The ICU Feels Like a Different Planet...

Cut to the Chase: General Surgery Survival Series — Post 25

"It's just the floor with more numbers."

A senior said that to me on my first day in the unit and he meant it kindly. He was telling me the work was learnable.

He was half right. They are the same numbers.

What he left out is that up here somebody is paying for every one of them.

Read the flowsheet on the woman in bed four. Sixty-one, colectomy on Tuesday, four days of this. Mean arterial pressure 68. Saturation 96. Creatinine 1.1. Resting quietly, no distress.

Now read the rest of the screen. Norepinephrine at 8. FiO2 of 80 percent. Continuous renal replacement therapy since yesterday. Propofol since midnight.

Every number in that first set is normal because something is making it normal. Half of what's on that screen isn't her. It's us.

Before you call anything on this screen normal, find the drip or the setting producing it. It takes fifteen seconds and it is the difference between reading her and reading us.

You already know how to read a trend. That's a floor skill, and it still works up here.

The pressor is the cleanest case. Her pressure has sat at 68 all night, flat, boring, the kind of number your eye slides off. The norepinephrine was at 4 at midnight.

Nothing happened to the blood pressure. That's the point. Somebody held it there, and the holding doubled while nobody said a word.

Check the pressor dose against what it was at midnight before you look at the pressure it bought. A number that hasn't moved in eight hours is not automatically good news.

One caution, because this has a floor. A pressure of 78 on two pressors doesn't get a slope. It gets action. Read the direction when there's time. When there isn't, treat the number and argue about the trend later.

The ventilator runs the same trick. A saturation of 96 tells you the machine is working. It says nothing about the lung underneath, and the lung is what you came to see.

6 mL/kg and a plateau under 30 describes almost every post-op patient here. Whether we're asking for less today than yesterday describes this one.

You don't wean the ventilator. The patient weans. Your job is to notice.

There's a job here before rounds, and it isn't copying the night into a notebook. Go system by system. What are we doing, why, and can we do less of it today.

Sedation, ventilator, pressors, kidneys, gut, antibiotics, lines. Seven answers, none of them longer than a sentence.

That last question is the difference between the floor and the unit. Downstairs a good day is a day you added the right thing. Up here the direction of travel is out.

Asking for less is also how you find out what she's doing on her own. Turn the propofol down and you learn whether she wakes up. Come off the norepinephrine and you learn whether she needed it.

Floor thinking is serial. One problem, one fix, next problem. The floor rewards that, which is why it survives into a room where four problems are being treated at once by people who are never standing in it together.

The interactions still belong to somebody. Usually whoever is closest to the bed. Nothing here is treated alone, and nothing is treated for free.

Every order you write has a second half. Before the 500 of crystalloid, before the PEEP change, before the drip you nudge on the way past the room, say what you'll look at and when.

Say what you will look at and when, out loud, before the fluid runs. If you can't name the number you are going to check, pick one now, because nobody remembers to check anything at four.

Get your eyes off the screen long enough to put a hand on her. Warm, or mottling to the knee. Check the tubing while you're there, because a fair number of the crashes you'll chase this year are a kinked line or somebody's heel parked on the arterial cable.

Now you have something to say out loud. Not this: she's on norepinephrine at 8, lactate 3.4, two liters positive, urine output 20 to 30 an hour.

That's the notebook, read aloud at the foot of the bed.

This instead: the norepinephrine has doubled since midnight, the lactate came up from 2.1, and she's two liters positive with the urine falling off. I think she's still under-resuscitated, and I'd give volume before I go up on the drug.

Same numbers. The second one has a direction in it and a recommendation at the end, and both can be argued with. Nobody argues with a notebook.

I spent a night as a third-year resident tuning a ventilator against a blood gas. Draw, adjust, wait, draw again. Every adjustment made the gas prettier, and around four I was pleased with myself.

By six the gas was beautiful and the man was worse.

You aren't weaning the vent this year. You aren't titrating the pressor, deciding about dialysis, or calling the extubation. Those sit above you, and they should.

What sits with you is the question I skipped that night. Whose number is this.

Know whose number each one is, hers or the machine's, before rounds. Nobody expects you to make the call this year, and you are the one who will be asked what it was doing overnight.

The flowsheet never gets narrower. You'll still be scrolling in your tenth year.

What changes is that you stop reading it as a report on the patient and start reading it as a report on the effort. Most of it holding steady. One column climbing quietly while everything else looks fine.

The senior was right about the numbers. They're the same numbers, and she's the same woman you'd have had downstairs.

It was never a different planet. What's different is that up here the price is printed beside everything, hour by hour, and somebody has to read it.

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What to Read Next: Post 26, "The Blood Pressure Is Dropping." Up here you get to watch it happen in real time, which sounds like an advantage right up until it's your turn to say what to do about it.