Category: ICU

Hangry in the Hospital

Posted on by Amalia Cochran MD

Admit it- we’ve all been there.

You’ve got all of 5 minutes to get lunch before the next thing on your schedule and your pager goes off about something that needs your attention urgently.

You haven’t peed in 10 hours and a staff member who needs something for a patient starts to follow you into the bathroom (even though the patient need is not truly something urgent).

You’ve been taking care of everyone but you for the last 29 hours, a patient decompensates, and you’ve got to handle it because no one else is available.

You get paged at 2 am for berry blast tums because the patient doesn’t like the usual flavor (yes, this actually happened, though not to me).

The truth is that our healthcare system isn’t well designed for us to partake in self care.  While I know it most intimately from the ICU physician/ surgeon side, I see it exacting similar tolls on nursing staff, aides, PTs and OTs, pharmacists…really anyone who is involved in the nitty gritty of patient care. We get hungry (or hangry), we get tired, we get pulled in at least 6000 directions, all because we’re trying to do our best to take care of the patients and their families.

On Tuesday my team and I attended the March installment of Schwartz Rounds at the University of Utah, and the title of the session was the same as the title of this blog post.  We got to hear from people who work in the healthcare environment in very different roles and get their perspective on how challenging our jobs as caregivers make it to take care of ourselves, and there was a great discussion about the role that culture plays in that.  If I ask the staff to try to let me catch a 20 minute catnap while it’s slow, am I perceived as weak? If I call my supervisor to let them know I’m currently overwhelmed with patient demands, does that make me an incompetent resident? Putting those potential opportunities for shame into context was, quite honestly, eye opening.  Our culture in healthcare mandates that as care providers we all run fast, leap high, and do all of the right things for everyone with a smile on our faces at all times.  Reality mandates this simply can’t happen because we’re all human.

We all have basic things that we can try to do to help ourselves just a bit.  I have a cache of healthy snacks at all times and I have two water bottles in the hospital (one in my office, one on the ICU).  One of my “treat” tricks is that I have a stash of teas that I can brew up for me, which is an inherently stress-reducing activity, and that I am willing to share with team members as a boost. I’ve been doing this more recently and I’m starting to wonder if good loose-leaf tea simply has magical calming properties, even when it’s got caffeine.

One of the things that struck me the most during the Schwartz Rounds discussion was the role that leaders and teammates can play in creating a culture where we’re allowed to be human, where we somehow manage to get something nutritious to eat, where we can actually function at our best because we’re taking care of ourselves in the little ways that can add up when we’re stressed and tired and hungry.  I realized as I was listening to a few horror stories that we are so fortunate in our unit to have a culture where we try very hard to take care of one another, be that by grabbing a coffee for someone’s morning fix, running to get someone lunch who is swamped, or simply having that willingness to step up and lend a hand when it’s crazy so that no one person has to shoulder too great of a burden.

Here’s my challenge for each of us this coming week: Think about the things that you wish someone would do for you when you’re hangry in the hospital. Then offer to do one (or more) of those things for someone on your team. You never know when you’ll need the same favor, and I can assure you they’ll be grateful for the kindness.

 

 

 

Stop explaining, stop talking.

Posted on by Amalia Cochran MD

One of the places in medical education where I am well-convinced that we are still failing our trainees is teaching them how to have hard conversations. It’s simply not a part of the curriculum, so they rely on role modeling; as we know, that role modeling is as likely to be negative as it is to be positive. We also know that our students lose empathy over the course of their clinical training, and that the loss of empathy contributes to physician burnout and all of the negative repercussions associated with burnout.  And, of course, there’s the simple issue of the fact that no one actually enjoys delivering bad news and having hard conversations with patients and families.  It’s emotionally easier to not have the talk, or to deliver platitudes, or even to provide that little bit of false hope they can grasp on to so you don’t have to be the bad guy or bad girl.

The erosion of empathy has been a long interest of mine for both personal and systemic reasons.  Personally, I know I suffered from a tremendous (and in hindsight somewhat embarrassing) loss of empathy during the 100+hour workweeks of my residency, and that paucity of empathy applied to pretty much everyone, not just patients and families. I’m not saying I do it right 100% of the time now, but I’ve at least developed a tool set so that I’m usually aware if I’m entering an empathy-loss danger zone. And, of course, I’m interested at a systemic level because of the impact that empathy loss has on professionalism and our ability to work effectively as a team member or leader.

