Critical Care Medicine Life in the MICU

Today I was working in the medical ICU again in the urban hospital, the Inner City Urban Hospital. I arrived there about 4:30 in the morning and the on-call senior resident was slammed.  The whole unit looked like it was hit by a tornado; and so right as I got there, plenty early to help out, I received a bonus in the form of a very sick patient who had been transferred over from another unit without any information about her.  So this was an inter hospital and inter department transfer.  A dying, crashing patient. 

Normally when I am not on call, I get there at 4:30 or so; 4:00, sometimes 5:00, whatever, and my job is to take current patients that we are already managing from days before. I am not responsible for new admissions when I am not on call. I  start to see these patients in the morning and work on their current problems and treatments.  Generally the person who was on call, particularly at 4:30 in the morning, is responsible for admitting those patients and later in the day we will help with new admissions.  This was above and beyond my duties, but they had had a rough night, so the senior resident said, "Aw please take this patient in Room XYZ and she's very sick".  And I said, "Well, what can you tell me about the patient".  She said, "Aw nothing.  They just dumped her here.  I'm not sure who it is."  That is how my day began.  I went into the room to see a elderly lady, probably 91 years old, with extremely low blood pressure, you know, 50/palpable, meaning I couldn't get the diastolic.  You know, normally 120/80 is normal.  This lady was 50/who knows what.  So diagnosis, or differential diagnosis in that kind of a scenario often includes sepsis or cardiogenic shock and there's a couple of other things that can cause that kind of presentation.  Often with elderly patients, particularly who had come from a nursing home, sepsis is high up on my list for diagnosis. I looked at some of the medications that were running and from the department that had transferred her over to me, it became apparent that they thought this patient must be septic because of the treatments they were using. 

However, this patient didn't look like a typical septic patient.  It seemed like something else was going on.  So I immediately began to assess the patient and examine the patient and found some notes about the patient and tried to sort out what was going on, but in the meantime, the patient was awake and her gag reflex was protected, meaning she wasn't about to lose her airway.  So my first and foremost priority was covered and I did not need to intubate her to protect her airwaiy; but she was sick nonetheless and I needed to get her blood pressure up. I noticed she also had congestive heart failure.  I did not  want to slam her with IV fluids because you can essentially drown a patient who has congestive heart failure if you give them too much fluid. 

My options were to give her pressors, which are medications that help your heart and vascular system move blood.  I did an EKG, a chest X-ray, started some fluids very carefully and started her on medications, which brought her blood pressure up.  That bought me some time.  I started some antibiotics, in case there was some sepsis going on, and then I started to look at the patient's care to kind of see what was going on and basically the story was this was a "semi healthy" patient, but we weren't sure if she had dementia or not, who was transferred to our hospital from another hospital a few days ago; I think on Sunday, where she had presented to their emergency department for something we call altered mental status, confusion, and they admitted her and then realized the scope of her treatment that was required was beyond their hospital abilities and so they transferred her over to our hospital. 

Initially she was on a general medical floor and then as she progressed to get sicker and sicker, at 3:00 in the morning, they decided to transfer her over to the ICU, and shortly thereafter I came into her life. 

It's kind of like detective work to a certain degree.  I just started reading her charts and notes and found some family members' numbers. I ordered a bunch of labs.  As some of her labs are came back my suspicions were confirmed that this was not sepsis nor was it necessarily cardiogenic shock. I noted she had coronary artery disease and congestive heart failure and that was bout it.  So I ultimately got a hold of some of her family members and had to talk to them about do not resuscitate, do not intubate and update them on their mother's situation, and I was able to find out that on Saturday night they were with her and she was fine, not confused at all.  Then Sunday she started to get kind of tired and confused and that's when they decided to bring her to the other hospital.  This information shed some light on what was going on and I was able to ask them about some of her past medical history. 

As the day went on, her hold on life was tenuous at best.  She was hanging on by a thread and I kept having to manage her medications to kind of keep her from crashing and ultimately, by late afternoon of balancing her medication, we never had to intubate her, but by giving her some forced oxygen, she was able to start turning around.  Finally I did a 2-D echocardiogram, which is like an ultrasound of the heart, and was able to determine that she has pulmonary hypertension and basically a pretty bad heart, and so that gave us an idea of what was going on.  It turned out it was a multifactorial combination of things that was causing her, to be sick and she's not out of the woods, but she is much more stable tonight than she was this morning when I inherited her. It will be interesting to see how she does over the next few days.  In talking to her family, she is full code, meaning they want us to resuscitate, they want us to intubate if necessary. 

