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Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.

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May lay in a hospital bed, her wrinkled and mottled skin covered with leads, and sensors that monitored her every breath and heartbeat. A camera that was mounted on the wall allowed a doctor to zoom in closely enough to count her tattered eyelashes. Her husband  sat at her bedside, gently stroking her withering gray hair  as her chest moved slowly up and down accompanied by the soft whoosh-whoosh of the ventilator that breathed for her. He stared expectantly at her face as if at any moment she would rise and free herself from the myriad tubes that sustained her.  Her adult daughters sat and stared blankly at the floor, waiting for something, anything. The streams of data transmitted from her body were monitored closely both by a team in a remote electronic-ICU bunker 50 miles away and her ICU nurse 15 feet away. Yet what May could not have realized was that despite her family’s presence at her bedside and the twenty-four hour care she received, she had been abandoned. She was alone. 

Several weeks earlier, May came to the hospital from her nursing home, “yet another pneumonia”, the note in her chart said.  “She seems to get one of these every few months” said her husband “can’t we give her something for that?”. The Emergency Room physician explained that she had aspiration, essentially choking on her own food and spit. She would continue to get pneumonia, until she eventually passed away. This wasn’t the first time he had heard this. “They told me before to let her die, but I didn’t listen to them, I told them to treat her anyway, and she made it through. I didn’t give up on her then and I’m not going to now”, adding “she’s a fighter”. Her husband Daniels countenance was such that the Emergency physician admitting May to the hospital didn’t bother asking whether his wife should be resuscitated in the event her heart  or lungs stopped working and she needed to be put on life support. May was admitted to the general medical ward, and was started  on antibiotics, but she eventually got worse. Sometime in the middle of the night a nurse found her ashen and struggling to breathe, and called a “code blue”. May’s breathing had gotten so bad that she needed life support, she had a tube put down her trachea and was taken to the ICU where she was put on a ventilator.

Doctors worked on her for more than a week,  treating her pneumonia with powerful antibiotics. But even as her pneumonia cleared, her body withered. Her skin hung from her bones as her muscles wasted away, her eyes hollowed, and the skin of her arms filled with bruises as nurses struggled to find a place from which to draw blood. On the second Sunday of her ICU stay, the doctors tried a “trial extubation”. As the family understood it, her lungs had improved to the point that she might be able to be taken off the ventilator, but her body was now so weak, they did not know whether she would actually be able to breathe on her own. If she had to be put back on the ventilator, the doctors told them, she would require a tracheostomy that would allow her to live on the ventilator long term.  The social worker would then seek placement in a long term facility for patients on long term ventilators, essentially a hybrid hospital, rehab, and nursing home in one. Her breathing failed within minutes of being taken off the ventilator, and she was immediately put back on life support.

It was the following day, Monday morning, that I met with May’s family to discuss what had happened the day before, it was the beginning of my ICU week. For May and her family it was the beginning of their third week in the ICU, and it showed. Her husband, Daniel looked unkept, his thick shock of gray hair was whirled and tangled, his flannel shirt partly tucked into ripped and stained jeans. He gave the impression of someone who had not been taking care of himself, let alone someone who could take care of his chronically ill wife. His visage upon seeing me betrayed both surprise and regret as he recognized me from four months earlier.  I was the doctor who told him that May was going to die. Continue reading “Not Dead but Not Alive; The terminally unhealed languish in America’s hospitals.”

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Devastation in Puerto Rico leads to hospital shortages in U.S.

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Hospitals run short of critical medications after loss of production in Puerto Rico facilities. 

“Doc, you mind switching that to an oral preparation?”, our clinical pharmacist inquired during multi-disciplinary rounds as intravenous infusion devices beeped annoyingly in the background.  Taking care of ICU patients can be extraordinarily complicated, so doing it as part of a team helps make sure that all bases are covered. ICU’s like ours have a BEEP BEEP BEEP. Excuse me, for a moment,  Staci, can you get that thing to stop, please? BEEP, BEEP, BEE– Thanks, Staci!. As I was saying, like many hospitals, ours uses a multidisciplinary model which makes rounds on all patients in the ICU.  An ICU nurse, clinical pharmacist, dietitian,  social worker, pastoral care, respiratory therapist, each provides important insight and perspective that guides patient care in the right direction.

