Hi Everyone,
My residents got me through a tough week in the MICU. They were awesome: they knew the facts, wrote superb notes, ran to emergencies, challenged my assumptions, welcomed nurses to rounds, and spoke sweetly to patients. They also indulged me as I plucked pebbles from my sneakers, like these:
- Vanc/Zosyn for All: Everyone with a fever or white count gets Vanc/Zosyn, and I’m not exaggerating (much). Bacteria at Yale don’t stand a chance, except those nasty, resistant varmints like VRE, ESBL gram negatives, and C diff, who snicker, ready to strike as we depopulate patients’ intestines. Don’t get me wrong: treat broadly when your patients are immunocompromised, hypotensive, or colonized with funky bugs, but don’t forget that when you kill susceptible bacteria, the resistant hordes rush in. So, be judicious when your patient is stable, deescalate when cultures allow, and don’t treat longer than necessary.
- Listening Over the Gown: You want to know what rales sound like? A pericardial friction rub? Crepitus? They sound exactly like polyester sliding across a stethoscope. You can’t hear heart and lung sounds through a hospital gown, so lift the gown and plunk the stethoscope down on the chest. And while you’re at it, peek at the patient’s skin; it’s the best way to find a rash.
- Problems by Propofol: When I was a resident, our MICU participated in a propofol trial. That milky liquid seemed and still seems like a godsend. Patients wake up minutes after you stop it, even patients with liver and kidney disease. It’s great for hemodynamically stable patients, especially the ones you hope to extubate soon. But for the love of God, can we please stop the propofol when patients are hypotensive? Propofol is a vasodilator and may be the sole reason your patient needs pressors! And then we have to worry about calorie overload, pancreatitis, hypertriglyceridemia, and propofol infusion syndrome. It doesn’t even treat pain. And for what it’s worth, propofol turns your patient’s urine green! Yes, propofol has its role, but like Vanc/Zosyn, it’s not for everyone.
- Forgetting Classic Studies: In 1991, Yang and Tobin published one of the classic studies on weaning from mechanical ventilation, showing that a frequency/tidal volume ratio (F/VT) of 100 distinguishes patients likely to wean successfully from those likely to fail. High numbers tell you the patient’s breathing is rapid and shallow (bad), while low numbers tell you their breathing is slow and deep (good). In the original article, patients were disconnected from the ventilator and their respiratory rates and tidal volumes were recorded for a minute in order to predict how they would do on a weaning trial. But 34 years later, we use an entirely different method: we keep patients on the ventilator and use pressure support to assist their breathing. Instead of recording numbers before the trial, we often crunch them at the end. None of this makes sense: we’re misapplying a method developed with different equipment in a different patient population. Conceptually, assessing the F/VT makes sense, but it’s a stretch to assume that a threshold of 100 remains the right cutoff. Anyone want to do a study?
- When Happened to the Pee? Several years ago, I was tapped to represent the American Thoracic Society (ATS) at a meeting of the Acute Kidney Injury Network (AKIN). At the meeting, I sat at a conference table with some extremely smart nephrologists,* who were debating the merits of biomarkers to detect AKI at the earliest possible time. My sole contribution, with all due respect to novel assays, was to suggest that we should pay closer attention to urine output. It’s simple: ask the nurse
As you can see, I’m on a roll. I’ll return next week with MICU Pebbles (Part 3). Today, I’ll be back on the bike trail before spending the afternoon reviewing residency applications.
Enjoy your Sunday, everyone,
Mark
*All nephrologists are smart. In my book, if you can calculate anion gaps, delta-deltas, free water deficits, FeNas, and osmolar gaps in your head, you’re a genius.
P.S. What I’m reading and listening to:
- After Years of Living With Grief, Joy Has Moved In By Roger Rosenblatt
- What 20 Years of Listening to Vaccine-Hesitant Parents Has Taught Me By Jennifer Reich
- There’s a Path Out of This Divide By David French
- David Bau on How Artificial Intelligence Works On “The Good Fight” with Yascha Mounk
- Is AI Really About to Solve Human Disease? An Interview with Dr. Lloyd Minor on “Plain English” with Derek Thompson
- I’ve Got Time: A Zen monk's guide to a calm, focused and meaningful life. By Paul Loomans