April 15, 2009

Day 21

Follow-up to Day 15 from Philip's blog

Last week I did 4 night shifts on ICU. It was definitely worth doing as ICU seems to be a place where a lot of things happen at night. Having said that the first night on was pretty quiet and nothing particularly exciting happened while I was there. I left around 1am and apparently a few minutes after I left someone on the ward was recognised to have a pneumothorax and so a chest drain was inserted.

The next night was really useful for me - one of the registrars was putting in a central line and an arterial line and asked me if I wanted to have a go at the art line. He talked me through it step by step and then I put in the art line which I was pleased about - it was made much easier by the fat the patient was unconscious during the procedure. It was good to have a go at finding the radial artery and feeding a guide wire through. Then the registrar showed me how to suture it in as well which is a skill that has eluded me up till now! Other than that there was a 30 yr old lung transplant patient who had been admitted for respiratory failure who went into SVT at about 170bpm. She was given IV adenosine which casued the AV block showing underlying p waves so she was in sinus tachycardia. She was then given esmolol which is a very short acting Beta Blocker to slow the rate while listening carefully to her chest incase she had a wheeze. Her chest was clear so she was then given metoprolol to slow her rate down which was successful.

On the third night, there were 2 fairly urgent intuibations carried out in quick succession. The first one was for a was a guy in cardiothoracic ICU who had been admitted post mitral valve replacement. While seeing him on the ward round he had increasing confusion, dropping oxygen sats and his CXR showed extensive consolidation on his left lower zone - so had worsening pneumonia. He was intubated and put on mechanical ventilation to stabilise him. I got to put on the cricoid pressure as he was intubated - this compresses the oespohegus which helps to prevent reflux up the oesophegus that can lead to aspiration. It was good to get involved with the procedure which was succesful. Then the  second case was a guy with a weeks history of diorrhea, fevers, rigors who devoloped a cough. On his CXR there was complete white out of his left lung indicating a severe pneumonia. His blood gases showed normal pH but low CO2 and low bicarb - due to metabolic acidosis with bicarb loss in diarrhoea, then hyperventilation leading to lowered CO2 and correcting the pH. He was stuggling to breathe with Bipap non invasive ventilation and was hyperventilating at a rate of 40 breaths per minute. Therefore it was decided that he should be intubated to relieve his difficulty breathing - again I put the cricoid pressure on during the procedure. After this guy was intubated, the reg put in a central line and I catheterised the patient which was good practice.

The final night wasnt as interesting - saw one of the registars admit a patient who was in septic shock and had not responded adequately haemodynamically to 7 litres of crystalloid over the preceding few hours. He then put in a cental line and an arterial line.

Yesterday was my last proper day in ICU. I was with the external team who go and see patients recently discharged from ICU and check up on their progress. All patients with tracheostomies are followed up unti lthey are taken out. It was interesting to see patients out of the ICU setting and was great to see how much better some of the patients looked - the guy with pneumonia hyperventilating at 40 breaths/min and then intubated was now practically ready to go home. Then, today I did a presentation at the ICU teaching seminar. I presented a case of lady who had a sub arachnoid haemorrhage after rupture of an aneurysm. I then talked a bit about one major comlication after SAH which is cerebral vasospasm which is a major casue of ischaemic neurological defecits and looked into some of the evidence behind various treatments used to treat vasospasm. I think it went ok!


April 02, 2009

Day 15

Follow-up to Day 11 from Philip's blog

This week I've spent 4 days in the General ICU pod. I've seen a really interesting case mix in this section - stroke, burns, SAH, acute liver failure, post op AAA and acute renal failure and chicken pox with severe complications (pnemonia and probable encaphalitis.)

The guy with liver failure came in after being found collpased at home with a GCS of 3. He has a long of history of alcohol abuse and has all the classic signs - palmar erytheme, spider naevi etc. When he came into ICU he was incredibly yellow, very unkempt, bruised and oedematous. He had an ammonia of 300 which was likely to have caused hepatic encephalopathy, bili of 300, INR of around 4 and an albumin of 13. He was found to have gram -ve rods in blood culture and so was put ceftriaxone, this sepis was probably the cause of decompensated liver failure. When I saw him the next day he had blown up to about twice his previous size after being given IV infusions of concentrated albumin. I dont think I've ever seen anyone with that much oedema before, he was like Mitchelin Man!

The guy with chicken pox (varicella zoster virus) was interesting. He has a widespread vesicular rash and when he presented he had haemoptysis and general symptoms of infection. Since then his resp function rapidly deterioated and he was intubated for hypoxia. He has been diagosed with varicella pneumonitis and is on ventillation for this at the moment. He has recenly been persistently febrile over the past five days and it is thought that this may be caused centrally in the CNS or by a drugs. On neuro examination, he had clonus and this in conjunction with this unconscious state suggests that he may have encaphalitis which is another varicella complication. Therefore a lumbar puncture was carried out today to look for signs of infection in the CSF which I assisted in.

