Reading-Round Up, February 2017 edition

As promised, here’s the February reading round-up.  What’s caught my eye recently?

I was at SCCM two weeks ago, and would encourage anyone with an interest in critical care to read the Plenary Articles published in Critical Care Medicine.  These presentations at the meeting were all nothing short of amazing.

And… the Sepsis Guidelines have been updated (note: it’s mostly tweaks, little that’s entirely new).  If you’re not a critical care doctor, this is still important and relevant if you want to provide evidence-based best care when your patient has something go wrong.

In surgery we sometimes get to have conversations with patients and families when we don’t anticipate a completely smooth clinical course.  I’ve been playing with this framework since Gretchen Schwarze came and talked to us about it last year, and I find it helpful.  You might too.

Here’s some background work (with more great work coming) from my colleague Chris Pannucci on Anti-Xa level monitoring and perioperative use of enoxaparin.

Last year at the ASE meeting I was a little dismayed to find the frequency with which medical students use Wikipedia as a reference during the clerkship.  This article provides some justification for simply embracing it and makes me question if we should have a Wikipedia “hackathon” during 2018 Surgery Education Week.

I’ve preached about the importance of allies for women in male-dominated fields before in this blog.  Here’s another confirmatory article from HBR. Men, we really need your support, and if done right we can even benefit from your leadership.

Happy reading, all.

One…more…thing!

This past week I attended the Society for Critical Care Medicine Critical Care Congress.  Sure, the venue was a draw (Honolulu), as was the opportunity to spend time hanging out with my favorite pharmacist (Ann Marie is a rockstar and wonderful human). More importantly, I always leave this meeting feeling like it was time and money well spent.  This year was absolutely no exception (and yes, Burn Unit colleagues…be afraid.  I have at least 5 new and improved ideas for us!).

One of the standout sessions was a 2 hour discussion of burnout in ICU providers.  The session focused on physicians and nurses, and I’ll grant I would have liked more inclusion of information for our APCs, our PTs/OTs, and our pharmacists.  In spite of that, there was a lot of great discussion around the topic; if you want to see what it looked like on social media, check out the #StopICUBurnout hashtag on Twitter. It’s clear that we need to take a team-based approach to burnout because of the impact on team dynamics (it’s contagious) and patient outcomes (it’s negative).  Oh, and it also negatively effects our learners.

Here’s the conundrum around burnout.  A certain amount of stress can be positive and constructive under appropriate circumstances.  Plenty of  literature demonstrates that we adapt, both individually and collectively, with a certain amount of stress and that these changes can be for the better.  The issue becomes when the amount of stress is simply too much and we can’t manage another thing.

Like this:

Just right 👌

Posted by The Awkward Yeti – Nick Seluk on Wednesday, January 18, 2017

I’ve been there, and if you’re honest with yourself you’ve probably been there too. That’s when stress can become negative and maladaptive and push us into that “burnout” space.

What if going for a run or going to yoga or doing whatever your “thing” is- what if that were actually helpful even when you’re heading into what I’ve referred to more than once as “the land of overwhelm”?  Or…to ask it another way, how many times have you not done something that you know is good for your mind, soul, and body because you simply have too many other things to do?

Again, yes, count me amongst the guilty. But what if that “one more thing” is actually something that really is regenerative for you?  It might actually help you to become more productive and more focused.  And if you’re a leader in your environment, by being authentic and engaged (and less stressed), you’re setting the best tone for your team to thrive as well.

Try it.  Let me know how it goes.  I promise I’ll work on doing better with this as well.

Brave enough

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.

The beginning of the end

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

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.

“Why are the surgeons so quick to trach?”

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.

My primer on Critical Care

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.