How to ICU

Nearly 4 weeks into ICU and I am still uncertain as to what is going on. On a regular basis. It’s been a strange rotation. Partly because I have missed an inordinate amount of time on this rotation combined with having patients that are extremely complicated. Luckily, much of the ICU is managed by a team of  really good RNs, Respiratory therapy, social work, and solid pharmacists. And of course your Pulmonologists/Critical care doctor. It really takes a team to manage one patient.

Overall, I have enjoyed the freedom provided on this rotation as I am able to pre-round independently, write my own notes, and present my patients to the team. Being able to do your own thing is really nice. But fear not! – a Resident is always around in case I have lingering Q’s. Something that I found to be immensely useful is chatting with the nurses before ICU rounds. These nurses know their medicine and are some of your best allies when training and beyond.

Before I started ICU, I didn’t really know what to expect and relied on the google machine to help me out. I stumbled upon these resources and reviewed them throughout the rotation:

I guess that’s not too many. I also relied on good ol’ fashioned uptodate and Medscape app.

The majority of your time will be spent reviewing drips and vent settings. Having a good understanding of pharmacological sedatives and vasopressors will serve you well. Additionally, knowing how vent settings work is helpful; at the bare minimum you should know how to interpret them. Jenny did a great job detailing this in her ICU video, so give that a listen for more info.

Everyone that warns you that ICU will be depressing was right. I had a patient die each day. Not fun stuff. Plus your patients are either intubated on a ventilator or altered or sedated so you can’t interview them. You end up relying on their vitals, PE, labs, and imaging to communicate with you their progression. Some of the more interesting cases included:

  • Meth user with valvular vegetations and septic emboli to the pleura causing pneumothorax requiring multiple chest tubes.
  • Former meth user found down in his trailer found to be in DKA and septic shock with a necrotic right foot that underwent emergent guillotine below knee amputation (BKA).
  • Diffuse scleroderma in a young adult resulting in advanced interstitial lung disease complicated by pneumomediastinum.
  • Lung metastases secondary to advanced ovarian cancer, undetected until admission.

Image result for ICU medical school memes

Of course, we also had a lot of the bread & butter cases like COPD exacerbation, isolated DKA, toxic vs metabolic encephalopathy, acute respiratory failure, and septic shock. I also was able to get in a couple of procedures: intubation and placing chest tubes. Nothing too crazy. Oh, and in case you’re wondering, I only missed time because of residency interviews – those wait lists are no joke – if you pop off of one, you find out last minute!

By the way… anyone notice the fog after January 20th? I think the Dementors were let loose from Azkaban.

Nari

All that Wheezes

We had a really interesting case this past week, please let me share.

A 47 yo male with a meth addiction comes into the ED complaining of lower extremity cellulitis that was making him really sick and uncomfortable. In the ED he was afebrile but tachycardic with an elevated WBC, lactate and ESR meeting sepsis criteria. So ED doctors started him on 3 different antibiotics thinking that the cellulitis was causing bacteremia, drew blood cultures and admitted him to the med-surg floor.

Upon examining this guy in the ED, it became clear to my team (IM) that the cellulitis appeared chronic in nature. What was more concerning was his complaint of mid-epigastric pain that with further questioning he reported was present after eating for the past week. He also complained of shortness of breath, ongoing for the past year but worse in the past week, post-prandial nausea, and anorexia. He had a couple episodes of diarrhea while in the ED and was feeling very uncomfortable over all. He denied fever but had chills intermittently.

On exam, he is a young-appearing guy with multiple tattoos and piercings laying uncomfortably on his right side. Heart and Lung sounds were normal. Abdominal exam revealed a distended abdomen with hypoactive bowel sounds and tympanic on percussion with tenderness to palpation in the mid-epigastrium and RUQ. Lower extremity exam showed dusky colored feet and ankles with poor capillary refill, edematous ankles b/l, color changes consistent with chronic venous stasis with scaling and a 1 x 3 cm superficial ulcer on the right anterior tibia. Similar to below, but with more ankle and foot edema.

