Tag Archives: ICU

Team captain call

Tonight will be my fifth “Team Captain”, or “TC” call.  The standard anesthesiology overnight call team at my training program includes an attending, a senior resident (the TC), a junior resident (the assistant TC, or ATC), and two first-year residents.  There are also six “short call” people who typically go home somewhere between 1800 and 2230.

This call team is distinct from other call teams, which include a cardiac call team (an attending and a resident or fellow who take home call), an ICU call team (an attending who takes home call, two in-house fellows, and a handful of residents/physician assistants/nurse practitioners), the Pain Management night-float resident, the pediatric call team (an attending and a senior resident or fellow who take home call), and the obstetrical anesthesia call team (an attending, a night-float resident, and a 24-hour resident).  There’s also a liver transplant attending who only comes in as needed.

The Team Captain functions as a junior attending.  He is the point person for the OR desk when new cases need to be scheduled.  He delegates responsibility to the various team members, including setting up operating rooms and assigning cases.  He speaks with the surgeons if there are issues that need resolved before a case proceeds.  He is the first person the junior residents call if they have intraoperative problems.  He manages the PACU (Post-Anesthesia Care Unit).  He advocates with the ICU fellow for ICU care for appropriate patients. He resonds to requests for “stat intubations” and medical codes in the hospital wards and sometimes even the emergency department.  On occasion, he assists the pediatric team or advises the pain resident.  He orders food for the team.

When starting a case, the TC generally aims to have a room set up, the patient’s pre-operative evaluation done, the junior resident briefed, and the patient in the room before the attending is called.  This way, the attending can simply swoop in, sit in the corner of the room while the TC induces anesthesia, and then stumble back to bed.  Of course, if there are medical or anesthetic concerns, the attending will be called much earlier at the TC’s discretion.

In sum, this is a multifaceted, interesting, and challenging role.  I think it’s one of the strengths of my training program, since it prepares us not only to be anesthesiologists, but to be managers of the entire perioperative process.  After every one of my team captain calls, I’ve thought, “I should come home and write a post about this.”  Unfortunately, in my sleep-deprived state, I usually collapse on my bed for a good four or five hours and awaken in an afternoon haze, when writing is the last thing I want to do.

Some notable parts of my last TC call:

  • Reintubating a post-operative patient in respiratory distress within fifteen minutes of my arrival and within thirty minutes of his arrival in the recovery room.
  • Getting something on the order of 30 pages between 1600 and 2200.  This averages out to only five pages per hour, but when they come in quick succession, it sure feels like a lot!
  • Managing multiple ICU level patients in the recovery room (PACU) who were there because the ICU was full.  Their problems included mild myocardial infarctions (heart attacks), profound bradycardia (slow heart rate), and hypotension/sepsis (low blood pressure due to a bloodstream infection).
  • Putting in a subclavian central line (a large IV just under the collar-bone) all by myself.  Regrettably, anesthesiologists at my institution are a little paranoid about subclavian lines because of the increased risk of pneumothorax (accidentally puncturing the lung and developing an air leak around the lung, preventing it from inflating fully and requiring  a chest-tube placed between the ribs to help re-inflate the lung).  I’d done nearly 40 of them as an intern, but only 1 or 2 as an anesthesiology resident.  This PACU patient already had a chest tube from his surgery (and he needed a central line), so I figured it was a good time to put in a subclavian, since the treatment for the potential pneumothorax was already there!  It was gratifying to get blood returned from the subclavian vein on the very first try.
  • Bread-and-butter PACU problems like post-operative pain in a shoulder surgery patient requiring massive opioid doses when his nerve block wore off (I nearly asked the attending if he would supervise me placing another nerve block for post-operative pain), managing fussy epidural catheters, taking care of routine post-operative respiratory failure, etc.
  • Starting two “ASA 5E” cases almost simutaneously at 0630.  When I got the calls about these cases within minutes of each other, I paged the entire call team, because I knew I would need everyone’s help.  See next few bullet points…
  • The first case I was evaluating was a 65 year old woman in the medical ICU (MICU) who appeared to have dead intestines and was looking sicker by the minute (with no invasive blood pressure monitoring).  While starting to look at her chart, I got called by the neurosurgery resident…
  • “We have a 35 year old with a subdural hemorrhage who’s dying.  We need to come down [from the neurological ICU] right now.”  When a neurosurgeon says that a patient is dying and they need to come now, I tend to believe him.  I told him to come right away, and I had two of my team members meet me there.
  • Within minutes we had the neuro case underway, and I returned to the MICU to help transport the general surgery patient.  With very little down-time, the patient was intubated and the surgery was underway.  The patient’s femoral (groin) central line was difficult to access, besides not being a very “clean” site, so I slipped in a neck line under the drapes.  Given her short neck and obesity, this was going to be potentially challenging. I had one of the first-year residents retract the patient’s breast under the drape so as to stay out of my field while I quickly prepped with a sterile cleaning solution, draped, and cannulated the internal jugular vein with only one minor redirection of the needle.    By this time, it was 0730, and I turned the case over to the attending and resident who’d come on for the day.

