August 23rd, 2017
Is Transferring a Patient to the ICU a Failure?
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:
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.
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.
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.