TILIF #11: Class is in session... again!

Tuesday is lecture day for the PICU fellows. As we continue along the protracted, gradual transition from students to student doctors to doctors, dedicated didactic time decreases but never truly stops. In undergrad or early med school lectures were all day everyday. Then you start clinical rotations, and it becomes more sporadic, with lectures at the beginning of a rotation and a half day or two each week. In residency you have some sort of educational conference on most days, like morning report, noon case conference, grand rounds, morbidity and mortality (M&M) conferences in addition to a half day of protected didactic time per week.

The protected aspect is important, because it is easy to make excuses to take care of sick kids, or for other members of the care team to guilt you into putting lectures on the back-burner. But you still have a lot to learn and you will take care of your patients better if you dedicate some time to studying with your full attention*. As I move on to PICU fellowship, there are still hour-long lectures scattered throughout the week, but they are not protected - it's generally thought to be more educational to be at the bedside for a procedure or acute management of a critically ill child.

A fun thing about lectures this week is that they are PICU lectures! Each step from undergrad to now, it is really exciting to have the first few months of lectures. At the end of each the previous stage, you get quite comfortable with most of the content. Rarely do you get exposed to something you've never seen before; you either know it, or know you should know it.

Tuesday's lecture was considered quite basic and yet half of it might as well been a different language. And that's exciting! This is the time of my training that I am expected to know nothing, so I'm not going to disappoint anyone by honestly saying "I don't know" or asking "what does that term mean?" I have everything to learn and this stuff is really interesting to me, which is why I went into this field.

Original content by Christopher Monson - ok for non-commercial reuse

TILIF: The waveform of the arterial line can be super informative. Up until this point, I've really only cared about the accurate blood pressures and easily accessible arterial blood that you can get from having an arterial line in the patient. But if you graph the blood pressures over time, you get a wave that has even more information packed into, if you know how to interpret it.

I made a diagram (seen on the right)! In the red area, the blood pressure goes up as the heart squeezes blood out. In the blue area, the heart isn't able to push any harder, but the wave of blood needs time to spread out to the distant tissues. What about the squiggle in the green area? That's the "dicrotic notch" which is a little pulse of pressure radiating out through the arterial blood vessels caused by the aortic valve slapping closed, closing off the heart so that it can fill back up with more blood for the next beat. 

One cool thing about this notch is that it can tell you how far away your sensor is from the heart. The vessels by the head are relatively close to the heart, so the wave comes earlier - closer to the peak. Similarly, your arms see that pressure wave before the legs. By the time you reach the feet, the notch is all the was at the bottom of the downslope.

*Of course this is a "do as I say not as I do" moment, since I am usually falling asleep in my chair  during even the most riveting lecture

TILIF#10: Jury-rigger extraordinaire!

I love problem solving; more specifically, I love finding a way to use a limited set of tools or resources to find creative solutions to problems. I've always been drawn to this sort of activity: assembling custom Lego creations using the pieces from random old sets, building imaginary spaceship instrument panels out of the doodads from my dad's workbench, or playing Minecraft in survival mode where you need to harvest limited resources before you can construct anything.

That limitation fosters creativity and forces you to think outside the box. My favorite real-world example of this is depicted in the famous scene from Apollo 13, where the flight director gathers the smartest engineers at his disposal into a small room and dumps a box of parts on the desk, explaining that they need to find a way to fit a square tube into a round hole with only these supplies and then come up with a procedure so the astronauts can follow those instructions to fix the crippled spacecraft.

The ICU is always pushing the boundaries in medicine, so we often don't have the technology mass-produced to fix the problems we see. Often these kids have very unique problems. One of my favorite examples is chronically trach dependant kids who have a hole in their neck with a tube that goes in and takes a 90° turn into the trachea. As you might expect, such an unnatural connection between a foreign device and the body leads to funky changes to the tissues in the area (think earring hole mixed with a callus). Every tracheostomy tract is a little different and most kids need a custom tube that's a certain width, depth, length, flexibility, etc.

If that tube gets plugged up, suddenly the kid can't breath. Usually you can just replace the tube, but sometimes tissue damage can make that very difficult, so you may have to find creative ways to ventilate the patient. You can try passing a long flexible oral tube through the hole in the throat. You can essentially plug up the hole with your finger and use a bag-mask over their mouth (assuming their upper airway connects, which is not always the case!). You could even put a mask over their neck if you can get a good seal and plug up the mouth and nose. Whatever works!

One of the goals of fellowship is to accumulate a magic show's worth of tricks that you can adapt to any audience. It's amazing to see some of my attendings' ability to pull a rabbit out of a hat, even if they've only managed that trick once or twice... often in their fellowships.

