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Things I've noticed while visiting the ICU

trevorklee.substack.com

161–170 of 387 posts

Re: Things I've noticed while visiting the ICU

#161
I'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit.

There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it will certainly be lost as soon as you are off for a few days, or even as soon as a new nurse comes on. To think of a somewhat crude example, if you find out that it is much easier to obtain a blood sample from the veins on the left arm of a patients vs the right, many nurses will still stick the right arm countless times hoping to get something.

And you can leave a chart note about things like that or speak about it during report, but for the most part few people will think "hm, I wonder what everybody else had to deal with." They are probably too busy handling a thousand different things happening all at once. And, even if that is not the case, from what I observed it's simply not part of how things are done. And very often patients will get (justifiably) angry, saying "I've been complaining of x thing for days!" or some version of that. I think it would be much better for both patients and healthcare staff alike if there was a greater emphasis placed on focusing on the series of successes and failures that happen over the course of someone's care, not just seeing it as a single shift or a single problem happening in some isolated point in time.

Re: Things I've noticed while visiting the ICU

#162
It’s worth noting that the patient’s condition is not an independent variable with respect to the level of care - the author’s father got moved to step down because they got better…and I’m glad to see that they continued to get better in step down.

A UK judge once talked about balancing the “benefits and burdens of treatment” when making medical decisions, I think that’s a good way to think about it. The benefit of ICU care is less chance of deterioration and death - the burden is the pain, medication effects, discomfort, noise, confusion and many other things described in the article.

It would also be less confusing for the family if the doctors could explain their thought process well, but a) not everybody is good at this, b) not every family member can necessarily even understand or remember this when they are distraught and sleep-deprived, and c) the health system (and patients) don’t want to pay for the time - if they paid double, the doc could spend twice as long with them, as happens with boutique / concierge doctors.

Regarding the ICU doc disregarding the consult recommendations- the ICU described sounds like a “closed “ ICU where the intensivist makes the final decision, vs an “open” icu where a hospitalist will often be the one making the final decision regarding care. Either way, it seems obvious that someone has to coordinate the care and decide what’s important right now and what’s not - there are many tests that a consultant may recommend that won’t improve the chances of the patient improving right now, and can be done later on the med-surg floor of the patient survives that long. Many of the consultant recommendations may also be contradictory, someone has to take responsibility for picking and choosing a course of action

[edit: fixed typo]

Re: Things I've noticed while visiting the ICU

#163
post #138

Earlier quoted context omitted.

> I also pay taxes Do you really get nothing ? And who is paying for whose care? You mention taxes, but they've probably been paying taxes even longer. And why do you think health care is a strict quid pro quo anyway? Some of us believe care should be allocated where it's needed, not where it's paid for. Put another way: why is it a problem that they are getting care? Isn't it that you aren't ? This doesn't have to b…

I wish we (Americans) had universal healthcare, but at this point I'm pretty jaded about that ever coming to pass. So I agree with you there, and your point about them having paid taxes is also a good one. That said, we do care for the elderly because of their vulnerability but we then shit on younger disabled people. Old people can have assets, most younger disabled people can't, and younger disabled people can lose…

People who are net-contributors feel like they're likely to eventually be elderly, and unlikely to become disabled, I guess (so the inverse of your feelings)- combined with deception by governments that social security programs are like a savings account for the future, not a tax to pay for today's expenses.

From each according to his ability, to each according to his needs is the only solution for healthcare.

Re: Things I've noticed while visiting the ICU

#164
post #88

> There’s no sense of a scientific method, reasoning from first principles, or even reasoning from similar cases though. It’s all shooting in the dark, and most of the time I felt like I could have done just as good a job on these longterm issues... This articulates very well what I've usually felt when dealing with doctors. It's like the story of a programmer finding that his code outputs 5 when it should be 4, and…

I'm sorry but curiosity and creativity are certainly the n°1 enemy of the patient, especially in ICU settings. Curiosity and creativity are grandpa's medicine, and a total antithesis to evidence-based modern medicine, that attempts (and largely fails) to be an application of science instead of the whims of the decision-makers. What you should want is curious and creative _researchers_, but precise and totally unimagi…

I appreciate your perspective as a professional in this area.

Yeah, I'm not really looking for doctors to demonstrate creativity (although House does), so I don't think I'm asking for anything at odds with evidence-based medicine. What I'm saying is that I think you need to get to the bottom of what's actually happening (i.e. why is the program outputting 5 when it should be 4) before you can know what evidence-based medicine to apply in a "precise and totally unimaginative clinical" way to actually fix the problem. As a patient, it just feels like the system, and therefore the doctors in the system, lack the curiosity to figure out what's actually happening. We often get the treatment for the most common issue even though it doesn't quite fit the real issue, or the common issue seems to just be a downstream effect of the real issue.

