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Critical Care Conversations with Josh Trester · Style Points

0:10
And welcome to another episode of Style Points.
0:14
Today, we're talking to my friend and colleague,
0:16
Dr. Josh Trestor, who is the program director
0:18
for the Critical Care Fellowship here at UC.
0:21
Before we get to that, I'll hand it over to my
0:24
colleague, Dr. Nate Moore, who's going to introduce
0:27
this month's RSI. Thank you, John. Next up is
0:30
Dr. Joey Sandolo. He's a CA3 here who's breaking
0:33
our hearts and going to Yale next year to take
0:36
care of more hearts as a cardiac follow -up.
0:37
He's going to tell us a little bit about the
0:39
hemodynamic implications of pregnancy. Thanks
0:41
for having me, Nate. We'll talk a little bit
0:43
about hemodynamic changes in pregnancy. I have
0:46
a little case for us and the listeners to think
0:49
about while we talk about this stuff for the
0:50
next few minutes. So we have a 32 -year -old
0:53
woman. She's at 38 weeks. She arrives in active
0:55
labor. She has a history of moderate mitral stenosis
0:58
from childhood rheumatic disease. Her heart rate's
1:01
110. She's short of breath between her contractions.
1:04
And every contraction is pushing 300 to 500 cc's
1:07
of blood back into her circulation. That auto
1:10
-transfusion will spike her preload and her left
1:12
atrial pressure. With each contraction, her dyspnea
1:15
will worsen, her respiratory rate will climb,
1:17
and the fetal heart rate begins to show subtle
1:20
late decels. Let's say you did her epidural without
1:24
too much thought. Now her blood pressure is suddenly
1:26
dropping. There's a mix of sympathetic blockade
1:29
and aorta cable compression. And now her fixed
1:33
stenotic mitral valve can't accommodate the increased
1:37
flow demands. Her pulmonary pressure starts to
1:39
climb, her oxygen saturation is falling, and
1:42
she begins to look overwhelmed by the physiology
1:43
of pregnancy. So there's a lot going on in this
1:46
sort of mini case. And a lot of things for us
1:50
to think about from a physiologic standpoint.
1:53
And if you're not careful with what you're thinking
1:54
about, you could find yourself up a creek without
1:57
a paddle pretty quickly. Well, I definitely want
1:59
to have a paddle and I'm sure our listeners do
2:01
too. Can you tell us a little bit about what's
2:03
going on in the background in pregnancy from
2:05
a cardiac standpoint? Sure. So one of the biggest
2:09
things we think about when we talk about the
2:11
hemodynamic changes of pregnancy is volume expansion.
2:19
angiotensin RAS system and aldosterone, your
2:22
blood volume will expand by about 50%. So that
2:26
could be up to two liters in a pregnant patient.
2:30
And you also get an increase in EPO. So that
2:33
will increase your red cell mass, but not to
2:36
the same degree as your total volume expansion.
2:39
So you actually get a hemodilutional anemia,
2:40
which is beneficial for, let's say you're having
2:44
postpartum hemorrhage, that is beneficial. But
2:47
if you have some cardiac valve lesions that we'll
2:53
talk about later, that can be problematic. Additionally,
2:56
your cardiac output will begin to rise as early
3:00
as five weeks into pregnancy, and it kind of
3:01
peaks about halfway through. Your heart rate
3:04
will increase 10 to 20 beats a minute, and your
3:06
stroke volume rises because of this increased
3:09
preload and afterload that we kind of talked
3:11
about. And then during labor, every uterine contraction
3:16
auto -transfuses. like we had mentioned, about
3:19
500 cc's back into circulation. And this cardiac
3:23
output can increase another 40 to 60 % on top
3:25
of the baseline and peaks immediately postpartum,
3:28
which is something for us to think about during
3:31
delivery. And that rapid shift is why women with,
3:34
for example, mitral stenosis, aortic stenosis,
3:36
and hokum, or pulmonary hypertension, are particularly
3:41
vulnerable during delivery. Makes sense. With
3:43
the change in how the cardiac output is functioning
3:45
during pregnancy, is there a change in things
3:47
like SVR? Well, I'm glad you asked, Nate. Indeed,
3:50
there is. So pregnancy is a decreased systemic
3:53
vascular resistance state, mostly driven by progesterone,
3:57
which relaxes the smooth muscles. The nitric
4:00
oxide production goes up, and the placenta sort
4:04
of acts as a low -resistance circuit during this
4:05
time. Makes sense. I've noticed, too, whenever
4:08
I'm in a C -section, they seem to put this wedge
4:10
under the patient. What's that for? You know,
4:13
I'm glad you asked this because I was very confused
4:16
the first time that the OBs asked me to help
4:18
them wedge the patient. I actually had no idea
4:20
what they were talking about the first time I
4:21
did this. But as the uterus grows, it starts
4:25
to compress the IVC and sometimes the aorta,
4:28
especially when the patient is lying supine.
4:30
And this decreases venous return and reduces
4:33
the cardiac output, causing hypotension and decreased
4:36
utoplacental perfusion, which both of those are
4:39
obviously bad. And then... For us as anesthesiologists,
4:44
the left uterine displacement is kind of like
4:47
what we talked about with the simple wedge on
4:49
the right hip, is one of the most effective interventions
4:51
that we have. I'm guessing if you're asked on
4:53
oral boards, you should verbalize that you're
4:55
putting a wedge under your OB patient. Yeah.
