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Video Transcript: Surgical Critical Care

Part One:

Ellen Beth Levitt: Welcome to Maryland Health Today. I'm Ellen Beth Levitt. On the show today we'll discuss critical care medicine and find out the questions you should ask if you have ever a loved one in intensive care. My guest is Dr. Steven Johnson, chief of surgical critical care at the University of Maryland Medical Center, which includes the R Adams Cowley Shock Trauma Center. Dr. Johnson is also a professor of surgery at the University of Maryland School of Medicine.

Ellen Beth Levitt: Welcome to the show.

Steven Johnson, M.D.: Thank you. Glad to be here.

Ellen Beth Levitt: Could you tell us about your job as head of surgical critical care? What does that involve? And how many units do you oversee?

Steven Johnson, M.D.: As the chief of the division of surgical critical care I have a multidisciplinary group of physicians who help take care of the sickest people in the hospital, as well as caring for people from throughout the state who have critical illness or critical injury. We have all together six surgical ICU’s in the University of Maryland, including three in the shock trauma center. They run about 40% of all the shock trauma beds and we keep them pretty full all the time with critically injured patients that get flown in to shock trauma.

Ellen Beth Levitt: What is the difference between surgical critical care and intensive care?

Steven Johnson, M.D.: Surgical critical care is a component of the overall field of critical care medicine. There is different areas of surgery critical care, pediatric critical care, anesthesia critical care.

Ellen Beth Levitt: Some places call it intensive care, others call it critical care but it is the same kinds of patients and support systems?

Steven Johnson, M.D.: Yes those are synonymous words and oftentimes interchanged.

Ellen Beth Levitt: I have heard the term intensivist, a specialist in critical care medicine. Could you tell us a little bit about what an intensivist is?

Steven Johnson, M.D.: An intensivist is a physician specially trained in caring for people with critical illnesses and critical injuries typically board certified with an additional certification in one of the other specialties, whether it is surgery, anesthesia, pediatrics, pulmonary critical care.

Ellen Beth Levitt: Interesting. Are a lot of intensive care units using intensivists nowadays?

Steven Johnson, M.D.: We use intensivists in our care units. There is an overall shortage of properly trained people for this. We feel it is important to have an intensivist available around the clock 24 hours a day 7 days a week helping care for our critically ill patients. Having an intensivist readily available has been shown to reduce mortality rates, and reduce time patients spend in an ICU. It is one of the criteria the leapfrog organizations uses to document and demonstrate excellence in critical care and something we have quite a bit of pride at the University of Maryland, having been a leapfrog participant and successfully meeting those criteria for the past three years.

Ellen Beth Levitt: The group as I understand it grew out of the business round table. And that is a group of corporations and the big insurance companies, and their whole goal with his to save money in either covering people for insurance or having their employees having healthcare and they came up with quality measures, which would lead to the best outcomes and they figured the better someone's cared to the fewer complications they have the fewer times they have to be remitted to the hospital, the less costly their hospitalization or care would be. And I know the University of Maryland medical center has been one of the leapfrog top hospitals for three years in a row. So that is interesting, though, that the intensivist coverage is one of the quality measures they look for. What are some of the needs that your patients have? Why would someone need surgical critical care?

Steven Johnson, M.D.: The surgical critical care population is typically people who have undergone a major operative procedure. They typically will be on a ventilator or breathing machine after that surgical intervention. So being able to manage a ventilator and manage the pulmonary system is really fundamental to taking care of this patient population. But they also have specific needs and they are specifically at risk for certain complications such as bleeding and infection. That are specific to the surgical population. So, it shares a lot of aspects with other forms of critical care, special needs of critical care but had specific aspects that are specific to the field itself.

Ellen Beth Levitt: Sometimes people in intensive care need a trach tube.