Re: Things I've noticed while visiting the ICU

#165

His observation that the ICU is full of the elderly reminded me of the Obamacare debates when I was younger. I always felt like I was taking crazy pills when I would leave my conservative elder parents who hated the idea of universal healthcare, and go to my younger liberal friends who were all for it. It was such a clear case of peoples ideology running directly against their self-interest. Young people being agains…

I would hope that liberal young people (and we millennials) wouldn't be against paying for old people's health insurance at all. The hardest part of believing in a principle is doing so when you aren't benefitting from it.

While I have little patience for Fox News lemmings of any age, I have noticed that the relative lack of older folks in our daily "internet trenches" has caused the digital zeitgeist to take on a distinct anti-elderly tone. From lighter- hearted mockery, to blaming a nebulous organized "boomer" class for birthing every modern sin of civilization, and everything in between.

In any event, as more internet literate adults experience the full lifespan, it may create a corrective trend.

By the way, nearly every reply in this thread has been more informative and thought-provoking than the original article on Substack. A really interesting thread to follow, thanks to the contributors.

Re: Things I've noticed while visiting the ICU

#166
post #149
post #60

These threads always have lots of people jumping on doctors and their decisions/callousness/lack-of-reason/etc.etc.etc. My wife is a physician (OBGYN) at a major city hospital that primarily serves a very poor population. I'd like to share her schedule, and see if you think what kind of care you could perform under these circumstances: Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to start rounding on…

It's kind of amazing anyone chooses to go into healthcare having to work like this. It's the absolute last field I would ever want to go into, even as an engineer who wouldn't need to actually practice medicine. Seems like you need to practically give up your life to save countless others. Your wife, and those like her, are truly performing an innately critical job at an absurd cost to themselves - God bless.

It depends a lot on the specialty. Obgyn is particularly hellish.

But yeah, there's a good reason why suicide rates are so high for doctors...

Re: Things I've noticed while visiting the ICU

#167
post #161

I'm a nurse and I find the 7th point on the post especially relevant. I will add a disclaimer that I never worked in the ICU so I can't speak for what happens in that type of unit. There is a serious issue with the flow of information in healthcare, (or at least in the U.S, I never worked elsewhere to know if it's any different). But If you find something during your shift which will be important to know later on, it…

This comes up every once in a while when discussing the crazy 24+ hour shifts that doctors in residency are often assigned. One argument in favor of keeping the hours is that continuity of care is by far the factor most strongly correlated with good patient outcomes. So the argument goes that a change in caregiver is more detrimental to the patient than continued care from one doctor even if that doctor is sleep deprived.

I am not knowledgeable or qualified enough to weigh in on this, but it's something I've heard cited by multiple friends in the field.

Re: Things I've noticed while visiting the ICU

#168
post #131

Earlier quoted context omitted.

> The social isolation of old age is the same everywhere That is certainly not true. Traditional societies and non-western societies have far different ways of relating to elders than we do, and even among western societies there are variations.

Well, yes I see what you mean. What I meant was: it's the same in the US and western Europe. But certainly if you go to more "old fashioned" places, the elderly usually live with the family and are taken care of. To be fair, this still happens even in "advanced" western societies. I seem to recall this also goes together with a lot of elderly abuse.

I wonder if elder abuse is correlated with younger people "having their lives to live".

Re: Things I've noticed while visiting the ICU

#169
post #60

These threads always have lots of people jumping on doctors and their decisions/callousness/lack-of-reason/etc.etc.etc. My wife is a physician (OBGYN) at a major city hospital that primarily serves a very poor population. I'd like to share her schedule, and see if you think what kind of care you could perform under these circumstances: Monday - Friday - Wake up at 4:30 AM - Get to hospital by 5AM to start rounding on…

That is insane. For some reason, airplane pilots have very strict rules about how long they can be in the cabin, how much they must rest, and similar stuff. (Also, they have checklists, plenty of checklist, but medical doctors don't like checklists.)

Even bus and truck drivers have a more sane maximal shifts restrictions.

Re: Things I've noticed while visiting the ICU

#170

Earlier quoted context omitted.

It’s painfully easy to start thinking in numbers when you’re paying six thousand a month to warehouse your grandmother’s body. The number of tests people want to run on someone we all hope dies tomorrow is insane.

Funny, I pay even more than you mention to support my own mother in relative comfort in a nursing home, and I don't find it "painfully easy" to think that way at all. I certainly don't hope she dies tomorrow. You might want to reconsider saying such things in public. Note: my mother, not my grandmother, and I have lived that ordeal for several years. Some interaction is still possible, but recognition has been beyond…

Before you jump the gun like that again: The context is most likely about the suffering of the patient in question from simply existing in that state, and there being no way to alleviate the suffering (only prolonging the life). Not about saving money.

So it’s a lose-lose: the patient suffers and society has to pay for their privilege to suffer (without recourse, most likely).

And maybe you disagree fundamentally with things like assisted suicide. But someone who posts something like what you replied to most likely do not.

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