4:58
A little pro tip out there for your CA3s about
5:00
to take boards. These are interesting hemodynamic
5:02
details. How about how clotting works in pregnancy?
5:06
For us as anesthesiologists, it's important to
5:08
think about the hypercoagulable state of pregnancy.
5:11
Fibrinogen and other clotting factors will rise,
5:14
protein S will drop, and resistance to activated
5:17
protein C will increase. And this increases the
5:21
risk of DVT and PE, especially postpartum. But
5:25
it also affects how we manage women with mechanical
5:27
valves and other congenital heart disease because
5:29
they often can require an anticoagulation adjustment.
5:32
Makes sense. Well, thank you. I think this is
5:34
really helpful. Can you bring us home with just
5:36
a summary of some of the cardiac lesions that
5:38
you might need to think about in pregnancy? So
5:40
some of the high -risk cardiac lesions to think
5:41
about during pregnancy, severe aortic stenosis,
5:44
there's a fixed obstruction, and you're really
5:48
going to want to avoid drops in SVR. Mitral stenosis.
5:53
sort of the same principle as aortic stenosis
5:55
and tachycardia is your enemy in both of those
5:58
lesions. For pulmonary hypertension, you're going
6:02
to want to avoid stress in the RV as well. So
6:04
you want to avoid hypoxia, hypercarbia, and acidosis
6:07
during this period or any period when you have
6:10
a patient with pulmonary hypertension. Thank
6:12
you very much, Dr. Sandolo, for making the OB
6:14
world slightly less scary. You're welcome, Nate.
6:16
Thanks for having me. Josh Dresser, thank you
6:25
so much for joining us. Dr. Crow, thank you so
6:28
much for having me. I'm thrilled to be here on
6:30
your podcast. You don't have to call me Dr. Crow.
6:34
I know, I know. But, you know, when you work
6:37
together for this long and you know each other,
6:39
it just kind of hits different, I feel like.
6:41
I think when we call each other Dr. So -and -so,
6:45
it's more to make fun of each other. Sometimes,
6:47
yeah. I guess it depends on the moment, right?
6:50
And what's going down. I've actually... Started
6:53
telling some of our senior residents to try to
6:56
start calling me by my first name instead. The
6:59
goal being to get them used to it. Because I
7:01
remember when I transitioned being in attending,
7:03
I was initially really afraid to call people
7:09
by their first names. So I'm trying to get our
7:13
senior residents to try to transition into the
7:16
first name concept. Yeah, I did residency where
7:19
I now work as faculty. And with that transition,
7:23
it took about three, four years until it transitioned
7:25
away from just being Josh and Dr. Trestor. Yeah,
7:29
that makes sense. Well, thank you so much for
7:32
joining us again. We are here to talk about your
7:36
specialty, which is ICU medicine. Yeah, that's
7:40
right. I've been practicing critical care medicine
7:43
now for, oh my gosh, eight years as faculty.
7:47
And it's been a fun, wild ride to say the least.
7:51
So first off, I want to start with a get to know
7:54
you question before we dive into the ICU world.
7:57
So my favorite get to know you question that
8:01
I have asked on the interview season as well.
8:04
Let's say that you could have over a dinner guest
8:07
and this dinner guest could be somebody from
8:09
history or from fiction or really anybody in
8:13
the world. Who would you invite over for dinner
8:15
and why? Now, I've been asked this question a
8:18
few times throughout my life, and I struggle
8:20
with this question. I think it's hard because
8:22
I have two answers. So can I get permission to
8:25
give you two responses? Is that okay? I mean,
8:27
there aren't any real rules here, Josh. Okay,
8:29
perfect. So my visceral response to this question
8:33
has always been something like... i would go
8:37
i would find somebody from back in time who was
8:39
like a terrible horrible person like a dictator
8:41
or somebody who did some terrible things and
8:44
and try to meet with them before and have a meal
8:47
with them and say don't do the things you're
8:49
about to do this is terrible you don't want to
8:50
do this this is not going to end well for you
8:52
And so that's always been my visceral response
8:54
to this question. But logically, I guess it probably
8:58
isn't as real as I would like to think because
9:00
these types of people don't change. You know,
9:02
they do terrible things and their motivations
9:04
are who knows what. So you want to go back and
9:06
stop Hitler with a good conversation. Right.
9:09
Exactly. Again, that's the that's the naivete
9:11
that comes into this. Good luck. I know. Right.
9:15
But I think my my in my true heart answer is
9:19
actually Anthony Bourdain. an incredibly thoughtful
9:24
person who, like me, enjoyed traveling, exploring
9:27
the world, good food, and interacting with other
9:31
people around him in a way that left meaningful
9:33
relationships. And so he's my honest answer to
9:37
that question. You know, that is perhaps the
9:40
least amount of surprised I've been by the answer
9:42
to the question so far. That just really very
9:45
well matches with what I know of you and your
9:49
proclivity for traveling and everything else.
9:51
I'll take that as a compliment. It is. I mean
9:54
it as such, but it is also just very unsurprising.
9:59
Well, thank you. I appreciate both of those answers.