As a pulmonary, critical care doc, I’m lucky to have a great team, so my ears perked up when I heard the suggestion. This was now the third patient he had made a suggestion to switch a medication to the oral route from the intravenous route. “What gives, Scott?” Over the past few years, we’ve been experiencing alot of spot medication shortages either because of inadequate supply, or because of precipitous price increases;  we can usually change to an alternative. But today was different. Today we were switching a number of different medications, all of which were intravenous to oral formulations of the same or similar medicines.

“It’s not the medicines,” he replied, “It’s the bags they’re in”. Continue reading “Devastation in Puerto Rico leads to hospital shortages in U.S.”

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It’s Time to Move On From ACLS Certification.

I can recall, though it seems quite long ago, my first Basic Life Support (BLS) course as a first year medical student. The instructor dutifully demonstrated on a mannequin to eager young medical students what to do if someone is found unresponsive. Shaking the unmoving mannequin she said loudly,  “Sir, are you ok?” Then hearing no response she showed us how to check for a pulse and spontaneous breathing. “if not present” she said, “call for help and start CPR”. Me, ever the smart-ass, took my own approach. “Sir,  are you ok?” Then, grabbing the mannequin tightly to my chest “NOOOO! why? WHY?!”

This didn’t enamor me to the instructor very much and earned me most of the difficult clinical scenarios of the day.

Classes like these are now mandatory for those working in hospitals. Just about all employees have to go through BLS training, and many employees in more advanced clinical settings are also required to take Advanced Cardiac Life Support (ACLS). ACLS  is an advanced skill set taught to medical personnel who work in areas of the healthcare field who may have encounters with patients that require interventions beyond the scope of BLS.

Those of us in the medical field who are required to recertify ACLS have long dreaded the process of ACLS recertification. Part of that is because it can be an intense course that makes many feel nervous. Part of it is also because it is expensive and time consuming. But the greatest reason why most who undergo ACLS training  object  to it is for a different reason entirely: they feel that is simply unnecessary. Continue reading “It’s Time to Move On From ACLS Certification.”

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The PROCESS Trial: End of the Line for Central Lines?

A lot of things change for doctors once we’re done with training. Most of us leave behind the ivory tower that is the academic medical center to plow the common fields of private practice. We no longer have the weekly journal clubs, the Grand Rounds, the CME lectures. But what we gain is practical hands-on experience with what works, and what doesn’t. A nuanced knowledge of what’s accepted vs. what’s acceptable.

One such area has been the approach to sepsis. Manny Rivers et al published  their game changing study on early goal directed therapy (EGDT) in the treatment of septic shock in 2001, and the result became scripture in the field of Critical Care Medicine. The knowledge that tying sepsis resuscitation to the measurement of central venous oxygen saturation (ScvO2) and central venous pressure (CVP) using a central venous catheter, lead to a surge of recommendations.

The brain trust spewed forth these recommendations in various forms;  Surviving Sepsis Campaign, Sepsis guidelines, Sepsis bundles, Sepsis video games and Sepsis action figures. Somewhere in that sentence I may have transitioned to hyperbole.

Those of us in clinical practice didn’t always follow the drumbeat. Many of our patients with sepsis it seemed, did just fine without a routine central line or blood transfusions, or dobutamine drips. Why use invasive measures when we don’t really need them, and we’re not really sure that they’re helping? Still, when I talked to my ivory tower friends, the response was same, “We always use central lines and follow the EGDT”, they would say.

In case you’re thinking that I’m a maverick, well, it wasn’t just me. Surveys/studies that have looked at compliance with EGDT show compliance anywhere from as low as 0.1% to just above 50%. Clearly people were pushing back against the guidelines, and many began to publicly question whether results of EGDT could be generalized to the general population with sepsis. Continue reading “The PROCESS Trial: End of the Line for Central Lines?”

