Philip Greenspun’s Weblog

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

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July 2019. I meet the SICU team at 6:00 am for handoff. The 35-year-old PGY3 “upper level” surgical resident is in charge of our team (he worked a Navy desk job before going to medical school), which includes a visiting fourth-year medical student (on an “AI”; see the end of Year 3) and two Critical Care fellows, one from internal medicine (Pulm/Crit) and one from emergency medicine. Both are already physicians, but are under our PGY3. We meet our attending, a cerebral 6’5″ trauma surgeon balancing male-pattern baldness with a thick brown beard. He doesn’t seem to have slept for years due to a combination of 24-hour calls, a 13-month-old child with a wife recently returned to her nursing job, and constantly refreshed waves of ignorant and incompetent students and staff, for which his patience is now limited: “Why would you give the patient 250mL for a fluid bolus? That’s like 75 mL intravascular. The response is worthless information. If you think the patient is volume-depleted, give volume.” 

Patients include trauma (car accidents, shootings, etc.), high risk operations, operations gone awry (e.g., perforation, anastomotic leak, etc.), and neurosurgical patients (e.g., brain bleeds, aneurysm clipping, and tumor resections). The nurses say this is the only real ICU, compared to the cardiac care unit (“CCU”) and the medical intensive care unit (“MICU”).

Tuesday is a typical day in the SICU. I get in at 5:30 am to review my three patients’ morning labs and any overnight events. I then head up for 6:00 am handoff from the night team in a conference room. We “run the list” going through each patient using the Epic handoff note that has free text bulleted information about each patient and a “To Do” list. The exhausted night team disbands, while our day team assigns each patient to a team member (students don’t count). We pre-round on our patients until the attending gets in at 8:30 am to start rounds. There are 18 patients on our census in the two-floor SICU. We are part of the 24/7 ICU team that manages the patient independent of the surgeon who actually performed the operation. This structure is referred to as a “closed” ICU.

Rounds last from 8:30 am to 1:30 pm. We do system-based rounds. I summarize the patient. “19-year-old Jehovah’s Witness presenting as MVC [motor vehicle collision]. He has bilateral leg injuries and a right proximal humeral fracture. Orthopedics is following and plan to take him to the OR for a left BKA [below-the-knee amputation] today. They splinted the right ankle for an unstable tibial fracture that will need surgical intervention at a later date. Overnight, the final read on the CT shows a submassive pulmonary embolism.” Then I go through each system:

• Neuro: he is on fentanyl 50 mcg/hr for pain.
• Respiratory: normal pulmonary function, ABG shows pH of 7.35 and CO2 of 40.
• Cardiovascular: he has not required any pressors, he remains tachycardic in the 120s. His CT shows he has a pulmonary embolism in a right pulmonary segmental artery. Echo shows no right ventricular strain. Do you think we should anticoagulant him given his blood loss? 
• Hemoglobin is 6.2 down from admission of 11 (normal is above 12. If not for his religion, we would have transfused him. The family says he would prefer to die rather than receive a blood unit.)
• Hematology: we already discussed his hemoglobin. Orthopedics is okay with taking him for the operation at this level. White count is normal at 8. 
• Infectious Disease: no antibiotics or signs of infection.

The resident or fellow would take over the presentation if I miss anything important, but hasn’t needed to. Nonetheless, there are interruptions. Desperate to impress (he’ll be applying here for a residency), the visiting medical student jumps in frequently and tries to get the last word.

We have some extra time in the afternoon, so one the Pulm/Critical Care fellow teaches me and the AI on different pressors and ventilator settings. 

Wednesday at 3:00 pm, we get a 70-year-old admission. He was driving (without a seat belt) and was “T-boned” by a meth head. Both came to the ED around 2:00 pm, but the meth head was quickly discharged. The trauma team met the patient in the ED’s trauma bay, and although he had a positive FAST (focused assessment with sonography) exam for a small amount of free fluid in abdomen, they elected to defer exploratory laparotomy. Like all trauma patients, he was “pan-scanned,” (head-to-toe CT scan) which was similarly indeterminate for serious abdominal problems.

[Editor: the multi-thousand dollar imaging bill to Medicare will not be indeterminate.]

He was sent to the SICU for observation. Around 4:30 pm, he became hypotensive in the 50/30s and responded to 1L bolus and pressors. Throughout he was alert and conversant. Our attending explained we needed to explore his abdomen. The patient vehemently declined. We stepped out to allow his son and daughter-in-law to talk it over. We once again explained the need for the surgery. Around 10 minutes later, he called us back in and consented to the operation. I asked the trauma surgeon if I could scrub in. I ran ahead of the patient transport as I changed out of my dress clothes and into my scrubs. Lesson: no doctor gets anything done wearing dress clothes.