10:02
I think that you probably won't have much luck
10:06
with the time travel, but otherwise. So let's
10:12
talk about ICU. That's what we're here to talk
10:14
about. I remember when I was doing my ic rotations
10:18
as an anesthesia resident and i remember them
10:23
being busy and i felt very confused much of the
10:26
time and i spent a lot of time writing notes
10:28
and all those things together made me feel like
10:32
that maybe wasn't the type of specialty that
10:35
i should pursue or the specialization but a lot
10:38
of people felt differently so what made you choose
10:41
icu medicine you know i think Our experiences
10:45
in training often have a huge role in determining
10:49
our future as physicians. And when you have an
10:57
experience in training that may be different
11:00
from what it actually is like to practice the
11:03
specialty at its core as a faculty member. I
11:07
think that is where sometimes these types of
11:10
mismatches where some people are like, oh, I
11:11
don't really like the ICU. It just wasn't for
11:13
me. I sometimes remind our trainees to try to
11:16
fill in that gap and recognize that it is very
11:19
different experientially as an attending doing
11:22
critical care medicine, supervising a team, managing
11:25
a group of residents or APPs or other professionals
11:28
in the ICU and caring for a host of patients
11:31
that ultimately you're responsible for. for a
11:35
while be it a few days or weeks um and so that
11:40
they i think the experience from training to
11:42
faculty is is a big is a big difference and what
11:45
made me to answer your question to make me what
11:48
made me love critical care medicine and and find
11:51
i think a lot of joy in it was how the complexity
11:57
of care for me translated into resuscitation
12:03
So I worked in a cardiovascular intensive care
12:05
unit where complex resuscitation is what we do
12:08
quite frequently. We manage patients with complex
12:10
shock states. And I always thought the resuscitation
12:13
in the operating room was interesting. And that
12:17
natural transition between resuscitating people
12:20
in the OR and then doing it in the ICU on a more,
12:25
I would argue, a more frequent basis in the ICU
12:27
with different and more variety pathologies.
12:31
is what made me fall in love with critical care
12:33
medicine so what's different about resuscitating
12:36
somebody in the or versus the icu well i mean
12:40
in the icu you're often doing it on multiple
12:41
patients at once you're not just doing it on
12:43
one person and that that that's when i change
12:46
my hat from like my blue or hat to my bald head
12:49
when i'm in the icu it uh it um that's that's
12:54
the biggest difference for me is that it's the
12:56
multitasking you know it's i've got a patient
12:59
in one bed who we might be resuscitating from
13:01
hemorrhagic shock and in a bed next door to them
13:04
we might be resuscitating from cardiogenic shock
13:06
and we might have somebody who's septic right
13:08
next to them and in the or i might only have
13:11
one patient that i need to really focus on acute
13:13
resuscitation on and then they are it's almost
13:15
always drug shocked from hypotension from the
13:18
anesthesia or a hemorrhagic shock from bleeding
13:20
in the or now that's not always the case certainly
13:23
there's lots of pathologies that go in and based
13:25
on the type of case that you're doing in the
13:27
or But that love of resuscitation really is what
13:32
drove me, I think, to the ICU. So before we talk
13:37
too much more about what you do in the ICU, I
13:40
want to talk a little bit about the pathway to
13:43
becoming an ICU physician. Now, it's a little
13:45
bit different with anesthesia than it is from
13:48
internal medicine, even though you both might
13:50
be doing essentially the same sort of job. Can
13:53
you talk a little bit about the difference between
13:55
how to get there and how you got there versus
13:58
maybe what an internal medicine doc might do?
14:00
Of course. So the classic pathway for anesthesiology
14:05
trained individuals is to do a four -year anesthesiology
14:07
residency, get certified as an anesthesiologist,
14:11
and then do a one -year anesthesiology critical
14:14
care medicine fellowship after. So it's a total
14:16
of five years of post -medical school training
14:18
for folks who want to become an anesthesia trained
14:22
intensivist. There's a number of routes to critical
14:25
care medicine through other specialties, albeit
14:27
through internal medicine, surgery, even now
14:31
emergency medicine is getting accredited through
14:34
our training pathway. I've seen something about
14:37
that, yeah. But multiple specialties offer this
14:40
route in training, and the pathways are different
14:43
based upon the differing certifying bodies. So
14:46
the American Board of Internal Medicine. versus
14:48
the American College of Surgeons and how they
14:50
certify their individuals. The most common pathway
14:54
for those who are IM trained internal medicine
14:57
is to complete an internal medicine residency.
14:59
Most of those are three years. And then to do
15:01
an additional three years of sleep, pulmonology
15:06
and critical care medicine. There are some other
15:08
fellowships that offer just a one to two year
15:11
critical care medicine training for IM trained
15:13
folks. But again, for anesthesia trained individuals
15:16
like ours, it's a four -year residency plus the
15:19
one -year fellowship to become board certified
15:21
in both anesthesiology and critical care. So
15:25
what do you think the advantages are of doing
15:27
an anesthesia residency prior to going into ICU
15:31
care? I have a list that's so long. It is so
15:37
long. And maybe I'm biased given the background
15:40
and the folks that I teach and where I work.
15:44
I think training as an anesthesiologist uniquely
15:49
prepares you to become an intensive care physician.
15:53
And I think this is for a number of reasons.