Steven Johnson, M.D.: We have to apply the air directly in through a breathing tube. Goes through the mouth through the vocal cords into the windpipe. When we do a tracheotomy, what we do is put a small incision at the base of the neck, right about where mai thai is. And do an incision that goes directly into the windpipe and put the tube directly there. That allows us to reduce the complications associated with the breathing tube going down the mouth but it also is more comfortable for the patient to have the procedure done.

Ellen Beth Levitt: Can they still talk?

Steven Johnson, M.D.: While they are on the breathing machine they can't. But when they come off even with a trach in place, we can give them a special valve that allows them to talk.

Ellen Beth Levitt: I guess this is important for some people who have severe inability for their lungs to function properly.

Steven Johnson, M.D.: Yes. When people have severe problems with their lungs and their inability to exchange oxygen properly or get rid of carbon dioxide properly, being on a ventilator helps in augmenting and supporting that patient and getting them over the period of time that they are injured to have their critical illness.

Ellen Beth Levitt: So it is kind of like a bridge?

Steven Johnson, M.D.: It is a bridge. Breathe being on a breathing machine done in and of itself change things. It supports it is patient while the lung improves.

Ellen Beth Levitt: There is also something that supports the lungs.

Steven Johnson, M.D.: It is a step beyond breathing machines. In that situation, we actually take blood out of the patient, run it through and oxygen nature the blood and put it back in the patient. It pushes air into the lungs and lets the lungs exchange with the blood, but this actually changes our ability to support and actually provides that interface between the blood and oxygen and pushes oxygen into the blood itself. We have got quite a bit of experience using it, at the University of Maryland and at shock trauma and we are very happy with our success rate. We have been doing this for a number of years. Very recently, there is a major study out of England that showed providing it to patients early makes a difference in their outcome, something we have been seeing as well.

Ellen Beth Levitt: There is a newer device. I know the chief of cardiac surgery has been working on this to have a small portable artificial lung that would enable someone instead of lying in bed immobile, sedated while they are being supported, to actually walk around and even get on a treadmill?

Steven Johnson, M.D.: Yes.

Ellen Beth Levitt: While they are waiting for perhaps a lung transplant or something else that can support their lungs?

Steven Johnson, M.D.: That's correct. You know one of the great things about being in critical care is I get to interface with a lot of really smart people like Bart Griffith. With that his efforts have been a tremendous asset, especially for his group of patients that need lung and heart transplants along the way.

Ellen Beth Levitt: Let me also ask you about supporting the kidneys. I know sometimes in critical care the kidneys might fail and you need to support them. Is the device you used in intensive care similar to kidney dialysis someone would have if they need dialysis on the outside?

Steven Johnson, M.D.: The people who have problems with organ failure involving their kidneys, we can do that dialysis, but frequently because of their critical illness and the fact they have low blood pressure or are in shock, we can't do the dramatic changes in fluids that intermittent heme know dialysis causes. In that it can go from many days on end where we are just continuously filter the patient. It is a smoother and more efficient way of taking care of the kidney function.

Ellen Beth Levitt: We saw a picture of someone in an intensive care room and you can see all of the different equipment and so forth. So many machines to support people. I guess do you also have something to support digestion when people are in this kind of critical care situation?

Steven Johnson, M.D.: Yes. You know, in critical illness, oftentimes the intestines and the stomach will go to sleep. Creates what we refer to as an ileus, and it becomes difficult to get them adequate nutrition. In that situation, we'll do a couple of things. We would prefer to use the intestines, because that is the best route forgetting nutrients in and we will sometimes place tubes. Other times we have to completely forego using the intestines the norm mat way, and we'll instead directly deliver the nutrients into the bloodstream.

Ellen Beth Levitt: Is there anything to support the liver? I think of all the major organ systems, they say if your liver isn't working you can't live. But is there something that is coming down the pike, so to speak, that would support a liver?

Steven Johnson, M.D.: The liver, as you alluded to, is a very complex organ and has multiple functions that have been very difficult to fully rep kate along the way. New machines are coming out for liver dialysis close on the horizon and hopefully will be available in the very near future.

