“I'm not taking your patient anywhere until you actually stabilize him! How about you guys at least hang some fluids? I mean, come on, what the hell are you doing down here?”
I hate getting yelled at.
I go into this total fight-or-flight thing, I get super-defensive, and I swear I can even feel my heart strain for a few beats from the increased afterload.
And there's nothing I hate more than getting yelled at for a patient I signed out. The sign out is usually fine; everyone in the ED thinks the patient's admission is on autopilot, and then out of nowhere, someone just goes off on you while you're scrambling to look up the finer details of the patient in the chart.
So this was, of course, the patient, post-op from a mass removal, who must have popped a suture and started hemorrhaging from his arterial remnants. Belly full of blood on FAST, blush identified on the CT after being scanned by my co-resident. Two large-bore IVs. Fluids hanging. Initially a little tachy, and that resolved. Surgery called. They recommend IR.
Both services start fighting with each other through me (it's a Sunday evening). You know how they do that, and after their hour-long argument, they both finally agree to come in. They get in touch with anesthesia to come in as well. So for two hours I fielded 40 phone calls between the three of them, the patient's blood pressure crept down from the 160s to the 100s, and then I get yelled at by the anesthesiologist for not “stabilizing the patient.”
The anesthesiologist also does not like it when I point out that, just like in trauma, I can very easily transfuse him two units, but it's just going to end up in his belly. Permissive hypotension? There's nothing I can do to stop this vicious cycle.
I'm reminded of this whole situation not because of my mental scarring, but because of the clear Catch-22 it presents: I can give fluids or pressors or blood, but sometimes I cannot stabilize a patient in the ED.
I was talking with my friend Javier, a critical care fellow, about this, and he said something puzzling: “All patients should be stabilized in the ED before they come to the ICU.”
His perspective had literally never crossed my mind because it seemed so contradictory to me, like how you can't use the word you're trying to define in its definition. I should stabilize unstable patients … who I'm sending to the ICU … because they're unstable?
If someone is hypovolemic, give me a couple decently-bored IVs, and I'll stabilize him. If someone's septic, I will happily start him on some early goal-directed therapy, fill the tank, antibiose him, and turn on the norepi drip. But trying to achieve “stability” is the wrong interpretation of what the ED can and should do.
Walker Postulate 1: We in the ED frequently do not have the time to dedicate to a critically ill patient. I am very proudly of the triage mindset that our focus should be on sick patients. The not-sick patients can wait. Door-to-doc times for toothaches, small lacerations, and subconjunctival hemorrhages should be several standard deviations from the mean when critically ill patients are in the ED. But even this attitude has its limits.
On slow days, I prefer — and enjoy — sitting in the room with a critically ill patient. I can resuscitate, help with central access, optimize ventilator settings, and call consults. On busy days, I can't. I will give the vast majority of my time to the critical patient, but what about the other patients coming in or the ones I've already seen? What about the patient who is getting some labs and ends up being in renal failure with a potassium of 6.5? Or the well-appearing kidney stone patient who turns septic on you? Or the two chest pains waiting to be seen? Or the febrile child with the perforated appendicitis? Where do our loyalties lie with them versus the patient who is critically ill upon arrival?
I'd argue that on these busy days we have to get the already-identified sick patient out of the ED. Intubate him if needed; get good access. Start him on the right medicines. (We are better at this than anyone in the hospital.) But then move him out of the ED because he will not get the same level of care that he would in the ICU, no matter how great the emergency physician and nurse because the nurse and physician have two or six or 10 other new, active patients on their minds, especially when the intubated patient has no chance of significantly changing his disposition in the next 24 hours.
I love caring for acutely critically ill patients; I'm often a little jealous when another attending is managing someone really sick, but when my brain is split between thinking about all the things that one needs to process with the critically ill and talking with family members and calling consults and trying to keep up with labs and studies on four other patients who are all potentially sick and begging for their patience, my caffeinated, optimistic brain still can't do it all.
Walker Postulate 2: The ED should be used for initial diagnosis, risk stratification, and treatment. Further care should be done as an inpatient. The patient I hate to navigate is this one: the septic, mildly hypotensive old lady. Her pressure is hovering around the 80s and 90s with fluids, and her lactate has cleared. She looks pretty good. Should she sit in the ED for another four hours to see what her vitals do while we keep getting new patients and need the bed? I don't think so. Should she go to the floor where she might poop out and go unnoticed? Not a great option either. Should she go to the unit where she might get quickly transferred to the floor? Seems like a waste of ICU resources, too, but less likely to miss badness.
What's the solution? Maybe a small stepdown unit. After talking with some critical care colleagues — thank you, Jarone Lee and Haney Mallemat! — I wonder if a stepdown unit is a good option for these patients. Maybe they have a maximum of 12 hours there, and if they fly, they go to the floor; if they fail, they go to the ICU. It would remove some of the apprehension of floor docs and nurses having a very sick patient among their big census, it would prevent the ICU from losing a bed that could go to someone sicker, and it would remove some of the Goldilocks disagreements between hospitalists and intensivists in which we inevitably get stuck: “She looks too good for the unit!” vs. “Her numbers look too sick for the floor!”
I think Javier now sees my side of it a little more, and we've found some common ground: All patients should be resuscitated in the ED before they come to the ICU. We may not always do things perfectly in the ED. We may put IVs in foot veins that a floor nurse wouldn't dare touch. But if there's anything we excel at, it's getting things done and done fast. We can send off a full panel of blood work, get the CT, the chest x-ray, and the urine, tap the belly, and move on to the next patient. Resuscitate? Yes. Diagnose? Most of the time. Stabilize? Only time will tell.
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* Use Dr. Walker's medical calculator at www.mdcalc.com and his number-needed-to-treat tool at www.thennt.com.
* Read all of Dr. Walker's past columns at http://bit.ly/WalkerEmergentology.
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