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CRITICAL CARE MEDICINE: Cristina A. Reichner, Julie Anne Thompson, Sharon O’Brien, Tunay Kuru, and Eric D. Anderson Outcome and Code Status of Lung Cancer Patients Admitted to the Medical ICU Chest 2006; 130: 719-723 [Abstract] [Full text] [PDF]

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Two out of three ain't bad

Paul W. Santoro, D.O.   (19 September 2006)

Two out of three ain't bad 19 September 2006
Paul W. Santoro, D.O., Internist none Send letter to journal: Re: Two out of three ain't bad pscumberland{at}aol.com Paul W. Santoro, D.O.	Dr Reichner, Although your research is interesting, I have a real problem with your conclusion, i.e. I take issue with the final line in your conclusion; "...perhaps because of their availability in the MICU and also because of their sense of responsibility in maintaining and withdrawing life support." Your study was done at a 19 bed MICU in a tertiary-care university hospital. Do you really think your results extrapolate to the real world of community and non-tertiary care hospitals? I am on the staff at a few different hospitals, one a small community hospital and two teaching institutions. The larger tertiary care hospital with residents and fellows from an Ivy League University has a "closed MICU." The other is another hospital from the same system but is not a "closed MICU." These 2 hospitals have plenty of house staff around to meet your presumed finding of "their availibility in the MICU." Do you really think the attendings are the ones making these decision to have these discussions? I'd suggest that this is true most of the time. But, how long each day are the attendings there to be involved beyond the 'critical decision making time' formerly known as "MICU rounds?" One of the these hospitals actually has a Respiratory-ICU(RICU) and the patients admitted there are very well cared for by Pulmonary/Critical Care fellows. The same argument applies though. Although they are BC/BE in Internal Medicine, they are not the attendings of record. More importantly, the M/R-ICU attendings are not the primary care physicians nor are they involved in any of the patient's prehospital care, in most if not all of these cases. So, who is providing the "availibility" in these units? I would suggest that the ICU nurses provide much more availibility and have a closer rapport than the doctors do in these tragic cases. I challenge you to provide evidence of "availibility" by the attending in these large teaching institutions, including yours at Georgetown. And by "availibility" I don't mean on call to answer phone calls from home or out of the hospital. Do you take call in house? Is the attending at the bedside when the endotracheal tube is removed? I can only relay the information that my patients tell me about being treated in a large teaching hospital ICU, they feel powerless. And for good reason, as I said one of the hospital's ICUs are closed to so called outsiders, the other Board Certfiied Internists that have spent many hours/days/weeks/months covering ICUs during their residency programs. Other patients have had great experiences but they are in the minority and mostly at the smaller hospital that has an open ICU, in which I can actually place orders in the chart. Well, the orders actually get typed into a computer and copies end up in the chart in legible form. On to the rest of the real world inpatient care facilities, not tertiary care facilities. I am on staff at a small community hospital that provides fantastic ICU care. There are no residents nor fellows covering the unit. The house doctor runs the codes, but the Pulmonary/Critical Care attendings, both of them, make rounds daily and have private office practices to maintain as well. The economics of real world non academic medicine requires them to leave the hospital campus and rely on the wonderful nurses that are their eyes and ears for most of the patient's stay in the ICU. Generally, the primary care doctors are notified and are aware of the patient's ICU admission since the patients get transferred to them on discharge out of the ICU. Primary care doctors are encouraged to be involved while the patient is in ICU. We have an open ICU that doesn't require intensivists to care for our patients there, but I always consult one. Although I feel they play a crucial role in the ICU care for which they have specialized knowledge and expertise, I still think the primary care doctor needs to be involved and communicate with the patient and family daily. The primary care doctor should be responsible for code status discussions with patients and family. I make it a point to speak to my patients, or their next of kin, about code status regularly and especially ON ADMISSION to the ICU. The patient, family and I have established rapport previously and this most important decision must be made with conviction, respect and without reservation. In a community hospital that I am affilated with, there simply is not a Pulmonologist/Critical Care doctor in house 24/7. In an ideal world every ICU would have one there all the time, unfortunately doctors at non academic hospitals have to pay bills and with decreasing reimbursement, this is economically not feasible, at least in the community in which I practice. The next line in your conclusion is a biased subjective uninformed and insulting statement, "their sense of responsibility in maintaining and withdrawing life support." How does the methods section of any study address RESPONSIBILITY? How do you study responsibility in maintaining and withdrawing life support? You imply that the other doctors involved do not share the same 'sense of responsibility' as Pulmonary/Critical Care physicians. I am aware that you have amazingly advanced skills and technology at your disposal but how does that enhance your 'sense of responsibility' in these cases? It doesn't. Where are the results to sustantiate the evidence based (medicine) conclusions in your article? This is an example of one universtiy's tertiary care ICU with lung cancer patients. I would suggest that you most likely have a closed ICU covered by house staff 24/7; and that often there were not other subspecialists consulted because of the vast knowledge, expertise and abilities of the Pulmonologist/Critical Care attending/fellow. Obvioulsy, using your model, the intensivist will be involved 96% of the time in the code status changes, who else is there to pose the question? What percentage of patients' primary care physicians were involved in their ICU stay? In what percentage were other subspecialists involved in their ICU care at your facility, 35%? Who was the attending of record in your ICU, likely the Pulmonologist/Critical Care physician? You met the first two objectives of your study. It is the third in which I feel you fell a little short. If you would have mentioned expanding this research to include all types of hospital ICUs, not just an academic tertiary care institution, this would be a good start which I hope will ignite significant debate, discussion, research and insights into providing more appropriate care to our patients at this critical time in their lives.