While the majority of the 11th annual conference by the Foundation for the Advancement of Cardiothoracic Surgery was focused on cardiac surgery topics, Dr. Namrata Patil, the Director of the Thoracic Intermediate Care Unit (and thoracic surgeon) at Brigham & Women’s Hospital in Boston, MA gave an excellent presentation on the management of critically ill thoracic surgery patients.
Early Intervention, Rapid Response versus Failure to Rescue
Rather than an exhaustive review of the literature, Dr. Patil’s lecture gave a much-needed bedside perspective on the care of these patients. She stressed the importance of remaining hypervigilant as well as the need for early identification and early, aggressive intervention in these patients.
While the majority of the conference focused on ECMO, LVADs and transplant patients, Dr. Patil’s presentation was a crucial reminder of the pitfalls of falling into complacency when caring for our vulnerable thoracic population. While these patients do not always attract the attention that patients with artificial life support mechanisms (like Heartmate II patients), it is a mistake to think that these patients are less fragile or critically ill. By definition, these lung patients, (who frequently have underlying lung disease and other serious comorbidities) are compromised – and acutely ill.
This means that clinicians need to shift their focus from the intensive care unit to the telemetry and floor units without losing their critical care perspective. Too often, when patients are transferred to step-down units, critical care concepts are relaxed because of preconceptions based on assumptions regarding patient acuity. But as anyone with thoracic experience knows, a ‘stable’ patient can easily descend into a downward spiral if not managed aggressively.
“Is this acceptable to me?”
As Dr. Patil reminds us, clinicians need to be vigilant when caring for patients of all acuities. She’s not asking us to chase ‘zebras’ but instead gently reminding clinicians not to dismiss important clinical findings. Instead of attributing low-grade fevers and cloudy X-rays to atelectasis, intervene early to prevent the next step in deterioration; pneumonia or respiratory compromise. Remain vigilant to detect later stage complications instead of racing to discharge on marginally functional patients.
She encourages clinicians to educate patients, providers and families; to teach as part of efforts to prevent complications. She also advocates for the increased development of protocols specific to the thoracic surgery population and better communication with all members of the care team; including the patients and their families.
Ethics and Advocacy
She also spoke on the ethics of caring for these patients and advocating for the rights of patients, particularly elderly patients. In an era of increased awareness of POAs, and Advance Directives, there is often a push (from the hospital administrators, nursing staff, and other medicine specialities) to advocate for a Do Not Resuscitate (DNR) code status. Unfortunately, many of the people pushing for this designation have forgotten that this is part of a patient’s right – and automatically assume it should be a decision based solely on age. This ageism is contrary to our duty to protect, to advocate and our patient’s right to self-determination.
This ageism also ignores one of the widely held truths in our society; that for many people, “Age is just a number” and that the patient’s functional status may not reflect their actual age. We’ve all met 50 year-old patients who have been debilitated by chronic and prolonged illnesses and may have a much poorer functional status than an active, alert 80 (or even 90) year-old patient. Assigning or encouraging a DNR status in these patients based on age is not only incorrect, but unethical.
In a time of an increasing push for standardized, ‘one-size-fits-all” care and ‘Angie’s List” style medicine with emphasis on short length of stay and rapid discharges, Dr. Patil’s more personalized approach will actually engender better clinical outcomes by reducing morbidity, mortality, and re-admissions. It also helps clinicians, like myself, sleep better at night – knowing we have been as aggressive as possible to prevent complications in our patients.
Using 3rd world skills to augment diagnostic technologies
Dr. Patil’s talk also highlighted the importance of clinical judgement and clinical skills in caring for these patients. While heart patients routinely have advanced life support and hemodynamic monitoring devices such as Swan Ganz catheters, NICO and telemetry, excellent clinical skills are needed when relying on less invasive measures such as physical exam and basic radiology. Her background, of practicing medicine in India (and the related limitations in resources) has added to her skills as a clinician and diagnostician without relying on expensive or extensive use of technology. In an era of rapidly expanding concerns regarding resource management and cost-containment, this skill is crucial, just at a time when new medical school graduates are focusing more on advanced diagnostics over basic clinical assessment skills.
Dr. Namrata Patil
Dr. Namrata Patil is a polyglot (English, Urdu, Spanish, Hindi and Marathi) with extensive surgical and intensive care experience. Originally trained as an ENT surgeon, over the years she has added to her body of knowledge with residencies in Burn/ Trauma, Psychiatry, Thoracic Surgery and Surgical Critical Care.
She is an associate surgeon at the prestigious Brigham & Women’s Hospital in Boston, MA as well as a Professor of Surgery at Harvard Medical School.
Her most recent list of publications reflect her wide range of training and experience.
1. Checkley W, Martin GS, Brown SM, Chang SY, Dabbagh O, Fremont RD, Girard TD, Rice TW, Howell MD, Johnson SB, O’Brien J, Park PK, Pastores SM, Patil NT, Pietropaoli AP, Putman M, Rotello L, Siner J, Sajid S, Murphy DJ, Sevransky JE. Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*. Crit Care Med. 2014 Feb; 42(2):344-56.
2. Weinhouse GL, Schwab RJ, Watson PL, Patil N, Vaccaro B, Pandharipande P, Ely EW. Bench-to-bedside review: delirium in ICU patients – importance of sleep deprivation. Crit Care. 2009; 13(6):234.
3. Lumeng JC, Patil N, Blass EM. Social influences on formula intake via suckling in 7 to 14-week-old-infants. Dev Psychobiol. 2007 May; 49(4):351-61.
4. Memtsoudis SG, Besculides MC, Zellos L, Patil N, Rogers SO. Trends in lung surgery: United States 1988 to 2002. Chest. 2006 Nov; 130(5):1462-70.
5. Lindblad-Toh K, Winchester E, Daly MJ, Wang DG, Hirschhorn JN, Laviolette JP, Ardlie K, Reich DE, Robinson E, Sklar P, Shah N, Thomas D, Fan JB, Gingeras T, Warrington J, Patil N, Hudson TJ, Lander ES. Large-scale discovery and genotyping of single-nucleotide polymorphisms in the mouse. Nat Genet. 2000 Apr; 24(4):381-6.
6. Malathi A, Damodaran A, Shah N, Patil N, Maratha S. Effect of yogic practices on subjective well being. Indian J Physiol Pharmacol. 2000 Apr; 44(2):202-6.
7. Cargill M, Altshuler D, Ireland J, Sklar P, Ardlie K, Patil N, Shaw N, Lane CR, Lim EP, Kalyanaraman N, Nemesh J, Ziaugra L, Friedland L, Rolfe A, Warrington J, Lipshutz R, Daley GQ, Lander ES. Characterization of single-nucleotide polymorphisms in coding regions of human genes. Nat Genet. 1999 Jul; 22(3):231-8.
I have asked Dr. Patil for a copy of her presentation for use on this site. As soon as these slides are published at facts-care.org, I will provide a link for readers.