Hi everyone,
When our youngest was a baby, she was hospitalized for dehydration. Aside from the worry-related trauma, my most vivid memory is Heide guarding the door to her room, allowing no one to enter when Francesca was sleeping, even to check vital signs. To Heide’s reasoning, it was insane to awaken a sleeping baby.
Far be it for me to critique pediatric vital sign policy, but I do have opinions for grownups, particularly as critical care is practiced worldwide. We excel at diagnosis and treatment. Need a CT, echo, or paracentesis? It’s done. Do you need fluids, pressors, or antibiotics? The orders are in. Do you have an MI, PE, or GI bleed? We’re on it. But we could do more to promote healing. Much more. Even previously healthy ICU survivors are left with physical, cognitive, and emotional scars, requiring months to recover, if they recover at all.
Many factors beyond our control leave their mark, like systemic inflammation and medication side effects, but many practices undermine recovery, even if well-intentioned. Heavy sedation exacerbates delirium and deconditioning. Lines and catheters tether patients to beds. Bright lights, alarms, loud voices, and pre-dawn physical exams disrupt sleep. Visitor restrictions undermine family support.
Several ICU practices offer no benefit and may even cause harm. Recently, we learned that many patients with septic shock can be managed without arterial lines, that hypertonic saline doesn’t help most patients with airway secretions, and oseltamivir is ineffective in hospitalized patients with influenza. We can add these findings to the graveyard of discarded ICU practices, including the routine use of right heart catheters, high tidal volumes, daily chest x-rays, and placing central lines in every patient on pressors.
I don’t oppose aggressive therapy when necessary. When patients can’t breathe, they need intubation. When they’re septic, they need immediate antibiotics. When they’re bleeding, they need lines and blood products right away.
But sometimes we overdo tests, medications, and procedures while underdoing the care that really matters. How many patients truly need labs every day, let alone multiple times a day? How much C diff, and how many resistant infections, could we prevent by peeling back antibiotics? How much delirium could we avoid by lightening sedation, ordering physical and occupational therapy, removing needless catheters, and dismantling visitation barriers? How much psychological trauma could we allay by spending more time at the bedside addressing patients’ fears? And how much recovery could we promote by letting stable patients sleep?
I just finished another week in the MICU, feeling proud of the magnificent work by our nurses, therapists, APPs, and physicians. Like most intensivists, I gravitate towards heroic interventions, but this morning, I want to thank my team—Irvin, Nayda, Darshi, Nayiri, Aryana, Wolf, Yaa, Gracia, Martin, and all the nurses and therapists—for striking the perfect balance between life-saving care and creating a place for healing.
Enjoy your Sunday, everyone. Now that the downpours have ended, I’m headed to the beach.
Mark
What I’m reading and listening to:
- Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk By Harlan M. Krumholz
- Post-Intensive Care Syndrome By Brad W. Butcher
- The ABCDEF Bundle in Critical Care By Annachiara Marra et al.
- For Many Patients Leaving the ICU, the Struggle Has Only Just Begun By Paula Span
- This Is Why Women Are Scared to Tell Their Doctors the Truth By Allison Sweet Grant
- A.I. Is Everywhere in China. See For Yourself. By Agnes Chang, Vivian Wang, Jiwoong Hong, Aaron Byrd, and Qilai Shen
- Crew Resource Management — Navigating AI’s Automation Paradox By Raja-Elie E. Abdulnour et al.
- CT hospitals expected to lose hundreds of millions of dollars due to Medicaid work requirements By Livi Stanford
- How Feelings Make Us Smarter On “Hidden Brain” with Peter Salovey
- Finally, here’s where Connecticut’s New York-Boston sports divide actually falls. By Philip Bump
- Demon Copperhead By Barbara Kingsolver