Tuesday, August 2, 2016

The Interminable ICU Stay – CHUK, Kigali, Rwanda

Erin Blackstock, MD  
Resident in Internal Medicine, MGH

During previous rotations, I had been told that medicine patients are often not admitted to the ICU because of their poor prognoses.  While medicine patients may in fact have poor prognoses, I do not think this is the reason they are infrequently admitted to the ICU.  During my rotation, consistently 5-6 beds of the 7 bed unit were taken by neurosurgery patients, the majority after severe TBI.  As one bed opened, the bed would immediately be filled with another TBI.  Some attendings suggested that this occurred because the neurosurgeon advocates strongly for his patients.  He did, but so did other surgeons and internists.  Rather, I think this distribution stems from a severe bottleneck.  Severe TBI or other neurological ailments resulting in coma typically require weeks to months of ventilator support as we await potential recovery.  LTACs do not exist.  If no one leaves, no one enters.  The absence of a bed, however, does not necessarily stop an intubation in the ED.  Waiting for days (with or without a ventilator)in an overworked, understaffed, chaotic  ED is not the place where a patient intubated because they “can’t”  breath thrives, but a patient who “won’t” breath may do just fine.  Days later a bed opens and the comatose patient who survived days in the ED moves in. 

How can we start to remedy this bottleneck issue? Callously one could recommend not intubating these patients with terrible GCSs since the prognosis is truly poor.   Unfortunately it is difficult to determine the prognosis immediately on arrival.  Alternatively, increasing training and comfort with goals of care discussions may allow providers to help families consider withdrawing care.  During my three week rotation, no goals of care discussions were held.  Withdrawing care is not seen as an option.  Not only for the use of resources but also for the quality of life of these patients, these discussions are fundamental to ICU care.  How can we as visitors, outsiders, begin to engage in these discussions with providers and potentially with families and patients?

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