Stabilityisanillusion.

Everyaspectofaperson'sexistence(bothinternalandexternal)
fluctuatesatvaryingfrequencies,withobviousindividualdifferencese.g.hormonalflux
(daily,monthly,andoveralifetime),physicalfitness,degreeof"success",etc. Ona
larger scale, I perceive life as a series of background, though frequently
dominant,vicious cycles. Often viewed (and sounding) negative, I define these as
sequencesofreciprocalcausesandeffectsinwhichtwoormoreelementsintensifyand
amplifyeachotherendlesslyunless"broken".Theycanbepositiveornegative.Ifthis
soundssimilartothetheoryofbiorhythms,apseudoscientificfadpopularinthe1970s
which applied mathematical formulas to the three oscillating variables (emotional,
physical,intellectual)tomakedailypredictionsbasedonbirthdate,ImustadmitthatI
wastheprobablytheonly8yearoldkidwhosefavoritepartofthenewspaper(exceptfor
theSportssection)wasthedailybiorhythmchart!
Indailylifetheintensityofcyclingoftencorrelateswithselfesteem.Intheextreme,a
glasshalfemptytypewillperceiveeverychallengeasinsurmountable,everyoversight
asapersonalaffront.Increasedstressandnegativeinternalfeelingsresult.Aconstant
frownandquicktemperincreaseisolation.Thecycleturns.
A glass halffull type will feed off random fortuitous events, increasing personal
satisfactionandconfidence.Energeticandsociable,interactionswiththeworldreinforce
hispositivesenseofself.
Formostofus,maintainingabalanceofyinandyangisthegoal.Whenbadbecame
worseforme,mymomusedtosay,thistooshallpass.

AsanICUphysician,Iutilizetheviciouscycleconceptwhenteachingandwhenhelping
surprisedfamilymembersunderstandwhytheirlovedone,sovitalonadmission,willnot
survive.Anegativeviciouscycledefinesthelastdays,weeks,etc.ofmostprolonged
hospitalizationswithanunhappyending.Unlesstheoriginalinsultisselflimited(e.g.a
viralinfection)orisinterruptedbyexpeditious,appropriatediagnosisandtreatmentin
"time" to avoid the next derangement, the patient will becaught in a vortex. Age,
comorbidity,andqualityofcarearerelevantvariables.Hospitalsarenotoriouslyharsh
environments.Patients are subject tomultiple local or systemic insults (e.g. device
related infection, inactivity, poor nutrition), thatprolong hospitalization andresult in,
orpotentiate, other undesirable physical and emotional effects such asgeneralized
weakness,lossofgutandskinintegrity,stress,depression,etc.Redundantandpernicious
cycles carry the patient further and further from the premorbid state despite some
expectedvariability(gooddaysandbad").
Thereisarelativelynarrowbutvariable"window'oftimebeforeagivenpatiententers
the"hospitalviscouscycle".Thoughmeasurescanbetakentoforestallentryorbreaka
cycle, a long enough hospital course makes the phenomenon nearly inevitable. A
relativelybriefanduncomplicatedhospitalstayagesevenapreviouslyhealthyand
youngpatient.Withtheexceptionofmanyelectivesurgicaladmissions,itisraretobe
dischargedwithoutrequiringsubstantialtimetoregainpreviousvigor.
Liketheworksofaprolificromancenovelist,thecastofcharacters,setting,andplotare
unique, but afamiliar theme marks the course of each patient that succumbs to the
cycle.A typical case begins when a reasonably healthy elderly man, Mr. X, slips,
sustaining a hip fracture. Despite appropriate perioperative support and expeditious
surgerythepatiententersadownwardspiralleadingtodeathintheneartermor,often
worse,intheintermediatetermwithoutreturninghomeorregainingsignificantfunction.

