Notes

[...] As an ICU fellow, I often get consulted to see a patient in the emergency department or floor who is in the gray zone of whether they need to come to the ICU. Perhaps the [...]

[...] fellow carrying the phone is the main gateway for patients to be admitted to the ICU. The emergency department calls us with new patients who have medical critical care needs, from sepsis and [...]

[...] room? And though we all expect patients to enter the health care system through the emergency department or urgent care, it's entirely possible that they can show up to an unrelated clinic or [...]

[...] to the ICU; all the patients who come in, through transfers, the operating room, the emergency department, the floor, and from codes go through one of the fellows. A lot of this clinical [...]

[...] The hardest and most emotionally trying things I deal with in the intensive care unit is the end of life. Recently, I struggled with one particular situation that was medically, [...]

[...] Over the last six months in the intensive care unit, I've found that one disease we underestimate in medicine is cirrhosis. When family [...]

[...] that they really help make things pain free. A victim of a near-drowning has been in the intensive care unit at a large community hospital. The settings on his mechanical ventilation are pretty much [...]

[...] , when I probe further, I find out that not only does that other hospital have an intensive care unit, but the patient may not need ICU level care in the first place. After two liters of [...]

[...] while. After three years of 60 hours a week, I've made anesthesia rote and muscle memory. The operating room is my home and I feel exquisitely comfortable there. But during my year of critical care [...]

[...] difficult airway cart. I placed a laryngeal mask airway, something seldom done outside the operating room, but with my background, something I felt incredibly comfortable with. This freed up hands, [...]

[...] valve rupture is made. He is near death, requiring code doses of epinephrine. Rushed to the operating room, he undergoes a mitral valve replacement. His heart has suffered such an injury that he is [...]

[...] , compressing it, and rapidly killing him. I drop everything else I'm doing, activate the operating room, and wheel him back as I dose epinephrine. I stay until the surgeon evacuates the blood and [...]

[...] narrow slice of medicine and now I want to step back and learn everything else. This year as an ICU fellow is a great opportunity for me to undust those books on infectious disease, engage those rusty [...]

[...] As an ICU fellow, my best friends are our critical care crisis nurses. Whenever we respond to a code blue, rapid [...]

[...] Every hospital is different, and getting to know your hospital is a big part of being an ICU fellow. When we make decisions about a patient's "disposition" - that is, what level of care [...]

[...] , and to have confidence that I could rescue the patient if things went wrong. Now that I'm an ICU fellow, I don't intubate all that much, but occasions like these are ever so exciting. [...]

[...] . A stat CT scan of the brain shows a severe brain bleed, probably from uncontrolled high blood pressure. His neurologic exam is deteriorating; he doesn't wake up to voice or touch, and he cannot [...]

[...] where the brain is asleep and the patient doesn't breathe, but if they feel pain, their blood pressure and heart rate will rise. I can achieve a state of anesthesia where the body knows nothing; a [...]

[...] the ICU after the case. He was fairly hypotensive and so we resuscitated him, supported his blood pressure, and extubated him from mechanical ventilation. Boy, did he have a personality. He learned [...]

[...] 's oxygenation is so bad that you've maximized your ventilator, what do you do? When someone's blood pressure is refractory to every drip you can think of, what do you order? When a patient's on every [...]

[...] spreads to Europe or the United States, this will become a major problem. Image is in the public domain, from Wikipedia. [...]

[...] press. Image of nurses caring for a patient with Ebola from a 1976 Zaire outbreak is in the public domain, from Wikipedia. [...]

[...] and other health care workers. Image of an air-transportable isolation module is in the public domain, from Wikipedia. [...]

[...] a challenge is presented and I use all my skills and experience to conquer it. Image is in the public domain. [...]

[...] to risks of the ICU and aren't allocating resources appropriately. In many ways, the VA is a health care bubble that is isolated from the pressures of the private practice environment. The VA doesn't [...]

[...] . Over lunch, the panelists, Dr Nussbaum, and I mulled over some of the changes happening in health care, problems with our current delivery system, and possible innovations to meet our dynamic health [...]

[...] delivery of health care is impeded if patients refuse to seek care when they have symptoms. These countries are poor; [...]

[...] indigent of San Francisco, those who have nowhere else to go. It plays a critical role in the health care safety net of the city, a place for rehabilitation, AIDS patients, dementia, and chronic [...]

[...] vacations, nutrition management, and glucose goals were fairly novel when I started as a medical student; back then, we'd discuss these "exciting" papers and now we frown upon anyone who [...]

[...] of nurse practitioners who help us out. These are some of the best NPs I've worked with as a medical student and resident. Some have been with the CVICU for a long time. There is always a nurse [...]

[...] I recently got a great comment from a medical student interested in anesthesia but concerned about the future of the specialty. There is a worry [...]

[...] ! I remember reading books about the first cases in the 80s, seeing acute HIV infection as a medical student, memorizing the early antiretrovirals as an intern, and now perusing the HIV issue of JAMA. [...]

[...] Every day in the medical ICU, I attend multidisciplinary rounds where I review my list of patients with a group of nurses, [...]

[...] On the medical ICU, one of the fellows is always carrying the "phone," which is a bit like a hot potato. [...]

[...] send their patients to Stanford. They triage patients and if a patient sounds like they have a medical ICU need, they give the ICU fellow a buzz. For us, it feels a bit like a chore. We are busy with [...]

[...] - play into the calculation of whether to take a patient from another hospital to our medical ICU. It's something I look forward to learning, and a real challenge, especially since our [...]

[...] nutrition for her. We could not salvage the kidneys and had to start continuous renal replacement therapy. In retrospect, she was not an appropriate surgical candidate. Although you [...]

[...] , pushing medications, starting paralysis, doing serial echocardiograms, managing continuous renal replacement therapy (he had gone into kidney failure during this). And we managed to tide him through [...]

[...] and the accumulation that would occur over time. Similarly, I saw a lot less continuous renal replacement therapy then than I do now. Not all the changes are good; our bugs are more resistant, and [...]

[...] , liver failure, an ongoing gastrointestinal bleed, and kidney failure. He's on continuous renal replacement therapy, blood transfusions, and broad-spectrum antibiotics. The ICU doctor over there [...]