TILIF: "Post-pump slump" is a phenomenon seen after children come off of cardiopulmonary bypass. When you are doing open heart surgery, you need to divert blood to a mechanical pump that keeps the blood oxygenated and flowing until you can put back together and restart the patient's heart. After these kids return to the PICU, you need to watch them closely - for lots of reasons, one of which is a period of low cardiac output that is not entirely understood but seen fairly frequently.

TILIF#8-9: On the subject of clouds

Doctors are incredibly analytical; intensivists even more so. I want ALL of the data available so I can hyper-analyse the situation and pick an appropriate plan. But in certain areas, we are consistently superstitious. Some examples:

• Never say the "q-word,"
• Don't definitively tell a family that they are going home on a particular day/at a particular time
• Some people have clouds

This last one is shockingly widely believed with a degree of tongue-in-cheek seriousness that makes you wonder if it is really tongue-in-cheek. The idea is that some people have dark storm clouds following over their heads portending a flood of admissions, high acuity, and irrationally bad outcomes - these folks to be or have black clouds. The opposite is people for whom everything seems to work out well, irrespective of talent or deservedness - these are the white clouds.

If you ask any medical provider they can instantly tell you which kind of cloud they are associated with and even how it has changed throughout their career. These designations are generally arrived at by group consensus and altered with feedback (e.g. "What?! You're not a white cloud; remember last Sunday? It was a nightmare!").

In residency I had a reputation as a white cloud, which was lovely in some ways - smooth shifts are always pleasant. But for my PICU blocks, and now as I start fellowship, I really kind of want experience. I want things to go wrong now, while I'm still learning and have supervision, so I can build up my knowledge and problem-solving skills.

We jokingly never wanted to work with our co-residents who were black clouds, because it often meant more work. But by the end of residency, it was those residents who we wanted on with us because they had seen everything and had a better idea what to do thanks to having seen most situations before.

TILIF: My co-fellow appears to be a black cloud.

From Wikimedia Commons/CDC

If a baby is blue/"dusky" on day 0 or 1, then they have transposition of the great arteries (TGA). There are many cyanotic heart lesions but only one that can cause cyanosis that early in life. TGA is when the blood circulation to/from the lungs, and to/from the rest of the body are pumped by the heart in parallel rather than in series. In other words, the two sides never mix. Oxygenated blood from the lungs goes right back to the lungs and deoxygenated blood from the body gets sent right back out to the body. Once the heart's prenatal holes that allow for mixing convert to the normal post-birth configuration, things take a turn for the bad quickly.

Another cyanotic heart lesion, truncus arteriosus, is when the two outflow tubes from the heart are joined together into a big... trunk (hence the name!). The aortic and pulmonic valves that normally block reversal of flow back into the heart are smushed together as well. Each normally has 3 leaflets that close up each tube, but what about when they are combined? Actually the super valve usually still has only three leaflets (~50%), next most common in 4 leaflets (~35%), with the rest being a mix of 1/2/5 and very rarely 6.

Ooh Rah! (Virtual) Pediatric Critical Care Medicine Fellow Bootcamp (TILIF #5-7)

This weekend I was able to participate in a CoVid-modified version of a pediatric critical care (PCCM) Fellow Bootcamp, a first-year fellow right of passage that became yet another victim of the 2020 dumpster fire.

Normally, the new fellows from all across the country come together to one of 3 locations to learn/refresh themselves on the basics of pediatric code situations, resuscitation management, teamwork, and leadership skills. It's a crazy weekend of taking turns at being team leader while a fake patient is dying and then doing chest compressions under someone else's direction. Both mentally and physically exhausting.

This year, we were forced to stay at our home institutions, Zooming into group meetings to discuss cases and then running simulations on mannequins with our own co-fellows and attendings. It actually worked surprisingly well in most respects. What we lost in regards to learning to work with a rotating group of strangers (an important skill on code situations), we gained by learning to work with our actual colleagues. Turns out my co-fellow and attendings are pretty cool.

The biggest loss was meeting new future colleagues. Pediatric intensive care is a small world and we will see these folks throughout our careers both at our future hospitals and at conferences, meetings, etc. The usual highlight for the group that meets in St. Louis is a big party at a local program director's house with a pool. Ah well. This pandemic has caused so much heartbreak that my little troubles are nothing by comparison. Really wish I could have gone to that pool party though.

Lots of things learned from this weekend:

A good description of critical care doctors: Intensivists are like ducks swimming on the water - they appear very calm, but they are a flurry of activity below the surface.

Command the room. It needs to be clear who is leading the team so that at least one person knows what everyone else is doing. If you are short, grab a stool, because people naturally talk to the tallest person.

Automate repetitive tasks. If you're running a code, there are certain things that need to happen at regular intervals that are great for delegating to someone else. Examples are giving epinephrine or checking for a rhythm. It's much nicer to have someone ask if they should give another dose every 3 minutes. If that's their only job, then it's less likely to be missed.

For some things, there are many right answers. Shop around for your mentors' preferences and find an option that you are comfortable with to be your go-to. On the flip-side, also take note of choices that keep leading to poor outcomes, because sometimes an otherwise great mentor might be most comfortable with outdated modalities. 

Once you've tried the basics, don't forget to address the underlying cause of the situation, e.g. if the patient isn't breathing because they are seizing, you need to fix the seizures; if they are seizing because of their low blood sodium level, you need to fix that.

Then do it blindfolded.

This was one of the more fun things that managed to withstand the CoViD conversion. After practicing a bunch of codes, they then blindfold the leader. Then you are brought to the foot of the bed and need to lead your team through the resuscitation of a dying patient with your eyes blindfolded. You might think this would make things harder, but actually it's a great way to remind you to not focus in on any one thing and to delegate everything to your team so that you can be free to think.

TILIF #4: I need some gum, now! STAT!

Due to some unusual activities scheduled for the upcoming weekend, today is the last day of my first research block of fellowship. Most fellowships have a large research component, with some being a full two years of the three years of the program. Mine is very clinically heavy so we only have 18 months of our three years dedicated to research. Of course, since our hours are pretty terrible while we're on clinical service (generally around 70 hours per week), research blocks are also for getting caught up on sleep, studying for boards, doing errands, etc. You can still put in 40 hours a week and get all that other stuff done. By comparison it feels luxurious.

My research goals for this week were pretty mellow. I was browsing labs and clinical research projects that might become my big scholarly project that is required for sub-specialty board certification. More on that later. Blocks in my program are two weeks long, but I'm not back on research until block 4, a full month from now.

TILIF: Funny what basic facts you can miss through 7 years of formal training and many more of informal exposure. "Statim" is latin for "immediately" and is the basis of the medical term for the highest level of urgency, stat. You often see "STAT" fully capitalized, so it might seem like a acronym, but really it's just a clumsily abbreviated word, like "etc." being short for "et cetera."

TILIF #3: As easy as *snap*

Today I learned a new technique to open a patient's mouth one handed as you prepare to maneuver the laryngoscope blade in the patient's pharynx. Then use your dominant hand (which you are keeping free for placing the tube in a moment) and place your thumb against your middle finger, as though you are going to snap your fingers. You then let your fingers slid past each other onto the patient's lips, such that your thumb is now pressing down on the lower lip and your middle finger is pressing up on the upper lip. With a sort of scissoring action, you can now open the moth one handed to allow access to your off hand which is holding the laryngoscope blade (basically a fancy tongue depressor with a built in flashlight and handle).

This was all part of our first weekly PICU fellow lecture series. I love that my lectures have become so focused onto things that I actually find interesting and useful - a far cry from required topics like histology in med school, or newborn care in residency.

TILIF #2: Planes, train(ing)s, and how a heart heals

I think today marks the end of my official orientation activities for this job. Maybe? We needed to be oriented to the University, to the Department of Pediatrics, and to the Division of Pediatric Critical Care - each with their own priorities and complicated logistics to communicate. There was an amusing progression from less to more relevant information and tours of smaller and smaller areas.

For example:

"Over there is the children's hospital!"

to

"This floor is the PICU!"

to

"This corner of this storeroom is where the ultrasound machines are kept!"

Of course the end of orientation implies that I now know the minimum information to do this job, which is surprising. I guess the important thing is I know where to find any information I'm missing going forward.

TILIF: Always place a chest tube for any size pneumothorax before transporting the patient by air. A pneumothorax (pneumo- = air, -thorax = chest) is when you have air in your chest but outside your lungs. This can be caused by external trauma (e.g. knife to the chest) or internal trauma (e.g. popping a lung from having too high of ventilator settings). The problem with this is the air has no where to go and will continue to fill up the chest, taking up the space that the lungs and heart need in order to work. A small pneumothorax is no big deal and will be reabsorbed by the body in time; a large one will tamponade the heart, preventing it from filling with blood and killing the patient.

If you are transporting a patient by air, the lower pressure experienced even in a pressurized cabin* will allow any air of a pneumothorax to expand to a larger volume, which, per the principles above, could be deadly. Accordingly, before putting someone with a pneumothorax on a plane, have the referring hospital put in a chest tube, so that any increasing volume of air can be safely vented thanks to a one-way valve on the tube. Pro-tip: flush the chest tube with some water to minimize any additional air in the tubing that might expand at altitude.

I also learned, there are two broad types of heart transplant: orthotopic and heterotopic, aka "piggyback." Orthotopic is basically what you think of as a transplant, when you put the patient on bypass, take out the old heart, put in the new heart, and take the patient off bypass. Heterotopic heart transplants are much less common and consist of leaving the old heart in the patient and installing the new one, essentially in parallel. A reason you might attempt this is if the native heart just needs time to recover from some insult but has the potential to return to full strength in the future. Additionally, a benefit of keeping the old heart in place is that you can fall back on it if the new one goes into acute transplant rejection. However, this type of transplant is much more complex and not seen as worth the risk now that we have better anti-rejection medications.