In order to remind everyone about the difference between empathy (healthy, connecting) and sympathy (not healthy, disconnecting), here’s a brief video lesson:

 

So, empathy is feeling with people. Courses are being developed to help us respond to patients and families in a more empathetic manner, and those courses often prescribe similar interventions:

  • Give the patient/ family, not the computer, your undivided attention.
  • Sit down!
  • Avoid medical jargon. Remember that part of medical school was learning that 2nd language of medicine- how would you explain this to your Aunt Velma, the 3rd grade teacher?
  • How you say it may matter as much as what you say.
  • If the patient is telling you about their feelings, don’t respond to them with facts. Doing so implies that you’re not hearing them.
  • When you’re scheduling a hard conversation, allow more time than you expect it to require.  This is not a time to be in a hurry.
  • Stop explaining. Stop talking.  Sit in the silence, no matter how uncomfortable it makes you. I love the quote that “doctors are explainaholics” (because we are).  Again, stop talking. It’s amazing what you can learn when you give people time and space to share with you.

As an additional aside, I would add that fostering these communication skills is also helpful for having hard conversations as a leader. While some of the details are different (you can probably use medical jargon with a junior colleague if it’s needed), all of the other rules absolutely apply.

Empathy is hard. It requires work, and it’s something we have to practice routinely in order to become good at it- much like being a surgeon, being a musician, or being a person. We need to recognize when we’re offering up unhelpful silver linings (or sandwiches) rather than genuinely connecting.  It’s scary, but it’s also worth it for our patients, their families, our colleagues, and ourselves.

 

Brave enough

Posted on by Amalia Cochran MD
Believe
Believe

 

Dear one,

Before I get too immersed in all of the other things that make up my crazy life, I wanted to write you a letter.  It was important to me that you know what you meant to me, what I believe you meant to our team, and how the last 4 1/2 months of your life changed all of us.

I first learned about you the day after you landed in our care.  I remember thinking that whatever your outcome from your injury that it was going to be hard-fought- and that was before I got to know you and know your family.  That was before I learned that just as we gave 110% for you every day (and I hope we do for all of our patients!), you gave 110% every day too- even on the days that it hurt and it was hard and scary.  That was before I got to see a very sweet smile, before I learned about your gift of silliness, before we knew about your love of Dirty Dr. Pepper.  That was before I got to know your parents, who are some of the most grace-filled people I have had the privilege of meeting in my life.  In short, it was before we fell in love with all of you.

I told your parents this week that while I will never be comfortable with the reason that we all came into each other’s lives, I will always be grateful for knowing you and knowing them.  I also often say that I have a collection of angels watching over me when I am doing my work- I believe our whole team does- and I now count you among them.  In our world, we are given the gift of taking care of people who make us all better people.  You were one of those people, and your family is some of those people too.

Our team started the week with a group hug in your honor, and I’ve lost track of how many hugs have been given among our team this week because of you.  We miss you.  We miss your parents.  We miss your brothers (though Natalie’s cell phone may not).

And I am so, so grateful for what you gave us this summer and fall as we loved you and cared for you and tried to put you back together.  While your light isn’t here on this Earth with us any more, I know that it brightened each of ours just a bit.  That is a gift that will have an impact for years to come.

Wishing you peace, dear one.  Thank you for being part of us and for being so brave.  You will not be forgotten.

Sometimes

Posted on by Amalia Cochran MD

Most of us go to medical school (and nursing school, for my nursing friends who read the blog) with this idealistic idea that we want to be able to help people.  We want to be able to heal people.

Here’s the dirty little secret that gets left out when most of us are considering medical careers:

Sometimes we can’t heal people.  Sometimes the disease wins.  And sometimes…sometimes the best thing that we can do to help is to support patients and families when it is time for us to keep them comfortable and to stop trying to heal them.

