The more things change

I have a day off from the ICU today and I’m sitting in Starbucks, putting together a poster for the annual ASN meeting next week in San Diego. I finagled another day off for the conference and will fly to San Diego and back all in one day to present my poster and hopefully meet some of my future colleagues in academic nephrology. Catching a 6 AM flight only to fly home 15 hours later doesn’t sound like much of a day off, but that’s probably just the crazy-tired talking.

The crazy-tired does a lot of talking these days. Truthfully, the ICU has been harder than I expected. Part of the problem comes from that fact that our VA ICU is an MS-ICU, which means that both medical and surgical patients are cared for by the same ICU team. In some ways, this is a good thing. For one, my residents this month come from general surgery and anesthesia, as well as medicine, and I’ve enjoyed meeting and learning from this diverse group. For another, managing a post-CABG patient, the bread and butter at our VA, is good learning for medicine interns. Where else do you consistently encounter concomitant distributive and cardiogenic shock? On the other hand, some of the differences in approach between the two services (medicine and surgery) are -- how to put this delicately? -- frustrating.

Right now in our ICU there is a patient with severe congestive heart failure, in cardiogenic shock. Essentially, the pump function of his heart is failing and he is unable to pump sufficient blood forward to supply oxygen to his organs and tissues. One consequence of this problem is that the patient’s lungs slowly fill with fluid as it backs up behind the failing pump. The medical approach to such a patient is to temporarily give medicine to augment the strength of each heart contraction (inotropy), as well as medicines to reduce the extra fluid in the lungs (diuresis) and to lower the pressure against which the weak heart is pumping (afterload reduction). The surgical approach, apparently, is to insert a chest tube to drain the fluid around the lungs. The surgeons are also refusing to allow the ICU team to provide afterload reduction. Meanwhile, the patient is requiring ever-increasing doses of inotropic support, in the form of intravenous dobutamine, which increases his risk of a dangerous arrhythmia. Our various consulting teams are wondering, first politely, and now with escalating boldness, why -- why, exactly? -- the ICU team is mismanaging this patient so spectacularly. It’s an irritating situation and brings to mind that old joke about the various specialties: Internists know everything and do nothing. Surgeons know nothing and do everything. Psychiatrists know nothing and do nothing.

But despite the irritation and the crazy-tired, I’m doing OK. Brian is home from Japan, finally and blessedly. And Sam is Sam. And that right there is enough for today.