ThoughMr.Xinitiallydoeswellanddischargeplanninghasbegun,onpostoperativeday
2herunsalowgradefeverattributedtoaninfiltratedintravenousline.Heistiredand
anxious,uncooperativewithphysicaltherapyandrefuseslunch.Mr.Xisprescribeda
lowdosebenzodiazapineasasleepaid.Paradoxically(butnotsurprisingly)hebecomes
deliriousthatnight,requiringmoremedication.Hebecomesdehydratedasthecareteam
doesnotanticipatehisneedforwater.Nowsomnolent,inbedandquiteweak,hisvoice
iswetandhiscoughisinadequatetocleartenaciouslungsecretions.Anewchestxray
revealspartialleftlungcollapseasretainedmucusplugblocksanairway.Anewfever,
rising white blood cell count and green sputum are suggestive of hospitalacquired
pneumonia.Culturesaredoneandantibioticsarestartedempirically.Despitethis,MrX
continuestodecline.Heremainsinbed,eithersleepingorconfused.Heisswollenand
pale.His breathing becomes labored andirregular.Heis immuneto theencouraging
words and increasingly frantic exhortations of his family. Intermittent moans and
restlessnessspeaktohisdiscomfort.HisfamilyiscalledtogetherbythePalliativeCare
Teamjoinedbyhisprimaryphysicianandhisbedsidenurse.Thedecisiontoinitiate
"comfort"careismade.Mr.Xistransferredtoahospicefacilitywherehepassesaway.
Thescenariodescribed(andallitspermutations)isplayedoutdailyineveryhospital.
Restoring"health"whileminimizinghospital"exposure"shouldbethecombinedfocus
ofthehealthcareteam.Toalargedegree,theoutcomeofamajorityofpatientsadmitted
toanacutecarehospitalispredeterminedorrelativelyindependentofthecareprovided.
Attentiontothe"littlethings",oftenovershadowedinitiallybythedominantissue,is
oftenthekeytoescapingthe"cycle"fortheminorityofvulnerablebutviablepatients.
Provisionofadequatefood,water,activityandsleepwhileminimizinglocalexternal
stressors(e.g.excessiveambientnoiseandunnecessarydisruptionstothesleepwake
cycle) and avoiding seemingly inconsequential medical errors is both asubstantial
challengeandessentialforthiscohort.

Onapositivenote,occasionallyapatientclearlytrendinginthewrongdirectionwill
haveagoodperiod.Intheabsenceofadefiniteterminaldiagnosis,andinthepresenceof
meticulouscaremakingitpossibletostringtogetherasustainedperiodofgooddays
(sufficientcalories,exercise,nonewinsults),Iwillworkhardtohelpthepatientclimb
outofadeephole.Thoughreachingthegoalisrare,itistrulyprecious!

TheLittleThingsthatmakeabigdifferenceitsallaboutANTICIPATION!

Wheneverappropriateandpossibleensureadequatecaloricintakeusingthegut

Watchforearlysoftsignsofsepsis,e.g.muscletwitching,lowbody
temperature,rapidbreathing

Ensureadequatehydration

RemoveanyunnecessarylinesandcathetersASAP

Usemeasurestoensureadequatesedationbutavoidoversedation

Utilizephysicaltherapistsearlyandoftencommunicateneeds

UtilizeDoctorsofPharmacy(PharmDs)ifavailabletheyareindispensible

Handwashing

Ifwelcomedusealternativetherapiestodecreasestress,e.g.musictherapy,
touchtherapy,etc.

Doeverythingpossibletoavoidskinbreakdown

Beverycautiouswhenprescribingpsychoactivemedicationstotheelderly

Useappropriateprophylaxis,e.g.VTE,stressulcer

Thinlungsecretions(guaifenisin,hydration)andutilizecoughtrainingwhen
appropriate

Beparsimoniouswithbloodtransfusion

Foreseeratherthanreacte.g.restorepotassiumandmagnesiumasyougivea
drugthatwillincreaselossofwaterandsalts(diuretics)beforeaconsequence

Valueandimprovethemechanismstotransferpatientstoalowerlevelofcare
andbedischarged

UtilizepreICUorprecodeteamse.g.MedicalResponseTeams

DavidRSchwartz
ICUphysician
AssociateprofessorofClinicalMedicine,NYULMC