Sometimes we don’t even get the opportunity to know the patients who come into our care and who die there; we see perhaps a small piece of who they were.  I often wonder what it would have been like to get a glimpse into their life and to know them in some way before they landed in my care.

Sometimes we grow to love the patient and their family because we’ve spent so much time talking about care, talking about prognosis, working together to try to do the right thing at every juncture in the care process.  Those are the losses that shake us more deeply, the ones that leave us wishing we had something more we could do, the ones that do hurt…but we keep coming back to help the new patients because we know that is what this patient and his family would want us to do.

Sometimes we struggle with moral distress when we care for patients who are nearing end-of-life, and we have to figure out how to mitigate that sense (hopefully with functional coping mechanisms).

I’ve written before about the tendency of Americans to not die how they really want to; so much of this is predicated on American culture, the denial that there may be things worse than death.  For the record, many of us who work in critical care (I might even argue most of us) would tell you that there are many things worse than death, and it breaks our hearts when we have to drive those processes.  See above about moral distress.

Culture is a tough thing to change because so much of it is unconscious.  All we can do in medicine and nursing is keep providing care with compassion and commitment, keep educating families honestly about prognosis and possibilities, keep teaching people that being comfortable and being supported by family- without heroic medical interventions- really is a good goal of care at times.

Because sometimes?  Sometimes life and death has nothing to do with how talented we are as a team or how great of care we provide.  Sometimes it’s not ours to control.

Sometimes our greatest work is for those patients who don’t survive.

 

The beginning of the end

Posted on by Amalia Cochran MD

Last week the Institute of Medicine released their report Dying in America and it received a fair amount of press.  I’ll be honest- I waited a bit to write about it not to revive any furor, but because I was processing some of my own experiences as a critical care surgeon who is frequently involved in end-of-life discussions.  When I am working in the burn unit, where I spend the preponderance of my clinical time, it is rare for us to be able to send patients home for their last day or days; I have been able to do this only a handful of times in my career, and it always leaves me with a mixed sense of loss and gratitude.  When I am working in the oncology ICU, a place I spend about a month out of my year, I often find myself wishing we had the opportunity to help people plan a kinder end to their story than what we are able to give them.  Unfortunately, by the time many of them get to us there is painfully little we can actually do to help them.

This leads me to where the system is coming up short, time and again, and in a way that impacts both of my areas of clinical practice.  We aren’t having the right conversations at the right times.  As a medical student and resident, I had no formal teaching on DNR orders, POLST forms, or communication with families about goals of care.  These are skills I had to pick up on the job, watching those around me, praying to have some good role models from whom I could adopt practices.  But, again, if I am the one having these conversations with patients in the ICU- or with their families- I’m not having it at the right time unless it’s a review of existing plans or wishes.  These are conversations that patients should be having with “their” doctor, be it a primary care physician or a specialist.  These are conversations that families should be having so no one has to guess what Aunt Ethel would want if she were in the hospital on a ventilator and requiring dialysis and a feeding tube, with little hope of recovery to her twice a week golf game and bridge club.  These are conversations so that you and I and the people we love the most can write the end of our own story in a way that makes the most sense to us, whatever that is, and have it honored.

I’m not saying all of this in the interest of saving money, though the maze of end of life care as we currently practice it in the US is a tremendous drain on healthcare dollars and hospital care days.  The hyperbole of “death panels” was a terrible straw man, when all that was really wanted was for physicians to be reimbursed for the work they do on end-of-life planning with their patients (something that is both time-consuming and sometimes emotionally draining).  Educating the next generation of physicians in palliative care and hospice, and the important roles that they play for patients, is critical.  Quite simply, this is something that we can and must do better in terms of education, quality of care delivered, and public policy.

Establishing goals of care for a patient based upon their wishes is arguably one of the most important things that we have the opportunity to do.  Here’s to hoping that the IOM report will spur us towards a system that supports doing it better than what we have now and in a way that truly honors the dignity of each of our patients.  That’s the very least that they deserve.

Making a list, checking it twice

Posted on by Amalia Cochran MD

Prior to 10-15 years ago, the idea of checklists in medicine seemed ludicrous.  After all, the solution to a problem isn’t a piece of paper.  Or is it?

