Transcript:
Episode 001: Clinical Medicine: Critical Care Medicine
Professor Hare: [00:00:00] Hey folks, this is our first episode of be excited. We started this podcast to provide context learning and information on the physician assistant profession at a time when hybrid and online learning often substitutes for personal and in-person experience. You may be wondering why we call this podcast be excited.
Professor Hare: It has been documented in various studies that one way to combat test anxiety and anxiety in general is to convert it into a very similar emotion, excitement. So after describing this technique to my students at the beginning of the year, I encourage them before every exam to convince themselves or at the very least say it out loud that they are Excited.
Professor Hare: Just having them say I’m excited can really help their testing anxiety. I remind them before every exam in my classes to say that and do that. And so this be excited, exhortation was the overwhelming favorite when I ask students to help me think of a name for this thing that we’re doing.[00:01:00]
Professor Hare: We will have for this podcast, at least at the start three tracks: Clinical Medicine, which is focused on the PANCE blueprint for certification and the PA jobs that treat those conditions. Interprofessional, in which we will talk to the people and professionals that PAs work with to make healthcare run.
Professor Hare: And finally,PA School where we discuss student needs from PA school admissions to finding that first job all right. So at this point we will introduce our guest today, our first guest on be excited. This is Jeff Bright. Who’s a critical care PA. Jeff, would you mind introducing yourself just a little bit?
Jeff Bright: Absolutely. And thanks, Jason, for having me on the podcast, I’m honored and excited to be a part of this and to get involved. my name’s Jeff Bright, I’m a critical care physician assistant. I work in the Pittsburgh area. But prior to this, I worked two years or so as a hospitalist physician assistant, in addition to providing adjunct faculty role to the University of Pittsburgh
Professor Hare: [00:02:00] okay. Yeah. And Jeff is not only one of the alumni of the university of Pittsburgh graduated in 2017. He was my student at the time has graduated, moved on but he still comes back and is an adjunct professor here in the program and provides my class, especially with a lot of good and intensive learning and the topics that he knows best.
Professor Hare: So thank you for being here today, Jeff. So tell us about why you Like and love, presumably critical care Medicine.
Jeff Bright: Absolutely. So ultimately here, I feel that the, at least for me, the draw to critical care came down to several things. The acuity of the patients, the opportunity to do procedures and ultimately really the adrenaline rush of the environment, which is something I really enjoy.
Jeff Bright: Additionally, I’d also say the autonomy. I have at least with my own particular position with overnight independent practice allows me to really work to the fullest extent of that license. So all of those things combined, I would certainly argue that I do love critical care medicine itself.
Professor Hare: So you were a hospitalist previously.
Professor Hare: Tell me if you described to most people in [00:03:00] medicine, a hospitalist, a PA, or say that you’re a hospitalist PA. You’ll get a variety of images popping into everyone’s head about what that might look like, because there are hospitalists who work in a variety of different settings from the very mundane to the very ridiculous on the far end of that.
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Professor Hare: How would you say critical care medicine as a position, which seems to me to be a more focused kind of position compares to that variety of hospitalist training and position that you work in.
Jeff Bright: Absolutely. certainly it’s, it’s very core critical care medicine difference from hospitalist medicine in this, for the sake of acuity.
Jeff Bright: If that patient does require more advanced therapy, then they need to have escalation of care and then be transferred to the ICU. One big thing that. I would also note as having experience in both would be perspective. I remember as a hospitalist physician’s assistant, particularly for rapid responses or this and that you have one idea of the patient.
Jeff Bright: You’ve known this patient for four days, but it is refreshing to have a new set of eyes. [00:04:00] And now myself as that new set of eyes that focuses. Very dramatically on stabilizing patient airway, breathing circulation, let’s dispo, this patient let’s get things moving. So that’s a perspective change that I’ve had both of which has certainly been rewarding to see.
Professor Hare: for those of our listeners who are not perfectly familiar with the differentiation can you tell us what the difference is between Critical Care medicine and the CCU and intensive care medicine and the ICU?
Jeff Bright: I think it comes down to what’s the focus. So at least at the facility that I work, the ICU is essentially just one ICU.
Jeff Bright: There is a cardiovascular unit that we have that primarily focuses on the open heart patients, the cardiac valve replacements and so on and so forth. But ultimately at the end of the day, If a patient’s in the ICU or the CVU, then they’re going to be under the, either my service or the cardiothoracic surgeons.
Jeff Bright: Okay.
Professor Hare: Okay! and CVU is cardiac or
Jeff Bright: cardiovascular unit CV.
Professor Hare: [00:05:00] Cardiovascular unit. Okay. Excellent. Well, that’s good to know. So my other question, one question I had for you on this topic was what are your most common consult in that setting? Do you do a lot of consulting of other services from the CCU.
Jeff Bright: I would say primarily when it comes to our consult services, it would really have to be in nephrology and infectious disease.
Jeff Bright: We get some, some nasty bugs that we really need to thick and set of eyes on from the specialists themselves when it comes to ID. And certainly a lot of patients that have progressive renal failure or come in and need emergent dialysis. So nephrology is something that we lean on quite, quite frequently.
Jeff Bright: Okay.
Professor Hare: And How about trauma patients, post post-traumatic patients, car accidents, things of that nature. Do you get a lot of folks like that in that setting? No. So
Jeff Bright: fortunately at least at the facility that I work in, it’s not a trauma center. So if they come into the ER and they are a trauma, a patient, a motor vehicle accident, there’ll be.
Jeff Bright: Triage and sent downtown very quickly. Maybe every once in a while, our request is to help stabilize vent [00:06:00] management. But that’s few and far between, I believe since I’ve been there, I haven’t experienced that. Okay. Excellent.
Professor Hare: Moving on to some of the the clinical topics here. You know, we often start in our lectures in, classes with RPA students with in that area, at that particular area of medicine what are, they must not miss diagnoses?
Professor Hare: What you know, of all the differential diagnoses that pop into your head when you see a patient there are often a few that are. Really important, more emergent things that we need to get an answer on more quickly. So what are your most common must not miss diagnoses in these patients?
Jeff Bright: I would say my not must miss diagnosis would certainly be pulmonary embolism, sepsis and encephalopathy.