15:56
First is what we do in the operating room every
15:58
day. The acute resuscitation, the management
16:02
of airway, the management of hemodynamic instability,
16:05
the management of ventilation, both simple and
16:07
complex, the establishment of IV access and arterial
16:12
access. understanding the limits of physiology
16:16
and how that applies to the human body, you know,
16:19
the list goes on. But I think what we do in the
16:22
operating room uniquely prepares you to be an
16:26
intensive care doctor. And your time as a fellow
16:29
training in critical care medicine, where other
16:32
specialties are playing catch up on a lot of
16:34
that physiology and procedural teaching. Our
16:37
fellows are able to run with that already and
16:39
focus on the more very focused critical care
16:42
topics for things like end -of -life care, nutrition,
16:46
interacting with families and the social aspects
16:51
of critical care, how to treat infections and
16:55
manage antimicrobials, for example. So a whole
16:59
host of other things that you can learn about
17:01
in the ICU that... There's a lot to learn. There's
17:06
a lot to learn in all that. But our fellows come
17:09
in uniquely prepared with a lot of that resuscitation
17:11
knowledge and acute care knowledge already under
17:14
their belts. And I think that sets them up to
17:17
be prime ICU doctors to care for some of the
17:20
sickest people in the hospital. And I think that's
17:24
also why anesthesia intensivists are so often
17:27
found in... really complex care ICUs like cardiovascular
17:32
intensive care units where they're managing life
17:34
support pumps and transplant patients and really
17:37
complex cardiopulmonary physiology. So speaking
17:41
of the most complex patients that you might be
17:43
managing, what are some of the big cases that
17:46
you see the most commonly? What are some of the
17:49
big ICU cases that keep you busy all night? Do
17:53
you want to know what keeps me busy or do you
17:55
know what keeps me terrified at night? Because
17:56
those are different things sometimes. I would
17:59
love to know the answer to both of those questions.
18:01
So what makes me scared at night, I will tell
18:06
you, is that there's a whole host of things that
18:10
can be really scary in the ICU, but things like
18:13
pulmonary hypertension. Oh, sure. Right ventricular
18:17
failure. Patients with massive pulmonary emboli.
18:22
And patients with complex airway problems in
18:25
the ICU are the things that I think can scare
18:28
me the most. You know, the things that keep us
18:31
busiest overnight and the things we see most
18:33
commonly, at least in our unit, which is a mixed
18:36
medical and surgical cardiac care unit or cardiovascular
18:40
intensive care unit, we see a lot of cardiogenic
18:43
shock and we see a lot of post -cardiac surgical
18:45
patients. And those two collective things probably
18:50
keep us the busiest. And it's managing the post
18:54
-op care of patients after cardiac surgery that
18:57
our service really spends most of its time doing.
19:01
Now, while I'm not an expert in this, it does
19:04
seem to me like there is a huge need for anesthesiology
19:08
-trained intensivists basically everywhere. Is
19:12
that concurrent with your experience? The last
19:16
sources I read on this said somewhere around
19:19
5 % of all intensive care doctors are actually
19:22
anesthesia trained intensivists. Oh, wow. And
19:25
most people find themselves working in kind of
19:29
an academic environment, tertiary care center,
19:31
somewhere between 70 and 80 % are more focused
19:36
in academic workforce environments. And then
19:39
somewhere 20, 30 % find themselves in private
19:42
practice, community hospital settings, working
19:44
in various ICUs. And so if you're looking at
19:48
nationwide, if there's a need for people to care
19:51
for complex care after surgery, complex cardiopulmonary
19:55
disease in the ICU, then yes, I would argue there
19:59
is definitely a need. The SCCM has predicted
20:04
that there is a potential for a shortage of intensivists
20:07
in the future. Society for Critical Care Medicine.
20:10
Correct. Predicted that there's a shortage for
20:13
intensivists in the future. And even though over
20:15
the last couple of years, there's been a slight
20:17
bump in the number of certifying intensivists
20:20
nationwide, which is a good thing, we're still
20:23
projecting with the increased complex care accompanying
20:26
care in the United States, the increased number
20:29
of patients getting admitted to the ICU. The
20:33
aging population, all of those things collectively,
20:36
there's a forecasted need that we're going to
20:38
need more intensivists. So what kind of shifts
20:43
did you see with the pandemic with critical care?
20:46
Because I know that that was a major touchpoint
20:51
for critical care when the pandemic hit. Everybody
20:55
was talking about ICUs and being on ventilators.
20:57
That was in the zeitgeist. What has been the
21:02
fallout from then now five years later? How has
21:06
it affected the care that you do today? The COVID
21:10
-19 pandemic brought numerous changes to how
21:14
all of medicine in America works. Certainly the
21:18
ICU was a focal point of that, like you said,
21:20
and I worked in it. While I normally do about
21:24
50 % of my time in the operating room and 50
21:26
% in the ICU, that shifted during the pandemic
21:29
where I was doing... closer to 80 % of my overall
21:32
time in the ICU for the 2020 to 2021. The year
21:39
2021 was also the year that had the highest number
21:42
of anesthesia critical care medicine fellowship
21:44
applications ever. Oh, wow. And then it's fallen
21:48
since then. And so I think what came out of COVID
21:53
initially was, like you said, a lot of kind of
21:56
pulp culture concern about Critical illness and
22:00
managing patients with respiratory failure, which
22:02
we've done for a long time in the ICU, right?