This patient was one of the five patients that I was in charge of taking care of today.  She took a lot of time because she was very sick. These are the kind of patients you take care of in the ICU.  Another exciting day in the medical ICU.

ICU Medicine (MICU) The sickest of the sick

It is the middle of November, and I have started a new rotation.  I am now working in an inner-city Medical ICU, it is called MICU.  These kind of rotations are always slightly horrendous because the hours are extraordinarily long, the patient pathology and acuity is extraordinarily complex, and it's just all around an intense experience.  You're dealing with the sickest of sick patients with the worst of the worst diseases and often they are dying, so how this rotation works is generally I report at 4:30 or 5:00 in the morning to the Medical ICU floor and pick up anywhere from three to four patients for that day; some of them might be patients I've been following from the day before, some of them might be brand new patients that came in overnight, some of them might be patients that somebody else was following the day before.  Essentially I go in and examine each of these patients and check with the nurse who was there overnight with them about any new events or new complaints, and I write up a note that kind of explains what is going on with the patient and their disease, processes, and any new findings like laboratory findings, vital signs.  A lot of these patients are on breathing machines or respirators/ventilators, and I might have to adjust the ventilators depending on the labs that have returned whether the patient is acidotic or alkalotic, and I have to check all of the sites where they have tubes or catheters placed and look for any signs of infection or other problems.  So, I do this.  It takes a couple hours and so by 7:00 or so, I present to the senior residents my findings and what I found and then they kind of go from there and present to the attending physicians kind of the course of the patient's evaluation and treatment and then we meet and then while they're doing that I continue to write my notes for the day which unlike emergency medicine notes, tend to be very long and elaborate, small volume novels written about every aspect of the patient's treatment and care.  So this takes a little bit and somewhere around I don't know 10:00 or so in the morning while I'm in the middle of this, we meet with the attending physicians and round on the patients; all of the patients on the ICU. 

This particular ICU has 16 beds, and there's generally three or four interns and two seniors and so we have the patients divided up and then we go and see each of the patients with the attendings or the physician who's in charge.  We get quizzed and grilled about their condition and differential diagnoses and what could be going on and what medications should we start or what settings should we do or what kind of imaging studies do we need or labs, etc., etc., and we might be rated about the course of treatment or evaluation, and we look at any films like X‑rays, CT scans that have recently been done and we're asked and grilled about the findings, and so we look at the X‑ray and attending physician will say okay what is this here, what causes this finding, where is the catheter or central line on this X‑ray or whatever, and so you kind of have the whole pain there while the attending physician grills you and might say well what kind of bacteria can cause this pathology, and okay well what kind of antibiotics are best for this pathology, and you may know the answers, you may not. 

The supervising physician will keep going until he stumps you no matter what, so this takes an extraordinary long period of time and you kind of go through and everyone takes their turn getting abused and then once that is done, three or four hours later into the afternoon and you go back over the patients that you were managing and examine them again, writing more notes on them, and you might change any course of therapy or add therapy depending on recommendations from the attending physician, and oftentimes, many of his recommendations are why don't you get infectious disease involved or pulmonology involved or nephrology or cardiology depending on the illness the patient has, and so you spend the afternoon tracking down the various specialist and telling them about the patient and asking them to see the patient and following up on different things.  So as this goes on, somewhere around 5:00 or 6:00 at night, everything is finished up, and you're allowed to leave.  So you get there at 4:00-4:30, leave 6:00 sometimes 7:00 and then every fourth or fifth night you have the pleasure of being on call, so when you are on call, you come in that day at the same time 4:00-5:00, and you follow the same schedule I just explained.  However, at about 5:00, 5:30-6:00 when everyone else is starting to leave, you take sign-out which is where the physicians taking care of the patients that you are directly in charge of will update you on their condition and what kind of things are going to happen overnight or what you should look for, what you should treat and then they leave.  Now, generally there's two physicians on call; a senior resident and junior resident like myself, but instead of covering 14 beds, we're covering 28 beds because we also cover while we're on call the floor that is right next to the Medical ICU which is the progressive CCU or progressive Cardiology Care Unit, so there's 14 beds there with patients who have severe coronary or cardiac illness and so overnight as a junior resident you are covering the PCCU or the Cardiac Care Unit which are all patients you are unfamiliar with because you've been working the days over on the other ICU.  So, that's kind of how it goes, and so when you're on call, you stay and you get there at 4:00 in the morning, and you stay all the way through the day, through the evening taking new admissions and putting in orders for patients that need stuff, coding patients, or you're running CPR or announcing patients dead or whatever may occur overnight, and like I said admitting all the new patients that come in overnight, and this basically keeps you up all night so the next morning, 24 hours later at 4:00 or 5:00 when the team comes back, you start the day like you would any other day picking up new patients and examining them, write notes on them, and the difference is you stay until about 11:00 the next day, and you do presenting to the attending physician and then once 11:00 or noon hits, you are free to go and then you go home, go to sleep, and start all over the next day. 