As an intensivist, I work in the clinical environment with the most evidence for checklists.  Thanks to the extensive work of Peter Pronovost, who has committed his career to quality and safety in patient care, a variety of checklists in the ICU setting have been shown to be of benefit.  My personal favorite is the daily goals form for ICU rounds, though I will also confess that this has proven challenging to implement in my own environment.  Culture change is tough. His work that has had the most broad reach is his work on reducing central line associated bloodstream infections (CLABSI), a key component of which is an evidence-based checklist.   This checklist has subsequently served as the foundation for the Michigan Keystone Project, a statewide quality improvement effort that has generated amazing amount of scholarly activity as well as a dramatic reduction in CLABSI rates.

Atul Gawande, surgeon-author extraordinaire, became interested in this idea of checklists.  He wrote a 2007 piece for The New Yorker.  This later served as a foundation for his book The Checklist Manifesto.

IN 2009, NEJM published the findings of a prospective, multicenter implementation of a 19-item surgical safety checklist (Gawande is part of the author group).  This checklist was implemented in highly diverse clinical settings, and the authors from the Safe Surgery Saves Lives group showed a significant reduction in both mortality and in-hospital complications in patients who received care following checklist implementation.

WHO Surgical Safety Checklist

 

While arguments can be made about the potential for Hawthorne effect impacting the findings, the results were still impressive- particularly so since this was implemented in not just economically developed countries, but in low-middle income countries as well.

In the last month, more data have been published about the effect of a surgical safety checklist.  A systematic review and meta-analysis in the British Journal of Surgery indicated that current publications are “highly suggestive” that the WHO list reduces both mortality and complications, but bemoaned the lack of higher quality studies that would allow a definitive recommendation.  Then, this week from Ontario comes a multi institutional study showing at best equivocal differences in complications and mortality.  While this large study does bring into question the efficacy of surgical safety checklists, the accompanying editorial from Lucian Leape takes a pragmatic approach to these findings, focusing on a variety of reasons why the Ontario study might have the findings that it does.

My current institution does have a mandated preoperative time-out, but we have not yet adopted the WHO safety checklist or a modification thereof.  If we do move in that direction, significant stakeholder buy-in is crucial to minimize “gaming” of the system.

And as a disclosure, our ICU committee just approved a central line insertion checklist that I’ve spent the last 8 months developing, revising, sharing with colleagues, revising again…so yes, I am a believer in checklists.  I believe in patient safety, and I believe in the fallibility of humans.  While a checklist can’t make us perfect, it certainly appears likely to allow us to reduce errors in complicated care to an absolute rarity.

Have you had your flu shot? Why not?

Posted on by Amalia Cochran MD

I’ll open with a confession:  One of my annual fall complaints involves getting a flu shot.  I’m one of those people who tends to get low-level flu-like symptoms after my shot, so I invariable set aside a day or so to not feel great afterwards.

That said, if I weren’t required to get a flu shot for work, this is the winter when I would have made sure to get one. It’s been a brutal influenza winter.  Want proof?  Here’s the CDC map from week before last:

usmap3 January 18

 

It’s bad.  It’s really bad.  I have heard countless tales of woe from my MICU colleagues about how many flu patients are in their ICU, and many of them do not fit the profile of who you would normally expect to be critically ill from flu (younger, no chronic diseases); this is likely because the most common strain this year is H1N1.  The common theme for almost all?  No flu vaccine.

How can you prevent yourself from getting the flu?

Obviously, the first thing I’m going to tell you is…get your flu shot!  I simply can’t emphasize that enough this year.  If you are over 6 months of age, you need one (with exceedingly rare exceptions). If you want to see if you’re an exception, look here.  The list of who should not get one is really, really short.

Other helpful tips for all of us?  Wash your hands.  Get rest.  Eat well.  Cover your nose and mouth with your sleeve when you sneeze or cough.  In other words, do all of those things that your Mom always nagged you to do (she was right).  Oh, and if you’re still smoking, the flu is another reason to quit.

How do I know if I’m getting the flu?

The video is far more efficient and effective than anything I can say.

Then what do I do about it?

First, be kind to those who work or go to school with you- STAY HOME!