One last side note–because the job of TC is so demanding and because we expect to get no sleep and to be on our feet almost the entire night, the shift begins at 1600 and ends at 0700 the following morning.  In comparison to my ICU calls, TC call doesn’t involve the same level of acuity (since most of the patients I’m dealing with are not ICU-level patients) and it’s more in my comfort zone (dealing with intra-op and post-op issues is what I’ve mainly been doing for two years, compared with only two or three months in the ICU).  However, there’s no “wall” of an intern or junior resident between the TC and the PACU “nonsense”, so I’m the first up to deal with everything from simple issues like low urine output or a patient missing standard post-op orders, to more complicated problems.  Thus, by about midnight, I usually feel a bit like a trampoline which is stretched equally in all directions.  But overall, I’ve found the calls to be challenging, interesting, and often rather fun but exhausting.

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Columbia & Jazz

I’ll have to write more later about the nearly three weeks I have spent as ICU senior (or “junior fellow”) in the surgical and cardiothoracic ICUs.  The days are packed with intensity, from unstable patients, to hectic call nights, to diagnostic dilemmas, to withdrawals of care.  Add to that the month of August (only one month into the medical new year) with its fresh interns, and my job becomes that much more difficult.

After nearly no sleep on Tuesday night but finishing my shift with a relatively stable 21-bed cardiothoracic intensive care unit, I crashed at home well into the afternoon.  I ventured out only late in the afternoon to get some tile sealant and sticky mouse traps.

I will spare you, gentle reader, the details of catching yet another mouse, and there’s really no need to mention how a friend told me about the humane execution method of drowning the struggling rodent in a bucket of soapy water.  No, the average Mulberry Street vistor will have no interest in knowing that the soap does wonders to the surfactant lining those rapid little lungs, but she, in her sensibilities, and if pressed, would admit this does seem more humane than throwing the critter away live, whiskers tucked back, the thin rope of a tail flicking yesterday’s can of tomato sauce.

Instead, I thought, how much better to share the pictures I took as I sauntered around Columbia’s magnificent urban campus in the slant of the late afternoon sunshine, and later, as I lounged with other Harlem residents at the foot of Grant’s Tomb as we listened to live jazz in the perfect summer evening.

The lower plaza, with Butler Library to the right.

Alma Mater“, her back toward the grand Low Library.  The university’s architect worried initially about what kind of statue would be placed in front of his masterpiece.  Upon the unveiling, however, he was pleased.

A corner of the upper plaza, with 116th Street separating the upper from the lower plazas.  One of the most incredible urban spaces in New York City.  I like the patches of green beside the fountain.

The grass had an otherwordly green hue in the sunlight.

The picture also seems effective in black and white.

Approaching Grant’s Tomb.  The week before, I was lured over from nearby Sakura Park by a jazzy version of “Over the Rainbow.”  I am a sucker for “Over the Rainbow.”  Versions that grace my iPod include those by Katharine McPhee, Ray Charles, Iz, and Eva Cassiday.  The instrumental version was really cool.

My Harlem neighbors enjoying the jazz.

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Maybe I should get a desk job…

Editor’s note: I wrote this post some time ago, but waited an unspecified length of time to post it to protect patient privacy.  It should be noted that the post portrays graphic medical situations in raw, unedited detail, so readers with a delicate constitution may wish to stop reading here.

Yesterday afternoon’s code was one of the…shall we say…earthiest I’ve ever been to.  My friend Jen, carrying the code pager for the day, had grabbed the orange “arrest bag” which was stocked with medicines, airway equipment, and gloves and was headed out of the anesthesia workroom.  “Code blue, sixth floor,” she said tersely, “Want to come?”  Given that I find participating in codes strangely rewarding, I tailed her.  It’s satisfying to make a huge difference in the acute trajectory of a patient’s health, and once an endotracheal tube is successfully placed, one can sense the rest of the medical team breathing a collective sigh of relief.  I’ve also noticed that walking into a crowded room, assessing the situation, and taking charge and communicating effectively seem to restore a bit of order to the chaos.  It’s good practice for learning to function well in highly stressful situations.

As Jen and I rounded the corner, we saw a small gaggle of medical students clustered around a door near the nurses’ station.  They talked quietly in intense conversation among themselves, their short white coats’ pockets bulging with reflex hammers, pocket references, and “to do” lists.  We immediately headed toward that door.