Jeff Bright: And particularly when it comes to encephalopathy, not missing. Large, massive CVA or status epilepticus. Okay.
Professor Hare: So cardiovascular accidents, strokes, things of that nature. Certainly. We’re going to have a significant impact on the patient’s care. How do you assess those those patients who come in with a with concern for a neurologic condition of that sort like a CVA or as you say, [00:07:00] status epilepticus that needs to be either broken or dealt with.
Jeff Bright: So encephalopathy itself can have a laundry list of different differentials on it. It’s going to be something bad. It’s metabolic. Maybe it’s a toxic encephalopathy itself from some sort of drug administration, whether intentional or unintentional. Or it can be organic things like stroke and status epilepticus.
Jeff Bright: If someone comes into the hospital and they’re admitted to the ICU where there are rapid response on the floor, so to speak when I have an encephalopathy patient, I typically order basic lab work to try to further delineate what’s going on and try to get some answers and if needed different types of imaging modality.
Professor Hare: Okay. So what would your lab work, your bloodwork? Presumably the first step would be trying to get a little bit of a history and, or a physical exam on the patient, if possible, the ABCs then moving on to blood work. So what would your blood work look like in that scenario?
Jeff Bright: Usually when it comes to blood work, typically CBC CMP, getting a TSH with concerns, maybe myxedema or severe [00:08:00] hypothyroidism and ammonia level to be concerned with hepatic encephalopathy and even a vitamin D level.
Jeff Bright: Certainly a lot of these metabolic conditions themselves can present with encephalopathy. So making sure we’re not missing something fairly straightforward when it comes to underlying
Jeff Bright: encephalopathy, blood sugar at bedside is always a quick and dirty way to figure out why someone’s obtunded and something that’s usually, I wouldn’t say usually, but can be overlooked and super easy to treat as well.
Professor Hare: Okay. Yeah, it’s, it’s interesting that in my work and family medicine in a psych hospital, I during my clinical practice, I had a very similar beginning workup, at least. And often we weren’t moving on to imaging for those folks, or at least the imaging was going to be delayed by a little bit of time before we got a good picture of those patients, but those psych presentations coming into an emergency room department.
Professor Hare: You know, we had a set of labs. We had a, a broad set of labs that would kind of cover a lot of those things. There was a first psychosis breakup, for [00:09:00] instance, when there was a a workup that we would do for patients who were say depressed, and we’re looking at their B12 levels, we’re looking at anemia, we’re looking at all kinds of Systemic things that can potentially cause those psychiatric illnesses can also, cause it sounds like some of the the acute mental status changes have an encephalopathy as well on the other side.
Professor Hare: So we’re essentially looking for very similar things in a very different setting, absolutely work setting. Okay. Excellent. Thank you. So. The other ones here on the list, pulmonary embolism is another one there. And so the, the great pretender as they call it. Right. I think it’s the great pretender is in your lecture?
Jeff Bright: I remember medical masquerader
Professor Hare: right.
Professor Hare: So yes, some funny names for a pretty serious condition, certainly. the number of presentations that can come up with, do you see these pulmonary embolism cases. Presumably you get some of them that show up in your unit are those things that show up mid pulmonary embolism. Do you already have a relatively set diagnosis before you get to that point?
Professor Hare: Or are you often [00:10:00] doing the initial diagnosis of those folks?
Professor Hare: So,
Jeff Bright: what comes to these folks? I feel like I’ve seen them in all areas of that spectrum itself, whether this is someone with a. Large submassive PE that does have some RV strain that’s going for catheter-directed thrombolytics and then coming to the ICU after their intervention, that someone that I get any patient that’s been on the floor or had some dyspnea that we really can’t figure out what’s going on.
Jeff Bright: Let’s say their chest x-ray is clear, but they’re dystonic. And to give Nick and still something that was brewing, we went on Noah. Go ahead and consider a PE do you
Professor Hare: look at the extremities for a deep vein thrombosis in that scenario, a D dimer and a, an ultrasound, a Doppler ultrasound. Are you going straight to the lungs?
Professor Hare: And that
Jeff Bright: usually, if I’ll, I’ll tell you what one of the NPs that’s become a close friend of mine had always brought up the idea that if you think about it, go ahead and just order the CTA because. You’ll kick yourself in the end. If you had two days later, they ended up having a PE and you missed it just for the sake of, ah, no, that’s definitely couldn’t be it.[00:11:00]
Jeff Bright: So if you think about it, just order the CTA, I usually, if I’m that concerned about PE I’ll forego the, the Dopplers and the dimer, and I’ll get that later on in a couple of hours, but if I’m that concerned, I’m just gonna order the CT angio. Okay.
Professor Hare: So presumably the reason for The variety of presentation, there is that so many different areas of of day-to-day life can cause a DVT, pulmonary embolism including, you know, being, being on the unit after surgery post-op folks can have some Moving into the area of a lung lower extremity folks from home people who are not up and moving around a great deal, have the potential for that DVT and pulmonary embolism.
Professor Hare: So, so being at home, being in the hospital, there’s a variety of ways in which those things can present to you. So what’s your what’s your go-to imaging on the, on the pulmonary embolism side of it.
Jeff Bright: Oh, I 100%, I’ll go with the CT angiogram of the chest. Let’s say just the criterion standard as of today, when it comes to identifying and diagnosing pulmonary embolism, if you have to, you can always consider a [00:12:00] VQ scan, but usually in the folks that I’m seeing that need an answer now I’ll usually go for the CT angio and.
Jeff Bright: risk stratifying, but take the hit when it comes to their renal function. If that’s a concern,
Professor Hare: if it’s necessary. Yeah. And the ventilation perfusion scan is that oftentimes I find myself talking to students and talking about things that they need to know, but we don’t really see them as much anymore.
Professor Hare: And the ventilation perfusion scan is one of those things. I feel like I don’t see a lot of that in the community or in the lab work and the in electronic medical records. I don’t see that showing up for very often anymore. I
Jeff Bright: would certainly agree. We don’t order them very often especially working with the Pulmcrit folks that I’m with a lot of the, the outpatient Pulm folks who order VQ scans for chronic thromboembolic pulmonary hypertension, just as the gold standard there.
