Coronavirus: ICU and the Human Factor

The summer of 1979 is permanently etched into my memory. I walked into the Intensive Care Unit at U.C. San Diego Medical Center as a newly minted intern. I walked over to ICU-Bed 1 to be introduced to my first patient, a frail teen aged boy who was tethered to a ventilator. “He is day 30 with respiratory failure from disseminated coccidioidomycosis,” my internal medicine resident informed me. “He is your responsibility now, and don’t f__ it up.” An impending wave of anxiety enveloped me as I visually tracked the unending array of IV’s, feeding tube, central line, temporary pacemaker leads and monitoring equipment surrounding his bed. Over the next 6 weeks, I quickly learned that I was a small cog in the care that navigated his course away from almost certain mortality. As the credits to a movie may roll for minutes with names that do not have an apparent effect on the finished product, so too is the list of people who render care to the ICU patient. The pulmonologist, critical care specialist, critical care nurses, respiratory therapists and anesthesiologists represent a core team. Integral to their support are those that are in the supply chain providing meds, equipment (lines, pacemakers, intubation equipment, personal protective equipment, monitors, ventilators) and those that support and repair these items. Additionally, consultative services such as cardiology, infectious disease, gastroenterology, neurology, hematology, surgery and ENT to name a few, are involved with medical and surgical issues that arise from the prolonged hospital course and many complications that arise in patients that cannot provide critical organ function. Furthermore, ICU patients consume intensive utilization of laboratory and radiology service. Ethics committee members may be involved in deciding end of life and medical futility issues. Family adjustment and bereavement may also need social work and psychiatric services to cope with these psychosocial issues. The work day of the ICU is punctuated by “crisis moments” as each patient may have a life threatening arrhythmia, mucous plug in a large airway preventing oxygenation, massive gastrointestinal bleed, pneumothorax from high ventilator pressures to name a few of the “falling dominoes” of the critically ill patient.

Universal precaution implementation is, in an ideal world, best adopted in a slow, compliant fashion with a critical care or scrub nurse equivalent monitoring the provider for breaches in technique while putting on and removing personal protective equipment. In real life, emergent events require rushed donning of masks and gowns with possible gaps in the mechanical barriers. Of course, infective risks are greater with the lack of N95 respirators and the use of less protective surgical masks. Now, let’s look at the public risks of community exposure when the family equation is factored in. At least a dozen or more providers may enter an ICU bed in a given day. Most of the health care professionals are young, have families and extended families that they interface with on a daily basis. A four person household with a dozen personnel exposed to COVID-19 and a national number of 85,000 ICU beds creates a potential exponential source of infection in the community.

More masks, more providers and infrastructure are needed now. Can this be possible? Innovation in equipment, medical therapy and healthcare delivery are possible given the resiliency of Americans devoted to the well being of the United States. Is it possible? I have faith that this can be overcome. And, yes, my teenage patient  in 1979, after 30 more days in the ICU, walked out of the hospital with a smile on his face and his health intact.

Should you retire? A Cognitive Test of Retirement-Worthiness

There are plenty of retirement calculators on the internet using your financial health as barometers of retirement. For those that want to supplement your retirement decision, take the following quiz.

  1. The patient is “digitized” means digoxin rather than  an electronic medical record.
  2. You know the difference between ouabain and digitoxin.
  3. Your mentors are Ben Casey and Dr. Kildare.
  4. Your go to analgesic is Zomax.
  5. Your peptic ulcer patients all go on heavy cream (Sippy diet).
  6. You were the treating physician at the Legionaire’s conference in 1979.
  7. You still carry two or more pens “just in case.”
  8. You are comfortable with terms like “thymol turbidity” and “Wasserman testing.”
  9. On the radiology order form you search for “pneumoencephalogram.”
  10. You enter the room and are surprised nobody offers their seat to you.

Score:

10/10:  Methuselah  Doc: go straight to retirement and offer your services to a Medical History Museum.

7-9/10: Research 55 and older communities: notify your colleagues of impending obsolescence.

4-6/10: Double your CME: spend more time with millennial docs.

0-3/10: Rest easy: proclaim you’re youth in the twitterverse and toss out a few Smiley emojis. You are low on the Obsolescence curve.