We then got the following Imaging and Labs with these results:

Imaging Results:

  • CT Angiogram: negative for PE and PNA
    • noted: right ventricular hypertrophy
    • Pulmonary artery transverse diameter: 3.9 cm (upper limit of normal: 3.3 cm)
  • Venous Doppler: negative for DVTs
  • Ankle Brachial Index: normal, no evidence for peripheral arterial disease
  • RUQ Ultrasound:
    • Gall Bladder wall thickening of 8 mm (normal: 3-4 mm)
    • no evidence of gall stones
    • Hepatic venous congestion
  • EKG: normal sinus rhythm @ 96 bpm, no ST elevation or depression

Labs:

  • Troponins: < 0.024
  • BNP: 307
  • Alk phosphatase: 188

With the Ultrasound findings & labs we were certain we had a diagnosis: Acalculous Cholecystitis. A HIDA Scan was promptly ordered, but he was unable to complete the study due to abdominal pain. His elevated BNP levels were concerning for heart failure, in a 47 year old., so an ECHO was then ordered.

ECHO results:

  • Left Ventricular systolic function normal with LVEF of 55-60%
  • Mild Aortic Valve Stenosis
  • Severe Tricuspid Valve Regurgitation
  • Severe Pulmonary Hypertension
  • Pulmonary Artery systolic pressure of 79 mm Hg (normal is 15-30 mm Hg)

Meanwhile, the patient’s labs began to return to baseline: no leukocytosis, normal ESR and downtrending Lactate, but the patient did not look better at all. Clinically, he looked more uncomfortable, more distended, and then started complaining of worsening discomfort with breathing.

A CXR was done and revealed a pleural effusion leading to a thoracentesis. Pleural fluid labs compared with serum labs:

  • Pleural Fluid LD/ Serum LD Ratio = 0.55
  • Pleural Fluid Protein/ Serum Protein Ratio = 377
  • According to Light’s Criteria, this is a Exudative Effusion

Now we have the following working diagnoses:

  • Acalculous Cholecystitis
  • Right-sided Heart Failure secondary to Pulmonary Arterial Hypertension
  • Pleural Effusion with an Exudative process
  • Sepsis, improving

There were many trails to follow with this fellow, but I’ll summarize now.

Essentially we have a meth addict, smoking meth 1-2x/day for 15 years who is found to have Pulmonary Arterial Hypertension from meth use that caused a right-sided heart failure leading to Tricuspid Valve regurg, and chronic stasis dermatitis. His complaints of dyspnea, abdominal pain, and lower extremity edema were consistent with right heart failure as fluid congestion in the Hepatic Vein, Portal venous system and IVC were increased. His sepsis was likely related to his exudative pleural effusion and maybe with an element of cholecystitis contributing.

The picture was very clinically confused and we chased every lab and imaging available. This was such an interesting case to me because there was a lot of clinical judgement that came into play. Each day, we had to step back and re-think what the patient’s presentation combined with imaging and lab results were indicating to us. It was not straight-forward and, though we threw a ton of imaging at him and daily labs (we even worked him up for Lupus and Rheumatoid disease and Scleroderma!) a team of 4 plus me the med student, were stumped until the end. That is to say, not all that wheezes is asthma, keep digging and keep the bigger picture in mind.

Reality Check

Inpatient IM Round #2 is bringing me back down to Earth.

It has been a reality check to sit in on family meetings, assist in a code blue, and watch loved ones crying outside the door of their family member while stat CXR and EKGs and trops, etc are being done. Today’s group rounding was interrupted by a page for one of our doctors to go discuss with the family that their loved one had a massive intracranial hemorrhage and would not recover. Following this was a code blue where a huge medical team arrived to resuscitate a patient. Then an improptu call from a nurse relaying that one of our patients was acutely short of breath pulled us away once again. The feeling of being acutely concerned for the life of another person doesn’t dissipate easily. It stays with me and reminds me of my role, or future role, in these patient’s lives.

The past few afternoons of Inpatient IM have been spent in family meetings. What are family meetings, you may ask. Well it’s when you consult with the family about whether the timing is appropriate to withdraw life support or continue pushing and waiting for your loved one to recover. It is easily the most difficult conversation you will have with a doctor or health care professional and them with you.

This is the side of medicine that can really be the hardest to practice without becoming jaded or cavalier. It is easy to over-think the cost of death and worry about the expenses of keeping someone on life support in the ICU ($25K/day). It is also easy to let yourself get too emotionally involved with the patient and disregard your years of medical training. Finding that balance of being supportive of the patient and family members, incorporating your fount of knowledge, and remembering what is in the best interest of your patient is at the heart of how we manage these situations respectfully. It is a tough balance to strike and one I hope to learn well.