22:05
But we suddenly had a large influx of patients
22:08
with acute respiratory failure, ARDS, adult respiratory
22:12
distress syndrome. And this continued until,
22:19
and those numbers stayed high for a while until,
22:21
again, the vaccines came out and numbers started
22:25
to fall as a result of the. the immunity that
22:29
was built throughout the community and things
22:31
people are starting to get better and that which
22:33
is a great thing but with that also has since
22:36
fallen the number of people who've expressed
22:38
an interest in going into critical care and i
22:40
think a lot of this is what people saw healthcare
22:42
workers experience during the pandemic and that
22:46
was things like burnout moral injury challenging
22:53
situations with patients and their families You
22:56
know, the constant questioning of medical science
23:02
and how medical science should be applied to
23:05
patient care. And that left a lot of people wondering,
23:09
do I want to do that? Is that type of world a
23:13
place in which I want to work? And does that
23:15
type of science light my fire? And so there was,
23:21
I think, a paradigm shift in the medical community.
23:27
And there still is, I think, an ongoing shift
23:29
about how complex care and difficult situations
23:34
and long hours and burnout ultimately impact
23:37
your ability to be an effective clinician. I
23:42
remember back when the pandemic was in full swing,
23:45
I got an email, and the email was asking me to
23:49
sign up for critical care shifts, even though
23:52
I'm not technically trained as a critical care
23:55
doctor. I think the idea was that anesthesiologists,
24:00
generally speaking, are better equipped than
24:05
the average doctor to handle a critical care
24:08
environment, even if you don't have specific
24:11
training in that. And I remember signing up for
24:13
some of those shifts that fortunately I never
24:15
actually had to be part of. It had to do with
24:19
the disease was surging versus the numbers in
24:23
the ICU and such. What is your thought? Do you
24:26
think that anesthesiologists are specifically
24:29
capable of handling that sort of situation? I
24:36
would liken this response to if somebody asked
24:41
me to go and be an engineer and build a bridge
24:45
when I haven't built a bridge ever in my life.
24:50
Except maybe in like... an engineering class
24:53
in college or something like that get out the
24:55
toothpicks yeah or maybe you did a rotation in
24:57
the icu as a resident and you learned some tenets
25:00
of icu care but when you're not trained as a
25:03
subspecialty to do it on the regular and you're
25:05
not spending your time as a faculty member doing
25:06
it on the regular i mean how did that make you
25:09
feel did you were you were you like oh i could
25:11
do this 100 don't know let's go i'm ready to
25:13
run to the unit or oh no i was i was completely
25:16
terrified Exactly. And so this is what happened
25:20
during COVID is that we tapped a lot of people
25:22
to do a lot of things that are outside of their
25:25
day -to -day work because we had to. We had to
25:28
lean on some experience because we all recognize
25:33
in emergency situations and staffing shortages
25:36
that some is better than none when it comes to
25:38
experience. And so institutions built these pyramid
25:42
structures of supervision where they would have
25:45
like one ICU trained doctor who would supervise
25:47
10 or 15 other doctors who weren't necessarily
25:50
ICU trained, but had experience doing ICU related
25:53
things. Maybe working as an anesthesiologist,
25:55
which again has a lot of overlap for reasons
25:57
we've talked about already. And then supervising
26:00
that kind of hierarchical structure to manage
26:02
a large number of patients. Thankfully for us
26:04
in the Midwest here in Cincinnati, we didn't
26:06
have to really implement. that type of major
26:09
hierarchy but there were places throughout the
26:11
country in the world that needed to and so i
26:14
i get the tear we as intensivists also had the
26:18
fear of like oh my gosh like are we going to
26:21
be spending days nights weeks at the hospital
26:23
incessantly to do this work because there's only
26:27
so many of us we all know each other and we we
26:31
i remember sitting in a room with all of us and
26:33
thinking things like if we all get sick at once
26:36
What are we going to do? Yeah, yeah, I remember
26:40
those times. But let's also talk a little bit,
26:44
not just about the past with the ICU, but focusing
26:48
a little bit more into the future. There's a
26:51
lot of things that have changed over the past
26:53
few years, and I think a lot of things will continue
26:56
to change, things like AI -driven monitoring,
27:01
analytics, telehealth as applied to ICU. Where
27:06
do you see things going in the next five years?
27:08
What kinds of future things would somebody who
27:11
wanted to do ICU potentially as a future career,
27:15
what could they expect? I mean, the jury's out
27:19
on the role that AI is going to have on our lives
27:22
in the future. But I think that jury is leaning
27:24
toward it saying that it's going to have a big
27:27
effect. The details are what are ultimately going
27:30
to dictate how this new type of technology does.
