Friday, 16 October 2009

Now I Know

I’ve not blogged much lately because my current job is really hardcore and I haven’t had that much time and I didn’t want to spend the free time I have had blogging because it reminds me of work.

In August, when I started working in Intensive Care the lead consultant, Dr. Cullen, asked me whether or not I wanted to do Intensive Care as a future career. At the time I really had no idea, and told him as much. You see, to us anaesthetists, Intensive Care work is a bit like Marmite in that it we either love it or hate it.

I worked in ICU in my first year of anaesthetic training, but at that time, I felt I didn’t really get a feeling of whether it would be something I’d like to pursue further down the line. I felt that I didn’t know enough stuff to be really useful and I didn’t know enough to actually make a real difference to the patients that I was helping to look after.

I’m now coming to the end of my current attachment in ICU and yesterday Dr. Cullen asked me again if I would consider intensive care as a career. This time I had an answer for him – no.

There are things that I really like about working here, I like it when we’re given a rapidly deteriorating patient, and I can stop their demise and (hopefully) put them on the road towards recovery. I actually like going round the wards and being able to be useful to other doctors who are struggling to look after their ill patients. I like the fact that I can actually do the majority of medical procedures, I’ve done dozens of central lines, arterial lines, intubations, chest drains, difficult venflons etc… etc… and these things no longer hold any mystery or worry for me. I like the fact that the ICU nurses are so switched-on and the fact that there are so many of them means that they can help us doctors out more which means I get to concentrate more on actually trying to get our patients better.

ICU is no land of milk and honey though. There are lots of things I really don’t like. A while ago, I wrote about why doctors get stressed and about some of the ways they cope. I said that simply being around unwell people is uncomfortable for people who have dedicated their lives to trying to make people well. I’m finding this really true of myself. Even when everyone is totally stable and there’s not much happening, I find just being on the intensive care unit stressful. The constant beeps, the almost continual alarms of the infusion pumps, monitors and ventilators, the fact that I know that things can, and often do, go tits up at any moment, all this things conspire to put my blood pressure up.

Our patients are all teetering on the brink of death. Actually, it’s more accurate to say that they’re well past the brink and with our machines we are desperately trying to push them back ONTO the brink so they have a fighting chance of living. This means that one of our patients will frequently drop their oxygen levels or blood pressure to a dangerously low level. They often hallucinate and try to pull out the very tubes that are stopping them dying. While the nurses are very good at sorting these things out, often they’ll need help just to stop the patient from expiring and it’s me that has to go and sort these problems out. Often I feel I’m fighting a pitched battle against the very people I’m meant to be helping. I find it frustrating that I can’t talk to my patients and that they’re often on the ICU for so long with only very tiny improvements to their health each day.

And then there’s the relatives. Seeing your husband/son/mother/grandpa/sister/friend unconscious and hooked up to all our machines must feel horrible. I can’t even imagine how I’d feel if I saw my mother lying their as one of our patients, I shudder at the thought. We try our best to explain what we are doing but I find having these conversations difficult simply because I don’t know what’s going to happen to their loved one. The two commonest questions a relative asks are “Is my loved one getting better?” and “Is my loved one going to die?” And the trouble is, often I simply don’t know if they’re going to live or die and, unlike when I was a physician, often I don’t even have a handle on how likely survival or death is. The uncertainty is often really hard for relatives to understand and deal with. But what I think is even more difficult is the timescale. As I already alluded to, patients stay unconscious with only very slight changes in their condition for days or weeks. We as doctors can see the subtle changes in their inotrope requirement, ventilatory demands etc… but basically, from the outside they look exactly the same. (Actually, as time passes, ICU patients look aesthetically worse as they swell up with fluid and accumulate puncture scars from all the tubes we keep sticking into them.) While we try to explain what’s happening, the seeming lack of progress after such long periods of time is often really distressing because relatives are sort of suspended in a seemingly unending, hellish limbo. Seeing relatives upset in turn upsets me because I too want their loved one to get better quickly, but it’s rarely possible and it leaves me wishing I could do more when I just can’t.

Dealing with other doctors can be wearing as well. There’s a constant trickle of calls for little things like venflons, lumbar punctures, central lines etc…from acopic ward doctors but that stuff doesn’t really bother me. I use my discretion. I help out if the request is reasonable and I’m free and able, if they’re just taking the piss and trying to get me to do their job for them, I have no qualms about telling them where to go. No, there are two things that really get me. Firstly, some doctors seem to have the belief that every unwell person should be looked after by the intensive care team. This really isn’t the case. Sick patients often don’t need Intensive Care, but they need the ward doctors to pay close attention to their condition and give appropriate treatments and sometimes, it’s hard to get ward doctors to understand this. Secondly, there are the group of patients who have been blatantly mismanaged on the wards and then I get a call to see them and am somehow expected to perform miracles. This frustrates me no end too.