I also did a set of blood cultures today in a man who is an IV amphetamine user who has had a mycotic sub arachnoid anneurysm (apparently mycotic means infected)  clipped after haemorrhage. HIs veins were very easy to bleed - I guess from being an IV drug abuser.


Day 11

Follow-up to Day 9 from Philip's blog

Today was my last day in the trauma pod of ICU. Didn't really get to see or do as much as last week as it was very quiet. However, the man who had one muscle left across his hip joint ended up having his whole leg amputated - everything below the acetabulum was amputated due to the increasing amount of toxins being released from his necrotic leg tissue. I also saw a lady who was just admitted after having a grade V Sun arachnoid haemorrhage clipped in theatre. She was started on triple H therapy - haemodilation, hypertension and hypervolaemia to try and reduce the risk of intracerebral vasospasm - a major risk after a sub arachnoid haemorrhage. I've got to do a presentation at a weekly ICU teaching seminar in a couple of weeks time, so I'm thinking of using this case and making SAH the topic for it.


Day 9

Follow-up to Day 8 from Philip's blog

I spent the day with the MICA Ambulance sevice in Melbourne.

They're a bunch of highly trained parademics who deal with the most difficult medical emergencies. They're trained to intubate patients, administer ionotropes, fluids and whatever else is needed for the immediate care of the patient. The service seems very impressive but unfortunately today was a very quiet day and I didnt get to see them in action with any difficult cases - they call it the observers curse! I did however get a comprehensive tour of melbourne in an ambulance and got to spend a few hours chilling out infront of the TV in a big, comfy, reclinable man chair!


March 23, 2009

Day 8

Follow-up to Day 7 from Philip's blog

Today Im moved onto the Trauma section of ICU which was definitely less busy than it has been in the Cardiothoracics section. The majority of patients in the trauma section have been in some kind of road traffic accident. One poor bloke had hit a wombat while quadbiking and was in a fairly bad way beacause of it - definitely an Australian injury!

There was one particular case which I found quite interesting. The patient is a 37 year old male who was involved in a motor bike accdient around 3 weeks ago. He had multiple traumas at the time including rib fractures, vertebral compression fractures and a left hip dislocation. In association with the dislocated hip, the blood supply to the left limb from the femoral artery was compromised and he had an acutely ischaemic leg. He ended up with compartment syndrome and had a fasciotomy in his thigh and calf muscle compartments. However he ended up with multiple muscles necrosing such that only one muscle across the left hip joint remained attached to the femur, this was the iliopsoas muscle. Due to rhabdomyalasis, he then developed acute renal failure. His renal function has not returned over the 3 weeks so he is now requiring haemofiltration. If acute renal failure such as this lasts for over 7 days, the prognosis of the patient regaining renal function is poor. I went into theatre today with this man to watch the anaestheetists put in a Vas catheter into his subclavian vein - this is used for haemofiltration. He was in theatre to get a Vac Pack on his left leg changed which is used to suck out the toxic waste products from the necrotic muscle. The surgeon operating was not happy with what he saw and expressed concern that the iliopsoas muscle was not functional, therefore leaving no muscles across the hip joint. This may mean that amputation may be the only option - I will see how this progresses over the next few days.

Tomorrow I've got a day with the ambulance sevice which I'm looking forward to.


March 19, 2009

Day 7

Follow-up to Day 3 from Philip's blog

Today is my last day in the Cardiothoracics section.

It has been a really interesting 7 days and I've started to feel a tiny bit of use during ward rounds now as I've taken on the role of filling in pathology forms and sometimes writing the ward round notes. Today I attempted to take some blood cultures from a patient who is in end stage heart failure (waiting for heart transplant) and was therefore very oedematous - I failed so more practice is needed with tricky patients I think. I'm really impressed by the team work here on ICU as after every ward round the whole team sits round and has coffee where any loose ends can be tied up and afternoon jobs planned. I even drank a cup of coffee today which is a first as I'm a life long tea drinker!

The patient who I talked about in day 3 who had the failed intubation has been found to have severe hypoxic brain damage from the event. I did a neurological examination and his GCS is 4 (extensor response to pain) and has up going plantars. His EEG was isolectric and the Consultant today had to explain to the family that he is effectively brain dead and that the situation could have been prevented. The whole event has had a profound  effect on all concerned. There was a morbidity/mortality meeting about it yesterday and I think there were some interesting points made:  

1) Before doing a procedure such as intubation, the doctor doing the procedure should talk through with the rest of the team exactly what the protocol is - inculding how patient is monitored and what the plan is if the procedure starts to go wrong.

2) It can be worthwhile for everyone to take a step back for a few seconds if things don't go to plan so that a rationale plan of action can be made - it is  easy to get lost in time and lose the big picture when the situation gets stressful.

