Posts Tagged ‘ICU’
I have a colleague who has lost his capacity to continue practicing pediatric critical care medicine. It didn’t happen suddenly; it came on gradually over a year or so. It also didn’t follow from a single event or bad experience. It was just a creeping uneasiness that culminated in his unwillingness, after two decades, to go on doing this. Even though I’ve been practicing pediatric critical care for thirty years, I don’t share his discomfort, at least for now, but I understand it. I can’t say much about other specialties because I’ve only done this one. So I don’t have much insight into the specific stresses other kinds of physicians face. I assume that these specifics matter to some extent.
There is a large body of research on occupational burnout in general and physicians in particular, one which I don’t pretend to know very well. You can find a good recent example here. That study, a survey of over 27,000 physicians, defined burnout as the presence of a loss of enthusiasm for work, feelings of cynicism about the work, and a low feeling of personal accomplishment. Those strike me as pretty broad categories, things that would include most of us from time to time. So I am not surprised that an average of 46% of physicians reported at least one of those symptoms. I would have thought it would have been higher. Still, compared with the general population, physicians were around 50% more likely to report these symptoms.
The physician group most likely to experience these feelings were emergency physicians, with primary care practitioners close behind. This particular study didn’t say anything about my specialty of pediatric critical care, or even critical care generally, but did note that general pediatricians were among the least likely to report such feelings.
It is my impression that critical care medicine as a specialty has a fairly high burn-out rate. By that I mean something more than the survey: I mean people who actually leave the practice of critical care. Some of this comes from the hours we keep and some comes from the continual crisis mentality you find in many ICUs, but I think mostly the reason comes from within us. Each of us has a finite capacity for tolerating stress, a fact known for many years. Old studies of combat fatigue from World War II even estimated precisely how large that capacity is, on average. When that limit is reached, we are done and our bodies make us stop, even if we may not want to. This is something worth remembering for everyone — not just ICU doctors, but everyone.
My own view is that this individual well of resistance to burnout varies a great deal from person to person. Perhaps this is innate, perhaps it is greatly modified by our past experiences. What I think, after many conversations with colleagues about it, is that nobody knows when they choose a career how deep is their well for tolerating this. I don’t know of any way of determining this, either, although perhaps psychologists have some tool or other for assessing it.
What I do know is that the effects on the individual can be very grave, especially if that person has no choice but to carry on as best he can. Have a look into the eyes of Abraham Lincoln in portraits taken at the beginning and at the end of the Civil War. His trial was a terrible one, far worse than any of us face. But if a man like him was so used up in four years, how can any of the rest of us avoid it unless we find ways of sharing our stress with others. It may be a blow to our medical egos, inflated as they often are, but if you feel it happening to you, it must be done if you want to continue on.
I’m a fan of the cartoonist who draws xkcd, which the author describes as “a webcomic of romance, sarcasm, math, and language.” This particular one well illustrates something that happens a lot in medicine, especially the ICU, because we order a lot of tests. We get back a test result that is nothing at all what we expected, one which gives an answer to a question we didn’t even ask.
Patients (and their families) not uncommonly want us to do a lot of tests, especially if what’s wrong is not obvious. Why not order a large panel of blood, urine, and x-ray tests? We might turn up something that will help. We might. But we also may turn up something that is unanticipated and totally unexpected. Once in a while this is useful and gives us the answer. But many other times we are puzzled by the result, and to resolve the puzzle we order even more tests, maybe ones that we never would have ordered otherwise. These new tests may turn up yet another unexpected result or two, which we pursue with yet more tests. You can see where this is going.
The best way to prevent this cascade of unintended consequences is to avoid scatter shot testing. We need to make sure there is some logical reason for the test, often from the patient’s story or examination, that makes sense. All medical tests have possible error built into them. It is often said if you order twenty tests you’ll get one that is a false positive, potentially leading to a wild goose chase.
If a doctor orders a test for you or your child, ask just what — quite specifically — the test is for. More care is not better care — it can also be worse care.
Many patients in intensive care units, children included, require what we call a central venous catheter (line) or CVL. This is a plastic tube that enters the skin at one of several places — the neck, upper chest, arm, groin — and has its tip end up in one of what are called the central veins. Here’s what such a line looks like. The pointy end goes into the patient. This particular one only has one tube, called a lumen. But we often use lines with several lumens, all contained within the same overall size tube. It’s like having two or three CVLs simultaneously.
Then central veins are inside the chest just outside the heart. Here’s an illustration of what they look like and shows the various approaches we can use to insert a CVL. The picture shows a subclavian approach — the vein under the collar bone. But we can use the veins in the arms or in the neck as well. Or, as is common in children, we can use the vein in the groin and approach the heart from below.
