Physician at Work: Tipping the balance in critical care
Advancing medicine is helping Peter Marshall save more patients
When it was time to select a specialty in medical school, Peter Marshall, MD, MPH, had little doubt. A significant family history of asthma steered him toward pulmonary medicine. During his residency, caring for patients with respiratory failure sparked his interest in critical care medicine.
Today, he finds that caring for critically ill patients can be a balancing act in which the outcome isn’t always optimal—but advances in medicine can often make a difference. In the case of a 16-year-old boy brought to Yale-New Haven Hospital in cardiac arrest, Dr. Marshall and his colleagues used therapeutic hypothermia to cool the boy, even though the technique isn’t usually used in pediatric patients. The therapy worked and the patient was able to return to school within a few weeks. “It’s a very powerful and lifesaving intervention in post-cardiac arrest care,” Dr. Marshall said.
The technique involves putting gel pads on the patient’s body to maintain a core temperature between 32 and 34 degrees Celsius. The patient is kept at a stable temperature for 24 hours, then slowly warmed up over the next 24 hours. According to Dr. Marshall, therapeutic hypothermia is recommended by the American Heart Association for cooling cardiac arrest patients, but only about 10 percent of hospitals offer it, even though it cuts the death rate of those who have an out-of-hospital cardiac arrest by a third. Dr. Marshall and his colleagues are also using it to treat patients with liver failure prior to transplant, as well as stroke patients.
In addition to therapeutic hypothermia, Dr. Marshall has developed expertise in treating pulmonary embolism. Standard treatment involves anticoagulants to prevent blood clots or thrombolytics to dissolve them, but sometimes surgery is necessary. Dr. Marshall and his colleagues are hoping to have Yale-New Haven Hospital and Yale School of Medicine participate in several clinical trials involving thromboembolic disease.
Together with his colleagues, he is in the process of bringing to Yale a novel catheter-based treatment known as EkoSonic Endovascular System© (EKOS). “It’s an option for delivering medication at a lower dose, so there are fewer complications, and yet it allows us to treat patients with submassive pulmonary embolism, that is those patients that are sick but not frankly in shock,” he said.
When treating pulmonary embolism, Dr. Marshall has to gauge what therapy to offer patients. “The potential side effects of thrombolytic therapy are so lethal and deadly that a lot of thought has to go into whether or not we use them,” he said. Sometime he will place a filter in the inferior vena cava—the main vein that carries blood from the legs to the upper body—to prevent clots from traveling to the lungs. But there is controversy surrounding the removal of filters that are no longer indicated.
“Over time the filters can cause complications, such as further clotting, erosion of the vena cava, or chronic low extremity swelling because of the clots they form,” said Dr. Marshall. Timely removal by an interventional radiologist is usually fairly simple. However, filters are often placed and never removed because doctors lose track of them. To help address this issue, Marshall runs a weekly clinic that accepts referrals for patients who have filters. “We need to provide better care for these patients by making sure all of these filters are removed,” he said.
Name: Peter S. Marshall, MD, MPH
Title: Assistant professor of medicine, pulmonary and critical care medicine; interim medical director of the medical step-down unit and of respiratory therapy, Yale-New Haven Hospital
Area of expertise: Pulmonary and critical care
Place of birth: Montreal, Canada
College: Yale University
Medical School: University of Connecticut School of Medicine
Training: Internship and residency in internal medicine, Yale-New Haven Hospital; fellowship in pulmonology and critical care medicine, Yale School of Medicine; master of public health, Yale School of Epidemiology and Public Health
Family Married to Tomeka Jackson-Marshall; daughter, Makenna, 11; stepdaughters Aliyah Moore, 13; Alyssa Moore, 19
What is most challenging to you in academic medicine? I find managing time between patient care, academic pursuits and family most challenging.
What is most rewarding? The appreciation that is expressed when a patient or family is pleased with the care provided. This is especially the case in critical care, when often families are most appreciative of the care provided when a loved one passes. It is uplifting to receive praise even when the outcome is not the desired one.
What do you like most about your practice? I enjoy the variety in my practice and the opportunity to travel along many clinical avenues.
Personal interests or pastimes? Sports (especially soccer), movies, traveling
Last book read: “Soccernomics,” by Simon Kuper and Stefan Szymanski
What would you do to improve our clinical environment if you had a magic wand? Ensure adequate staffing in all clinical environments, which should reduce provider stress, and improve patient care and patient satisfaction