August 23rd, 2017

Is Transferring a Patient to the ICU a Failure?

Cassie Shaw, MD

Cassie Shaw, MD, is a 2017-18 Chief Resident in Internal Medicine at Saint Louis University Hospital in Saint Louis, MO

As I sit with one hand wrapped around a greasy diner cheeseburger, eating my feelings — I mean, my dinner — it sure feels like failure. It’s 7:22 pm, and the first patient with my name listed as the attending is being packed up to roll into his new room in the intensive care unit. Did I mention it’s my first week on service? Okay, so I’m probably being dramatic, because the patient, although very ill, is only going to the ICU because he needs closer monitoring for the next 24 hours. However, this was my exact biggest fear as I began attending. In the scenario that plays out in my head, it’s a missed diagnosis that is obvious to everyone else; the patient has decompensated due to my mismanagement, a rapid response has been called, and I hang my head in shame while my patient is urgently transferred for higher care. I know I’m not alone in this fear. As I reflect on this feeling, I have to ask myself several “why” questions:

cheeseburger

Confession: I don’t actually regret this delicious cheeseburger

The first “why” is “Why is it so hard to give up the care of a patient to another physician?” ICUs are designed for taking care of patients that are too sick, too needy, too unstable for the floor. Even in a closed ICU, those physicians are our colleagues. I’m currently practicing at the hospital that houses my residency, so the residents who will be taking care of my patient are physicians that I worked beside for years. I know them, I trust them. Further, the ICU attendings are physicians that helped educate me for the last 3 years. I know them too, I trust them too. Is it pride that ties us so tightly to our patients, then? Maybe. But more so, I think we simply want to be *the one*. We want to be the one who gets the satisfaction of making a diagnosis, we want to be the one to help the patient. It’s satisfying work, and it’s why I chose Internal Medicine, where I get to be the primary team; the team that gets to be the one. However, it’s important to remember caring for a patient never takes place in a bubble. It requires teams of nurses, social workers, care partners, custodians, kitchen staff, pharmacists, therapists. I readily accept the assistance of those individuals on every patient, and I need to learn to more easily accept the assistance of my colleagues without feeling like I’m going to lose that “the one” high.

steak and cheese

This buttery, garlic steak and heart of brie were not Band-Aids for worrying about a patient, but they will work to calm fears.

The next “why” is “Why am I worried about having to use the ICU?” Well, as I implied earlier, I think this is a projection of my fears that I might a bad physician. In medicine, we are used to constant, out-loud comparisons to one another: test scores, mid-rounds pimp questions in front of our team mates, even our notes outlining our thought processes are up for judgement by colleagues. In fact, just tonight, I wrote an addition to my residents’ transfer note to further explain why I had broadened antibiotics — because I knew my management would be scrutinized by the ICU team. Although stressful, and driving my diet into the ground, I think this fear can be beneficial when used wisely. Cheesy as it sounds, this fear forces me to double and triple think my decisions. The mismanagement scenario was definitely playing through my head as I ordered the chest CT, sealing his fate to move to the ICU. Without that fear would I be as careful? Would I be as thorough? Would I be as thoughtful? As I write this, it’s occurring to me that maybe this “fear” isn’t lack of confidence; it’s care for the patient’s outcome.

Cassie with ribs and beer

St. Louis style ribs from Pappy’s and Urban Chestnut craft beer work for both celebration and guilt. No excuse needed.

Going forward, I have no doubt I will have patients whose diagnoses I will miss. They will unexpectedly decompensate, and they will end up in the ICU. When it happens, I’m going to get my physician high from knowing that I helped the patients get to the level of care they required. Until then, I have to remind myself that my nervous, churning stomach that can only be quieted with high-calorie comfort food is, in fact, a surrogate marker for me wanting to do right by the patient. Well, that, or a peptic ulcer.

 

NEJM Resident 360

7 Responses to “Is Transferring a Patient to the ICU a Failure?”

  1. Max Voysey says:

    Cassie – you are truly FEARLESS. Any physician who would publicly post eating a cheeseburger (a days worth of saturated fats, toxic trans fats, 1700 mg of sodium (think of that in litres of NS); followed up by a steak – in the face of over hundreds of thousands of peer reviewed papers that each of these activities is toxic, if not actually lethal – deserves to be called a HERO!
    Or uninformed and self destructive.
    Go to http://www.nutritionfacts.org for a summary of 2600 research (only), independently appraised, charitable foundation funded, conflict of interest free and declared, hard scientific data.
    And don’t be so hard on yourself – it’s your education that has been a failure – not you!