Contact your physician.  If it’s early in the course, treatment with antivirals can reduce the length of time you’ll be ill with the flu.

 

For a great review of preventing and controlling flu, this NEJM Perspective piece provides an excellent summary.

“Why are the surgeons so quick to trach?”

Posted on by Amalia Cochran MD

The title question was asked of me by a pulmonary intensivist about a month ago.  My pulmonary colleague simply said, “The evidence doesn’t seem that great for it, so I don’t see the harm in waiting.  We keep people on the ventilator for a month sometimes in the MICU without a trach.” I was fascinated because I hadn’t really given the subject a great deal of thought (probably because I am one of those dreaded surgeons!), and the good news was that it drove me back to the literature to see what we really know.  I try my best to practice based upon evidence, acknowledging that in burns and critical care that evidence is limited at times.  And while I was pretty certain that a patient who has been on the ventilator for a month deserves a tracheostomy, I wasn’t sure when the best timing really is.

A great deal of the early literature on the benefits of early tracheostomy came from the trauma world; while early trach didn’t influence mortality in trauma patients, duration of mechanical ventilation and ICU stay were both shortened.  A recent propensity analysis in patients with traumatic brain injury confirmed these findings, but also added decreased rates of pneumonia, DVT, and decubitus ulcer to the benefits of early trach.

A 2005 systematic review that included a more broad ICU population demonstrated again that duration of mechanical ventilation and ICU stay were shortened, albeit with no reduction in mortality.  This lack of mortality benefit has been repeatedly confirmed, and was also shown with the 2012 Cochrane review of early versus late tracheostomy.  The Cochrane review appropriately noted the generally low quality of most studies in this area and the need for multicenter RCTs to provide definitive information.

Two posters at the recent Critical Care Congress addressed the issue of early tracheostomy, one in pediatric patients, the other in adults (but bringing a new angle in to the discussion).  As someone who does care for critically ill children who can and do have prolonged ventilator courses, the reduction in length of stay with early (<14 days) tracheostomy in pediatric ICU patients was notable to me.  However, I also recognize that their patient population in a “regular” PICU is very different from the pathophysiology of our pediatric burn population.  The Hopkins study that evaluated quality of life is the one that I find the most compelling, and is the most likely to inform my practice.  The simple fact that adult patients who underwent tracheostomy reported better quality of life than ventilated patients who did not, much less that early trach showed a significant quality of life benefit over late trach, encourages me to look at 10 days as a “fish or cut bait” point for tracheostomy, both in the Burn unit as well as the oncology ICU.

Now if I could just overcome my irrational fear of percutaneous tracheostomy…but that’s a blog for another day.

Choosing Wisely in the ICU

Posted on by Amalia Cochran MD

It’s Thursday, so it’s clinical blog day.  As you are aware, I just got back from the SCCM Critical Care Congress in San Francisco, and while I’ve said that this Congress left me a bit less excited than they traditionally have there was still some great material to share.

The single item I am the most excited about is the extension of the Choosing Wisely campaign into the ICU setting.  Choosing Wisely is an ABIM initiative designed to encourage discussion between patients and physicians about the necessity of tests.  Because of my life as a medical educator, I also see it as consisting of important things we need to be teaching our learners.  There’s a terrific list for many different areas of medical care of things we probably shouldn’t be doing routinely, all of which are driven by evidence and by the specialty societies in the various fields.  The general surgery list was released as part of the initial group; as someone who hasn’t taken general surgery call in a while, I was delighted to see the Critical Care Societies Collaborative list.  And without further ado, the list with some comments…

1.  Don’t order diagnostic tests at regular intervals (for example, every day), but rather in response to specific clinical questions.  I’m a bit notorious for grilling my residents with the question, “What are you looking for?  And what are you going to do about it?” If the answers are “I’m not sure, and nothing,”  then a test isn’t worth ordering.  Cathy DeAngelis, the former Editor-in-Chief of JAMA uses a phrase that’s less eloquent but equally effective:  “It’s like picking your nose- what are you going to do if you find something?”

