Admission to the Intensive Care Unit is a major stressor for the patient’s family and friends. Dealing with the patient’s family is an essential part of the ICU physician’s practice and recognizing the emotional phases that the family is going through will facilitate communication and decision making.

Every family is different. The way the family will cope with the critical illness of their loved one, to a large extent, depends on the family’s personality. Regardless, most families are going through three distinct phases:

Phase #1: the Shock Phase
The patient is being admitted to the ICU in critical condition. The family is just getting the news. People start showing up in the ICU without a clear understanding of what is going on. Anxiety, confusion and uncertainty are at a heightened level and some people are simply too overwhelmed to comprehend and respond appropriately to the situation. Depending on the patient’s condition, over the next day or so, the family members might be sleeping in the waiting room and keeping a 24 hour vigil in the ICU. The family members will be exhausted, stressed and overwhelmed. This should be considered when trying to make important decisions regarding the patient’s care. The information should be communicated in a concise and easy to understand manner.

Phase #2 the Adjustment Phase
The gravity of the situation will start sinking in. At the same time, the family will start adjusting to the fact that recovery might take time and life is going on. The family members will be trickling in and out. The key family members (husband, wife, parents, children) will, actually, be able to get some rest. The family members will have a better understanding of the disease process and will focus on supporting their loved one. This is a better time to make important medical decisions including withdrawal of care.

Phase #3: the Exhaustion Phase
For some patients recovery takes time and the patient might need to spend days if not weeks in the Intensive Care Unit. This, surely, takes it’s toll on the family as well. The family wants to see signs of improvement and recovery and if this is not happening, a realistic prognosis should be communicated to the family. This also a good time to discuss placement or transfer to an outside facility (nursing home, ventilator facility etc.) if discharging the patient home is not a viable option. Establishing a good relationship and regular updates to the family are very important to facilitate transition to a subacute environment.

Nothing makes me more nervous than a phone call about a lost airway. If the airway is lost and the patient is unable to breath on his own, you have just a few minutes before the level of oxygen drops to a dangerous level. Once the level of oxygen is low, the patient goes into a cardiac arrest. Brain damage from inadequate oxygen supply is also possible. Depending on the patient’s preexisting condition and the severity of the situation, you might only have three to tens minutes to reestablish the airway and provide oxygen delivery to the vital organs. When I get one of those calls, I do not walk, I run.

There are two types of airways being used in the ICU - the endotracheal tube and the tracheostomy tube. The endotracheal tube is a temporary option. The flexible plastic tube is inserted through the patient’s oropharynx into the trachea. The presence of the plastic tube in the throat usually makes patients very uncomfortable. The tube might get dislodged with moving. It is also not unusual for the tube to be pulled by inadequately sedated or restrained patient. Once the tube gets dislodged, in most cases, it needs to be replaced. Replacing the endotracheal tube, usually, is not a big concern as long as the patient is not unstable or has a difficult airway.

The tracheostomy tube (trach) is surgically inserted directly into the trachea through an incision on the patient’s neck. This tube is considered a long term option. The trach rarely gets dislodged. Once it happens, though, it could be a really big problem. The first question to ask is how long the trach has been there. If the trach was inserted more than ten to fourteen days ago, the tract is usually mature and you can try to reinsert the trach through the same hole. You might also consider taking a smaller size trach to facilitate insertion.

If the trach is new (less than ten days), then you might have a problem. The tracheostomy tract is not mature at this point and you are at risk of inserting the tube into the subcutaneous tissue (tissue beneath the skin) instead of the airway. If you try to ventilate the patient with the trach in the subcutaneous tissue, the patient will develop subcutaneous (SQ) emphysema (air under the skin). The patient might look like a Michelin Man. SQ emphysema is not the biggest problem. Remember, the patient is still not getting oxygen and the clock is running fast.

An alternative option to reestablish the airway, if a fresh trach gets dislodged, is to intubate the patient from above using the endotracheal tube. This option is preferred if the trach is very fresh (one or two days). It usually works unless the patient has a difficult airway.

One thing to remember when dealing with a difficult airway: try to get as much help as early as possible. Calling anesthesia and surgery is always a good idea if things are not going well.

Time goes very, very fast if you have an airway problem. You have to think and move fast as well. Otherwise, it might cost the patient his or her life.

Snowmobiling can be fun. It could lead to tragedy as well; especially if you are drunk or not paying attention.