And finally, there are the times where it really does all go wrong. There’s the fast bleeps, there’s the trauma calls and there’s the cardiac arrest calls. On average, I go to two or three of these every shift (my record is eleven). These are the situations where people are literally at (or through) death’s door. Sometimes, there’s not much for me to do at these calls, but sometimes there is. Often they’re just a horrible disaster and often the patient dies, sometimes in a more painful and disgusting way than you ever thought was possible.

So all in all, I’m working hard in Intensive Care, but I’d hate to do this forever. There’s too much drama, too much stress, too much politics, and too much frustration. If I had to do this forever, I think I’d end up worrying myself into an early grave, there are far easier ways of earning a living. I don’t think it’s any coincidence that two weeks ago, I found my first grey hair.


Geneviève said...

Excellent post!

I'm a 3rd midwifery student/aspiring medical student with an interest in anaesthetics.

I've mostly observed obstetric anaesthesia and have been dying to get to main theatre and the ICU if possible... your account has really brought to life what the ICU is like, however I suspect you can never really imagine until you have actually 'been there and got the t-shirt' as it may be.

Anonymous said...

Hi Michael.

Great post. It's really got me thinking.

Medics cover ITU over night in our hopsital. And The thing is that I really like all of this stuff. I'm even ok with the relatives and the high stakes. I don't find looking after it too stressful.

The thing is that I'm a geriatrician by trade. If I still enjoy it after a year then I might apply to anaesthetics to be an intensivist. After all MRCP and a year as a med reg won't do any harm will it?

Dr Michael Anderson said...

Thanks Genenieve & Dr Z

I have nothing but respect for the people who do ICU, I can certainly see the appeal, but for me I find the rewards too few and far between to warrant all the physical and emotional effort that ICU requires. It's just a personal thing I suppose

Anonymous said...

go into dermatology for a nice and rewarding career

Anonymous said...

You know I can't get this post out of my head. I never realised that not all anaesthetists liked ITU. Now I'm starting to realise that I might be a strange sort of person who could do ITU. I'm wondering if this means I should. I'm really struggling with it.

I did medical training because I thought MRCP would be a good basis for any future career. And then feel into Geriatrics because I didn't want to do anything else. I mentioned at geriatric teaching today I was thinking of becoming an intensivist - and got odd looks all round!

I'm sure it's just a brief addiction because I've saved 5 out of the last 6 arrests I've led. And actually saved - expected to leave hosptial, not just dragged things out for longer as usually happens.

Feroza said...

It's amazing how u've managed to describe EXACTLY how my friends n I feel working in the ICU. I'm a medical officer into my second year in the anaesthesiology and intensive care dept in one of the busiest general hospitals in Malaysia. we're about 1 hour away from Kuala Lumpur.
Some common things we share:
Annoying unnecessary referrals from the wards(mainly becoz some of the patients have been mismanaged & they expect me to perform a miracle, or for some peripheral or central line setting when it's so obvious they never attempted themselves yet);
ICU doctors expected to play God and bring people back from the brink of death;
dealing with distraught relatives daily;
handling an overload of critically ill patients when the ICU is full, sometimes I have to ventilate up to 12-15 patients in the general ward on portable ventilators& BIPAP(although I dont't think u guys over there ever do this at all);
etc. etc..the list goes on
My interest to work in ICU hasn't waned yet, and I don't see myself working in a different field.
I hope I don't burn out anytime soon.
p.s.I still can't stop grinning to myself reading your blog entry, it's amazing how similar we feel when we're halfway around the world

purplehearts said...

Great post
I'm not a 'medical' person, and I have no medical experience but my son was in intensive care last year. He was 5 weeks old, and went into cardiac arrest at home. His heart had stopped (and tests showed no oxygen was reaching his brain) for nearly half an hour when the resus team managed to ventilate him, and he was taken up to ICU. He had suffered irreversible brain damage and we later took the decision to turn off his life support.
The ICU struck me as a very grim, depressing place to be honest, and I have nothing but respect for staff who choose to work there.It must be very difficult working with patients who are unlikely to get significantly better. As you say - doctors go into the profession because of a desire to make people better - it must be very hard working in an environment where most of your patients have little prospect of recovery.
From a patient's point of view, I understand your decision totally.

purplehearts said...

Sorry - I posted the above before I'd finished.
I meant to add this to my post also:
I'm not sure if this is what you mean when you talk about patients who have been 'mismanaged' - but I felt my son was. He had been deprived of oxygen, with no pulse and no signs of life for half an hour - we were told that this meant there was absolutely no prospect of recovery. So I couldn't help wondering why he was even brought up to ICU, why the doctors on AndE continued to attempt ressucitation even though they knew he had no prospect of ever getting better and they were effectively just prolonging his suffering.
The doctors on A and E actually told us very little - just that our son had been ventilated and was being taken up to ICU. We were so relived - we thought that must be a good sign - it was left to the doctors on ICU to explain to us just how dire my son's situation was, and deal with the fallout.

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Antonina said...

You know I can't get this post out of my head. I never realised that not all anaesthetists liked ITU. Now I'm starting to realise that I might be a strange sort of person who could do ITU. I'm wondering if this means I should. I'm really struggling with it.