 

Internal Medicine – Inpatient

Hello All!

Hope you are all doing well. I recently finished my inpatient IM rotation. It was awesome. We have locum hospitalists who come to Walla Walla and stay for a week at a time, living at the hospital and then having a week off. I worked closely with 2 doctors (they kept switching off) and had a great time. The lifestyle seems great–I just know it’s not for me–I wish I could be disciplined all the time, but if I had a week off, I would probably not go to the gym and eat a ton of junk food… imagine if that was every other week?!

Anyhoo… Got to see some incredible things: like an infected pannus (it was huge, like a third leg), GI bleeds, strokes, ACS, alcohol withdrawal and toxicity, possible poisoning by spouse (probably not, but we hypothesized…), vancomycin rash, bowel obstruction, CHF exacerbation, COPD exacerbation, idiopathic chorea, lots of falls, sepsis, and cardiac cath procedures (our cardiologist let me get gowned up too!).

I saw a patient pass away from iatrogenic causes 😦 sometimes medicine can do so much harm!

I also got to help with a peds case–we had a newborn with congenital diaphragmatic hernia and lung hypoplasia. I got to help with resuscitation, putting in an umbilical art/vein cath, and shipping him out to a NICU in Spokane. I think he’s doing OK. This case was intense; I was really lucky that the nurses told me to go check it out and that I got to help out with it.

Our hospital also has a daily care conference where the doctor, nurses, social worker, outpatient scheduler, home health, and other coordinators all meet for an hour to discuss each patient and the next steps in the care. It’s a great way to touch base and ensure that no patient falls through the cracks, especially as hospital work has shift changes (the docs, nurses, etc)!

My next rotation is surgery, and to be honest, I’m scared and excited. I’m really looking forward to using my hands (hopefully my preceptor lets me do more than just hold retractors). Plus I’ve got a new preceptor…. so it’ll be an adventure for us both! Wish me luck!! 🙂

Have a great week and happy valentine’s day!

-Priya

In the House of God

Greetings EDC,

We are approaching the Merriest time of the year and I am so happy it is finally here! The Xmas tree is up, the stockings are going to come together eventually, and this weekend we will hang Christmas lights outside! On a side note, I have also gained an appropriate amount of Christmas cheer in the form of a chubby gut and slightly thickened double chin. ‘Tis the season.

Today marks the completion of 4 weeks of Inpatient Internal Medicine and it was pretty awesome. I have many comments to make about this rotation as it was easily one of the best ones I’ve gone through. In an effort to hold your attention, I will employ Benjamin Franklin or Abraham Lincoln’s tactic of splitting this into Good and Less Good parts of my experience.

Good:

  • My Residents. I got really lucky and wound up with the nicest set of residents one can imagine. Seriously. They were all DOs, very supportive, eager to help me out, and I learned a lot from them. Some of them even encouraged me to apply to their residency program, and their confidence in my ability to even be taken seriously by residency programs was really heart-warming and reassuring.
  • Practicing putting together a solid H&P, doing patient presentations and learning how to defend my evaluation and treatment plan, and getting feedback (PIMPED). On my last week the Attending grilled me non-stop on everything. On my last day we sat down and he made me walk him through how to read EKGs, interp all the AV blocks vs. Afib, diagnose hemolytic anemia, diagnose AKI and nephrotic syndrome… the list goes on. I learned a lot.
  • Learning more about what Intern year looks like. Intern year is notorious for being the hardest year of a doctor’s career. In the House of God by Samuel Shem he portrays the Intern year as being marked by trauma, failures, and coming to the realization that learning the art of medicine is a messy affair. After seeing it in the flesh, I’m less fearful of what it holds, in fact I’m excited to be in their shoes one day and look forward to when I can be closer to a competent physician.
  • The Complex Pathology. Very few patients come into the hospital with less than 10 medications. Each of these medications needs to be accounted for and understanding their impact on disease patho-physiology & pharmacology is clearly essential to their clinical improvement. Understanding their chronic conditions and overlaying their acute conditions is a challenge and makes you appreciate the intricacies within each body system.
  • And, finally, My Patients. Inpatient med does not permit a ton of time to sit and hang with patients in the morning, but after Rounding is complete, the notes are in, and your stomach has finally been satisfied, you get a chance to revisit your patients and see how their day is going. Sometimes it was great to just walk down the hall and peak in on your favorite patient with Dementia and see if she remembered you that day. Other times it was less fun to see your chronically ill, not improving since Day 1, patient get wheeled down to X-ray once again looking less than pleased.
  • Almost failed to mention my favorite part of the day: watching the sunrise while eating a veggie breakfast burrito:

