to get the colostomy reversed after he has regained nutrition from this extended hospitalization.)
Thursday: interprofessional rounds at 10:30 am. The trauma and ICU team meet in a cramped conference room to run the list. The discussion is focused on getting patients discharged. Case managers and billers are in the room to go over questions and concerns. A common theme is a trauma patient, e.g., motor vehicle collision, now stable enough to advance to inpatient rehab (“IPR”) and do three hours of PT a day. Administrators go back and forth regarding one patient fo ten minutes until our attending jumps in: “We know this routine. We are waiting for workman’s comp to approve IPR and workman’s comp is waiting for the patient to look too healthy for IPR.”
Statistics for the week… Study: 5 hours. Sleep: 5 hours/night; Fun: 1 night. BBQ at Luke and Samantha’s.
The rest of the book: http://fifthchance.com/MedicalSchool2020