CVLs allow us to do several things. We can take blood samples without sticking the patient with a needle. This not only spares the patient a painful stick, it allows us to sample the blood in the central vein, which is often important. We can make useful measurements of the pressures inside the central veins, a key thing to know when caring for many patients. Because of the high blood flow inside the central veins, CVLs allow us to give medications that would burn or damage the inside of smaller veins like those in the hands and arm.
CVLs are important tools for managing ICU patients. But they are not without risk. Their tips can wander into places they should not go. More commonly, the CVL can provide a highway for bacteria living on the skin to gain access to the inner organs of the body. These bloodstream infections can be very serious, even lethal.
Some years ago research suggested very simple measures can reduce the chances of a patient with a CVL getting such a serious bloodstream infection. The measures are decidedly low-tech and common sense. Even though you are wearing sterile surgical gloves when you place a CVL, wash your hands before you start. Wear a full-sized sterile gown. Clean the patient’s skin off thoroughly. Use sterile drapes and barriers so that bacteria from the area outside the immediate CVL site don’t crawl into the sterile field. Finally, use a checklist to make sure the person putting in the CVL follows all the steps. This is all very simple stuff. Yet the effect of adhering to the protocol is to reduce the rate of infection. The Centers for Disease Control (CDC) recently documented a nationwide reduction in CVL-associated infections.
The take-home message is that in modern ICU medicine, high-tech as it is, low-tech, simple stuff can have profound effects. My grandmother, a nurse who was always after us kids to wash our hands, would not be surprised,
If you’ve ever been inside a PICU, or any ICU for that matter, I’m sure you were surrounded by fancy-looking equipment. There are monitors coming off the wall that measure a large assortment of patient variables. These can include include heart rate, breathing rate, blood pressure, amount of oxygen in the blood, amount of carbon dioxide in the patient’s breath. If the patient has various invasive monitoring devices in place in the bloodstream, or even in the brain, the monitors measure pressures inside the blood vessels and brain. Most of these monitors also display a waveform of these things moving across a screen in multiple colors. It’s very impressive-looking. If the patient is on a mechanical ventilator, a breathing machine, it has monitors built into it, too. This child has a bunch of those, including the brain one.
We use these monitors to measure important things, and they all have alarm settings that go bing or bong, often quite loudly, if the thing the monitor is measuring drifts outside whatever parameters are set for the monitor. That’s for safety. But many of those monitors are so sensitive that one or another of them is always making noise. Nurses are frequently resetting one or another of the alarm buttons. Virtually all the time it’s a false alarm in that the particularly bing or bong is not significant for the patient. Often it means there’s something amiss with the monitor.
I think you can see where this is going — alarm fatigue sets in. With so much alarm noise, most of it like the proverbial boy calling wolf, it can be a problem when to know when there’s a real wolf in the room. The FDA has recognized the problem, which I can tell you from practical experience is a real one, by scrutinizing new medical equipment for a balance between alarm sensitivity and usefulness. You can read more about that here.
The best advice for doctors and nurses in dealing with this issue is what the good ones always do: when some alarm goes off indicating a problem, look at the patient more than the monitor.
There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?
I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.
Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practices.
How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.
Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.
Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.
The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.
This is a cross-post of an item I wrote for Maggie Mahar’s excellent heathcare blog, Healthbeat
The electronic medical record, the EMR, is upon us. For those of us who learned medicine entirely with paper charts, some have enthusiastically embraced the EMR and some have refused, to the extent they can, to deal with it at all. But most of us have plowed ahead into learning how to use it as best we can. It seems to me that the degree of enthusiasm physicians show for the EMR relates less to the particular version of it we have chosen (or, more commonly, was chosen for us) than it does to the kind of medicine we practice. The old paper records worked reasonably well for all of us; in contrast, the several versions of the EMR I’ve used work very well for some kinds of doctors, but less well for other kinds. I think a good part of this disparity is that the basic purpose of the medical record has changed over the past half-century or so, and some of these new roles can conflict with the old ones.
The oldest repository of continuous patient medical records is at the Mayo Clinic in Rochester, Minnesota. In a very real sense the modern medical record was invented there, in the first decade of the twentieth century, by Dr. Henry Plummer. As the first multi-specialty clinic, it made more sense for each patient to have a single record that traveled from doctor to doctor with the patient, rather than having each doctor keep his or her own record for each patient. The idea was to have a single packet of paper that contained everything that had happened to the patient. From that it’s only a short step to the notion that the record should travel with patients wherever they go, even if it is to physicians not associated with each other. This is a key promise of the EMR.