Ellen Beth Levitt: With all this going on, a patient's family must be very concerned and have a lot of questions. What are some of questions a family member should be asking and things they should be looking out for?

Steven Johnson, M.D.: Probably the most common questions we get asked are prognosis and how is my loved one doing.

Ellen Beth Levitt: Sure.

Steven Johnson, M.D.: Those are obvious questions that weigh heavy on everyone's mind when they see their loved one lying if a bed hooked up to machines along the way. What I tell folks along the way, as they go through this process is I try to keep them abreast on what is going on with your organs going through an update from a day-to-day basis and updating them from the day before. And also, what's going to be going on in the next 24 hours, 48 hours. What am I looking for; both good and bad, to say that something is getting better, things are getting worse along the way. I stress to families they should write their questions down. Far too frequently I get done talking for a prolonged period of time I walk out of the room, ten minutes later they have the question that they had to ask me, they had forgotten. Write them down. I prefer when families come with a list of questions that we can walk through together. And answer directly. The other thing is families should not be afraid of writing down the answers. It helps in communicating to the other loved ones that couldn't be there at the meeting. It also helps in slid identifying what is going on for them.

Ellen Beth Levitt: And they can kind of think about it more and let it sink in, and analyze what is happening, though.

Steven Johnson, M.D.: The other things I tell patients in the ICU, if I say something you that don't understand, stop me.

Ellen Beth Levitt: It's okay. People are probably afraid to question or to probe in that way. But that is the only way they are going to get the information?

Steven Johnson, M.D.: That is exactly right. It is a waste of both of our times. But they may not be some words people understand on a regular basis. Just stop me. I prefer it if they stop me and say what do you mean? I'm okay with that.

Ellen Beth Levitt: Now infection must be something that is a big concern when someone is immobilized in critical care and so forth. What is sepsis?

Steven Johnson, M.D.: Sepsis is the body response for an invasive infection. It can be a situation in which bacteria gets into the bloodstream, but doesn't have to be. It can be as simply as pneumonia is causing an effect on the body or an abscess in the abdomen men causing an effect on the whole body. It is the body response to an invasive infection.

Ellen Beth Levitt: I guess in the critical care unit you have to really be on top of any signs somebody might be getting an infection and so forth?

Steven Johnson, M.D.: Yes. We would key in on infections quite a bit. Because infections leading to organ failure is our most common reason die in a surgical intensive care unit. Our goal is to try to find andee eradicate infections early on in the process before they have an effect on the other organs.

Ellen Beth Levitt: What are some of the symptoms of sepsis?

Steven Johnson, M.D.: Most commonly we look for elements of fever. We look for heart rate going up, respiratory rate going up or the need for more support on the ventilator. We look at changes in the mental status or confusion of patients along the way. Low blood pressure can be a sign of septic shock.

Ellen Beth Levitt: Can you usually overcome these when they are identified early?

Steven Johnson, M.D.: If you identify them early your chances of surviving are better. Our ability to treat them is easier. So we can get people, too. But typically, people who get have sepsis run at least a 25% chance of dying. If they get septic shock it is oftentimes over 50%.

Ellen Beth Levitt: Well, we have to take a break. When we come back, we'll talk about a condition known as pancreatitis. Stay with us. We'll be right back.

Part Two:

Ellen Beth Levitt: Welcome back to Maryland Health Today. I'm Ellen Beth Levitt. On the show we are talking about critical care. My guest is Dr. Steven Johnson. He is chief of surgical critical care at the University of Maryland medical center, including the R Adams Cowley Shock Trauma Center. Dr. Johnson is also a professor of surgery at the University of Maryland School of Medicine. I know that one of the areas of special interest for you is a condition called pancreatitis. Could you tell us what that is?

Steven Johnson, M.D.: Pancreatitis is an inflammation of the pancreas where the pancreas actually has injury to it that causes it to have problems with flawed, building up around it, as well as the juices of the pancreas eating away at the tissues around it.