Jeff Bright: But when it comes to an inpatient medicine perspective you should add or order them, unless patient has dramatic contra-indication to heparin or anticoagulation, but I’m really concerned that they might have a PE I’ll [00:13:00] order one, but more often than not, I’ll probably just go to the CT angio or nothing
Jeff Bright: at all.
Professor Hare: Okay, excellent. Okay. And then. Let’s talk a little bit about shock that this, especially the septic shock side of things, so shock can have its own set of etiologies that causes that can be can be really concerning and obviously have high morbidity and mortality associated with them.
Professor Hare: But if I recall you said that you had a relatively set approach to those. And can you tell us about that.
Jeff Bright: So any patient who comes in with shock ultimately here we need to identify what’s the underlying ideology. Is it a cardiogenic from a big MI instead obstructed from a pulmonary embolism or ultimately is it sepsis?
Jeff Bright: So any patient that comes in with shock, unless I’m 100% certain and instill some cases more often than not, I’m going to start empiric antibiotics more often we hear folks that perhaps missed the. Sepsis that was brewing. And then two days later, and unfortunately we can’t backstep from that.
Jeff Bright: So I’m more of the mindset of starting empiric antibiotics, even though, you know, it’s [00:14:00] cardiogenic, you can always take them off two days later, but you don’t get burned from missing that roaring UTI that caused their cardiogenic
Professor Hare: shock.
Professor Hare: Shock. Right. So presumptive. Infection in this case is something they’re going to go after immediately.
Professor Hare: Empirically treat. Can you tell me what kind of antibiotics are you using in that initial stage? For that broad spectrum? Most of the
Jeff Bright: time. So if patients are coming to the ICU and they do have shock, and now they’re on vasopressors and we’ve fluid resuscitated. And now I’m starting to think about empiric antibiotic coverage.
Jeff Bright: Certainly I’m more of the adage of go big or go home, especially when it comes to these folks. I’m definitely adding vancomycin. I, and. Other facility when I was a hospitalist, they were big fans of, of Zosyn. But here over at the facility than I am now, Cefepimeis usually the go-to just a little bit more narrow coverage.
Jeff Bright: We’re avoiding the use of Zosyn unless we absolutely have to. So if I really have to, I’m probably going Vanc, Cefepime, and Metronidazole or Flagyl.
Professor Hare: Okay. So that’s a good point to make when it comes to being a physician assistant, you know, the one thing [00:15:00] that I think that. Makes physician assistant, sometimes a little different from folks who might be an MD or a DO in those cases is that moving from place to place is more common for physician assistants because our licensure is more general.
Professor Hare: It provides us with the, with a latitude to work in a variety of settings, a wide variety of settings, which is certainly different from what you would see in most MDs. And so moving from place to place. Seeing the kinds of institutional changes, institutional protocols and policies that really impact PA medicine.
Professor Hare: As one of those things that I feel like is under appreciated, knowing that when you walk into your hospital on any given day Privileges at multiple hospitals, you might walk into one and the standard and the folks that you work with, the the infectious disease committees, for instance, who put together the protocols for antibiotic treatment may actually be very different than another hospitals, institutional policies and procedures.
Professor Hare: While the first line [00:16:00] treatment is often thought of as being very similar, you may be in a different geographic area. You may have areas where one antibiotic is not preferred. It may be a personal preference for some physicians in smaller practices, private practices, for instance I’ve worked with physicians previously that one gentleman didn’t like clarithromycin at all, he did not like it at all.
Professor Hare: So we were either on the low end of that empiric spectrum for prevention or we were going straight to Vancomycin once we got past that. So I, I think that’s an underappreciated aspect of physician assistant medicine sometimes. and certainly, you know, you’re, sure you’ve experienced a little bit of that between your hospitalist time and your critical care time.
Jeff Bright: Certainly. As silly as Tylenol. I remember at the one facility that I used to work at, we’d use IV Tylenol or Affirmev and we’d use it And then I tried to use it at the new hospital. And you would’ve thought I said the most horrific thing ever when the pharmacist looked at me and said, No, we will not order IV Tylenol and he’s like, the bioavailability is identical.
Jeff Bright: And one is [00:17:00] dramatically more expensive. And so it’s just little things like that, you know, from institution to institution, you are going to have a little bit of change. Yeah. It
Professor Hare: is an interesting thing. And Tylenol is one of those things often that gets. Well, it gets, it gets tossed around as it comes in and out a little bit over time, but certainly the toxicity issues with Tylenol, once you reach that line, that toxic toxic line with Tylenol.
Professor Hare: I worked in working in orthopedics for a time. The physician that I worked with, the orthopedic surgeon would not give a combination opiate and Tylenol medication because patients often don’t think about that combination. Right. And so Tylenol is another good example of ways in which an individual practitioner and individual institution will have their own ways of doing things when it comes to these things.
Professor Hare: And so, yeah, it’s good to point that out. I think today. let’s talk about your most common diagnoses in the CCU. I know that they include at least one or two that we’ve already spoken of a little bit today.
Jeff Bright: So I would say the three big diagnoses that I see rather routinely, and unfortunately do have a very high rate of mortality would be COVID pneumonia [00:18:00] and subsequent ERDs, septic shock, and post cardiac arrest with
Jeff Bright: anoxia.
Professor Hare: we already talked a little bit about septic shock, certainly. and the approach with antibiotics first, let’s talk a little bit about the post-cardiac arrest with anoxia side of things. So this is presumably anoxia because of lack of perfusion. All areas of the body have experienced that lack of profusion during that time.
Professor Hare: But what kind of things do you go after after that anoxic period and that lack of profusion to the heart?
Jeff Bright: So similar to, as we spoke before that time is brain and it really big things that come down to is how long was the downtime during cardiac arrest.
Jeff Bright: So some folks may be down for five less than 10 minutes and may have a better outcome, although not guaranteed. Compared to folks that are down for 20, 30, 40 minutes, an unknown downtime period, and as a result of a poor neurologic outcome, additionally, something that we need to consider is trying to preserve that brain as much as we can.