This is how the ICU works. In addition to my daily responsibilities, I do call every few days for the CCU.  I started the rotation this week and it's my fourth day on the ICU. I have had one call so far and a whole bunch of interesting cases and very, very sick patients. You may be asking yourself why does an emergency medicine physician, need ICU training? Given the current disaster of emergency room crowding we end up housing some of these patients for a long period of time so not only do we have to know how to stabilize the very sick patients, get them on the breathing machine (ventilator) but we also have to know how to continue to manage these patients because these patients will not actually leave the emergency department for even up to a day and so while they're in the emergency department, as our patients as an emergency physician, we have to know how to continue to manage their critical illness before they get up to the ICU, so it's great training but it's a different flavor of medicine. It is important as an ED physician that you have good ICU training. 

Emergency Medicine, Orthopedic cases

A couple of days ago I had another shift at the community emergency department in an urban setting and it was a busy day.  I saw 17 patients  in about a 9-hour shift and I saw all kinds of  patients.  The day went by in a whirlwind because I was busy, busy, busy.   I had a couple interesting orthopedic cases.  Oftentimes we see these things in the emergency department and treat them and send them home and they may or may not need any follow up after an accident.  

I had a gentleman who was hit by a car.  This  emergency department, although in a community, is tucked off on a very busy road and oftentimes we get motor vehicle collisions or MVCs or MVAs for motor vehicle accidents and this one was pedestrian versus car or car versus pedestrian, however you would like to say it, and usually it’s not difficult to figure out who’s going to win in that kind of a confrontation.  The car wins every time.  This gentleman was crossing the road and was struck by a car going maybe 20 miles an hour and had his leg run over and was rather fortunate considering the circumstances.  He was brought in by an ambulance and when I went to examine him it became very clear that his main injury complaint was his right foot and ankle, and when I examined him I quickly saw that his right foot was twisted in the wrong direction,  and that’s where most of his pain was coming from.  

I examined him completely from head to toe for other injuries that may not be apparent at first and when I found no other injuries, I returned to examine the right ankle and foot and it was an unstable injury.  So I sent him to X‑ray.  I gave him some pain medication first and then sent him to X‑ray and when he returned it was clear he had fractured his tibia and fibia, and also had another fracture in his ankle and so his foot was completely unstable and could pretty much turn it any direction.  I did not have any doubt there were fractures but we needed the X-ray images to fully diagnose the damage. The fractures needed to be reduced. I sedated him and reduced the fracture and put it in a splint and because of the nature of the injury, and it was unstable, he definitely is going to need surgery to repair the broken bones.  Through the reduction procedure we were able to get it more stable and reduced it back to where it needed to be and into a cast until he can get a surgery.  

The other case I had was a postal service worker who goes and delivers mail door to door by foot, and he came around a corner and three mad lunatic dogs, as he described them, charged him and he sprayed them and they continued to charge him as he ran backwards, and there was an incline in the yard that he didn’t see as he was going backwards and he fell back and landed on an outstretched wrist. He fractured his wrist in two places.  He had a radial and an ulnar fracture and he was in a lot of pain.  This was a stable fracture and we gave him significant amounts of pain medication to ease his pain, and then after we got an X‑ray that showed these fractures it needed to be reduced or set.  We gave him some conscious sedation and waited until he was significant unaware of his surroundings and reduced the wrist to get it back in its place and he will not need an operation, just a cast and he should heal just fine.  