The patient in his thirties lost control of his snowmobile hitting a tree at high speeds. He was flown to the Emergency Room where he was noted to have no movement in both legs. High dose intravenous steroids were initiated to improve his functional recovery.

In the tertiary trauma center he was found to have severe thoracic spine subluxation with complete spinal cord transsection. Surgical stabilization was scheduled. Intravenous steroids were finished per protocol.

Giving IV steroids early after spinal cord injury makes physiologic sense. By reducing spinal cord edema and, even more importantly, reducing lipid peroxidation, you improve the patient’s chances for neurological recovery. It even worked in experiments on rats. The clinical evidence, though, is inconsistent. For the most part, the difference in functional recovery was minimal if significant at all. So, why are we doing it?

This might be another example of the physicians practicing defensive medicine. If the treatment MIGHT help, yet the evidence is inconsistent, you have to use it. Not so much for the patient’s sake but for the lawyers reviewing the chart later.

Can you, actually, do harm with high dose steroids? Absolutely, you can. Inhibiting immune response of the, otherwise, critically ill patient, you increase the risk of infection and sepsis. The patient on a ventilator will be at a higher risk for a ventilator associated pneumonia which will significantly increase the morbidity and mortality.

More evidence is needed to support or reject the use of steroids for the patients with a spinal cord injury. Meanwhile, do what you think is right…

Several years ago, I was given a small statuette of a fireman by the ICU nurses. Everybody thought it was funny since just a few days earlier I had put out a small fire in ICU.

The patient in his forties was admitted with a subarachnoid hemorrhage due to a ruptured cerebral aneurysm. Suddenly, he went into a cardiac arrest. His monitor showed ventricular tachycardia. An immediate defibrillation was indicated. The crash cart was brought in and the defibrillator patches were applied (see chest XR above with arrows pointing to the defibrillator patches). In the excitement of the moment, nobody paid attention to the excessive hair growth on his chest.

The defibrillator was charged, the shock was delivered and…the defibrillator patch caught on fire. The hair on his chest started burning as well. The smell of burning hair was nauseating. I was standing right next to the patient and was able to put the fire out by forcefully blowing on it, the same way you blow on a cake candle. In the hindsight, I realize that BLOWING AIR ON THE FIRE WAS THE DUMBEST THING TO DO. Luckily, the patient was not on any oxygen. The smart thing to do was to throw a blanket on it. One more thing…watch where you put those patches on the patient. Chances are, you are not going to have enough time to shave the chest.

The patient required a single shock to convert back to a normal rhythm. His aneurysm was subsequently coiled to prevent further bleeding. He was discharged several weeks later with some residual neurological deficits.

The use of Intensive care Units (ICU) is on a rise in the United States. Recent data published in the Critical Care Medicine Journal indicated that, despite overall shrinkage in the number hospital beds in US, the number of the Critical Care Medicine (CCM) beds is on a rise.

There is no doubt that this trend will continue into the future. The cost of providing ICU care for any given patient will likely continue to increase as well. In 2005, according to this study, critical care medicine cost represented 0.66% of our gross domestic product. This is a staggering number if you think about it.

With the aging of the population in US, there will be even higher demand for ICU beds. The development of new technologies will allow us to treat conditions that were considered lethal just ten to fifteen years ago. We are also becoming better at what we do. The investment in research and science gives us opportunity to better understand how to treat critically ill patients. This means that ever sicker patients will survive in our ICUs, increasing length of stay and the cost of care.

Without introducing proper “checks and balances” and, yes, even rationing, Critical Care Medicine will take even larger bite out of our GDP. Considering the cost of care in ICU, Critical Care Medicine is a “Cadillac” of the medicine. And so it should be treated. The concept of nobody dies without admission to ICU will turn our Intensive Care Units into Expensive Care Units.

In my practice I see quite a few patients with severe traumatic brain injury. Previously in this blog we talked about decompressive craniectomy as a treatment option for head injured patients. Another aspect of daily management of these patients that has significant impact on recovery is fever control. There is no doubt that high fever worsens neurological outcome in patients with brain injury. Yet, cooling those patients to subnormal temperatures (32-33 degrees C) was not shown to be beneficial. I believe there are too many confounding factors in trauma patients making them poor candidates for cooling.
How do we maintain euthermia (normal temperature) in these patients? I have tried multiple modalities in my practice: ice packs, Tylenol, cooling blankets, fans, gastric/bladder lavages. High fever in neurological patients is often hard to control. None of the options mentioned above work consistently well. The newer fever control modality that I have tried is endovascular cooling. Inserting a special cooling catheter (see picture above) with a cold saline circulating thru 3 or more coaxial balloons into a central vein makes cooling these patient much more consistent and controlled.  This is only one of the few new (intravascular or external) cooling devices available. It would be interesting to see if anybody has more experience with any other devices or techniques.
 