Jeff Bright: there’s been some articles that suggest against target temperature management and therapeutic [00:19:00] hypothermia, still up for debate, whether or not it’s worthwhile or more harm than good, so to speak, but something that we always need to consider as well as seizures and posturing that occurs as a result of
Jeff Bright: anoxia.
Professor Hare: During that, post cardiac anoxic period of time, does the workup look any different for that that anoxia the cerebral side of things, the encephalopathy potential after those kinds of anoxic injuries than it does after a CVA, a stroke, a cardiovascular accident of.
Jeff Bright: I would
Jeff Bright: say the big thing that kind of comes down to is how do they respond to our current therapy, either they so on that’s post arrest moving all four extremities, they’re able to communicate and follow commands, then press, we don’t go down that road as dramatically as intensely so to speak. But this is someone that remains obtunded
Jeff Bright: comatose is not sedated on mechanical ventilation. Now we need to consider things. And they non-con CT of the brain and MRI and EEG
Professor Hare: on the cardiovascular side of things we talked, we [00:20:00] talked a little bit about our consult services available to you and the CCU . Is the cardiac and the cardiac folks, a big source of consult for you?
Jeff Bright: I would say cardiology nephrology and infectious disease are probably our most common consult services. When it comes to someone that is post PCI or had a balloon pump or an Impella or something that place and needs further management cardiology needs to be on board. That’s a infectious disease, and certainly we have a variety of different nasty bugs and need the specialty’s eyes on them,
Jeff Bright: then infectious disease definitely needs to be on the board.
Professor Hare: So if you have a patient who is experiencing a cardiovascular accident or myocardial infarction while they are in, let’s say they’re in their bed and you’re concerned about a brewing myocardial infarction, And this is something that I’ve always been curious about.
Professor Hare: We call a code at my hospital and your team is, whoshows up. The cardiac the critical care folks from the hospital across the street. And so my [00:21:00] question for you is then if you have something brewing along those lines, are you then going to respond to that in house? Are you going to basically take care of it, of your own volition or do you call the code and have the cardiovascular team show up in those moments?
Professor Hare: Because you’re the team and in my hospital.
Jeff Bright: So is this a STEMI that we’re concerned with, or is this a cardiac arrest on the floor?
Professor Hare: The sake of discussion? Yeah, let’s go with the, with the STEMI, with the ST elevation, myocardial infarction, presumably the more severe version of
Professor Hare: that.
Jeff Bright: Deal.
Jeff Bright: So if I see, let’s say it’s a rapid response, in my hospital. But either way I’ve responded to a patient. We’re concerned that they’re having a STEMI. We get an EKG. At bedside, there does look concerning for. I’ll call cardiology or interventional cardiology rather. They’ll activate the STEMI alert which will bring in not only them, but members from the cat team that will all respond.
Jeff Bright: If they’re, let’s say it’s middle of the night, or if they’re during the day, they’re already there. And that patient will go directly from that bed straight [00:22:00] down to the cath lab where they can have intervention done.
Professor Hare: And so are you ordering, as this is going on Troponins, which are the cardiac enzymes released during one of these cardiac events.
Jeff Bright: So
Jeff Bright: usually if I let’s say a patient has classic presentation, I look at their EKG and bedside and identify ST changes and reciprocal changes as well. I’ll call cardiology and get the ball rolling. I might have. Lab come by and do a CBC, a CMP and troponins in the meantime. But ultimately the priority is getting them downstairs once they’re done and they can get back to me so we can reevaluate more often than not do a bedside ultrasound myself in order to form a one order Troponins, maybe even CK-MB as well.
Jeff Bright: Okay. And to kind of go from there.
Professor Hare: You’re ordering more cardiac enzymes, and then just each opponent. So troponin I I presume in
Professor Hare: that scenario,
Jeff Bright: I believe so. We recently got the high sensitivity Troponins, which to be quite honest, I think they cause more harm than good in some circumstances,
Professor Hare: Very sensitive, Right?
Jeff Bright: Yep!
Professor Hare: Yep! Hypersensitive in some cases and the CK-MB is something that you also order, so you’re looking for the longer [00:23:00] term increase.
Jeff Bright: absolutely. So again, it depends on the attending that I’m working with and quite frankly, the mood as well. But sometimes I will order CK-MB just to kind of see if there’s a secondary peak in trend that we missed before if Tropnonis are on the descent so to speak.
Jeff Bright: But now they’re having recurrent symptoms. Maybe if I’m trending CK-MB you can still get a better idea of what’s going on.
Professor Hare: it sounds like the EKG is really your primary initiator for this process.
Jeff Bright: I would say at least when I do see them on the floor, it’s happening right in front of me. Most certainly.
Jeff Bright: Yeah. What’s their presentation? What are their biomarkers? What are the EKG? And I can get two the three and it looks like a good case. I’m calling cardiology.
Professor Hare: the next step then in the hospital would be the cath lab. So PCI in that instance. Okay. So percutaneous intervention where they’re running a stent into the area , through the femoral artery, presumably all the way up into the into the hearts and allowing that and opening up.
Professor Hare: Vessels so that blood flow can be restored to that area. Often I can get a lot of discussion with my students [00:24:00] about the difference in the indication for PCI versus the indication for doing a CABG, which is the coronary artery bypass graft. a difficult thing to grasp sometimes that the CABG a longer-term thing. If we’ve got the time and the ability to hold off on that for maybe 24 to 48 hours, then that’s when the CABG takes place.
Jeff Bright: Would most certainly agree with that.
Jeff Bright: In most cases when patient does undergo cardiac catheterization we can either do PCI right on the spot. If it’s one, two, maybe three lesions that need to be placed. If there is for the most part, and again, I’d have to double check what the current CABG indications are at this time. But if it’s multi-vessel disease and they’re long segments and putting in 40, 50, 60 stents, certainly isn’t reasonable.
Jeff Bright: Then maybe that’s a patient that no intervention is done. They’ll continue on heparin with very urgent cardiothoracic consultation who then can start to decide whether this is an emergent CABG patient, or can we treat them for their [00:25:00] NSTEMI right now? And then do a CABG in two days, two weeks it, right.
Jeff Bright: Yeah.