27:34
thrown into our lives and upends the world but
27:37
things in the icu that stand out to me for potentials
27:40
are definitely decision models early warning
27:43
systems for when patients are decompensating
27:45
ways to import labs and other patient objective
27:49
patient data and get kind of meaningful responses
27:52
for interventions reminder tools for clinicians
27:55
on when to do things and how to do things because
27:59
we all know based on evidence that checklists
28:02
and medicine lead to better patient outcomes
28:04
and so this to me just seems like a kind of a
28:08
smarter form of the checklist you know um as
28:12
i sit here in an office with the checklist manifesto
28:15
right behind me it sure is you're right i didn't
28:17
even notice that that's funny um and so yeah
28:20
ai i think again decision making tools i think
28:22
will be a big thing in the future um but there's
28:27
so much more potential for what it could deliver
28:29
for us you know i see things like Advanced ventilators
28:34
that are able to interpret patients' respiratory
28:37
pathology and then guide the ventilation strategy
28:39
automatically what the patient needs. I see models
28:44
that can predict what type of vasoactive support
28:46
a patient will need and then start the pump automatically
28:49
and then titrate it. You know, a lot of these
28:51
things are things that we as clinicians, as physicians
28:54
or nurses or other ICU or other allied health
28:57
professionals do on the daily. But those are
29:00
things that could free us to do other things
29:02
that we need to do, like interacting with patients
29:05
and families, explaining the course of the illness,
29:08
really providing opportunities for us to do more
29:13
things like research and freeing us from the
29:17
clinical work, which sometimes can be burdensome
29:20
and prevent us from doing the other academic
29:22
things that we as academic physicians also want
29:24
to do. That's one area. Documentation is another.
29:30
We all think documentation in medicine is onerous.
29:32
I do. I think it's terrible. I hate notes. I
29:34
don't like writing notes. I have to write them
29:35
because I worked in the ICU, but I hate them.
29:37
And AI and this technology revolution really
29:41
has a chance to really make, I think, our documentation
29:44
problem in medicine get a lot better. And the
29:47
people that solve that and solve it well, I think,
29:50
are going to be leaders in medicine AI in the
29:53
future. I think that one of the things that I
29:59
remember wishing that I had more time for when
30:01
I was a resident in the ICU was spending more
30:04
time with patient families, being able to discuss
30:07
things with them, being able to help guide them
30:10
appropriately. But I do remember there was a
30:15
very significant part of my day that was spent
30:18
typing things into the computer, often just copying
30:21
them from one place to another, doing secretarial
30:24
work. I definitely feel what you're saying. When
30:31
you're talking to residents about how to approach
30:35
families, that's something that we do in anesthesia,
30:39
but not nearly as often. We're not typically
30:41
discussing end -of -life care with patients that
30:45
are coming for their laparoscopic appendectomy,
30:48
for example. Can you talk about how you like
30:50
to... bring this up with trainees, how you coach
30:54
them through these sort of complex moral situations?
30:58
Yeah, you don't see family members in the operating
31:00
room ever. Oh, I take that. You have to take
31:04
that back. Okay, fair enough. There's the OBOR,
31:08
which I've never seen you in. Take it back. Take
31:10
it back. I take it back. You're right. We not
31:12
as frequently see family members in the operating
31:16
room. But certainly, yes, in the OB suite, for
31:21
sure. Whereas every day in the ICU, we hope patients
31:27
have loved ones that are with them who are providing
31:30
them support and learning more about them and
31:33
wanting to help guide their care. And when patients
31:34
can't make their own decisions, we rely on their
31:38
next of kin, their healthcare power of attorneys,
31:40
their representatives to make decisions for them.
31:43
And those types of discussions are really, really
31:47
important. to guiding patients through their
31:52
critical illness. And it is a huge part of ICU
31:54
care that takes a lot of time to learn, and it
32:00
requires you to be compassionate, patient, caring,
32:06
knowledgeable in what's happening with the patients.
32:09
And it takes time to sit down and explain to
32:13
family members who maybe don't have any medical
32:16
experience or knowledge what... is happening
32:19
and and it is a skill and so i think it's something
32:24
that as anesthesiologists we don't do very often
32:29
but when you get into the realm of icu it becomes
32:32
a big part of your workflow and and i so what
32:36
i would suggest to the residents is while you're
32:39
rotating in the icu use that as a chance to do
32:42
the things you don't normally get to do in the
32:45
operating room interact with those family members
32:49
you know, learn about things like anti -infectives
32:52
and antimicrobials and infections, learn about
32:55
ICU nutrition, about renal replacement therapies,
32:58
about all the other kind of areas of critical
33:01
care medicine that you might have some knowledge
33:04
of in the OR, but you don't use on the daily
33:05
and use that as a chance to kind of supplement
33:07
your knowledge and go forward. And I promise
33:09
you, it will help you become a more multifaceted
33:12
and capable physician. My, one of my favorite.
33:18
patient memories from when I was an intern actually
33:22
was from a transplant ICU and it was a situation
33:27
where we had a patient who had a family member
33:31
that was very critically ill and I guess it's
33:36
somewhat paradoxical that I consider this one
33:40
of my favorite experiences but the experience
33:45
that I had was sitting down and talking with
33:48
a family member over a period of multiple days,
33:52
I think two weeks really in total, about maybe
33:57
it's time to think about withdrawing care. And
34:00
we eventually did. And it was the right thing
34:04
for the patient, I believe, at that time. But
34:08
the family member took a very long time to come
34:13
around to that point of view. And it took a lot
34:16
of time and discussion. But after all of it,
34:20
I remember feeling really that I had done something
34:24
right by the patient and by their family, by
34:27
helping them through that situation. Do you have
34:30
any examples that really affected you or made
34:36
you think more about critical care anesthesia
34:38
from early on or maybe even later in your career?