Medical records began as the possession of the doctor. This paradigm is changing. Very soon, although medical facilities will have copies, the records will essentially belong to the patient, with doctors only using them from time to time as need requires. Of course this could, in theory, happen with paper records, but it would be cumbersome. One of the things that first attracted me to pediatrics was the sheer size of the pile of paper that the medical records clerk would plop in front of the hapless medical student admitting an octogenarian to the hospital; in contrast, a toddler’s chart fits neatly in a small packet. The EMR allows these massive piles to be reduced to disks or microchips. It also allows the record to be organized into searchable form, so important things don’t get missed because they are buried in the disorganized mess of sequential folders.
Those are a couple of the brave promises of the EMR, but we all know we are a long way from realizing them. One huge barrier is that, as of yet, there is no standard platform for the EMR. Like many physicians, I’ve had to learn several because different facilities choose different vendors. In our pluralistic medical system (if one can indeed call it a system), it’s a free-for-all. And each of them has its own maddening quirks.
I think there is a broader problem here: over the ensuing years from Dr. Plummer’s era the medical record has taken on roles unheard of back then. For one thing, now the record is a legal document, a buttress against anyone who accuses us later of bad care. This process began long before the EMR, or course, which is one reason the charts I had to grapple with as a medical student ballooned so much. As a graduate student in history of medicine I had the chance to review many of the Mayo charts from earlier, simpler times. I recall one chart, from the nineteen-forties, describing the course of a very critically ill child. Overnight the child’s condition had markedly deteriorated; it was easy to see this from the recorded blood pressures and heart rates. The physician’s note for the following day analyzed these developments with only four words: “mustard plaster didn’t work.” Now the EMR offers the possibility of recording all we do easily and without getting writer’s cramp.
The medical record has also become something else it wasn’t back then: it is also now a commercial document, proof of what we did and why, used by payers to check up on us to make sure we should be paid for what we bill. Today’s payers want to know what the doctor did and why. They want to know, quite precisely, why that mustard plaster didn’t work and all that we did to make it work.
I think some of the problems with the promise of the EMR are that these legal and commercial roles can clash with the original purpose of the chart, which is taking care of the patient. The computer whizzes who design the software don’t always seem to me to have quite the same goals as we doctors who use it. The old paper charts were easy to adapt to new things, new procedures. All we needed was a different sheet to add to them and stuff in the folder. Upgrades and tweaks to the EMR are much more formidable things.
In spite of all these things I find the EMR to be a powerful addition to my practice. In fact, I think I’m a better doctor for using it. I think a key reason for that is because of what I practice – critical care medicine. In the ICU we love to measure and count things. We want minute-to-minute monitoring of variables, which in the old days resulted in huge paper flow sheets covered with dots and numbers. Rummaging through them to identify key moments in a patient’s care was often difficult. In the ICU, each patient gets a large number of tests each day, results which used to get stuck on clipboards with all the other paper. Important things got missed. Now I can sit at a computer screen and find it all with a mouse click, and the EMR makes it very hard not to notice anything important.
In contrast, I have friends who hate the EMR. It causes them hours of pain in training time, pain for which they aren’t compensated, and is slower for them to use than paper records were. In their minds, it gives them little or no advantage over paper in caring for their patients. I’ve noticed that they practice specialties that are less concerned with number-crunching than mine. They also tend to be office-based, rather then hospital-based, and don’t have to deal with as many other physicians as I do each day in the ICU. Thus many of their notes are written for themselves, not for other members of a large clinical team. Yet now they are asked to conform to how others want their charts to be.
I don’t know how all of this will work out. The EMR is here to stay. On balance, I think this will ultimately be good for doctors and their patients. But we don’t really know yet just what it is and what it should look like. I worry it will end up like one of those military boondoggles – it gets loaded with so many bells and whistles because it is supposed to serve so many purposes that it ends up being an expensive monstrosity that doesn’t perform any of its missions well.
Still, I’m an optimist. I prefer to be excited by the possibilities, rather than discouraged by the obstacles. I think the EMR will be good for patients, and will make us better physicians. For a while though, things will continue to be more than a little messy.
There is a shortage of intensivists in the US, both pediatric ones and those who care for adults. Intensive care nurses are in short supply, too. Yet the demand for intensive care services is growing. Part of the demand for adult intensivists is driven by our aging population, but what about children? Why aren’t there enough pediatric intensivists to go around?
I think the principal reason is that our national standard of care for children has changed over the past decades. When I trained in pediatrics over 30 years ago, only the largest children’s hospitals had PICUs. That has changed. The expectation these days is that medium-sized hospitals provide a much higher level of pediatric care than they did in the past, and that includes care of critically ill or injured children. Sometimes this means having a regional transport system so that such children can be rapidly flown to a larger center. But more and more it means that we need to have PICU capability in more places, and that means we need more pediatric intensivists.
Many have wondered if part of this problem can be solved by spreading the expertise of intensivists over a wider area, by taking advantage of all the communication and monitoring capability we have — that is, by establishing what has been labeled a “virtual ICU.” The idea has been gaining ground in adult practice; here is an example of what it means.