Professor Hare: Yeah. And I think, what’s interesting is we’ve moved into other areas of medicine from these generalist perspectives and the, and the CCU is an area where you’re looking, not just at the overall patient stability in the moment and you’re looking at their status, are they critical or not, but also looking at lungs, we’ve already talked about the lungs, the heart, you’re talking about the kidneys, we’re talking about the brain, you know, so this is a kind of a full body perspective on an emergency side of medicine, really, and maintaining that patient’s life.
Professor Hare: And so I can imagine in those moments why that is such a draw for you to, to do this particular job.
Jeff Bright: I liked it that much. Yeah. As you get to be know a little bit about everything, what does that phrase a master of all? And knower of, of
Professor Hare: Jack of all master of none,
Jeff Bright: that’s it? Yeah. And that’s something that I really enjoyed.
Jeff Bright: I didn’t like the idea of forgetting something. Then I spent two hard years working on and then unfortunately forgot it all,
Professor Hare: I definitely agree. So let’s talk about the COVID pneumonia cases.
Professor Hare: [00:26:00] I presume you’ve had a great deal of those. What percentage of your emergency room at the moment are COVID
Professor Hare: cases?
Jeff Bright: I would say right now we have a 20 bed ICU. And to be quite honest, we’re at capacity. We are, we have 20 patients more often than not. Sometimes we can make some moves so to speak and have
Jeff Bright: 12 to 15, but unfortunately very quickly they are going back up to 20 beds of those 20 beds. I’d probably say 75% is COVID pneumonia. Wow. On the vent or soon to being, unfortunately,
Professor Hare: and that’s come and gone at presumably over the course of the pandemic, I assume over the last couple of years. But it is really interesting.
Professor Hare: So you’re saying COVID isn’t a hoax.
Professor Hare: these patients coming into you, and this is one of those things that I think a lot of folks have difficulty it is usually the secondary issues that COVID causes in those patients, whether it’s vascular damage or pneumonia is,the big one.
Professor Hare: Right? And so, most of the cases of mortality in patients who die in. Care during care in the hospital, are pneumonia patients.
Jeff Bright: Absolutely. So a [00:27:00] lot of these patients certainly COVID is the initial flick of the snowball, so to speak, but it’s the. Progressive inflammation, the fibrosis, the ARDS, the renal failure, the secondary bacterial pneumonia that pulmonary embolism, the GI bleed from being on anticoagulation.
Jeff Bright: And unfortunately is ultimately what ends the, patient
Professor Hare: that snowball running downhill can turn into a lot of different things in that scenario. Have you and your CCU been putting a lot of patients prone during that time?
Jeff Bright: Usually we will unless there’s a dramatic contra-indication or relative contraindications, such as let’s say, if I have a femoral temporary dialysis catheter, those could kink very often.
Jeff Bright: I’m probably not going to prone that person. If there’s concern for. Any type of intracranial bleed. But I can’t take that patient to get imaging just because they are not so unstable. I’m not going to prone them, but more often than not, if we have a COVID patient, that’s on the vent, they’re getting proned, usually 16 hours on eight hours off
Professor Hare: and so that pneumonia that you’re seeing in those patients is.
Professor Hare: a secondary bacterial pneumonia in those [00:28:00] patients
Jeff Bright: it’s hit or miss. We have some folks that are genuinely pure COVID pneumonia and ARDS that results from it. Some folks have a concomitant bacterial infection, and some folks have been pure COVID pneumonia for the longest time. And we’ve had them for two weeks and then they get a bacterial pneumonia as well on top of it.
Jeff Bright: But more often than not, it’s a little bit of everything.
Professor Hare: Your treatment lineup for COVID pneumonia and I want to preface this by noting that the entire time that you would be treating a patient with COVID pneumonia and presumably even to walk onto that unit at this point, as it is in my psych hospital To walk onto that unit, wearing PAPR at this point, the overhead with the, air supply into the, helmet, or are you gowned gloved masked with,
Jeff Bright: Usually I’m going into one of those COVID rooms. We usually wear a, and then 95 or an N 100. Those are just the ones that have been most available and easier to distribute.
Jeff Bright: At least at my facility. I’ll usually wear one of those with a surgical mask over top of it. I wear a, I have some rec specs [00:29:00] that I wear that I enjoy wearing rather than a face shield, a hair net and gown and gloves. And usually that’s the, that’s the go-to for us right now.
Professor Hare: One of the challenges to me and I, had to gone into our COVID positive unit several times to see patients.
Professor Hare: The challenge for me is, you’re really seeing patients through. A lot of layers to get to that point. And, even getting your stethoscope out can sometimes be a or, a penlight is a challenge in that scenario sometimes. Yeah. So you’re treating that patient, let’s say you get a patient into the CCU house.
Professor Hare: How severe is that? What are the, numbers that really add up to bringing them into your unit at this point?
Jeff Bright: To be honest, it’s it really comes down to. Judgment call for a lot of them COVID is certainly changed ICU indications and the requirements to transfer down simply based on bed availability, as well as nursing staff ratios.
Jeff Bright: So perhaps realistically, what patient may more easily be brought down to the ICU for closer observation perhaps stays on the floor a little bit longer, and that’s just, unfortunately the nature of the beast right now. That’s certainly my biggest thing is, does this patient need to be put [00:30:00] on the vent right here right now?
Jeff Bright: Are they going to be ventilated within the next 24 to 36 hours? Or it’s a significantly high risk for a poor outcome. Those are three of my generic ways of saying, you know what, I need to bring this person down. And just refractory hypoxia. So someone comes in, they can’t get their sats over
Jeff Bright: 85 they’re on maximal settings of bi-pap I’ve already recommended escalating through oxygen therapy. And now we’re on the extent of bi-pap that we have, usually that person I’m going to bring them down because they have such a high risk for being put on the vent.
Professor Hare: Yeah, absolutely. And
Professor Hare: so those, those patients at 85 or below, we’re going to be presumably significantly ill at that point.
Professor Hare: Although I have seen some stories of folks who were relatively stable in those moments and able to maybe not walk into the ICU, but close to it. Making that decision to move in that direction and knowing that, that patients, morbidity associated with COVID is going to be significant.
Professor Hare: So do you have significant conversations with families before moving to the vent in those [00:31:00] situations?