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End of Life Conversations are Becoming End of Life Confrontations

“How Dare You!”

Life can change in a heartbeat. Most of us believe that our lives, our loves and all the that things that make us who we are is a gift from a higher power. One that can be taken away as swiftly as it is given. But somewhere in the shuffle of taking kids to practice, catching up on emails, worrying about bills, and the search for the perfect barbecue, it’s all too easy to forget the truth of life. The one truth. The one single thing that life guarantees each and every one of us. From the moment we take our first breath,  life makes to us but one promise. The promise that our life will someday end.

“Who do you think you are?”

For some of us, death comes after a lifetime of achievement, for others all too soon. For many it will be feared, for others it will be welcomed as their bodies wither away. But for more and more of us in our increasingly sterile and safe society, it is simply not to be thought of at all. An unwelcome stepchild locked tightly away in the attics of our consciousness. Like a demon in waiting, we reshape it, remake it, remold it, until it becomes an ever distant sunset that bookends a romantic dream of a life full of love, accomplishment, achievement.

“You have no right to say that!”

Until finally, that inevitable day approaches. A man or woman in a white coat tells you the terrible news that your loved one is passing away. That yes,  they are alive and can be kept alive, but there is practically no chance that they could recover. They will never go back to the person they were before.

“Where’s my regular doctor?” Continue reading “End of Life Conversations are Becoming End of Life Confrontations”

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The War Is Not Over: PTSD Common Among ICU Survivors.

The ICU is a terrifying place. The noise, the alarms, the invasive tubes and wires, and the loss of control all contribute to an overall feeling of anxiety and stress in patients and in families. Add to that the emotional burden of being ill or having a sick family member or friend, and you have a perfect storm for the development of post traumatic stress disorder.

As a health-care provider working in the ICU, it is easy to forget how desensitized we are to this environment. Recently, I took a phone call from my wife (who is a nonmedical professional) in the ICU. After a few minutes, she asked in a panicked voice, “Do you need to go get that alarm”?! And of course, it was a “first-level” alarm that I had completely tuned out and hadn’t even noticed. Looking around the ICU as I write this, I’m certain that I’m not the only one who is numb to these stimuli.

In a recent issue of CHEST, Dr. Bienvenu and colleagues report the findings of a study looking at posttraumatic stress disorder in the survivors of acute lung injury. They interviewed 60 survivors of acute lung injury 1 to 5 years after their hospitalizations. The authors compared a self-reported screening tool and a clinician-administered tool. They found that 27% of patients in this cohort had PTSD or partial PTSD, and that the self-reported screening tool was a reliable method of assessing PTSD in this population. This is promising, since a self-reported tool can gain more widespread use and may be able to help future investigators better determine factors associated with the development of PTSD in the ICU survivors.

Determining who would be likely to develop PTSD would be an important advance in critical care. Often I think we are surprised at how even our “good” outcomes can have long-standing functional problems following their ICU course. In the perfectly titled accompanying editorial Surviving the ICU Does Not Mean That the War Is Over, Dr. Schelling tells the story of one patient who survived extracorporeal membrane oxygenation (ECMO) only to report horrific memories of scenes from an apocalyptic warfare. These memories significantly impacted his quality of life and functional recovery, even though his overall outcome was “good.”

These studies add to the growing literature about the long-term effects of our treatments. I’d be eager to see more. We do not consider this important area of quality enough. With studies like this to help give us better tools, hopefully we will see more investigations into the long-term impacts of the life-saving therapies we provide.

Chris Carroll, MD, FCCP is a Pediatric Intensivist at Connecticut Children’s Medical Center, and my Social Media co-editor at Chest Journal. He is on twitter @ChrisCarrollMD. Be sure to check out our posts at the ACCP Thought Leaders Blog, where this article  was originally posted.