Hi Everyone:
I love the weekly “pebbles” you send the Chiefs. I wish we were perfect, but we’re not. No program is. But your suggestions make us better. Your recent pebbles brought meal cards back to the MICU, led to the purchase of new ultrasound equipment, and spawned a comprehensive overhaul of our procedure training.
This morning, it’s my turn. MICU Pebbles (Part 1):
- Fluid balance goals: I get it: If we want a patient to be a liter out by the next day, we need to state our goal and make a plan. But what about patients with functional kidneys? If we aim for one liter out and they pee two, are we going to give one back? If we want a patient to be even and they end up one liter positive, do we have to give them Lasix, even if they’re doing fine? Plans are nice, but why be rigid? Sometimes the kidneys know something we don’t.
- “Let’s just follow the systolic blood pressure”: No! Don’t do that! I know it’s frustrating when the systolic seems okay but the diastolic is low, but DBPs are important. Maybe you’re thinking, “110/35 doesn’t sound so bad,” but trust me, it’s terrible. We spend most of our lives in diastole, and a DBP of 35 means a lot of low flow. I’m sorry you can’t stop your pressors, but you can’t ignore low diastolics. Fix them.
- Head to Toe: My apologies to colleagues who ask interns to present from top to bottom (brain, heart, lungs, GI, kidneys, etc.), but that makes no sense to me. Do we really want to discuss why the patient is sleepy (they’re on propofol!) before we discuss the PaO2 of 50 or the K of 9.2? If a patient is a little confused because they’re in shock, hypoxemic, uremic, or septic, shouldn’t we focus on the cardiovascular, pulmonary, renal, and ID issues first? I say prioritize by severity: start with the most pressing problems and leave the stable stuff for last.
- Sedation to Oblivion: We want most ICU patients to be awake or easily arousable. Some patients with severe respiratory failure need heavy sedation to tolerate the ventilator, but they’re the exception. Unfortunately, many of our patients barely move when we say (or scream) their names; some don’t even respond to noxious stimuli. Can we lighten up, literally? Heavy sedation means patients can’t wean, walk, or work with us. Heavy sedation causes delirium, shock, and side effects. Your patient doesn’t need to be in a coma to be comfortable.
- The Holdover Black Box: For unclear reasons, when presenting holdovers, many interns skip from the patient’s ED presentation to the next morning’s events, skipping all that happened in between. We hear how the ED gave fluids, pressors, and antibiotics, but we don’t hear about the night team’s workup, thoughts, and interventions. The day team needs to know what the night team thought (the patient was dry), what they did (they gave more fluid), and what happened (the patient peed). Our talented night intensivists work hard, resuscitating and stabilizing the patients: don’t neglect their role in the patient’s story.
I know what you’re thinking: “Dr. Siegel, it’s Sunday morning! Stop complaining!"
Okay, I’m done for now. I’ll be back next week with MICU Pebbles (Part 2).
Enjoy your day, everyone. It’s time for me to bike down to New Haven to join my Red team.
Best,
Mark
P.S. What I’m reading:
- A.I. Isn’t Magic. Lots of People Are Acting Like It Is. By Cody Delistraty
- A.I.’s Environmental Impact Will Threaten Its Own Supply Chain Video by Kate Crawford, Ryan S. Jeffery, and Adam Westbrook
- The Debate Style That Propelled Charlie Kirk’s Movement By Ken Bensinger and Charlie Smart
- 3870 intern applications…