The Increased Use of the ICU

We are using our ICU's more often than we have in the past, according to a new study. As published in the Academy of Emergency Medicine, George Washington University researchers found a 50 percent increase in Intensive Care Unit admissions between 2002 and 2009. 

As the patient's get older, we are utilizing intensive care more often. The group with the largest jump in ICU admission was those over the age of 85 years. That isn't likely to surprise, given the aging population in the United States.

Yet, the recent study that highlights an increase in hospice admissions only after intensive  and expensive ICU care in the last few days of life highlights the fact that we are still aggressively treating patients in the last chapter of their lives. That Journal of the American Medical Association study appeared with an editorial calling for an end to aggressive hospitalization in end of life care by increasing planning and communication between patients, families and doctors prior those final days. 

The article also notes that patient's also spent up to 5 hours in the Emergency Department waiting to get into the ICU. 

 "Studies have shown that the longer ICU patients stay in the emergency department, the more likely they are to die in the hospital," Pines said. "Better coordination between the emergency department and ICU staff might help speed transfers and prevent complications caused by long emergency department waits," he said.

Ummmmm ... I don't think it is interdepartmental coordination and ED wait time that is increasing these critically ill patient's mortality rate. Might have something to do with the fact that they are sick. 

Patient's are often stabilized the ED prior to transfer to the unit. Often times our ICU won't even take the patient until they are stable for transfer, have all their drips hanging and they have a tube in every orifice. Moreover, with increased admissions, there are increased demands on staffing the ICU. We retain core staffing in the Emergency Department even when our census is low because our patient population in the Emergency Department can change in a heartbeat. Many times we've seen the ER go from empty to full in just a matter of minutes. 

ICU's however, often call off staff when their population is low. Therefore, we are often waiting for a nurse to come in to take our patient. That doesn't mean that there couldn't be better coordination between the Emergency Department and the ICU. Those two departments attract very different personality types.

However, I doubt that lack of coordination between the ICU and the ED that is the primary reason for the increased mortality of patient's needing intensive care in the last years of their life. It may have more to do with the need for better communication between providers and patients and families before those days arrive. 

Visualize This: When Neutrophils Attack!

A million years ago, when I was at Washington State University, one of the many jobs I held to pay my way through was working in the counseling psychology department editing grants and research papers for the researchers there. It was a great way to be exposed to all kinds of interesting research.

One of the papers that caught my imagination was by Arreed Barabasz - a researcher who is an expert in hypnosis for medical problems. At the time, he was also using sensory deprivation tanks. He didn't call them sensory deprivation tanks, they were Restricted Enviroment Sensory Tank since Altered States and LSD users had given them a bad rap. Anyway, Barabazs' idea was that floating in this darkened tank of body temperature salt water would provide a better environment for self hypnosis.

The paper I was editing was all about using self hypnosis to increase white blood cell counts. The visualization used while in the tank was to imagine white blood cells multiplying and ganging up on the invading bacteria or virus. The idea was to think of sharks chasing them down and devouring them.

This idea of self-hypnosis and visualization allowing one to have a positive increase on one's own cell count really got my mind going. I even wrote a research proposal for one of my classes based on his research. I've told lots of people about this research when they were facing illness, hoping the visualization would help and encourage them. I figured, it couldn't hurt. I've even tried it myself, but it has always been hard to describe what white blood cells look like when they are hunting their prey.

Then I came across this:

The footage is old, but it is a classic. Watch that neutrophil track down that bad guy and eat him. Love it. This will be my new mental movie the next time I get a runny nose.

As for the research, it was 20 years ago and I haven't heard much about it since. My guess is the initial positive results didn't pan out, or they were confounded by the fact that REST environment greatly reduced stress, which helps immune response. If you want to learn more about how the immune system works, you can check out this video:

If you need me, I'll be in my sensory deprivation tank.

Did You Check A Blood Sugar?