In the emergency department we see orthopedic injuries all the time. These are just a couple from one of my shifts that I treated  in the emergency department.  

Suicide by Tylenol

What happens when you decide to take several hundred Tylenol in an attempt to kill yourself?  You think about that for a little bit.  Well, let me tell you.  Generally, you're going to end up dead or a very painful and excruciating terrible death or you are going to end up with a ruined liver needing a liver transplant on the transplant list and suffering and if you get a liver, well, you might live, but your life will never be normal again and if you don't get a liver you'll die like in the first scenario.  So faced with in this past emergency medicine shift I worked, a young individual and presented after swallowing several hundred Tylenol and he was found vomiting and next to the toilet by his family and there was an empty Tylenol bottle and they only can assume he took the whole thing.  It was a sad tragic case, so, what do we do.  Well, the first thing we do is when the patient gets there, we make sure the patient is stable and then back in the day they used to try to make the patient vomit.  They also used to try to do gastric lavage (pump the stomach) to flush your stomach. That's no longer the usual approach any longer. c 


There is an antidote to Tylenol poisoning, it's called N-Acetyl Cysteine. We make sure that the patient is currently stable, not losing their airway or seizing or in some other form of immediate life threatening catastrophe.  Usually, on presentation, they're just sick.  We assess their vital signs run some labs to test their liver function and measure their Tylenol level and we also do a tox screen to measure other drugs including aspirin, that they may have taken, we can start to gauge how real the Tylenol or acetaminophen overdose is.   N-Acetyl Cysteine basically  prevents the Tylenol from being metabolized into a toxin that kills your liver and so then you can get rid of the remaining Tylenol without metabolizing it into a poison.  Sometimes a person really does a job like this individual did, even with the greatest medical care and quick medical care, sometimes will not save the patient. Sometimes you can't beat the suicide attempt that the patient attempted and in this case unfortunately this patient had done such a number on himself and even with the antidote he died before our eyes and was successful in his suicide attempt.  




Suicide is never an easy case to manage and the sad part is dealing with the family after the fact and those that are left behind.  That's probably even harder than dealing with the patient themselves, so Tylenol is not the answer.

Febrile Seizure, partial seizure and Lumbar Puncture (LP)

It was about 2:00 in the morning when I was typing my notes on the night shift for a patient that had presented with chest pain.  I was doing the usual workup to rule out a heart attack when I heard the radio go off and the paramedics and EMS say that they were bringing in a 3‑year-old boy with fever who may have had a seizure in the night.  I barely even heard it.  It was kind of almost in my subconscious as I typed away about my patient with chest pain.  In fact looking back I think it was more like my subconscious heard it.  I continued to ponder about my patient wondering if he in fact was having a heart attack or maybe it was anxiety or some other kind of chest pain, costochondritis, another form of chest wall tenderness, pneumonia .  It could have been a whole bunch of explanations for his chest pain and I didn't have his EKG back and was thinking to myself about how I was going to move forward with his management.  


About 20 minutes later and a couple patients later I happened to be coming out of an exam room and the paramedics were there in the entryway with the 3-year-old child on their gurney and two young adults that looked like they must have been the parents and two older adults who looked like they must be grandparents and the child was on the gurney screaming and crying obviously in discomfort.  I looked up barely to even notice the patient as I had two or three other critically ill patients and the paramedics said hey doc, what room should I take her to.  So, I motioned to them to take him over to one of the side rooms and let the family know I'd be in there in a minute and I told the nurse,  to start getting the patient hooked up to monitors, etc.  I thought to myself "oh this is going to be another febrile seizure", not a big deal.  We see these all the time. I entered into my office room to continue to chart on another patient.  There was something about the child's cry or maybe it was the parents' faces  I thought to myself, you know I better go and see this patient, this 3-year-old boy real quick and see what's going on.  I went in there and he looked uncomfortable and he looked "sick" and his parents were definitely scared but the parents are always scared.   I went over to the boy and looked at him to see if he was postictal and he did not look right to me.   I continued to talk to the parents and the nurses were scurrying around to get the orders that I had put in for the patient, getting a temperature, hooking the child up to the heart monitor and getting an IV access, etc., etc.  As I explained to the parents what a febrile seizure is and the nurse says to me "doctor, this kid's temperature is 105".  I said okay, give a Tylenol rectal suppository stat and at this point the mom was starting to cry and I put my hand on her shoulder and explained to her that we're going to take care of her child and just as I was explaining this the nurse yelled out, "hey doctor, pulse rate is 280".  


