I’m a fool, thou art nothing”
—King Lear by William Shakespeare.
Today at work we were talking about well…Sanity…
With 5 deaths in 3 days and at least 2 more on the way this week, we had an interesting discussion on how no sane person would choose to work in the ICU. It was the very same conversation I once had at a fire department. Most creatures on Earth run away from death and fire, so there must be something a bit askew in regards our mental balance.
One of the doctors opined it is not that we are insane; it is that we are stupid. Most of us are trying to “help people” or at least we believe we are. But in exchange we trade our time, health, sanity, and are not economically better off than any other doctor. In fact, we are less well off than most. He further described we have bought into some sociological bullshit that our sacrifice actually means something.
While I sat there listening to him, I tried to come up with a million reasons why he was wrong. However, his argument as to why (I just summarized it here)was both logical and compelling.
One of the other doctors I have great respect for shared his opinion that our mission is completely flawed. We have the most expensive and capable equipment (even if it is not always top of the line or new). We take into account most of the patient, and even the needs of the family (opposed to single organs, systems, or diseases). But our mandate is to treat people with 3 or more organ systems failing who have a reversible condition.
What kind of nonsense is that? First of all, the molecules that lead to organ failure are an irreversible cascade! Medicine has not advanced to the level where we can interrupt this cascade. We certainly cannot reverse it. So many of our patients get a very expensive and emotionally trying run through of the guidelines while we try to think up heroic measure to help. In almost all cases we identify what might have helped the patient before they got to this state. We say/hear almost daily, “if only they would have done X 4 days ago.” It is almost like reliving my many arguments about EMS treatment guidelines, which can be summed up “please stop doing X, you are just making it harder down the line!”
In my lecture about first aid for the non-medical provider, I have a PowerPoint slide of a response I was on with a FD rescue company. The bullet points are: “It is better to have help and not need it, than need help and not have it! Call early, call often.”
Why isn’t this same concept used in medicine? Is it hubris? Ignorance? The desire not to be responsible? The desire to not look incompetent? Pissing around the corners of our little kingdoms in order to protect our turf?
Now that we have restated the problem probably for the millionth or so time, let’s look at what we know. 1) It is easier to prevent an emergency than to reverse one. There are some studies that show in hospital emergency response teams have no greater impact on survival to discharge when responding to a “code”. The solution is going to be to prevent the arrest. 2) There is not, nor will there be enough intensivists or emergency experts to put one on every hospital ward. This leaves us with only 2 options. A) Said experts will have to respond outside of their respective department or B) Said experts will have to routinely be outside of their department looking for “trouble” patients. Perhaps a bit of both might work better?
I have noticed that most specialists fall into a rut in terms of their diagnostics and treatment. In fact, I am convinced what “specialization” really is about is training in repetitive tasks rather than knowledge. Various critical care experts are trained and repetitively look at the whole patient. No other specialty actually does that. Even internal medicine subspecializes or deals only with chief complaints. However, defensive medicine of running every test imaginable is neither economical nor practical.
In one of the books I do editing for, the author very accurately and scientifically describes what he calls “the human animal” or “gut feeling”, and of course advocates “listen to your gut.” The summary of his writing is basically: we are bombarded with sensory input, the brain attempts to prioritize certain inputs in consciousness, and the focus of our perception is not our total perception. We must understand and train ourselves to recognize when there is more than meets the eye. The mesenteric nervous system may or not be involved to certain degrees.
Some patients providers know or have a strong indication are going to be train wrecks. They come in with multiple major pathologies. Their file is so large it lags every computer on the network when you open it. You have seen them so often you know their medical record number and wonder what of their many problems it is today.
In the spirit of “call early, call often” it might work out if these patients triggered an automatic critical care consult? Perhaps not at the very moment of presentation, but in a timely manner. Within this population, certain patients would be flagged for closer observation, additional testing, and follow up during their hospitalization before needing admitted or transferred to an ICU or higher level facility. A similar problem in tertiary hospitals and outside hospitals is that once the problem is obvious, it is usually too late for the patient. A multi-disciplinary approach would probably be best. Especially where there are strict delineations of practice and authority. Some patients may even be pre-emptively transferred to the ICU.
We must also recognize futility earlier. “Reversible” is part of the ICU criteria. The contracted nursing home patient with pneumonia, previous stroke, and GCS <8 should not be a candidate for the ICU. This should be a palliative care consult or treatment plan. If IV antibiotics in the geriatric ward do not work, a vent in the ICU sure as hell won’t.
Obviously, there is a balance that needs to be made between admitting every patient to the ICU, dumping palliative care and otherwise futile patients in the ICU, and taking care of patients on medicine wards. The current way medical specialties are practiced does not lend to that balance. Certainly the practice of “punting” does not. But without some kind of change, the non-ICU services are not going to take care of people with more than 1 organ or pathology with any sort of efficiency. The practical and economic consequences of this are significant. Not to mention it makes the ICU not only undesirable from the standpoint of the amount of work to do, the constant futility and dealing with death and grieving family members will drive more practitioners away resulting in largely second rate care by any “band-aid” solutions that come along.