Hi everyone,
The MICU was intense last week, even for an ICU. We had one patient with a pH less than 7 and another with a pH above 7.6. We managed airway pressures in the 50s, glucoses less than 10, lactates above 30, and bilirubins above 50. We treated status asthmaticus, ARDS, DTs, pseudomonas bacteremia, PEs, profound hypocalcemia, adrenal insufficiency, liver failure, renal failure, and pancreatitis. We calculated PaO2/FiO2 ratios, dead space, driving pressure, airway resistance, and minute ventilation. We discussed renal perfusion pressure, plotted Starling Curves, and used simple math to diagnose RV failure- and then proved it with an echo.
We learned from nurses, pharmacists, and respiratory therapists. We called ID, GI, nephrology, cardiology, endocrinology, neurology, and palliative care. We saw elevated neck veins and an oval pupil. We heard wheezing and heart murmurs. We stared at ventilator screens, discovering double triggering, air hunger, and expiratory flow limitation. We gave fluids for pulse pressure variation and Lasix for B-lines. We pulled up Care Signature Pathways, contacted the author of a study on overnight extubations, and explored the mysteries of high flow oxygen. We debated treating anaerobes and the merits of Ranson’s Criteria. We struggled to make cranberry juice safe for a patient with dysphagia. We discussed Ulysses contracts. We ordered physical therapy, activated the ARDSNET protocol, used prone positioning, gave Lasix, calculated RASS scores (and stopped sedation), and removed unnecessary Foleys.
We cared for immigrants, a truck driver, a building contractor, a painter, a musician, and a retired professor. Families joined us on rounds. We rejoiced when tubes came out and paused to reflect when treatments failed.
I told my team I deserved to be thrown in ACGME jail because rounds were so long, but you do what you have to do when patients need you.
Thank you, Justin, Chiamaka, James, Ryan C, Ryan B, and Necia for reminding me why I do this. You’ll be in my thoughts today when I sit down to complete the rank lists.
Mark