Sunday, March 14, 2010

A Family Doctor in the ICU

As a Family Doctor, my would is much less high-tech than the world of the Intensivist! (That said, I'd invite any of Steve's doctors to spend a week in my world: moving from pelvic exams, to hypertension, to diabetes, to diaphragm fittings, to newborn exams, to assisting with the intricate processes of gender transition, to obesity management, to substance abuse intervention, to migraines, to skin biopsies, to depression...well, you get the idea! What we may lack in depth, we certainly make up for in the breadth of our specialty!)

In Intensive Care Medicine -- as in all medicine -- there's an urgent need to pan back and see the "big picture." A myopic specialist who sees his/her own specialty area in a vacuum would be inneffectual and even dangerous.

But journey with me now through Steve's ICU/CCU room. Surroundng him (highly sedated and essentially immobile - on purpose) we have the following:

1.  The ventilator, which breathes for him
2.  The CRRT Machine, providing twenty-four hour a day dialysis - resulting in his personal best creatinine of 1.2! We are joking that Steve could be a donor with such numbers! The advantage of CRRT, of course, is that it allows for small volumes of fluid extraction on an ongoing basis -- like healthy kidneys.
3.  The bank of IV medications with their respective pumps: at one point, he was on eleven different meds.
4.  TPN - to feed him through his central line while he is unable to eat.
5.  An impressive monitoring panel which monitors his heart rate and rhythm, BP, arterial blood pressure, pulmonary artery pressure, respiratory rate, oxygen saturation, end-tidal CO2, cardiac output and cardiac index numbers.
6.  Lines and drains:
  • three different central lines going into internal jugular vein
  • Naso-gastric tube
  • Endo-tracheal tube for ventilator
  • Chest tube to drain blood and secretions from chest cavity
  • Radial artery IV
  • Compression stockings with intermittent inflation to prevent clots in legs
(And the Intra-Aortic Balloon pump was removed yesterday, with Steve remaining stable.)

And what about nursing care? I have never seen better, more carefully performed ICU nursing than I have witnessed this week at Swedish Medical Center/Cherry Hill. This is not "following orders nursing;" this is minute-by-minute critical decision making. These outstanding nurses watch Steve for every nuance in lab values, vital signs, and any minute perturbation in his overall condition...and they respond instantly with appropriate medication adjustments and notification of other health care team members who intervene also.

It is all pretty impressive. In health care, we need everybody: primary care providers AND intensivists. It's very interesting to get such a detailed look at the other side of the spectrum. Of course, I wish it weren't in the context of my husband. But since it is, I am enormously grateful for the exceptional work being done on his behalf.

Take care. Linda Gromko, MD

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