Hi everyone,
In critical care, a host of small studies and patient narratives complement the influence of large, landmark trials, pairing micro to macro. If you’ve rounded with me in the MICU, you know I adore small papers. Here are five of my favorites, three single center studies and two narratives, that changed my practice.
Neurologic Status, Cough, Secretions, and Extubation Outcomes: We traditionally think of daily spontaneous breathing trials as key to ventilator weaning. But SBTs can only tell you about a patient’s strength and endurance; they don’t tell you if they can keep their airway clear. I’ve seen too many newly extubated patients require reintubation because they were drowning in secretions. A single center study led by my friend Const Manthous at Bridgeport Hospital identified three factors that reliably predicted successful extubation: strong cough, modest secretions, and good mental status (objectively measured). Somnolent patients with a weak cough and copious secretions won’t tolerate extubation, even if they pass an SBT, while patients with a strong cough, modest secretions, and the ability to follow complex commands are good to go. Isn’t this just common sense, you ask? Well, yes. But in medicine, common sense is not as common as one might think. So, please ask about cough, secretions, and mental status before pulling pull the tube.
What Now? What Next?: John Hansen-Flaschen is a giant in critical care—a master clinician, educator, and investigator—and he was also one of my attending heroes during residency. When we had questions, we asked “the Flasch.” Several years after I left Penn, Dr. Hansen-Flaschen described his admission to the MICU with a large GI bleed, highlighting his vulnerability, emotional lability, difficulty thinking, and need to trust his medical team. I think of his story often when I update patients, seek their consent for procedures, and help them navigate difficult choices. If a brilliant intensivist had such a hard time in the MICU with a relatively straightforward problem, just imagine how the average patient feels when we bombard them with facts, uncertainty, and big decisions. All patients, no matter how educated or sophisticated, need our empathic support as they traverse the thicket of serious illness.
The Critical Care Experience: The Patient’s View: Delirium is so common in critical care that we name it: “ICU delirium.” Each day, we’re supposed to assess patients for delirium, using an objective measure such as the CAM-ICU. The original CAM (Confusion Assessment Method) was developed by Dr. Sharon Inouye, formerly of Yale Geriatrics and a pioneer in the study of delirium and subsequently adapted for the ICU (CAM-ICU) by my friend Wes Ely at Vanderbilt along with Dr. Inouye. (Wes’s website, ICUDelirium.org, is an indispensable source of information). We’ve all cared for patients who pull at restraints, bite tubes, or, more commonly, lie strangely quiet, as if inhabiting a different world. In an account of her own experience with delirium, a Canadian philosopher Cheryl Misak described experiencing vivid nightmares and wild delusions as an ICU patient. Take a few minutes to read her story, which will drill home why we must work hard to mitigate the trauma delirium inflicts on our patients.
Nighttime Cross-Coverage is Associated with Decreased Intensive Care Unit Mortality. A Single-Center Study: We tend to think of handoffs as a source of risk, and we aim to give thorough signouts at shift changes so details aren’t dropped. But we should also recognize the opportunities handoffs create. For example, this study from Toronto showed that cross coverage by night teams was associated with lower mortality, possibly because night teams took a fresh look and were able to overcome cognitive errors made by the day team. A careful sign out and engaged night teams is a perfect combination.
Psychiatric Illness in the Next of Kin of patients who die in the intensive care unit: A few years ago, I worked on a research project with a YPC resident named Earle Hayes and an old college friend named Holly Prigerson, who is an expert on the relationship between end-of-life stresses and mental illness. Holly introduced Earle and me to tools that allowed us to diagnose psychiatric illness in the relatives of patients who died in our MICU. Our findings were sobering: in the months following their loved ones’ death, 34% of family members were found to have at least one psychiatric illness: major depression, complicated grief, generalized anxiety disorder, and/or panic disorder. An important risk factor for a psychiatric illness was the family member’s opinion that the ICU physician was “not comforting.” The study changed how I understood the struggles faced by patients’ families, who endure severe stress, sleep deprivation, and the burden of navigating difficult end-of-life decisions. With this knowledge, I’ve resolved to do everything I can be a source of comfort to my patients and their families.
I have great respect for the physician scientists who lead large paradigm-changing clinical trials. But I also have great respect for the clinicians who spend the bulk of their time at the bedside, teaching trainees and caring for patients, while making essential observations that elevate our profession.
Enjoy your Sunday, everyone. I’ll be spending the next two weeks with the family in Japan. Thanks for all that you do to care for our patients and sharing your own pearls of wisdom with one another.
Mark
P.S. What I’m watching and reading: