Understanding critical care in the ICU: then and now [PODCAST]

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“I write this as a caregiver, patient educator, and clinical researcher.

The coronavirus pandemic has shone a spotlight on intensive care units (ICUs).  Due to the rapid and continued increase in critical illness from COVID-19 infection, discussions about capacity and specialized equipment have become commonplace. Terms such as ventilators, ECMO, PPE, emergency use authorization, and proning have entered into the lingua franca.

Critical care happens in the ambulance, the emergency department, and across the hospital.  Ultimately the sickest and most severely injured patients end up in the ICU, or their medical providers are assisted virtually by trained clinicians (e-ICU). Before the pandemic, there were nearly 100,000 ICU beds across the U.S. COVID-19 has necessitated the creation of de facto ICUs, in repurposed operating rooms, in tents, and on ships. Non-critical care medical personnel have been deployed to meet the demand to render care for acutely ill patients.”

Sara L. Merwin is the co-author of The Informed Patient: A Complete Guide to a Hospital Stay.

She shares her story and discusses her KevinMD article, “Understanding critical care in the ICU: then and now.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we welcome back Sara Merwin. She is a co-author of the book The Informed Patient: A Complete Guide to a Hospital Stay, and she wrote the KevinMD article “Understanding critical care in the ICU: then and now.” Sara, welcome back to the show.

Sara L. Merwin: Thanks, Kevin. It’s good to be here again. Since I’m a repeat offender, I thought I would tell my story in a different way, just because every story can be told in an infinite amount of ways. So I should go right ahead.

Kevin Pho: Looking forward to hearing it.

Sara L. Merwin: OK. So I earned a degree in epidemiology, not the infectious disease branch, but I took infectious disease courses, and I worked mostly in hospitals throughout my career. So preventing infection transmission has been part of my training and experience.

And I have a very diverse career background. I’ve done so many different jobs, working in many different medical and surgical specialties in the hospital. So I’ve done scut work, like centrifuging blood. I’ve done clinical trials, enrolling patients and following them from the OR to their post-discharge visits. I’ve managed quality improvement projects, which meant working the floors and talking to the health care providers. I wrote grants and programs for scientific meetings. I collected data in all different kinds of ICUs for research studies. I’ve collaborated on scholarly papers and abstracts and held faculty appointments at NYU and Montefiore Einstein medical schools in medicine and orthopedic surgery. My favorite thing, however, is designing research studies and teaching research methods. So that’s my background.

Kevin Pho: Excellent. So let’s talk about your latest KevinMD article, “Understanding critical care in the ICU: then and now.” Now, for those who haven’t read the article, can you walk my audience through it and maybe share the story of why you decided to write it?

Sara L. Merwin: So Lakshman Swamy, who is an academic intensivist in Boston, was familiar with The Informed Patient book, in which we demystified the hospital experience for a general audience, including the medical terminology. He asked me to translate the medical jargon from the ICU into plain language for a board game that he devised about critical care. And that project evolved into collaborating with him on a book, which we are working on now, about the ICU for a general audience, which seemed timely given that ICUs are constantly in the news due to COVID.

So the article grew out of that brainstorming about the ICU book project. I arrived at this perfect but terrible storm, COVID-19, and the dual perspective from my professional experience and personal experience with relatives in ICUs. And I wanted to provide insight into what I had seen, studied, and lived, looking at the pre- and post-COVID era.

So I’d like to read a little story. It’s emotional, so I am not going to be able to do this without going to my note. And so here it is.

Late one evening, an ICU physician calls a family to say Dad’s breathing rate had slowed to such an extent that he did not believe Dad would survive the night without life support. This seasoned, experienced doctor added that he had never seen patients come back from this condition on their own. Although Dad had do-not-resuscitate orders and his children had agreed with his wishes to forgo extraordinary measures to prolong life, they were now faced with a difficult dilemma. Nothing prepares people for the excruciating decision to let a loved one go. Moreover, the decision had already been made in concert with their father’s wishes, in writing and by general consensus about his quality of life. Consensus had to be painfully revisited.

Ultimately, the family agreed to let nature take its course: no intervention, simply comfort measures. They relayed that message to the doctor, with instructions to call as the end drew near so they could be at the bedside. An anguished night followed, yet the phone did not ring. Morning dawned. The patient survived the night and awoke to eat breakfast, recovered, and went to a rehabilitation facility to learn to walk again.

The ICU is in the spotlight now because of COVID. The vocabulary alone has seeped into our everyday talk: capacity, ventilators, proning, the special meaning of beds, which are not just furniture, by the way, ECMO, which derives from the heart-lung bypass machine, which many people might be familiar with if they know someone who’s had cardiac surgery. And of course, there’s PPE, and then there’s discussion about the trained personnel to take care of the sickest patients for critical care. Since I see ICUs in the news, the challenge was to help people understand what it’s about. I wanted to paint a picture for those who’ve never walked through those doors.

Critical care happens mostly in the ICU, although it can begin in the ambulance, in the emergency department, and anywhere else in the hospital. But ultimately, the sickest and most severely injured individuals end up in ICUs. Before the pandemic, there were about 100,000 ICU beds in the United States. To accommodate the overflow and meet capacity demands for patients requiring critical care, many temporary ICUs have been set up in other areas and in field hospitals.