34:43
I'm reminded of some Patients that I took care
34:46
of in my first couple of years as faculty, respiratory
34:50
failure patients, complex, requiring extracorporeal
34:54
life support, VV ECMO, as we call it, for their
34:57
respiratory failure. And patients who are in
35:01
the hospital, in the ICU for a long period of
35:04
time, took a long while to get better. And I
35:07
remember day -to -day discussions with the team
35:09
of where we're concerned they're not going to
35:11
improve. We're concerned that, you know, where
35:14
they've been in the ICU for 40, 50 days and the
35:18
patient still hasn't gotten better. We're doing
35:21
everything that we know how to do to try to make
35:23
them better. And then we start to see improvement.
35:28
And then they do get better. And we discharge
35:30
them from the ICU. And then they come back months
35:32
later for a visit with the team. Walking, you
35:35
know, smiling with family members. Those cases
35:39
exist for me, a number of them. And similarly,
35:43
I have other cases where people, we do everything
35:46
we can and we're not able to save a life. And
35:49
when we all acknowledge that we're not able to
35:52
save a life, it does feel like you've done everything
35:55
you can and it exhausts you emotionally, intellectually,
35:59
because you've done everything that you know
36:02
how to do, that the medical science has taught
36:04
you how to do, that you can offer to this patient.
36:07
You can't make them better. And then resigning
36:10
to that fact. conveying that to family members
36:13
that that's a hard thing and so both of these
36:16
types of extremes stick with me for different
36:19
reasons obviously but the uh the the nihilism
36:23
that can sometimes accompany icu care the the
36:26
the feeling that oh these people are all sick
36:29
and they're not going to get better is is something
36:31
that i really sometimes push really hard against
36:34
because i have a number of cases where there
36:37
was a lot of nihilism around the patient's care,
36:40
either from providers or other subspecialists.
36:45
And we didn't have anything that stood out as
36:46
being completely irreversible that we couldn't
36:48
potentially fix with more time. And patients
36:51
did get better. And so avoiding that type of
36:54
nihilism in complex critical illness is something
36:57
that I really, really stress to people and say,
36:59
you know what, sometimes we just need more time
37:01
and opportunities to implement therapies and
37:04
try to make improvements before saying that we
37:07
can't fix somebody. Where a really, really, I
37:12
think, thoughtful intensivist can be really,
37:15
really helpful in explaining these things to
37:17
families is really focusing on the things that
37:20
are most likely or definitely going to be irreversible
37:24
versus the things that may potentially improve
37:28
with time. And explaining that to the best of
37:30
your ability is difficult. I haven't ever heard
37:34
it described as that, but as soon as you described
37:39
it as... a sense of nihilism towards certain
37:42
patients that immediately rang true to me. I've
37:45
been in situations where I have seen that happen
37:50
to a care group. So I really appreciate that
37:54
you called that out as something to watch out
37:58
for. It's almost similar to being in a critical
38:04
situation in the OR. and people aren't sure what's
38:08
going on, and somebody says the word anaphylaxis,
38:11
and it catches on, and everybody focuses in on
38:15
one single diagnosis, which may or may not be
38:18
the correct thing. It could be any number of
38:20
things. You're describing anchoring. Yeah. So
38:23
I'm wondering if the anchoring principle also
38:26
is linked to the nihilism that you described.
38:31
In the ICU, we call it care fatigue. Oh, really?
38:34
It's where someone can be in the unit for a long
38:36
period of time. Maybe they're a complex case
38:39
but are slowly improving. Maybe they've required
38:42
a lot of interventions up to this point, and
38:44
a lot of people on the team have cared for them
38:46
repeatedly. But care fatigue is real, and it
38:51
does impact providers. And similarly, it can
38:55
impact patients too. Patients can become fatigued
38:57
to their own critical illness when maybe they're
39:00
trached and on a ventilator, maybe they've been
39:02
in their ICU for a long period of time. And so
39:05
it's hard for everyone in the spectrum of ICU
39:10
care with these long stays. But that doesn't
39:14
mean we can't still work to make people better.
39:16
So let's say you're talking to a resident who's
39:19
considering doing critical care as a fellowship
39:22
or as a career, what would be some questions
39:25
that you would ask them to think about? What
39:29
is it about a resident that you would say, you
39:34
know, you would be a good person for the ICU?
39:37
I would ask them when they look at their day
39:40
-to -day anesthesia workflow, what about the
39:43
day lights or fire? When you come to the operating
39:47
room and you care for a patient, What stands
39:50
out and makes you interested? Do you love the
39:54
physiology, the complex ventilation and resuscitation
39:58
that goes into anesthesia? And do you enjoy doing
40:01
that every day? Do you enjoy the routine of anesthesia?
40:07
Because I sometimes do honestly take solace in
40:10
the routine of anesthesia when I'm in the OR.
40:11
Know that I can have a smooth start to a case,
40:14
a smooth maintenance, a smooth emergence. Patient
40:17
does great and I can go home and everybody wins.
40:19
High five, smiles. It's great. It's a great feeling.
40:22
I love that feeling some days. But if you come
40:24
to work and, you know, your fire is lit by this.
40:28
really interesting case of complex physiology
40:31
that you have to manage and maintain stability
40:33
in or even try to resuscitate from another place,
40:37
then I would say the ICU is a place that you
40:40
should really consider because it allows you
40:43
to practice that every day. If you enjoy talking
40:48
to patients and their family members and you
40:50
think that you can have meaningful relationships
40:53
and conversations with people about the people
40:58
they care about, then I think the ICU is something
41:01
you should consider. What about on the flip side?
