I love MICU: reason #1

I realize the past few posts have been harsh and negative. But there are a lot of nights I do love my job, love the ICU. So I'm gonna tell you about when I love the ICU.

Reason #1 is The ICU means Intensive care...

We do have the classic drama like on tv, (only always in the ER...the ICU does not have its own tv show.) I was there for our last cracked chest in the ICU...which does not happen in the ER. A suture on the junction from the pt's aorta to her heart muscle tore. Blood. Everywhere. Liters and liters of it. God, it was bad.

And tell me why don't we have our own tv show? Not that the ED isn't interesting, it very much is. But. But. The ICU is cool, too.

They don't have situations like my patient the other night in the ER.

Margaret is not my patient's name, and she's a train wreck. She came in for a complex vascular surgical procedure, developed a bleed...and 36 hours later she's in multiple organ system failure. Yeah. That fast.

In ICU, you meet patients at a life-or-death time of their lives. Margaret has in her living will that she does not want to be on life support for more than seven days. Today is day five. Don't think that isn't at the forefront at my mind at all times. A week ago, she was living at home independently. Having cups of coffee with her friends. Visiting with her grandchildren, walking her poodle. This was a scheduled, planned, surgery.

On this particular patient, we don't have an intensivist or hospitalist, so there is no one single MD brain drivin this train. It leaves a lot of holes for the RN to fill. I'm not going to blog on the appropriateness of this (it isn't) right now. What it does mean is that the day RN with whom I'm swapping this patient every day (Douglas) and I are operating in a frustrating vacuum. And a clinically challenging one.

What I do love about taking care of this type of patient is that I was busy all night titrating drips, titrating the vent, titrating the CRRT, getting the next round of labs and futzing all over again. Dressing changes, lab values to interpret, arterial and central venous pressure line waveforms to futz with. Oh, and she has a paced rhythm, too.

...I can't seem to get Margaret off the dopamine, even with cutting her CRRT rate in half. Her central venous pressure is THIRTY, and I'm slurpin out fluid at almost hemodialysis rates. But I stop that, hold the whiff of dopamine I'm giving her, her pressure tanks. Her heart likes the inotrope. Weird. (Gee, I wish I had an intensivist here who might have some more ideas on what's up with that....)

Incremental success for this patient is decreasing her oxygen by 5% and having her tolerate it for an hour. Five percent is no piffle. It will be the difference between whether or not she can attempt to wean off the machine, i.e. recovering or not. I am continually testing how her body responds to the changes in the meds, changes in the amount of fluid I'm pulling off her body, in the vent settings.

Let me underline: We have two days left to fix her. Before the family draws the line because of Margaret's previously stated wishes. If we can't fix her, we will stop the kidney machine, take the tube out of her throat and she will essentially....drown. In her own body fluids. Of course we're gonna have pain and sedation meds on board, but I realize how horrible this is.

We have 48 hours. Where else but in the ICU do you have this kind of situation?

In the ER, some of their adrenaline comes from the chaos, the randomness, the wildness. 'Turn and burn' is what the ED nurses tell me. It's a different adrenaline in the ICU. Continuous dose adrenaline, maybe. Adrenaline for control freaks (wonder if the OR is like that, too?) I didn't sleep well today, because I was thinking about what I may have forgotten, what I could have altered or improved.

I don't know Margaret. I see the pictures of her in her room. But my head is totally wrapped up in what we need to do to help her body heal from the inside out. Why the drop in crit this morning? Where is the bleed? Do we need to give her platelets because the CRRT is chewing them up? Why can't we get her off that blasted dopamine? Why is it sometimes I can doppler that left post tib, and sometimes I get it on the right but not consistently? What's going on with those sutures in there? Why are her LFTs still high even after we've stabilized her pressures? I wish I had a PA cath to see what's really happening with her hemodynamically. Her lungs DO sound better, but when she turns to the left, her sats drop, I wonder if we don't have an infiltrate on the right? Her CRRT "arterial" pressure kept alarming negative pressures, which might imply that she's vasodilating...etiology? Sepsis? No, we have her on enough abx to sterilize a barn. What are my other types of shock: spinal, no, anaphylactic, no, cardiogenic shock? That's the only one left...? Why, in a paced patient? Is that why I can't get off the dopamine? What's gonna help her...well if we do levo, we completely nullify the surgery that she came in here for...

Round and round.

I love this. I really do.


But reason #1 might be the reason ICU is Intensive Care. We have a different definition of intense here. It's not better or worse than similar nursing areas....and this kind suits me. I'm glad they love the 'turn and burn' in the ER, I'm glad they have the extremely sedated almost-dead patients that they 'put down' and revive in the OR, and that's not even the people that do oncology, or scarier...pediatric oncology. Intense in different ways.

We have 36 hours left to get her off that vent. It's a proFOUNDly complex puzzle for the team of people working with her to disentangle.

And it means life or death for Margaret. I'm sitting in her room, surrounded by pictures of her family, her pooch. They're waiting on us to be smart enough to get her out of this.

Thirty-six hours.