So how are ICUs different from general medical and surgical units? The hallmarks of critical care in ICUs are monitoring, via machines and humans, and extraordinary technology to keep patients alive. There are a host of medications and procedures which are only used in the ICU precisely because they need such direct monitoring. Staff ratios are also very important, since these fragile patients need a lot of attention and could have a downturn very rapidly, which would require intervention. End-of-life support is a big part of care in the ICU. It’s lower tech, and it is delivered with compassion and comfort measures.

And the ICU is characterized by a different kind of ambiance. It’s frightening and alien, with machines and buzzing and beeping, and yet there’s a hush. There’s a focus, there’s the attention and the vigilance of the staff, and there’s a certain sadness that permeates the atmosphere as patients leave the earth. Compared with the chaos of the emergency department, the feeling in the ICU is very controlled. So as frightening as some folks may find the ICU, more terrible and frightening still is that in the setting of COVID-19, it is often not possible to be with loved ones.

I provided a couple of suggestions about how people can best prepare for a loved one going into the ICU, whether remotely or whether they’re there in person. Preparing documents such as end-of-life wishes, medical orders for life-sustaining treatment, and do-not-resuscitate orders is very important to guide the care team for decision-making. For patients who have no medical background, understanding the jargon is a real challenge, and it’s important to look things up so that you can have a real dialogue with the care team.

Communication with the care team is so important. If there are a lot of family members involved, the suggestion is to appoint one spokesperson for efficiency and to streamline communication. And I also advise people to identify who’s in charge. Patients with complex medical conditions may have a lot of different consultants. It gets confusing, and we have to remember that each specialty may have their own investment in a different organ system and be in conflict or at odds with other specialists. Coordination is important to get everyone on the same page.

We always say, “Value the nurse,” particularly in the ICU. They are the interface with every single hospital service and every team member. And in the particular case where you’re not allowed to visit family members or friends, the nurse is on the front line at the bedside, and they will know the patient best. So, as always, stay vigilant and work as a partner with the health care team.

Finally, I’m a little bit of a delirium activist, and this is one area where families can be really helpful and involved. My dad was a sitting duck to develop delirium due to his age and pre-existing dementia. Being in the ICU is itself a risk factor. In his case, he swung from hyperactive delirium, in which he was agitated and sleepless for a couple of days, getting out of bed, pulling out his lines, and then he’d swing into hypoactive delirium, where he was unresponsive. And that was the point at which the intensive care doctor in my story about him called us about his decreased respiratory rate.

But delirium is common for all different kinds of patients in the ICU, and it’s important to identify it, if possible to manage it, to prevent it. And the reason for this is that not only is it a risk in and of itself for immediate harms, such as falling due to confusion, but there can be irreversible aftereffects on functionality. So the patient can help by bringing incipient delirium to the attention of the medical team, and also in redirecting the patient and orienting them.

Kevin Pho: Now, what are some things that clinicians and medical professionals can do to ease the experience of patients in the ICU, especially during the COVID era?

Sara L. Merwin: The personal connections become more important, particularly if family members are not allowed to be present. And this, of course, adds increased burden to the team, because everything about COVID has been new and is still evolving in terms of management and treatment, and the PPE is cumbersome, and it’s quite challenging. But liaising with the family is very, very important, so making time to do that is key.

Kevin Pho: We’re talking to Sara Merwin. She is the co-author of The Informed Patient: A Complete Guide to a Hospital Stay. She wrote the KevinMD article “Understanding critical care in the ICU: then and now.” Now, do you anticipate any long-term changes in the ICU that can stem from what we’re seeing now in the pandemic? Do you see that, with the advent of remote devices, perhaps improved communication after the pandemic ends in the ICU setting?

Sara L. Merwin: Well, one of the things I think we’re going to see is a change in the workforce, and the possibility of a scorched-earth landscape is there. We know that medical professionals are experiencing burnout and stress, and some will leave the profession. So I think that puts increased burden on patients and their personal advocates or care partners.

So yes, I think there are going to be changes. I think the emergence of tele-ICU, which has always been a modality in the background, is going to rise in prominence, as we’ve identified that in rural areas, we simply do not have the infrastructure in hospitals to support the number of patients that need care. And then, of course, we have the long haulers with the sequelae of COVID-19, who are going to need medical attention and may be back in the ICU for management.

Kevin Pho: And my final question, Sara, can you leave us with a take-home message that you want to share with the KevinMD audience?

Sara L. Merwin: It’s very difficult for patients and families right now, but I hope that they understand that the health care professionals taking care of their loved ones really do care and are really invested in making people comfortable and taking the best possible care of them. But it’s very, very difficult under these conditions. And so I ask patients and families to be more patient, to have more forbearance, and to show their appreciation.

At the same time, because of the increased burden on the health care system and profession, and medical professionals and paraprofessionals, it is going to become even more incumbent upon patient advocates to make sure that their loved ones are safe and to ratchet up the vigilance for this reason.

Kevin Pho: Sara, thanks again for coming back on the show, as well as for your time and insight. And thanks again for your expertise.

Sara L. Merwin: Thank you, Kevin.

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