2.  Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.  I’m debating between two stories here.  One is that of a self-assured neurosurgery intern who, when I was the burn fellow, made an independent decision early one morning to transfuse a child with a hemoglobin of 8.5.  When I questioned him on it and he told me, “Well, it’s my practice…”  he was cut off promptly.  While there was also a bit of chastising that went on, I promptly referred him to the TRICC trial that’s referenced in last week’s blog.  All of that being said, in burns there is currently a prospective RCT replicating TRICC to see if the rules are the same for us (we were excluded as TRICC patients).  I promise a big, glittery blog post when that study is published.

3.  Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.  That said, if someone is profoundly malnourished and they cannot tolerate enteral feeds, go for it.  Remember, though, if you can feed the gut…you should.

4.  Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.  Because of my anti-benzodiazepine bias, also discussed last week, I would add “Thou shalt not place a patient on a continuous infusion of a benzo for sedation unless you have exhausted all other options.”  We know that “Wake up and breathe” works, both in terms of delirium and in terms of pulmonary complications.

5.  Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.  One of the toughest parts of my job as an intensivist is working with families to make the move from our goals of care being cure to our goals of care being comfort.  Obviously this is the one of the recommendations that requires the most discussion with families, but for those who agree that their family member would not want a prolonged and somewhat terrible ICU course or would not want the functional result likely to come, it’s the most compassionate recommendation.  Palliative care makes a real difference when done well.

Choose wisely, readers, and I would love your thoughts on these recommendations.

My primer on Critical Care

Posted on by Amalia Cochran MD

I’m in San Francisco for the next several days for the Society of Critical Care Medicine (SCCM) Clinical Congress.  I intend to go home with some great new clinical blog topics for you all, but as a segué to whatever I learn here I wanted to get some key references out there for those who are newer to the world of critical care.  Secondary gain:  It makes a great resource for my students and residents.

This list is by no means comprehensive, and studies placed here are here based upon my opinions.  I’ve essentially selected one seminal or one “hot off the presses” publication for several organ systems.

Neuro:  Delirium is obviously one of our nemeses in the ICU, and we want to minimize the risks for it in our patients who require sedation.  Although it’s now 8 years old, a game-changer for me was Pandharipande’s study showing that lorazepam is an independent risk factor for delirium in the ICU.  Our pharmacist had the graph from the study taped to her laptop for over a year, and any time we started discussing sedation strategies I would point at it.  Related: Last January, SCCM released new evidence-based guidelines for the management of pain, agitation, and delirium in the ICU.  The guidelines are very helpful, but they also show many areas in which we still have significant knowledge deficits.

Cardiovascular:  I remember when I started my residency that levophed was typically referred to as “Leave ’em Dead.”  In hindsight, I suspect that this was simply because we weren’t using it optimally, and therefore our patient outcomes were impaired.  In contrast, I now often find myself trying to convince referring MDs that use of dopamine is probably not a best choice, even in refractory hypotension, because of the increased number of adverse events associated with its use.

Pulmonary:  Yes, it’s now 14 years old, but ARDSnet remains our standard of care for our patients with ARDS.  We may not always agree on PEEP or mode of ventilation, but low-stretch remains the standard of care.

Endocrine:  During my residency, we all got VERY excited about tight glycemic control in the ICU based upon the van den Berghe study.  Subsequently, we’ve found that tight control increases the risk of hypoglycemia, which in turn increases the risk for neuroglycopenia (which is bad) and mortality (which is worse than bad).

Nutrition:  The Canadian Critical Care group continues to lead the way in development of evidence-based guidelines.  These were most recently updated in April, 2013 (link is to the summary).

Heme:  The TRICC trial.  I’m eagerly awaiting our findings from the analogous burn study that is still enrolling patients.

Infectious Disease:  How many days of treatment are required for a ventilator associated pneumonia?  Less may be more.  Also, no learner should get through an ICU rotation without knowing about the Surviving Sepsis guidelines and being able to implement them in care of a patient.

Notes:  

  • The New England Journal of Medicine initiated a truly terrific case-based series of reviews on critical care last year.  These are highly recommended for practitioners new and old.
  • SCCM has a series of clinical practice guidelines, of which I have only highlighted a couple.  They are an excellent resource.
  • Again, these references are a starting point for core readings in critical care.  If I have committed a glaring omission, please let me know so I can addend.