Jeff Bright: You try to, the best of you can certainly, because visitation policies have been ever changing throughout the last several years or so. It makes seeing their family members so challenging.
Jeff Bright: So patients’ families understandably want good communication. Right. If I have time to I’ll try at the very least to make time to contact family, tell them of their transfer and confirm code status, that’s been a big thing over the last several years is confirm code status. Tell them that their loved one, unfortunately has a high risk and is going to be placed on the ventilator and telling them the risks associated, including cardiac arrest, peri-intubation.
Jeff Bright: I’ll give you a call when everything’s all done.
Professor Hare: Okay. And have you ever brought a family in to talk to the patient or presumably that’s a difficult thing to do by the time they get to the CCU, But have you ever brought family in to talk to the patient?
Professor Hare: say goodbye. The issue there is that when you intubate, presumably you’re putting them on sedation for that time and they may not be able to speak with them after that point. And given the mortality rates of patients who make it to that [00:32:00] point, it’s pretty significant.
Professor Hare: So is that something you’ve had
Professor Hare: to deal with as well?
Jeff Bright: It’s been challenging. And the biggest thing here is. Institutional policies when it comes to visitation they’re ever changing. But for, for a while now, there have been, times where there was no family members for a COVID patient end of story period.
Jeff Bright: So you could quickly try to set up FaceTime phone call is something that we tried to do, but unfortunately that patient has. A negative pressure room. They likely have very high inspiratory pressures on that bipap it’s very loud in that room they’re probably obtunded. So it makes it challenging, especially to, to say goodbye.
Jeff Bright: Yeah.
Professor Hare: And so not being able to say goodbye and not having the mental status capability to actually to speak with folks in the family. I can imagine that has the potential to be a particularly emotional moment to deal with I’m sure your patients and those families appreciate having you of all people to step in and.
Professor Hare: Give them some sense of what’s going on and your communication style, I’m sure fits that really well and helps those folks out to whatever extent possible. [00:33:00] That’s not, not an easy thing to do. So I guess what I’m saying is thank you for your service when it comes to COVID and the pandemic these days.
Professor Hare: So let’s, let’s move on if we, if, if you’re willing to do so to a couple more of our Other significant cases here that we have discussed. You know, we, we talked about the hypoxic and hyperbaric respiratory failure with folks. Can you give us an example of a patient, a Picture of a patient who is in that type of respiratory failure.
Jeff Bright: So particularly when we have folks on the floor or even in the ICU that have of high risk for decompensation, we order arterial blood gas is very, very often. Some folks in some providers like daily ABGs, that’s simply a style preference.
Jeff Bright: I think other folks, including myself, like to be able to. Do something with that knowledge and that information that you get with an ABG, but ABGs is what I’m getting is something that’s fairly frequently done. And so identify. PaO2 and PCO2 and identifying what type of therapy is best to help to [00:34:00] improve their overall oxygenation.
Jeff Bright: And,
Professor Hare: and so with the ABGs, you’re getting the pH, you’re getting the partial pressure of oxygen in the blood. So how much oxygen are they able to get into the bloodstream? And how much of the CO2 that is being produced by their body is actually being removed by the lungs on the far end.
Professor Hare: And is bicarb is my card as well. Yeah. Yep. And so those ABGs are arterial blood gases drawn usually from a femoral line in those cases?
Jeff Bright: More often than not, they’re usually radially done. If they’re a patient in the ICU, in the event of an arterial line already placed, usually we try just for the sake of institution, policy go radial rather than femoral.
Jeff Bright: But usually they already have an arterial line then we’ll just drive straight from there. If they’re up on the floor. They’ll try to do a, an arterial line or a radial ABG, just to the RTs. I don’t know if the RTs can do femoral sticks. But if there’s a tough one on the floor and we need an ABG then I’ll usually just grab the, the longer needle of the ABG kit.
Jeff Bright: Do a quick femoral stick and then be done with it.
Professor Hare: And Respiratory Therapists RTs, are certainly a profession that has been a frontline [00:35:00] Kind of profession that we are seeing really called to the forefront these days during the COVID pandemic, but also for a variety of other things, you know, in respiratory therapy is also providing care for our folks in the CCU for things like acute hypoxic, respiratory failure.
Professor Hare: ARDS we mentioned that briefly earlier ARDS being that buildup of fluid outside of the alvioli between the alveoli in the lungs and the and the bloodstream itself, which presents a fluid barrier to that oxygen making its way into the bloodstream. And of course the carbon dioxide and making its way back out of that bloodstream.
Professor Hare: What is your, what is your go-to treatment? So you treating the initial infection in those cases, the initial issues during those respiratory failure moments with ARDS, or are you going after ARDS itself with pressures?
Jeff Bright: I would say the big thing here when it comes to treating ARDS is trying to get the source under control more often than not.
Jeff Bright: It ends up being infection and not necessarily pneumonia all the time. Sometimes we can have ARDS from [00:36:00] inflammatory producing conditions, pancreatitis being one of them. But trying to get the source under control, most importantly we’ll try to keep these patients dry. If we can renal function permitting trying to use diuretics Right. And then lastly, when it comes to. Folks that more than likely are on the ventilator, high peep and low tidal volumes as per the big ARDS study that was done years ago.
Professor Hare: So we’re not putting a significant wave form on their ins and outs of, of that air going into the lungs.
Professor Hare: Yeah,
Jeff Bright: absolutely, yeah. Trying to reduce baro-and volume trauma as much as we can. I remember a physician that I worked with years ago. He’s kind of classified it and tried to describe it as a brown paper bag. Those alveoli that if we can fold up that lunch bag, nice and neat every day, it’s going to last a little bit longer, but if you blow that thing up and crinkle it up and then blow the thing up and crinkle it up again, you’re going to destroy those.
Jeff Bright: Desmosomes destroy those tight junctions and cause worse inflammation and just completely cascade. This ARDS even worse.
Professor Hare: I love to hear the terminology that I use in my physiology and pathophysiology classes brought to clinical use. [00:37:00] I love it. Fantastic. And I don’t, I, I probably didn’t teach you any of those.
