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A Night in The Pediatric Cardiothoracic Intensive Care Unit

David Epstein, MD, pediatric intensivist, shares his experience and perspective, while on overnight call in the pediatric cardiothoracic intensive care unit.

I sit in a relatively comfortable office chair with a flexible, mesh back and soft seat cushion.

Rolling the chair up to the conference table, the two pediatric ICU physicians on daytime duty in the pediatric cardiothoracic intensive care unit (CTICU) meet me for sign-out.

Sign-out is a time where one medical team hands over care to the oncoming team. It occurs in the hospital and other medical settings.

As the dayshift readies itself to leave and the nightshift gets ready to take over, one can see groups of physicians, nurses, respiratory therapists, and other staff talking intensely with each other to hand over care to the next team. Settling in and focusing on my colleagues’ voices, the stories regarding 20 children in the CTICU are relayed to give me enough information to take care of them through the night.

Some are children and teens, but most are infants and some not even a few days old.
All have some sort of heart disease with most of them being congenital (a problem that they were born with).
The two daytime physicians relay the details of all the children’s medical issues, from the diagnoses and surgeries required to improve or stabilize their heart problem to mechanical support and medications that they are using. I absorb the details and make mental notes about who the sickest kids are. I need to keep a close eye on the children with the most potential to deteriorate through the night.

After I receive all the pertinent information and organize my thoughts, I begin the process of familiarizing myself with the patients.

I take a look at the chest x-rays or other radiologic studies.

Infants and children in the CTICU often have a variety of tubes, lines, and wires placed into their bodies before or after their heart surgeries or have them in place for stabilization of other heart problems. So, proper placement needs to be checked daily in the most critical patients and a chest or abdominal x-ray is the most efficient way to make sure that all the tubes, lines, and wires are in proper placement. If they are not in the correct position, life-threatening complications can occur.

As I am reviewing the x-rays, I touch base with the critical care fellow who is on call with me.

At larger, academic hospitals, there are a variety of trainees. In a children’s hospital, there are pediatric residents who are completing 3 years of training after medical school to become a general pediatrician.

For those pediatric residents who want to subspecialize in pediatrics, they usually train for an additional 3 years to become a subspecialist and are called fellows. In this instance, the fellow who is on call with me is training to be a pediatric intensivist, or ICU physician, like myself.

As a trainee, they are responsible for managing the patients. In a training environment such as this, they are the first line of decision-making for the care. But, they are supervised by experienced physicians to make sure that the correct decisions are made.

Also, it is the experienced physician’s responsibility to teach them because it is, nevertheless, a training program. The ultimate responsibility for care and management decisions fall on the shoulders of the experienced physician, also called the attending physician.

After getting acquainted with the patients’ medical histories, reviewing the x-rays, and touching base with the fellow, I start my personal rounds where I travel from room to room and examine the children that I am most concerned about.

As I walk through the oversized hallway, I feel the squeak of my shoes on the routinely cleaned and polished floor.

As I enter each room, I introduce myself to the family to let them know who I am and what I am doing. There are so many people coming in and out of an ICU room, that it can be quite confusing and overwhelming for parents. I can only imagine them thinking, “who are all these people coming to see my child and what are they doing?” The flow of personnel in a pediatric ICU can be characterized as a village…because it truly takes a village to take care of these critically ill children. There are nurses, physicians, respiratory therapists, nurse practitioners, pharmacists, nutritionists, occupational and physical therapists, environmental services staff, administrative staff, social workers, and others who manage every aspect of the care to support the child and the family during their stay in the ICU.

 

I can only imagine them (the family of a sick child in the ICU) thinking, “who are all these people coming to see my child and what are they doing?” Click To Tweet

 

While in each room, I take note of the room’s video screen that continuously displays the patients’ heart rate, respiratory rate, oxygen saturation, blood pressure, and temperature in digital form with waveforms and numbers.

I check the reading on the screen that shows the electrical activity of the heart to make sure that the rate and rhythm appear normal. There are often machines supporting breathing (i.e., mechanical ventilators) and, occasionally, machines supporting the heart and lungs (extracorporeal membrane oxygenation) or the kidneys (i.e., dialysis or hemo-filtration). There are pumps infusing medications through tubing that is attached to veins with special catheters.

All of these monitors, machines, and pumps have electronic settings and electronic beeps and alarms. So, a patient’s room is never silent. It is always a cacophony of sounds that can feel like an assault on your senses or, over time, can be blocked out completely from those who are experienced and hear the sounds day after day and year after year. Nevertheless, the environmental noise in these rooms cannot be soothing for the patients.

 

Making my way past the equipment surrounding and entangling the patient, I examine them to make sure that I have a good baseline exam should things change. Also, checking in and seeing the patients makes sure that there are surprises later on.

For all the information that is relayed and the monitors and numbers that are visualized, seeing the child and examining the child is the one true way to see how they are doing. The ultimate evidence lies with the patient and how they are acting clinically. While it is tempting to treat numbers in the ICU, a place that is an island in a sea of numbers from monitors to labs to medication doses and measuring urine output and fluid input, one needs to see the child and what they look like…amongst all of those numbers.

Once familiar with all the children, I turn my efforts to retracing my steps and re-assess the children that are having the most problems.

There are times when children who were completely stable suddenly become unstable and vice versa. But, that is the life in the ICU. The only thing that is certain is that there is uncertainty and you have to be ready to deal with sudden changes for the better and the worse. So, throughout the night, we check and recheck how the children are doing. If there are children who need to be admitted because they are critically ill, we evaluate and manage them accordingly. There is never a dull moment in the ICU. You need to stay on your toes, be alert, and be ready.

There are times when children who were completely stable suddenly become unstable and vice versa. But, that is the life in the ICU. The only thing that is certain is that there is uncertainty and you have to be ready to deal with sudden changes for the better and the worse.
As the night finishes, the sun begins to shine anew. The daytime team comes back.
I sit back in my relatively comfortable office chair with a flexible, mesh back and soft seat cushion.
Rolling the chair up to the conference table, the two pediatric ICU physicians on daytime duty in the CTICU meet me for sign-out.

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