    • Harold Wilkins says:

      Ah a wild neckbeard has appeared.

    • Brit says:

      Interesting point of view Max. While it is difficult for me, myself, to determine the specific nutritional value of a picture of a reasonable to modest sized cheeseburger (appears to be one patty, one cheese slice, a bun, no sides of aioli or fries), your self confidence in doing so is quite impressive! Certainly, you would agree that moderation is a key ingredient to diet? And that the hyperbole of discussing stress eating is an eye catching start to an article in a physician based journal blog, as it caught yours. In my opinion, emphasizing moderation with diet, maintenance of a healthy BMI, with at least an equal emphasis on obtaining appropriate recommended levels of physical activity (https://www.nhlbi.nih.gov/health/health-topics/topics/phys/recommend) is a great starting place for optimizing healthy lifestyles in patients. I find most patients are much more capable of making small sustainable changes, along the lines of moderation rather than removal.
      I also find it humanizing that a physician would be willing to share their imperfections as above. Having complete confidence in every single one of your medical decisions seems a hard bar to reach for a medical professional; isn’t learning through and analyzing past circumstances not part of the wisdom that comes with practicing medicine? Perhaps I missed the class in perfectionism.

      • Max Voysey says:

        Thanks for these observations Brit. I think we can agree that a cheeseburger is a cheeseburger – it’s a high fat, animal based product – size flavour and cost to be individually assessed. Let me know if you feel this was a clinical conclusion not warranted by the available evidence. I do NOT agree that I suggested moderation (any more than moderation in smoking is “recommended”) – I am happy to suggest that if we don’t know the goals, how can we head towards them? Yes ANY progress towards them is SOME progress. Harm reduction is an approach – but not a cure. Your link to exercise is from a vested interest group focused on exercise – and they make many good points. Unfortunately I had to track quite a bit to find their dietary recommendations – point # 11 on their site – “individually tailored” was the only dietary recommendation that I could track down, not withstanding their great enthusiasm for actual weight loss.
        I hope my personal level of confidence does not influence the level of confidence that anyone can attain from a survey of thousands of research based guidelines over decades. . . . .I trust you feel confident in the ones that you are aware of and adhere to. Why are most physicians NOT aware of this data? (also answered in one of the 2600 brief five minute videos referenced above!!!). Again, please don’t conflate my desire for knowledge and clarity with any desire for superiority let alone perfectionism. Eat in health.

  2. Sandy Keene says:

    Cassie, you were a very wonderful third grade student! I’m very proud of you. I always knew you would do something wonderful even back in elementary school.
    My best,

  3. Pam Bryant says:

    Dr. Cassie Shaw, I would trust you with my Life any day as well as any member of my Family. Congrats to you in becoming a Doctor.
    Best Wishes and I know you will be, AWESOME in your field of work.

  4. Enrique Guadiana says:

    Hi Dr Cassie Shaw

    All I can tell you is that second guessing in medicine is not a good idea. You are nort God we are humans.

    One of my teachers told a few years back one lesson. I was with him making rounds and a fellow resident ask him to help in a cardioversion. He say yes, the procedure didn’t go well after a few hours of hard work we could maintain the patient stable enough. After that we continue our rounds an he told me, Did you see everything a did? Yes! Ok forget everything don’t do that ever.

    He told me if you did everything right and the result is bad don’t be concerned If you did something wrong and the result is good be concerned.

    What was the main problem? The patient wasn’t one of him. So from everything I read the thing that most concerned me was “Why is it so hard to give up the care of a patient to another physician?” you shouldn’t! I don’t care if the ICU doctor is the best of the word. If he o she doesn’t care his primary physician is in the case and he think you can’t contribute with anything, he or she is Wrong!

    We are physicians not specialist. A good specialist is a good physician with a better knowledge of small part of medicine. You can have a Chef who is very good making cakes if he only do that, he become a baker not a Chef. If you do something very well it doesn’t mean yo have to abandon everything else, you lose perspective and is against the art of medicine.

    Don’t be a Baker, is nor bad, but a Chef is better!

    Regards,

    Dr. Enrique Guadiana

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