A few years ago, I had a call about a patient coming in by ambulance as a stroke alert. Right side was flaccid, pt was aphasic. She had an the history of an old CVA some years prior, but after rehab, family said she no longer had deficits. I took the HEAR report and after listening to the patient's condition, I asked "Did you check a sugar?"
           There was a moment of radio silence.
 "We'll have that for you on arrival," was the response.
          On arrival, I was told her capillary glucose at 24 mg/dl. An Amp of D50 started resolving her neuro deficits.
       By the time she left, she walked out the door under her own power, laughing, talking and relieved that she wasn't facing a future of long and arduous stroke rehab.
      This was just one of several cases I've seen over the years of hypoglycemia masking as a stroke. That's why protocol is to check blood sugar on every patient with an altered level of consciousness - regardless of diabetic history.
       Yet, we often miss it. Sometimes we are more focused securing and protecting an airway, or getting IV access - when a quick check of the blood sugar with a finger stick could allow us to quickly identify and correct the underlying cause of the altered level of consciousness.
        Hypoglycmia can present in patients with no diabetes history.
        Alcohol can cause alterations in blood sugar, and too low or too high blood sugar can present as drunkeness.
        Unilateral deficits don't often trigger thoughts of hypoglycemia in our minds. Yet the brain needs glucose just as much as it needs oxygenated blood to function. Cut off the glucose and brain cells can act just like they are experiencing ischemia.
        Yet why would a patient present unilateral symptoms or hemiparesis if the whole brain is running low on glucose?
         In my experience, the patients I've encountered with this presentation have often had some sort of ischemic event in their past. Collateral circulation may have allowed the brain to recover full function after the event, but starving the brain can affect the weakened tissue or impaired circulation.
         What is collateral circulation? Think of a stroke as a wreck on the freeway, blocking traffic to a certain area of the brain. Collateral circulation refers to the smaller blood vessels that can be used as a detour when the freeway is blocked. Traffic - blood flow - goes to the local roads. In some circumstances, the body may even generate new blood vessels.
          We have known about collateral circulation for some time, but we are still learning about how it works, and how we can use it to improve outcomes.
          What about younger populations?
          Newborns of course have limited reserves and can get hypoglycemic far too easily -- particularly if the mother had high blood sugars while pregnant. If a newborn goes too long without eating, hypoglycemia can present quickly. Sepsis, too, can cause a newborn to burn through its sugar reserves.
         The first time you discover a type 1 diabetic, he or she is in DKA, with symptoms that can often be mistaken for viral illness or other conditions. Low blood sugar can cause seizures and so you should always check a sugar when you find a patient in a postictal state.
          Bottom line, a finger stick blood sugar is an easy thing to check, a cheap test to do and may diagnose a easily treatable condition. So whenever a patient comes my way with altered mental status, don't be surprised to hear me ask "Did you check a blood sugar?"

The Dope on SOAP charting

For some reason, SOAP charting seems to get people confused. It is an easy way to break down the information you are presenting if you do it right. The trick is to tell the story that allows the history to be separate from the observable findings. Why? Because what dispatchers and patients and families tell us, may or may not be what's actually going on.

S Subjective - things people tell you. 

• Called to scene for a...
• pt’s chief complaint is …
• pt’s s/o states...
• SAMPLE History
• OPQRST
• Medications/Allergies
• Medical History

O Objective - things you observe

• On arrival pt appears...
• Pt/Scene appearance
• AOX4 or AVPU
• Vital Signs
• DCAPBTLS

A Assement - what might be going on COPD vs CHF
chest pain protocol

• hypoglycemia
• hyperglycemia
• abdominal pain

P Plan - what you plan to do about it.

• o2 15L NRB, 12 lead, monitor, expedite transport, ALS ...

Little Things Mean A lot

One night when I had just started working in the big city ED, we had a ambulance come in the wee hours of the morning and the last hours of a long 12 hour shift.

 The call was for "leg pain" in a 48 year old female. When she rolled through the door, something didn't seem quite right. She appeared to be in excruciating pain, but EMS said her heart rate was brady at 54. Increasing pain should increase the heart rate. She also just didn't look well. I called for a 12 lead EKG before she was even off the gurney and started an IV and labs. 

A few minutes later, the ED doc held the EKG in his hand. "Who ordered an EKG for leg pain?" I explained my decision. Turns out she was in new onset of third degree heart block. 

We've had cases where nurses have caught heart attacks based on nothing more than a hunch. I've seen cases where present like a stroke and a blood sugar reveals that they were really just hypoglycemic. 

Little things, can protect you from missing the right diagnosis, the right course of action. 

Just had another case like this the other night. Call was for a 37 yoa male near syncope while playing pool in a bar. Hx of vertigo in the past but pt states "this is different." The Medic got the 12 lead = AFIB with RVR 170 - 190 with no prior history. If you think, "should I get a 12 lead/check a blood sugar" the answer is almost always yes.

Here's a good article on how doing little cheap things can reduce the risk of big failures. It's based on the new book Antifragile, which I haven't read yet - but based on this article, I think I'll check it out. 

"Thus the decision to withhold the 12-lead is in Taleb’s view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong."

Antifragile: Things That Gain from Disorder
Risk Assesment: From Streetwatch blog