Professor Hare: I’m not just talking about
Professor Hare: my current pathophys classes. For what
Professor Hare: it’s worth actually. Okay. So we talked a little bit about septic shock in the typical patient that we see with septic shock let’s talk about ATN and progressive acute.
Jeff Bright: So something that we see very often in the ICU is acute tubular necrosis.
Jeff Bright: And more often than not, it’s because of septic shock a pre-renal state and then is turned into what was just a prerenal AKI then becomes ischemic, ATN, and then unfortunate. Worse and worse urine output become oliguric and then require dialysis.
Professor Hare: We’re referring to the bloodstream before it gets to the kidney.
Professor Hare: Before that blood is taken to the kidney pre renally and filtered inside the kidney is where we’re seeing the difficulty that then results in the kidney. Having AKI is acute kidney injury, which is relatively short term. If we’re lucky, kind of an injury to the kidney and its ability to [00:38:00] filter.
Professor Hare: So oliguria being the far side of that, which means very little urine being produced or in some cases especially if we’re moving toward hemodialysis and end stage renal failure. We’re talking about anuria, which means the patient is not producing any urine through those kidneys.
Professor Hare: what are your first steps when you’re working with a patient who you’re concerned for that ATN and ARF.
Jeff Bright: I would say the big thing here is trying to identify the source and what’s driving this kidney injury in general. Is this our straightforward AKI? It’s prerenal it’s hypovolemia and hypoperfusion mediated, and simply we just need to improve their blood pressure, give them some volume and hopefully we start to turn the right direction.
Jeff Bright: Okay. Also, as you can imagine, we can also have a variety of other types of kidney injuries. Is this someone that I need to get some imaging of their belly to see if it’s obstructive neuropathy? And unfortunately now it’s an obstructive AKI. It get urine studies just to see if this is truly ATN or AIN in the [00:39:00] setting of eosinophils, the different medications.
Jeff Bright: But ultimately here, it’s trying to see where their urine output settles, in three, four or five days, keeping a close eye onthat urine output. And when that urine output starts to go, maybe give a day or two of like a Lasix trial, but ultimately here, you know, what’s going to happen and they usually end up on dialysis.
Professor Hare: So, if I’m in this situation, it sounds as if a lot of those patients and we talk about this a lot in, different areas of clinical medicine, Patients who are post-op patients who are post-trauma, let’s say, have a couple of days stay in the hospital. The old saw about, we need that patient to start making urine and be sure that they’re making your own before they walk out the door.
Professor Hare: Do you see many of those cases where we haven’t gotten to the point where they’re making urine from their AKI or that they’re they’re lapsing into renal failure during those times?
Jeff Bright: I would say I remember as a, as a hospice, that was always a big thing is especially postop patients. Are, are they making urine.
Jeff Bright: Please make sure you bladder scan them if they need a Foley put a foley in. And when it comes to patients that end up [00:40:00] in the ICU, they already have a foley in we’re getting very strict I’s and O’s, and we can kind of see are they actually making urine? Let me give them some volume. See if that helps.
Jeff Bright: They weren’t responsive. Maybe as a last ditch effort, you try the Lasix just to see if we can stimulate some urine production. But at the end of the day, when they start to become oliguric anuric We’ve already started that descent into considering hemodialysis.
Professor Hare: Do you miss the days of having a number of beds, more beds associated with things like kidney issues, as opposed to COVID pneumonia patients?
Jeff Bright: it’s tough. I like the certainly enjoy the variety. And even when the COVID waves, sometimes they decrease a little bit and you get a little bit more variety.
Jeff Bright: It’s always exciting. It’s refreshing sick as that
Jeff Bright: sounds
Professor Hare: well, I can imagine it, you know, the variety is the spice of life and I think a lot of PA’s appreciate about their jobs and being able to see a wide variety of things. And, you know, recently it feels like, as we said before, that, thing that really overhangs a lot of the things that we do on a day to day basis in medicine is, is [00:41:00] generally speaking cOVID How about the secondary bacterial pneumonia. So a lot of the cases, presumably we’re talking about necrosis that leads to a secondary bacterial pneumonia and those patients. Are you more often seeing the patients who are inpatient, the patients who are hospital acquired or is that, is this mostly community
Jeff Bright: say when we have a secondary bacterial pneumonia and I’ll generalize for the sake of our podcast, usually these folks have already been inpatient for a while.
Jeff Bright: And then they developed a new bacterial pneumonia on top of that.
Professor Hare: So this is
Professor Hare: hospital acquired, nosocomial. it poses its own set of increased challenges for, for those
Professor Hare: patients.
Jeff Bright: It changes the antibiotic coverage that we need to do. Usually MRSA and pseudomonas are the big bugs that I’m looking to cover, especially with my antibiotics and for someone who was, let’s say, postop left knee, they’re looking to get out of here and before you know it, now they have pneumonia. Now they have an AKI. Now they’re in new onset AFib and we’ve got a slew of new problems for you. And you [00:42:00] just came in to get your knee replaced.
Professor Hare: Right. And that convalescent time at the hospital after a surgery.
Professor Hare: Like a total knee replacement or something of that nature or a hip replacement is one of those things that is kind of underappreciated, you know? And I think unfortunately the, the shorter stays in hospitals these days make that convalescent period a little bit less relaxed.
Professor Hare: Certainly. We’re sending patients home more early on the other hand, those hospital acquired infections are, the nosocomials, are less likely to occur because we’re putting, giving them less time in the place where all the sick people live.
Jeff Bright: Absolutely. I’m always been a big proponent of all things within reason, but being a little bit more aggressive when it comes to discharge, especially as a hospitalist, more particularly is get this to get these folks out of here.
Jeff Bright: The longer you stay here, the sicker you’re gonna get, and that’s just the unfortunate reality of having comorbidities and being elderly in the hospital. The quicker I can get you out of here safely, the better.
Professor Hare: the last one on the list, I think is interesting pneumothorax and or pneumomediastinum , subcutaneous emphysema.
Professor Hare: It surprises me that that makes the list actually. But so I’m curious to hear [00:43:00] what, what sort of scenarios you see often with it involve those kinds of lung conditions and chest
Professor Hare: wall conditions?