How could that work? What most people mean by a virtual ICU is that intensive care doctors (or nurses) can sit in a room and monitor the vital signs, lab results, x-rays, etc., of patients in ICUs in another location. The monitoring doctor could see the patients with a video camera, too. The patients aren’t alone, of course — there are doctors and nurses at the bedside, just not intensivists. When the intensivist monitoring the situation spots something, or if the doctor on site needs advice, there’s the telephone.
Can this work? I have a friend who is an adult intensivist and who has done this for years. He’s enthusiastic about the concept. I’m not so sure about children, though. Maybe I’m a dinosaur, but there’s a fair amount of research that shows that the best way of determining if a child is really, really sick is to have an experienced person say that child is sick. Tests and monitors help, but the sixth sense that an experienced person brings to the bedside is invaluable.
Still, I think some version of virtual ICUs are in the future for children, too. The technology does keep improving, and we simply don’t have enough pediatric intensivists to go around. Looking at the number of pediatricians training to become intensivists, this situation isn’t going to change anytime soon.
The concept of a virtual PICU can also have another role — that of intensivists exchanging information and collaborating with each other. Children’s Hospital of Los Angeles has been running a site intended to do that for several years now.
The H1N1 strain of influenza — the “swine flu” — has gotten a lot of headlines this past year. You can find a summary of matters during the first half of 2009 here. That report studied 272 patients who were sick enough to be admitted to the hospital. Of these, 25% needed to be in the ICU. From my perspective, the interesting part was that nearly half were children; unlike usual influenza epidemics, only 5% were older than 65.
I didn’t see any severe cases of H1N1 until this past fall, but then I began to see quite a few of them. Of these, two were so severe that they required prolonged treatment with a mechanical ventilator, a breathing machine. Another child in our region was so severely ill that he required treatment with the most extreme kind of respiratory support, something called extracorporeal membrane oxygenation (ECMO). This machine bypasses the lungs entirely and uses a machine to get oxygen directly into the child’s bloodstream. Using ECMO is a complicated endeavor, one with high risks and high mortality. But sometimes it is all we have to offer.
My conclusion on the H1N1 flu is that it was every bit as severe as the experts predicted. Although the mortality was not anywhere near as bad as the great epidemic of 1918, we also have means of ICU support that physicians didn’t have back then. This year’s flu, like that of 1918, also seemed to affect the very young to a degree I haven’t seen before. To me, the massive campaign to vaccinate as many as possible was justified. Of course we don’t know if it helped reign in the epidemic thus far, but I think it probably has.
I have a colleague who has lost his nerve to continue practicing critical care medicine. It didn’t happen suddenly; it came on gradually over a year or so. It also didn’t follow from a single event or bad experience. It was just a creeping uneasiness that culminated in his unwillingness, after two decades, to go on doing this. I don’t share his discomfort, at least for now, but I understand it.
Critical care medicine as a specialty has a fairly high burn-out rate. Some of this comes from the hours we keep and some comes from the continual crisis mentality you find in many ICUs, but most of the reason comes from within us. Each of us has a finite capacity for tolerating stress, a fact known for many years. When that limit is reached, we are done and our bodies make us stop, even if we don’t want to. This is something worth remembering for everyone — not just ICU doctors, but everyone.
Have a look into the eyes of Abraham Lincoln in portraits taken at the beginning and at the end of the Civil War. His trial was a terrible one, far worse than any of us face. But if a man like him was so used up in four years, how can any of the rest of us avoid it unless we find ways of sharing our stress with others. It may be a blow to our medical egos, inflated as they often are, but it must be done.
The Blogosphere has seemingly millions of blogs, and many of these touch on important aspects of children’s health care. However, I found none about the needs of very sick children and their families. Well, now there is one – this one. My goal is to make a small room in the huge, many-roomed mansion that is the blogosphere where we who want to talk about these things can meet. I’ll be here at least every week, and I hope others – parents, grandparents, medical professionals – will come by and add their voices, too. Be as controversial as you like – medical politics, health care funding, end-of-life issues – but please respect each other’s opinions.
An important disclaimer. What the blog cannot be, of course, is a source for specific medical advice about your child. That only occurs in the setting of a formal physician-patient relationship, which this blog is not. So you should never take what I say as substituting for that relationship between you and your child’s doctor.
Introductions over, let me begin with my definition of what people like me are, which is akin to old-time general practitioners. That notion may sound strange to anyone who would see me on a typical day in the PICU surrounded by high-tech gizmos, but it is true: physicians who run PICUs are like general practitioners for the very sick child because we look after the whole child, not just one organ or another. Or at least we should do that. The paradox of the ICU is that low-tech humanistic skills are the key to success in medicine’s highest-tech place.
Sachin on 