*Bonus fact: Airplanes at cruising altitude are pressurized to the equivalent of 8000 feet, not sea level. So, one of the first things that is requested by health care professionals if there is a medical emergency on a plane is for the pilot to fly the plane to the lowest safe altitude. This is effectively like putting an oxygen mask on the patient, just because the partial pressure of oxygen is so much higher near the ground than at cruising altitude.

The Phoenix Rises Again: Fellowship Begins (TILIF #1)

Yesterday was my first shift as a pediatric critical care fellow. The last time I posted was in the midst of my pediatric residency, a three-year program meant to prepare me to either become a primary care general pediatrician or discover what type of subspecialist training I want to pursue.

I had a pretty clear understanding within a month of starting residency that I did not want to be a general pediatrician. It took longer to confirm which subspecialty I was interested in, because the one I was eying was not available to me until my second year of residency. After a couple rotations through the PICU, I was sold. This place had the most: the most interesting stories, the most extreme emotions, the most impact on families, the place where I was the most happy, and where I had the most to learn.

It's the last point that is most relevant for today. On the first day of residency, a pediatric resident is far less capable than a 4th or even 3rd year medical student because they have only done a couple rotations in their field and they are at least 6 months further removed from that experience than they were as medical students. Same goes for fellowship; I have only worked 3 months in the PICU in 3 years of residency, but now I'm a fellow who is supposed to lead a team of residents (under the supervision of an attending physician). As they say, if you already knew everything, then you wouldn't need med school/residency/fellowship/etc. It's still jarring - like starting high school: you may have been king of the campus in 8th grade, but now you're a lowly freshman.

There's a lot of critical care medicine that I do not know yet but some things that I do. I am effectively going to spend 18 of the next 36 months in the ICU and the rest doing research to add to the field, so I will have every opportunity to learn. Thankfully, some of my prior training does carry over. I know how to talk through complicated medicine with scared families. I know how to clear up and prevent miscommunication. I know how to be present for families when they need it. And I know how to throw myself at scary new situations with blind faith in the belief that I can figure it out as I go and survive to do better another day. These are the truly important things you learn in residency.

I was able to put several of these skills to work on my first shift, which helped me dampen the ever-present impostor syndrome and feel a little less useless. The hardest thing I did today is difficult to study for: I bore witness to the ritual of a brain death exam of a previously vibrant toddler.

This procedure is not really for answering a question, but rather affording an abundance of caution to the act of making official what we already firmly believe - that despite our most extreme interventions, our patient has died. It involves thoroughly testing all of the brain's most basic or primitive functions to see if any residual activity remains despite all outward appearances to the contrary. Before you can start you must have stopped any medications and fixed any abnormality that could cause the false appearance of death - such as sedatives or hypothermia. The exam culminates with an apnea test, where you turn off the ventilator that is breathing for the patient and watch for any response before checking a blood sample after 5 minutes to document that their blood hasn't been magically getting oxygen.

Watching a child not breathe for 5 minutes was rough, particularly for the parents (who can choose to be present or not). The hardest thing for me was seeing a stuffed animal fall to the floor in the shuffle of moving sheets. I had only known this patient for a few hours and only as a unconscious and unresponsive kid on a ventilator - which describes several children on the unit. But the ragged, discolored, stuffed dog ironically brought to life this child that we were in the process of declaring dead. The dog had been hugged, drooled on, dragged around, and generally loved by this child who would never play again. The stuffed dog won't someday be embarrassingly brought to a sleepover or college - not passed down to future kids. Only in that moment did I glimpse a sliver of the pain that the parents crying on the other side of the bed were going through. Managed not to cry until I got home. Little victories.

As melancholy as this experience sounds, it is such an honor to be a part of a family's story during these few days that will stay with them for the rest of their lives. If I can help them make the memories of this horrible time a little better, even if there was nothing we could do to change the physical outcome, then I'm more than willing to shed a few tears myself. I hope these situations never become mundane - these feelings never banal; they fuel my love of life, my respect for death, and my drive to make the most of the time I have. May the next three years help me continue to grow and learn from the extraordinary experiences in which I have the privilege of taking part.

TILIF: The Taussig-Bing anomaly is a version of double outlet right ventricle (DORV) congenital cardiac malformation where there is also a subpulmonary ventricular septal defect (VSD).

Tweezers are not as easy to come by here compared to my old hospital.

Time is relative. The 5 minutes before cardiac ICU rounds just flies by; the 5 minutes of a brain death apnea test last an eternity.