Recent article from the Critical Care Medicine journal analyses the use of sedation among mechanically ventilated patients in the United States. I agree with the main point of this paper: more and more patients are being sedated using IV Propofol rather than IV benzodiazepines (BZ).

Just a few years ago, Propofol was considered to be a sedative of choice only for a short term sedation. A very short half life of this medication allows for rapid titration and awakening of the patient. It was ideal for the patients with a neurological impairment since you can assess their neurological status shortly after stopping the drug.

Now, and this study confirms it, Propofol is being used even for longer term sedation.
This is not surprising considering the advantages of this drug over other sedatives including benzodiazepines. Form a personal experience; it often takes a long time to reverse the sedative effect of IV BZ after several days of sedation. I believe it is easier to wean the patient off ventilator when IV Propofol is being used.

In less critically ill patients with a need for mechanical ventilation, I found that using intermittent doses of if BZ might provide adequate sedation without a need for a continuous infusion. Ideally, the patient should be arousable, yet comfortable on a ventilator.

A new drug, Precedex, is being introduced into the clinical practice. So far, I have a limited experience with this drug. The capability of this medicine to be continued after the patient is taken off the ventilator makes it a good choice for the patient who is ready to come off the ventilator. I have used Precedex on a several patients with a severe alcohol withdrawal syndrome when a more conventional treatment including IV BZ and Haldol failed to adequately sedate the patient. The use of this drug allowed me to avoid putting those patients on mechanical ventilation.

Seven types of family you will encounter in the ICU settings

Communicating with the patient’s family is a very important part of my job. Updating the family and making decisions on the medical care for their loved one is as important as seeing the patients and performing the procedures. Talking to the family, sometimes, takes time. It could also be challenging or even frustrating as well. Over the years I have identified several types of families. Each type of the family requires a different approach and presents it’s own challenges.

Average Family.
This is, fortunately, the most common type of the family. It’s easy to communicate with the family members. They are readily available by person or by phone if I have a question or need to get a consent for a procedure. The expectations on the outcome are usually reasonable. The family members are friendly and ask the appropriate questions.

Overbearing Family .
Every time you come into the patient’s room there will be five or so relatives at the bedside. Some will be constantly readjusting the blankets or yelling at the otherwise unresponsive patient “Wake up, wake up, Dad”. Often we ask the family to step out of the room so that the patient can get some rest. If you have a family conference there will at least one family member writing down every single word you say.
Outside of the overbearing nature of this kind of the family, dealing with it is usually easy. You might need to spend some extra time with the family and maybe answer a few extra questions. The expectations, otherwise, are quite reasonable and the decisions are being made in a timely manner.

Paranoid Family
This is the most difficult type of family to deal with. Everything you say or do will be taken with a suspicion. The questions that this family asks are often “off the wall” and have nothing to do with the patient’s condition. There is always somebody with a “medical background” generating controversy and conflict behavior towards healthcare providers. (One time this medical expert was a dental hygienist from three states away).
The family conference with this family will be extremely painful and you will feel like the life was sucked out of you by the time you done talking to them.

Psychotic family.
This is another “challenging” type of the family. Fortunately, this is quite rare. Severe dysfunction, substance abuse, psychiatric illness and domestic violence are often rampant in this family. The threats of a lawsuit or even physical damage are not uncommon. If I have a family meeting, I never let anybody block the exit and I always have a witness in the room.

Religious Family
There is nothing wrong with being religious as long as this is not altering your common sense and the perception of reality. I have no problems with letting families perform some religious ceremonies in the room (like sprinkling with a holy water) as long as there is no harm to the patient and it does not interfere with the care. You will identify this kind of family if you get a response beginning with “I believe in Lord Jesus Christ….” To most of you questions and requests.

Absentee Family
This simply happens when the family is not around. The communication is difficult since you have to negotiate everything over the phone.

Indifferent family
The family members simply do not care. Once I heard from the mother of one of my patients: “Do not call me unless he dies. He was never a good son.” This is also rare, but it happens. This is very, very sad too.