I stopped mid-sentence with the mother and immediately went to the patient's side to begin further examination and looking at the patient, immediately noticed that the patient was having some kind of a seizure, not a toniclonic seizure where the patient is unconscious and their entire body is shaking all over but this looked like a partial seizure to me, where the patient appeared to be awake.  Both of his legs were stiff and plantar flexed and his right arm was contracted almost like he was having a stroke.  The parents could tell by the look on my face that this was a little bit more serious than I had originally thought and I had the nurses move the patient over to the trauma bay so we could prepare to intubate the child and further manage the child.  


The nurses took the patient to one of the resuscitation rooms and I explained to the parents what was going on and what I planed on doing to treat their child's illness.  Once over in the other room my attending physician finally came in and I was preparing to intubate the child and I was giving medications to stop the seizures. It's always difficult when you have a sick child.  You have to remember the pediatric doses and all the treatments are slightly more complicated because you are dealing with a much smaller patient. Everyone is on their toes when you have an innocent child suffering, it just creates a slightly more intense atmosphere. I let the parents and the grandparents stay in the room the entire time. They stood at the child's side and comforted him while what must have seemed like a ball of confusion whirled around them.  So, we gave the child medication.  We called respiratory down and prepared to intubate the child.  After two rounds of medication I was able to get the child's seizures to break.  I was able to get the child's temperature from 105 down to 101 and ultimately was able to intubate the child and it is no small task to intubate a small child, especially with the parents and grandparents in the room and get the child hooked up to the ventilator and we were able to do a spinal tap and start antibiotics and then get on the phone with a pediatric ICU hospital and have the patient transferred over where they had the facilities (pediatric ICU) to continue the long term treatment for the patient.


I have not yet heard what the pathology was in this case. I think that the child had meningitis or some other infection causing these high temperatures  leading to the seizures. However these seizures where not like the typical febrile seizures, so there may have been additional pathology going on with this child. He was healthy without any problems up until this point and hopefully he will return to his normal healthy state but you can't be sure. I will follow up with this case to see what ultimately happened. Hopefully his parents quick response and our quick medical management prevented any longterm deficits from occurring. We did everything we could in a quick fashion; stopped the seizures by bringing the fever down and giving anti-seizure medications, we performed a spinal tap to diagnose meningitis if in fact he had meningitis, we started broad spectrum antibiotics to cover for infections including meningitis, protected his airway by intubating him and finally we got him to a pediatric hospital where he could receive further care and evaluation. 

The overnight shifts in the emergency department.

I would have to say that I like the overnight shifts. There are many reasons why I like these shifts. The administrators are missing in action, they only work from 9:00 - 5:00.  It is a "when the cat is away" situation. Also the patients that come in to the ED are often interesting individuals. You still get all the life threatening illnesses but sprinkled in with the real emergencies are these fantastic characters that come out of the woodwork. You really can't make up these stories. It is a "real life is stranger than fiction" situation.

The other night I had an interesting patient. She drove herself to the ED on her hovearound scooter that was paid for by her public aid money, also known as tax dollars. This was a lady in her late 40's that weighed about 380 - 400 lbs and had been smoking since she was 9 years old. She was on disability and received disability funds. She assured me that she in fact had her last cigarette on her 3:00am scooter ride into the emergency department. Never mind that she asked if she could go out for a smoke 30 minutes later.

I asked the patient what her life threatening emergency was and she explained that she "felt winded"and could not fall asleep. She did not have any immediate life threatening emergencies but because she came to the ED we had to work her up and make sure there was nothing acutely going on. She demanded meals, drinks, warm blankets and something for her pain. I explained that chain smoking for 40 years can make anyone winded and that large consumption of nicotine and red bull will make it difficult to fall asleep. After running some tests and lab work and making sure she was not having an emergency I discharged her and she reluctantly went back to her scooter chained to a tree in the parking lot and rode home.

Although this case is pretty sad on so many levels, it makes the night shift a little more interesting.