BEST TG view

Less good, but still okay:

  • Checks and Balances: CHARTING. It’s the worst, but…you get used to it? Every single thought that crosses your mind about the patient and how you’re going to manage them has to be documented. The EPIC people will find you and call you if there is a mistake found. Luckily, being a 3rd year med student, I put the title “MED STDT” on each of my notes and EPIC will never glance at me. I will not have this luxury forever.
  • Of course, the hours:
    • Sign Out starts at 6 am
    • Pre-Rounding goes from 6:45-9:30 am (typically)
    • Rounding starts at 9:30 am and goes until either 11:30 or noon – depending on your Attending
    • Didactics run from 11:30 am-12:30 pm
    • THEN LUNCH!!!!!!!! happy happy happy
    • From after lunch until 6 pm (or 4:30 if you’re lucky and none of your residents are on-call) you take admits, visit your patients, and grab more coffee.

There are 2 more weeks left for my Internal Med rotation and they will be spent in an Outpatient setting. I will keep you all posted.

Until then, Happy Holidays from me and Wesley (who lives). wes xmas cat

Rotation #1 Review and Tips

Hi All!

My first rotation has been very interesting! I started in the ER (3 weeks), spent 2 days in Nephrology, and have since been in Internal Medicine (outpatient)! So I’ve got 2 reviews for everyone!

Emergency Medicine:

Working in the ER is tough; you have no idea what’s going to come through the door and the moment someone does come through, it’s GO, GO, GO! I saw MVAs, strokes, seizures, MIs, AKI, fishing hooks in fingers, lacerations, fevers, fractures, muscle strains, pain, wounds, bleeds, infections, and lots more.

  1. SCHEDULE: 12pm-12am shifts with certain preceptors; this allowed me to have several days off depending on when my preceptors where working (I think I worked 10-11 shifts total in 3 weeks, sometimes weekends). Make sure to eat before, have a snack on hand, and arrange for dinner.
  2. CLOTHES: change into hospital scrubs on site.
  3. SHOES: with 12 hour shifts, you need comfortable shoes; I have flat feet and own some heavy, super supportive Dansko shoes–however, my feet would be aching halfway through my shift. I bought a pair of Crocs (without holes) and they have been light and great–they just don’t have as much support. Some of the doctors also recommended Birkies (Birkenstock).
  4. Why it’s AWESOME:
    1. You get to see some really interesting pathology. I saw a patient with Erythema Multiforme (from Terbinafine use) and a patient with Temporal Arteritis.
    2. You get to do a lot! I removed stitches, help with reducing a shoulder dislocation, nail removal (super bloody), catheterizations, blood draws, IV line insertions, give shots! I even did a pelvic exam on a pregnant patient.
    3. In the ER, everything just happens. Literally. Blood work and imaging come back so quickly! It’s amazing. I got to go in for some of the ultrasounds and see the techs at work too.
    4. You get to do some OMM. I did some cervical spine treatments for a few patients after an MVA. However, in some cases the issue is too acute to treat with OMM.
  5. Why it’s TOUGH:
    1. You have to be prepared for ANYTHING. We had a patient come in from the Washington State Penitentiary (with armed guards!) with massive epistaxis–he lost 20% of his total blood volume! At first, I was apprehensive of both the patient (he was in an orange jumpsuit) and of all the blood loss (2 tubs were filled), but as I interacted with him, I was able to let go of my judgement and fear and simply treat him like any other patient.
    2. You have to be ready to do whatever you need to do in order help the patient–including getting out of the way.
    3. It’s difficult with kids–especially because they’re not feeling food, are injured, need to be cath’d, need to get a shot, or need to have their eyes dilated.
    4. You don’t know what’s going to happen to the patient. A lot of the time, the ER physician is simply trying to keep the patient alive. Long term issues or even concrete diagnoses are not always addressed. Everything is very acute and that was very frustrating for me. I wanted to get to the root of certain issues, but in the ER you just need to keep the patient alive and then release, admit, or transfer them.
    5. You don’t have time. You don’t get to really talk to patients and their families or get to know them. I realize that spending time with patients is limited in every setting, but I think getting to know patients is something that’s important to me.
    6. Your heartstrings get tugged on. We had a patient who was transferred to the ER from a nursing home, without any friends or family, because the nursing home knew he was dying. Since he was alone and my preceptor was catching up on some paperwork, I was able to sit with him as he passed. The experience still resonates with me.
  6. RECOMMENDATIONS:
    1. Studying:
      1. Know your ACLS algorithms, treatment for acute issues (like MI, stroke, CHF exacerbation).
      2. Review how to read a chest x-ray and EKG.
        1. CXR mnemonic: ABCDEFG-L (Airways-trachea, bronchi, Bones-ribs, clavicle, pedicles/SPs on vertebral bodies, spaces between vertebral bodies / Breast shadows, Cardiac – silhouette, size, aorta, AP window, pulm art, Diaphragm-costophrenic angles, air underneath, especially on the right as the left can often be stomach bubbles, Esophagus-not usually seen, Free air anywhere, Gunk anywhere, Lungs)
        2. There is no COMAT exam for this rotation.
    2. Brush up on your suture skills before this rotation
      1. Duke’s Suture Skills Course
    3. Get light, comfy, protective shoes
    4. Be mentally prepared for anything!!
    5. Take care of yourself; reflect on what you see and let it go.

