CRITICAL CARE.

Over the last five weeks I have been working in the intensive care unit (ICU) of a larger hospital. This is where the most critically ill patients are transferred in the hospital. Most patients need mechanical ventilation because their lungs won’t work on their own, or are on constant vasopressor medications to keep their blood pressure high enough for their heart to stay pumping normally. Often times, this is where people go before they die.

I promise you this will be the only sad and depressing post that I write.

One of the first few days I was there, it hit me.  A patient was brought in with hypovolemic shock and was on the brink of life and death.  Prior to admit: gunshot wound to the lower left abdomen.  Rushed in to the emergency department, surrounded by people, it was now the responsibility of the hospital to maintain life.

Upon being transferred to the ICU, my preceptor asked me what therapy I would recommend to treat this patient.  I started to search the literature, review guidelines, and come up with a response:

  1. norepinephrine drip – for blood pressure support
  2. IV normal saline – fluid resuscitation
  3. packed red blood cells – blood loss and severely low hemoglobin/hematocrit
  4. fentanyl – pain management
  5. pipercillin/tazobactam – broad spectrum antibiotic for gastrointestinal perforation

In the 45 minutes I had spent looking through sources and finding my answer, the patient had died.

These used to be concepts on a piece of paper that were made up to help students learn… But now each story is about someone real, who exists. It is no longer an answer on a multiple choice question that you can take your best guess on in order to get a passing grade.  Instead, it is a patient’s life that I am given the responsibility to review their therapy and make recommendations.

I never knew how it felt to have someone die right in front of me.

A SOBERING REMINDER 

There is often a lot to process after watching these situations happen.  This is especially true when it happens to someone relatively young, who would normally go on to live many more years.  Four different people all around the age of 30 impacted me the most:

  • Age 30: drank heavily for the last 12 years, currently has end stage liver disease with severe jaundice and ascites (fluid accumulation in the abdomen).  The one year survival rate for someone in this stage is about 45%.
  • Age 31: chronic hypertension and obesity, his blood pressures generally ran about ~190/120 at office visits, was prescribed several blood pressure medications but never took them because he felt healthy otherwise.  He now has Stage 5 chronic kidney disease is on dialysis 3 days a weeks about 4 hours per visit.
  • Age 24: IV drug user that frequently abuses methamphetamine and heroin, has a history of hepatitis C and HIV infections.  She has recurrent endocarditis (infection of the heart), two heart valve replacements, and probably another in the near future.
  • Age 33: punched in the back of the head by a family member during a fight.  Little did they know that he had an aneurysm that ruptured and caused a subdural hematoma (bleed/hemorrhage in the brain).  Patient was pronounced brain dead soon after, with no functional capacity, and being kept alive by machines in the hospital.

Watching, day in and day out, the end result of either unfortunate circumstances or people’s poor life decisions.  Although it would not help in every situation, sometimes I wish I could go 10 years back in these people’s life. To be someone who would prevent the progression of their life’s path to death.  I am looking forward to my next rotation in a clinic where I can talk to patients and hopefully make a difference in their lives.

A LOT OF LEARNING

While I do not think I would be able to watch the stark reality of critical care unfold everyday for the rest of my life, I have great admiration and respect for people that can.

A week prior to the rotation, my preceptor sent me 12 research articles and critical care guidelines (about 15 pages each).  After many hours spent reading, I finally got through all of them and was feeling like I had completed all the reading I would need to do for this rotation. I was completely wrong.

Each day he would either print out or email me several articles to read, and each night I was struggling to keep pace with all the articles I was being sent.  At the end of my rotation, I counted 104 articles (at 15 pages each that is 1560 pages total) that I had received.

What I started to notice about my preceptor though, is he knew the answer to every critical care question ever asked by a physician or nurse.  He was like a pharmacy encyclopedia with Micromedex permanently installed in his brain.  Absolute genius.  And this is a guy, one year away from retirement, who knew more about all the recent guidelines than me.  I quickly made the connection between all of the reading and all of the knowledge.  Similarly, when I am about to retire, I hope that I will be at the peak of my learning.

What better person to have as pharmacist in a critical care setting than someone so informed? While I sometimes lose faith in our healthcare system, people like my preceptor remind me that the United States truly has quality patient care happening.

Although I may not ever do a hospital residency like my preceptor encouraged me to do, this rotation was a great experience for me and exemplified the process of lifelong learning.  I am looking forward to finally returning home to the Rogue Valley for my next rotation after being away for 5 years.

Dane Michaelangelo Fickes

 

 

 

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