41:04
What would it be about ICU work that you would
41:08
say, boy, this was something I didn't really
41:11
anticipate was going to be this challenging.
41:14
And if this is something that's a sticking point
41:17
for you, maybe you should stay away from ICU.
41:19
What kind of concepts do you have for residents
41:23
for that? I would say if you're in the OR and
41:26
you have a complex case and you're like, man,
41:29
I never want to do this again. Maybe the ICU
41:33
isn't for you. That's okay. Maybe it is. And
41:35
that was just a bad day. And that's fine too.
41:37
That happens to all of us. We all have difficult,
41:39
tiring, challenging days. If, like I said, if
41:44
your love is the routine and the kind of rerun
41:49
and rerun of a straightforward general anesthetic
41:51
case, then the ICU probably isn't for you. It
41:55
may be, but I would say that typically is less
41:58
of what we see there. So you are the program
42:03
director for our Critical Care Fellowship. Recently,
42:08
you just got a new track approved for critical
42:12
care. I'd love it if you'd talk a little bit
42:14
about that. Yeah, we're really excited about
42:17
this. Over the last few years, we've been building
42:20
our curriculum. to allow for an integrated five
42:24
-year training program that we're here calling
42:26
the CCMT, or the Critical Care Medicine Track,
42:30
which, again, is an integrated five -year training
42:33
program for folks who are confident they have
42:36
an early interest in critical care, and they
42:38
want to maintain that through their anesthesiology
42:41
training and into fellowship. And so we intend
42:46
to offer this to new resident applicants, and
42:48
I know you're one of our Associate Resident Program
42:50
Directors, which is great. And so we're offering
42:52
it to resident applicants with the intent of
42:56
capturing those folks who are confident that
42:59
they have an early interest in critical care
43:01
and want to practice that in the future. And
43:02
so it will be accompanied by things like early
43:05
mentorship with our critical care faculty, early
43:08
integration into our critical care anesthesia
43:10
team where you'll get invitations to journal
43:11
clubs and other team activities and lectures
43:15
on service. And then it'll be a guaranteed fellowship
43:20
training spot after your four years of residency
43:23
is over. And then you'll come out of this five
43:25
-year combined program with board certification
43:27
in both anesthesiology and critical care medicine.
43:31
You know, that's really one of the greatest things
43:35
that we've been able to do in the past few years,
43:37
I feel like, is offer a combined track. Is this
43:39
something that you've seen a lot of programs
43:43
doing? Definitely some other large academic centers
43:47
have offered programs like this in the past and
43:49
still do. One of the reasons we really wanted
43:53
to implement it here is because I think we have
43:56
a strong critical care division in our department.
43:58
We have dedicated, interested faculty who really
44:01
like the specialty, and we wanted to take that
44:04
group of faculty and allow them to build the
44:07
next generation of critical care intensivists.
44:11
By offering this type of program, it allows us
44:13
to capture folks early on who have that interest
44:16
too and try to match interest to place. And so
44:20
what I would say to any applicant who's considering
44:23
anesthesiology because they have a love for critical
44:25
care, this type of program may be something that
44:28
you have a strong interest in to reach out to
44:31
us. So if you're applying in residency from medical
44:35
school and critical care is something you're
44:38
strongly interested in. Lastly, as we sort of
44:43
wrap up, I wanted to ask you the style points
44:46
question. You're allowed to chuckle at me for
44:50
that. What I'm curious about, Josh, is what style
44:54
points have you carried with you that have helped
44:57
you in your life and career in the operating
45:01
room, in the ICU, et cetera? I think one of the
45:07
things that I try to emphasize when I'm at work.
45:11
is I try to save the drama for elsewhere. Because
45:17
there's always the potential in the ICU or the
45:20
OR for things to get busy, hectic, challenging,
45:26
dramatic, complex interpersonal relationships,
45:29
both with other healthcare providers, patients,
45:34
and families. And so I think if you save the
45:37
drama, And you focus on the medicine and the
45:41
person in front of you and the people around
45:43
you and recognize that everyone around you is
45:46
trying to do good by the patient. That has carried
45:51
me, I think, the most. When I reflect on this
45:54
individually, I think that's the style point
45:58
that I think that I would most like to convey
46:00
is that, you know, let's save the drama for another
46:03
time and do what we're brought here to do. josh
46:09
this was really fun thanks for joining me and
46:11
talking about this stuff thanks john thanks for
46:18
joining us for this month's episode this month's
46:21
episode marks a milestone of two full years of
46:23
the podcast so far we've been able to release
46:26
an episode every month i'd like to thank my anesthesia
46:30
department here at uc for supporting the podcast
46:32
and making it possible as well as my co -host,
46:35
Nate Moore, and the guests I've been lucky enough
46:37
to talk to over the past couple of years. Importantly,
46:40
I also want to thank you for listening. I hope
46:43
you found it enjoyable so far. If you have been
46:46
enjoying the podcast, feel free to let me know
46:48
by giving us a five -star rating or review on
46:51
Apple Podcasts or Spotify. It helps other anesthesia
46:54
enthusiasts find the show. You're also welcome
46:57
to email me at stylepointspodcast at gmail .com.
47:02
Lastly, Take a deep breath. Open your eyes. We're
47:11
all done. If you figure out all the languages,
47:18
email me and I'll send you a prize.