We strode into the room that was packed with physicians, nurses, pharmacists, respiratory technicians, and the code cart.  Being nearly 6’4″, I had a decent view of the situation, but rather than seeing a patient, all I saw were white coats clustered around the bed amid a flurry of syringes and beeping.

“Anesthesia,” I announced loudly.  “Who’s the primary team?”

“Anesthesia, get in here and intubate this patient!” one of the surgery seniors commanded me.  A little taken aback by his tone, many thoughts quickly crossed my mind.  Why else were we here?  Tea and crumpets?  Of course we were going to intubate the patient, in the quickest and safest manner possible.  Jen and I were working our way to the head of the bed.

Rather than replying, “Can you communicate with me rather than barking orders at me?” I simply asked in a voice that carried across the crowded room, “Does he have any cardiac history?”  The surgeon didn’t seem to know.  Instead, in a more neutral tone, he said, “He aspirated.  He needs intubated.”  Aspiration is the medical term for when acidic stomach contents enter into the trachea (windpipe) and potentially cause grave damage to the lungs.  Most people who aspirate end up with in the ICU with lung injury; many die.

By this time, through the tight ring of white coats, I was able to see the patient at last.  They were doing chest compressions.  I looked at Jen and said, “Compressions.  We need to intubate.”  A true code–that is, a cardiac arrest–makes our job fairly simple.  No medicines are needed.  Just a laryngoscope and endotracheal tube.  And there’s really nothing worse than being already dead, so we don’t have to worry much about hurting the patient.  I’ve never heard of a patient saying, “Hey Doc, I wanted to thank you for saving my life, but I think you may have cut my lip in the process.”

The “fairly simple” task, however, became a bit more complicated as I got a better view.  The bed was only about two feet off the floor, making it more difficult to get a close view.  The patient had a huge stomach, which is usually associated with a thick neck and a difficult time performing adequate laryngoscopy.  In addition, he had a full beard.

“Move the bed out,” I ordered.  As the bed rolled forward, I noticed not puddles, but small lakes of brown liquid covering the floor at the head of the bed.  The white sheets covering the mattress were saturated with particulate brown fluid.  Donning gloves, I scarcely had time to process it before the respiratory therapist told me, “I’m having trouble moving air.”  With that, she removed the ambu bag and I saw the source of the effluvium.  It was erupting from the patient’s mouth with every compression of his chest.

“This’ll be tough, Jen,” I said, looking at my fellow senior resident.  “Do you want to do this?”  She shook her head no as I removed the head board and grabbed the suction tubing with the Yankauer tip.  This attachment quickly clogged with the particulate matter, so I removed it and placed the larger tubing directly in the patient’s mouth while the internists continued compression and rounds of epinephrine and atropine.

After thirty seconds, I realized that whatever I suctioned out was being replaced with more fluid from deep, deep inside this poor patient.  His mouth was like a storm sewer overflowing after an afternoon deluge.  If we didn’t get oxygen into his lungs soon, there would be no hope of resuscitating him.  I tried to think about my options: a fiberoptic scope would be useless with all the liquid, and it was downstairs anyway.  A laryngeal mask airway might help get oxygen in, but it wouldn’t prevent more fluid from entering the lungs.  I don’t feel qualified to do a slash-tracheotomy, and a needle cricoidotomy would be silly in this setting.  He needed a definitive airway–an endotracheal tube–and our main way of placing it–by direct sight–was impossible with the copious runny stool being forced up by the impossibly large gut.  My sense of smell, taste, and hearing didn’t seem to help me here.  This left me with one obvious answer.

“Jen, could you hand me a bougie?”  This somewhat rigid yet flexible tool saves lives daily in the operating room.  Its curved tip is designed to bounce on the cartilaginous tracheal rings, providing tactile confirmation that the bougie is within the trachea and not the esophagus.  Once in, an endotracheal tube can be slid over the bougie, the cuff inflated, and the bougie removed.

I grabbed the laryngoscope and pried open the patient’s mouth, while brown chunks seeped out the corners of the lips.  Advancing the laryngoscope by feel rather than sight, I knew that it would help me by lifting soft tissue out of the way, rather than providing a line of sight.  I took the bougie in my right hand and plunged it into the small pool in the patient’s mouth.  It met some resistance as I advanced, so I twisted and redirected a couple times before it finally sped forward.  I felt a subtle bump or two, suggesting tracheal rings.

Raising my eyebrows at Jen, I steadied the bougie while she advanced the endotracheal tube over it.  With deft hands, we inflated the cuff, pulled out the bougie, attached the carbon-dioxide sensor, and applied a few breaths with the ambu bag within seconds.  The sensor turned a reassuring yellow, and one of the keen internists called out, “Bilateral breath sounds!”  The tube was miraculously in place.