Internal Medicine (Outpatient):

Outpatient IM is a totally different world than the ER! You’re in an office setting with scheduled patients and you usually work set hours.

  1. SCHEDULE: 8am-5pm M-F
  2. CLOTHES/SHOES: Professional dress with white coat and comfortable shoes
  3. Why it’s AWESOME:
    1. You get to spend time with patients! You get to know them and you can counsel them on diet, exercise, and smoking cessation. We had a patient with Non-Alcoholic Fatty Liver Disease (NAFLD) and I was able to spend a few minutes with him talking about dietary changes and what to expect if the disease progresses. I couldn’t imagine spending that much time with a patient in the emergency department.
    2. You get to work on your H+P skills. My preceptor is really nice and the patients love him. He enters every patient’s room with me, introduces me and asks if the patient can spare a few minutes to talk to me while he finishes up some paperwork. I then get some time with each patient to complete an H+P, which has really helped me figure out what’s important to ask (any nausea or vomiting with your headache?) and to differentiate lung and heart sounds!
    3. You get to see some really interesting pathology. I saw a patient with argyria (blue man syndrome after years of taking colloidal silver suspension), Marfans, SLE, the aftermath of narcotizing fasciitis, candidates for bariatric surgery, psoriasis, shingles, and more.
    4. You get to do some OMM. You’ll see pregnant patients, patients with back, neck, leg pain, and so much more. My preceptor (who is an MD) asks if I can do some “magic” for these patients and it usually helps!
  4. Why it’s TOUGH:
    1. It’s a juggling act. These patients have many things going on–not just diabetes, hypertension, and hyperlipidemia, but anxiety, OCD, and stress.
    2. There’s always a time crunch. Each appointment is only 15 min long, and you’re seeing anywhere from 18 – 25 patients in a day and there’s still charting to finish!
    3. You’ve got to be up to date! Medications, research, procedures, insurance codes, other requirements are all constantly changing and growing. You’ve got to be on top all this information!
  5. RECOMMENDATIONS:
    1. Check your patient list before
      1. We are able to access our physician’s patient list on EMR, so we can check to see why patients are coming in (this is not always accurate though). If you can do this as well, I’d recommend brushing up on those things for that day.
    2. Know your meds
      1. Psych: There were a lot more patients that I expected who are on various combinations of antidepressants and anti-anxiety drugs, so it’s important to know the side effects and indications for these.
      2. Schedule II and III: Lots of patients come in for pain. They must come in to get their Rx filled every month or so.
    3. Lots of geriatric patients – make sure to speak up when they can’t hear you!
    4. Studying
      1. At our site, we have outpatient and inpatient IM (6 weeks each) and our COMAT exam is at the end of the 12 weeks. My next IM rotation isn’t until 2016. I would recommend going over some common chronic diseases (DM, HTN, thyroid, CAD), medications, and psych diseases.

I hope your Emergency Medicine and Internal Medicine rotations go well and that this long list is helpful!! I had a great time during both! 🙂

-Priya