Jeff Bright: I haven’t done as many pigtail chest tubes, and then I have in the last two and a half years, and it’s all COVID Frequently see pneumothorax and even pneumomediastinum, and sub Q air that really took a dramatic increase once COVID hit.
Jeff Bright: Unfortunately just with the damage that ensues as a result of the viral infection.
Professor Hare: that’s caused by the virus itself and obviously you’re being very, very careful with pressures being put into the lung with bi-pap and peep, but this is more of a damage and a chronic damage being caused by the infection itself.
Jeff Bright: I would even argue that because of the viral infection in the inflammatory cascade, as a result, they require such high levels of noninvasive ventilation with CPAP and bi-pap. So because of that and they have to be on, C-PAP of 15, 20 bi-pap of 25. when it comes to their IPAP, that unfortunately you end up blowing out one of the lungs.
Jeff Bright: Okay. We’ve even seen a lot of pneumomediastinum, and sub Q, air without [00:44:00] presence of pneumothorax just those tracheal rings start to have so much pressure in them that we get some air that starts to leak out and then fill the subQ spaces.
Professor Hare: that’s, unfortunate, and one of those underappreciated, I think things even amongst other medical professionals, understanding that really you’re pushing.
Professor Hare: The physiology of that patient when they have COVID and when they have these conditions sometimes to the point where what you’re doing for them is, reaching a limit. You’re reaching a limit where you, know, it’s kind of a risk reward thing where if you are doing more damage than good at that point, then you have to back off a little bit, but again, they may need that increased pressure and that increased oxygen presence in the lungs too, to help them just survive.
Jeff Bright: Yeah, absolutely.
Jeff Bright: It’s such a tough balance when they’re respiratory requirements are of a bi-pap of 25, over 15, so to speak, but you know that they already have pneumomediastinum. They’re going to blow out one of their lungs any day now it’s a fine line, but unfortunately, The mortality and morbidity at the very least ends up being pretty high for those folks that get into those
Jeff Bright: [00:45:00] predicaments.
Professor Hare: So for my physiology geeks out there we have our metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis in our four corners. Where do most of these patients. The COVID pneumonia patients, for instance, where do they end up? Most of the time. And are they able to compensate for that?
Professor Hare: Are you able to,
Jeff Bright: I would say for the most part, if I had to pick one of the four is a respiratory acidosis because of their poor gas exchange. And unfortunately, because of becoming increasingly lethargic and obtunded, they become hypercarbic very quickly. Okay. Not to mention if they have underlying lung disease and COPD to begin with.
Professor Hare: So not blowing off the CO2 becomes the big issue in the instance.
Jeff Bright: And then unfortunately, because of that, despite bi-pap, they may require some extra TLC when it comes to mechanical ventilation.
Professor Hare: Thank you for that. Some great indications and pathologies to discuss there. I say, great. I mean, unfortunate, but really interesting stuff. PA education in general is a generalist perspective that [00:46:00] we start off from that Jack of all master of none. As we said before, kind of perspective where I live in my family medicine practice in primary care internal medicine, your hospitalist practice, certainly.
Professor Hare: And your CCU practice, certainly land somewhere on that continuum. that’s where we start our education in physician assistant school. So tell me when is a generalist likely to need to progress to the kind of care that you give in your service?
Jeff Bright: I would say acuity and ultimately the need for more advanced therapies. So someone that is becoming more sick, they’re starting to decompensate whether it’s respiratory perspective that they need mechanical ventilation, whether it’s a hemodynamic perspective and that they need vasopressor therapy.
Jeff Bright: Those are the two big ones that then end up driving folks that do require ICU level care and monitoring and monitoring and nursing ratio is ultimately, which has certainly been a sore subject for most with, with nursing ratios.
Professor Hare: Certainly in every hospital in the world. I think at this point. So the most common handoff for [00:47:00] you then from a generalist is probably going to be coming from your emergency medicine counterparts down the hall in the emergency room.
Jeff Bright: Certainly that’s probably the most common handoff that I’ll get is having a call-out or a page out to the ICU. I’ll come down and already have looked at the labs and done some homework, come down and see the patient, talk to the ER provider and try to get a good game plan as to do they need to come to the ICU, or can they go to the floor, and can give me a call back later if they need.
Professor Hare: You had mentioned that you have a cardiac unit in your hospital. So if you have a post MI patient, are they more likely to go to the cardiac care unit or are they more likely to come to you and critical care?
Jeff Bright: Those dynamics are also always changing in terms of what types of patients can be in. Cardiovascular unit, so to speak more often than not if patient is hemodynamically stable, they’ve had an intervention done. They have no assist devices impella balloon pump. Those folks in my opinion, can go to a high telemetry floor.
Jeff Bright: But unless they need vasopressor therapy, they’re in [00:48:00] complete heart block. They’re doing, having a pacer onboard. Then they should probably go to the cardiovascular ICU unit,
Professor Hare: Really one of the, big considerations these days is where’s the bed that we have available.
Professor Hare: Is that bed going to be enough? Or, you know, intensive enough and it’s care for that patient to actually I don’t want to say do the job, but be comfortable with the care of that patient and those moments, right? Yeah. anything else that you wanted to talk about
Jeff Bright: I think we did a nice job of covering a little bit of everything and a nice introduction to kind of get us started. I’m excited to see where the podcasts go and to keep things rolling forward.
Jeff Bright: I appreciate being on board. It’s an honor.
Professor Hare: Well, we’ll certainly be having you back as soon as possible. the list of Topics include a lot of things that you are well-versed in, and I think we’ll bring you back for as many as we possibly can during this next couple of years.
Professor Hare: many thanks to our esteemed guest today. Jeff Bright PAC, always a pleasure, and I’ll see you in the classroom before too long. I’m sure. That’s it for now. Be sure to check out the podcast website, www.BeExcitedHQ.com (all one word) for more episodes, show notes and transcripts.
Professor Hare: Email us at [email protected] with any questions, comments, suggestions for future episodes. we appreciate those any comments that you might have, and of course, follow us on Facebook and Instagram at Be Excited Podcast for news, new episode notifications and maybe an occasional picture of a couple of gentlemen sitting at a desk.
Professor Hare: Thanks for listening and remain excited. Bye-bye.
