Monday, November 3, 2014

Critical caring.

The patient was sick. The kind of sick that isn't straightforward or classic for the textbooks, either. He had the kind of labs that make your head hurt from thinking; numbers that forced you to sit down at a desk with a pencil and paper to figure out calculations before writing orders. To make matters worse, he wasn't very old, either. And, generally speaking, when people aren't up in age and they're very-very sick, there is usually some unifying diagnosis to explain it all. Here's the problem, though: We couldn't figure out what it was.


I mean, it certainly wasn't from a lack of trying. We did our due diligence by combing the literature for case reports and consulting with experts. Despite all of these efforts, he continued to slide in the wrong direction. His vital signs teetered on that very fine tight rope between "intensive care unit team level of sick" and "step down with the regular ward service level of sick." On a couple of those days, I had my resident and interns call over to the critical care/ICU team to come and assess the patient for their team. Each time, they would look at everything and agree that it was perplexing. That said, with all of the very clearly ICU-level patients that they already had, they'd kindly decline. And mostly, that was fine.


I think a lot about triage decisions when I am working on the hospital service. Like, who should be admitted in the first place versus who should be on the medical floor versus who should be in a stepdown unit versus who should go to the intensive care unit. I speak to my teams ad nauseum about this, drilling it into their brains that, really, triage has a great deal to do with nursing needs. If there is something going on with you that will be difficult or dangerous to manage at home and having nursing support nearby will improve it, that's generally the first decision point. Especially if it is the kind of problem that could cause you to take a turn for the worse. Then, once we give the green light for you to stay, it comes down to how much attention might you need from your nurse. If you need a lot of attention---say because you have in lines or our intubated---you need a nurse that doesn't have much else to be focused on other than you. That generally happens in the intensive care units. The nurses there have one to two patients and can devote all of their energy on the shift to them. Contrast that with the regular medical floor where the RN may have as many as six or seven patients.


So what happens when a patient is waxing and waning in between? I'll tell you what happens. A collection of people deliver bursts of critical care (i.e. ICU level) while it gets figured out. Sometimes it is the nurse. Sometimes it is the physicians on the team. Sometimes it is even a family member standing vigil at the bedside. And mostly, it's okay as along as it lasts for very short periods of time until some clear answer is reached. But when it is prolonged, it robs other patients of time and energy that they deserve.


Here is the other thing that I think I never used to think about but now I do. ICU admission is about more than just nurse-to-patient ratios. It is about something else, too. Do you know want to know what that is? Well, I'll tell you: EXPERTISE.

Yes. That. 

When it comes to the sickest of the sick, nobody manages them better than doctors and nurses who work regularly in the intensive care units of hospitals. We call those physicians "intensivists." (That or we just refer to them as "the critical care guys.") Additionally, ICU nurses and even clerks are a special breed. They handle critically ill and seriously sick-sick patients all day every day. That crashing patient that freaks me and my team out is no different than a barking dog on a mailman's route to them. Not only do they not freak out--they thrive in it.


My colleagues like Greg M. and Annette E. who work in the ICU at Grady are pros at all of this. And, generally speaking, the sickest of our patients generally have several different organ systems going awry at once. And those critical care guys? Those intensivists? Their mental muscle is trained for all of this. They are thinking fast and working on all cylinders. Which is good when the issues are life or death. That's what this was becoming with my patient. I didn't know what else to do.

So here's what I finally did. With my intern, Leah R., I physically walked over to the ICU to speak directly to one of my intensive care colleagues. When I got there and found Greg M., he was gracious and patient as always. I let him know that not only was I concerned that this patient needed a higher level of nursing attention, but especially my patient needed an intensivists brain working to get him better. As a matter of fact, I think I may have even said, "This is more about me needing your expertise and experience to save his life than one-to-one nursing. I need your brain and your help." And Greg offered collegial suggestions and engaged me in a true medicine-nerd dialogue about what could unify all of what was happening with my young patient. He did all of that, yes. But then, without any push back, he accepted my patient to his service.


My intern saw the whole exchange as did the residents in the ICU. I realized what an important role modeling moment that was, watching two faculty members work through what was wrong and finding what was best for the patient. One attending admitting out loud that "I don't know what to do and I need your help" and the other saying "right now, I don't know either but I will help." I also had this ah hah moment that many times, that discussion has to take place at this level -- the senior physician to senior physician level--for things to move forward. I am glad my intern asked me to come with her to the ICU that day. It turned out to be pivotal.

So what happened? Well. Let's just say it was good that the patient was transferred to the ICU. Things got much, much worse before they got better. But when they did go south, you'd better believe those bad ass ICU nurses were all over it working in concert as only they can and those critical care guys put their ICU brains in turbo gear. They sure did. They ran codes on my patient, found answers, and fought to do the thing that they do better than anyone else in any hospital setting--save my patient's life. They sure did.

Here's the thing: In medicine, there is a lot of pride involved. We beat our chests and tell stories of how we intubated someone with one hand while placing a line with the other hand and doing chest compressions with a foot like some kind of one man show. But all of that idea is really ridiculous, isn't it? I mean, we are taking care of human beings. But the other thing is that WE are human beings. Human beings fall short and they don't know everything. They don't.

My lesson for my intern that day:  "Advocating for your patient sometimes start with admitting that you need help. And that you don't know what to do." 


Happy Monday. And shout out to everybody like Greg M., all those awesome ICU nurses, and so many more people who save lives in our ICU at Grady every single day. You are critical to what we do--thank you for your critical caring.


  1. Yes, you definitely are human, and that's a good thing, even when you don't have all the answers.

  2. If I could change one thing about medical education in this country, it would be this tendency to teach self reliance as an ultimate, desirable characteristic in physicians. From what I read here, you are teaching not just team based care but team based decision making, which is incredible. In my conversations with doctors about what they struggle with most in this "brave new world," it's that not enough young physicians get that perspective in either med school or residency.



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