Another thing I saw today that was intersting was a tracheostomy. It was carried out on a patient who had a motorbike accident about 2 weeks ago - he had sufferred with brain trauma, fractured clavicle and ribs and multiple pneumothoraces. He has been intubated for all of this time and is still unable to protect his airway so it was decided that in the long term a tracheostomy would be beneficial. The procedure went very smoothly and I found it useful to go over the anatomy of the larnyx/trachea.

Next week I'm onto the trauma section in ICU so looking forward to that.


March 14, 2009

Day 3

Follow-up to Elective in ICU, Melbourne from Philip's blog

Today was quite an eye opening day in ICU.

Firstly, the patient I talked about in day 1, has had a number of developments. Two nights ago, his oxygen sats were dropping and a bronchoscopy was carried out. He was found to bleeding excessively from his lung and a large qauntity of blood was sucked out at bronchoscopy. It was decided that he needed a thoracotomy and on opening up his chest, his whole thorax was filled with blood including organised blood clots in the trachea. He had a tidal volume of 5ml when on the ventillator. This morning, after the Consultant had a lengthy talk with the family it was decided that all of the machines keeping him alive should be switched off. I found out that he had first been given the diagnosis of testicular cancer around 1 month ago and prior to this he worked as a karate instructor, a sobering thought.

Another big event happenned today as well. It involves a patient who had a CABBG about 4 days ago after a STEMI 4 days ago. On the way to his hospital 4 days ago he had been shocked for about 10 runs of VT over half an hour or so such that his brain had been starved of oxygen during this time. Since then He had been exhibting some 'odd' behaviour so it was thought that he might have had some brain damage. However, he had been making reasonable progress so it was decided that he should be extubated today to see how he goes. Around an hour after he was extubated his sats started dropping and the registrar was called in - he decided to re intubate him. The intubation was very difficult and his sats started to drop further, then he went into asystole. The reg called for help and within about 10 secs there was a team or ten or so doctors and nurses around this patient. CPR was started and an anaesthetist took over the intubation. After around twenty minutes of chest compressions, shots of adrenaline and atropine and the use of a bronchoscope to check the ET tube was in the right space, there was no cardiac activity. The consultant in charge told everyone to stop as he would almost certainly be brain dead by now. Literally a few seconds after this there was a heart rhythm back on the monitor and he was abck in sinus rhythm. It was quite an incredible site.

Apparently the ET tube had orignally gone down the oesophegus and not the trachea  - the reg who had done this was extremely upset about this so it was quite a traumatic afternoon. It was amazing how quickly eveything happenned and how quickly things can go wrong. As soon as the team of doctors came in after the resusc call, the reg who had initially been intubating the patient left the room pretty quickly. It was a good lesson that if you make a mistake and other doctors turn up fresh on the scene, it's best to let them take over as they will have a much calmer and more objective view on the situation than you will.


March 11, 2009

Elective in ICU, Melbourne

Today, I started my elective in the ICU Department of the Alfred Hospital in Melbourne.

The ICU department is based in a brand new multi million pound biulding and the results are impressive. There are 45 beds split up into 3 sections : Trauma, Cardiothoracic and General ICU. Each section contains spacious glass cubicles along the sides where each cubicle has one bed. In the centre there are rows of very spacious work stations so the whole section has a very open plan feel to it. There is lots of natural light so the whole place is great to work in as well as being very high tech.

Today I started on the Cardiothoracic section. I get the impression that the department runs very smoothly with thorough morning handovers followed by a ward round. Then lots of jobs are carried out in the afternoon with an afternoon ward round at around 5 before handing over to night staff. The patients on Cardiothoracic ITU include patients such as post CABG patients and post valve replacement surgery patients. However, there appears to be a huge variety of patient cases that are seen here. One particular patient stood out to me today.

This patient is a 27 year old male who has recently been diagnosed with a teratoma testicular tumour. He had an orchidectomy plus chemotherapy. He was also found to have lung mets on a routine chest X-Ray. Recenty he has rapidly deterioated and is haemodynamically unstable and unable to maintain oxygenation. He was then put on an ECMO machine (extracorpeal membrane oxygenation) to increase blood oxygenation. This involves inserting huge cannulas into large veins ( in his case the left femoral vein and right external jugular vein), then artificially oxygenating the blood and pumping it back into his circulation via a canula that goes up the IVC and sits by the right atrium. I saw a trans oeosophegeal echocardiogram carried out and there was thought to be evidence of some metastasis attaching to the valves in the heart. This patient is in a critical state with severe pulmonary oedema, multiple infective organisms obtained from sputum cultures and bronceolar lavages. He has aslo developed systemic inflammatory response syndrome. All of this has happenned in a relatively short space of time since being diagnosed with a testicular tumour.

I also attended an ICU teaching seminar in the afternoon which was useful and accessible to someone like me with no experience of ICU. So first impressions of ICU are very good and I am looking foward to seeing more and hopefully doing more!


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