The trauma surgeon working the night shift is Dr. Cruella, the young universally-feared 39-year-old with whom I worked in Year 3, Week 4 (a spleen was thrown). The PGY3 is trembling: “She holds herself to extreme standards, and expects the same from others.” I remember her as a great teacher so long as she doesn’t think you will write her up for a non-PC joke. She allows me to make the first incision. The resident then takes over while the attending and I hold retraction to open up the fascia. Once open, the resident and attending explore the abdomen in an organized fashion while I hold retraction with the large “Rich” retractor. We suck about 1L of blood from the abdomen, which does not suggest a large artery bleed. “The liver looks good, no contusion.” She then looks at the spleen. “It looks ischemic [not getting sufficient oxygenation from blood flow].” We open up the gastrocolic ligament to enter the lesser sac where we can see the deeper abdominal organs. Blood fills this area and takes several minutes to suction and absorb with “lap pads”. We finally see a swirl of bright red blood amid the darker old blood. “Suction where we are exploring, not where you see fluid. Give it to [the resident].” The resident takes the suction and jabs it where the swirl is. “Guess we’re doing a splenectomy,” says our attending, and asks for a silk suture to close the artery.  After they gain control of the artery by suturing it proximal and distal to the injury, we apply two Kelly clamps to each ligament connecting the spleen.

The resident cuts the ligament in between the Kelly clamps with Mayo scissors, and ties silk sutures on the ends of the ligaments. This time the spleen is not thrown, but rather gently passed from the attending to me to the surg tech. We then finish the exploration of the abdomen. There are several hematomas in the mesentery of the small bowel, but nothing bleeding. We then notice a “bucket handle injury” of the colon. In blunt trauma, the deceleration force causes the bowel to shear off its mesentery, a fatty sheet with blood vessels connecting the bowel to the aorta. I can put my entire hand through the bucket handle injury. We then notice blood pooling at the base of the mesentery. The entire middle colic vein was transected. The hole abruptly stops at the middle colic artery on the right hand border (i.e., a bit more force and the artery wouldn’t have been strong enough to hold the colon). The pancreas is also injured, so we “paint” (cauterize) the pancreas that is bleeding, and place a drain, and pray. Dr. Cruella: “Never mess with the pancreas. We just have to pray it doesn’t get mad.” She asks, “What’s the cardinal rule of surgery?” I answer: “Never mess with the pancreas.”

We perform a transverse colon resection (removal of 8 inches of colon, out of a total of roughly 60) using a staple device. The attending and resident discuss if they should perform a “primary anastomosis” (connecting the two cut ends together). She asks the anesthesiologist, “How has the patient been doing?” The anesthesiologist explains he had come off pressors for 30 minutes after the four units prbc (packed red blood cell units) and 1 unit FFP (fresh frozen plasma), but recently went back on them. “Damn it. No anastomosis,” says Dr. Cruella. Instead of closing the abdomen, we put a series of plastic liners and foam connected to a vacuum device (“wound vac”) in the midline incision. We leave the bowel in “discontinuity” for a “take back” procedure tomorrow once he is resuscitated. I leave the hospital at 10:00 pm.

The next day I ask to scrub in on the re-exploration operation with a fresh-out-of-fellowship trauma surgeon. We remove the wound vac and don’t find any missed injuries. The pancreas appears quiet. Unfortunately, he is not stable and therefore we cannot reconnect his colon. We perform a colostomy with the proximal transverse colon and leave the distal colon as a large “rectal stump”. The attending explains, “He could not handle an anastomotic leak. This is damage control.” After his surgery, he is unhappy, but understands he is alive. He is exhausted and resigned to his new reality. It is conceivable that the colon can be reconnected six months from now, given sufficient health and nourishment.

Aside from the colostomy, this patient seems to have a good chance of recovering his life before the trauma. He has no neurological damage.

Unfortunately, however, when I come in on Thursday morning, the night team informs me that at 2:00 am he vomited a large volume of “coffee-ground emesis.” We order an EGD (esophagogastroduodenoscopy) to evaluate for active bleeding. The test is negative for a bleeding ulcer, but he goes into respiratory distress at around 2:00 pm. He is reintubated and once again requires pressors. He likely aspirated gastric fluid into his lungs. We start him on broad-spectrum antibiotics. I discover he also has a superficial surgical site infection. The PGY3 jokes, “Seems like you are the common link to both procedures. I hope you didn’t cause it.” Saturday, he is still intubated, requiring lower dose pressors. His bowels still have not woken up with no output from the colostomy. He hasn’t eaten in 5 days. If this doesn’t change, we’ll have to start him on TPN [total parenteral nutrition, all nutritional needs are given through IV because the bowels are not working]. I leave Saturday night, a little dispirited for my Sunday day off.

The most unusual patient of the week was a drug-free 40-year-old who had recently moved in with his mother. His father died five months ago, but he had been behaving normally and his family also seems normal. Last week, he applied an animal castration band to his testicles. They must have been on for at least 48 hours because they were completely necrotic when EMS brought him to the hospital. After he applied the castration band, he amputated his left hand with a circular saw, got on an ATV and drove around the forest using the remaining hand. He threw the left hand into the forest. The police were able to get him off the ATV and into the hospital. The sister was able to find the severed hand and bring it to the hospital. Our hand surgeon completed a hand replantation. We had to keep him intubated to prevent him from moving his hand, anchored with just two short metal pins and any tension would have destroyed the delicately reattached veins. His family was devastated and had no idea that he was

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