I called for a soft suction catheter, knowing if the patient stood any chance of survival I’d have to remove as much fluid as possible from the lungs.  As I removed the ambu bag, however, I didn’t anticipate the geyser of fluid pumped from the lungs, up the tube, and out onto Jen’s scrubs and a nearby internist’s white coat as another medicine doc continued forcible compressions.  We quickly suctioned and continued ventilating while rounds of epinephrine, atropine, lidocaine, and calicium were poured into the femoral line.

The story ends, sadly, as many codes do.  We were unable to restore a heart rhythm.  The code was “called” as no pulse was attained.  The room emptied in what seemed like seconds leaving Jen and me, with spinning heads, alone with the patient and our orange bag.  We wandered back downstairs to change scrubs and sit down for a few minutes of peace to restore our sanity.

In retrospect, I cannot think of much we’d do differently.  Attempting mask ventilation can force more fluid into the lungs in a patient with such copious gastrointestinal regurgitation.  We should have put on masks with face shields first thing for our own protection.  But in reality, I knew that our chances of bringing this fellow back were next to nothing with such massive aspiration.  Here is a situation where the patient is clearly objectified, as he should be in that moment.  He becomes a task, a problem, a challenge.  We solved it.  And even if saving his life was practically impossible, by restoring oxygen to the lungs, we at least gave a sense of closure to the medical professionals.  Everything that could be done had been done.

Images of those minutes kept coming into my mind during the remainder of the afternoon and as I tried to go to sleep last night.  Nearly every sense was saturated with input: slippery floors, shouted orders, red blood & brown stool, ringing pages, splatters, needles, cracking ribs.  And I wondered, “What kind of job do I have?  What would it be like to sit behind a desk, sip coffee, and sort through e-mail and messages?”  In medicine, we tweak the inner workings of an amazing machine, our finesse guided by thousands of years of experience, by the scientific method, by love, by art.  But in the crucial times, practicing medicine rams together the raw, animalistic, sloppy, dirt-under-your-nails sort of gritty survival instinct with placid, cerebral, transcendent rationalism.  And I marvel that this is all starting to become normal.

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Red up, blue up, volume in

Such is the chatter I pick up going on between the cardiac surgeons and the perfusionists.  The simplicity and efficiency of the lingo belie the complexity of the cardiopulmonary bypass machine.

My first month in cardiac anesthesiology nearly a year ago was rather stressful, with often difficult arterial and central venous lines, intense and dynamic physiological perturbations, and a general haze of confusion when it came to knowing exactly what was happening when.  One would think that that a major surgical event like, say, unclamping the aorta, would be heralded with a clear pronouncement, if not a chime, a blast from the trumpeter in the corner of the operating room, the unfurling of a scarlet “Aorta Unclamped” banner, and a few turns of the disco ball above.

Not quite.  In the midst of the rocky course of coaxing an octogenarian’s heart off bypass, dealing with hypothermia, metabolic derangement, coagulopathies, and blood volume shifts, I must pick up on quickly uttered words like, “Pressure down, off.”

As a whole, however, I’m enjoying this month much more than before.  Knowing the basics already of how to do straightforward bypass graft and valve surgery, I feel like I’m able to pick up on more details, like nuances of induction of anesthesia, performing transesophageal echocardiography, how to better communicate with the surgeons and the perfusionists, and pearls and pitfalls when it comes to coming off cardiopulmonary bypass.  Transporting an intubated patient with multiple intravenous infusions in a large ICU bed can still be challenging, but at least now I don’t feel overwhelmed by just setting foot in the cardiothoracic ICU.  Having rotated through six months ago, many of the nurses are friendly faces.

Even medical situations that used to be daunting now seem fairly routine.  The patient’s on 6 mcg/min of norepinephrine and 4 units/hr of vasopressin?  A little nitroglycerin?  No big deal.  Pulmonary pressures a little high? Let’s start some nitric oxide.  And I know it’s bound to come to an end at some point, but my hands have been golden this month.  Bright red arterial blood flashes back in my catheter with no redirection; the catheter slides right into the artery.  Central lines slip into the neck like slipping my fingers between the sofa cushions.  Difficult view on intubation?  I’ll just ease a narrow bougie into the trachea and glide the endotracheal tube over that.  So that’s at least been rewarding.

My biggest difficulty has come consistently toward the end of a run on bypass, when the circulating blood must be reheated in order to bring the patient’s body temperature back closer to a physiologic temperature.  (The patient is cooled during bypass to help decrease the brain’s and heart’s metabolic demands.)  Around this time, I page my attending to announce, “We’re rewarming.”  That’s the hardest thing to say, with all those R’s and W’s.  I’ve even tried coalescing the two R’s into one (“Weereewarming”), but I’m thinking of just shortening the message to “Rewarming.”  Or maybe just “Warming,” since, unlike leftovers, this is only the first time I’ve brought the patient’s temperature up.  I’ll try some of these out, and let you know what works best.

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