Ellen Beth Levitt: What is the pancreas? What is its role? What does it do for us?

Steven Johnson, M.D.: The pancreas sits in the middle of the abdomen above your belly button but below your rib cage extends from its close association next to the duodenum on the right hand side all the way to the spleen on the left hand side. It has two big functions to it. One it produces hormones, insulin and glucan. The other part of it is help in digesting meals that we eat. So it has a digestive function as well. In doing so it creates enzymes that will breakdown proteins.

Ellen Beth Levitt: To help us digest our food?

Steven Johnson, M.D.: To help us digest our food.

Ellen Beth Levitt: You were talking about insulin. That is why whether people have problems with their pancreas, they can become diabetic?

Steven Johnson, M.D.: That's correct.

Ellen Beth Levitt: How does pancreatitis occur? What cause if his.

Steven Johnson, M.D.: Pancreatitis can be caused by many different things. Most commonly it is a result of gall stones or alcohol. That accounts for about 40% each. The remaining 20% is a variety of different causes from medications to scorpion bites to just being, having the mumps or viral where the body actually attacks the pancreas.

Ellen Beth Levitt: What are some of the things people might feel if they have pancreatitis?

Steven Johnson, M.D.: The most common symptom is pain in the mid-portion of their abdomen. That pain can be excruciating and drill directly toward their back. It can also be associated with nausea, vomiting, patients may get a little bit jaundice, the whites of their eyes may turn yellow. They can get into problems with having a low blood pressure as the inflammation gets worse. Going from being feeling fine from one day to the next day being in a severe pancreatitis is not unusual.

Ellen Beth Levitt: You mentioned gall stones often can cause this. What actually happens the stones get out of the gall bladder and block a vessel going to the pancreas?

Steven Johnson, M.D.: Blocked the pancreatic duct, the main tube that extends the whole length of the pancreas. That happens when the bile duct has a gall stone in it. You see there the gall bladder is the big green bag that sits there and a stone can travel down the low tube to the main bile duct. It travels and normally would take bile directly to the duodenum.

Ellen Beth Levitt: What if the enzymes can't get out of the pancreas?

Steven Johnson, M.D.: They will build up and start eating away the pancreas itself. There is a lot of protein in the pancreas but also the surrounding structures around the pancreas will start getting broken down. The enzymes are doing what they are supposed to do inside the intestine but now they are outside the body. They are like consuming the organ.

Ellen Beth Levitt: That is terrible. My Goodness. Are there good treatments for this if it is caught early?

Steven Johnson, M.D.: If it is caught early, depending on the cause, we have various interventions we can do. One of the biggest things we need to do is support the patients with aggressive fluid support as well as maintaining their blood pressure and overall tissue profusion, but also by making sure they get enough oxygen out of their tissues keep other organs from shutting down.

Ellen Beth Levitt: How often does it happen where pancreatitis becomes that severe where they might need intensive care? Are most cases kind of mild?

Steven Johnson, M.D.: When we look at pancreatitis overall it is typically what most people haven't heard about but occurs frequently. 200,000 people in the united states each year get pancreatitis. Fortunately 80% have a mild form but roughly 20% of them will have a severe form that requires them to go to the intensive care unit and be in a life threatening situation.

Ellen Beth Levitt: If you took out the pancreas would that solve the problem?

Steven Johnson, M.D.: Then you wouldn't have the normal functions of the pancreas would be there. Only in severe situations will we take out the pancreas and the response to acute pancreatitis. In that situation, actually the digestive enzymes the pancreas has produced has already killed most of the pancreas. We are just cleaning up if you will and removing the dead pancreas.

Ellen Beth Levitt: If it is caught early and is caused by gall stones, would the answer be to do surgery and take out the gall stones that are blocking that vessel?

Steven Johnson, M.D.: This is a situation in which close collaboration with our gastroenterologist and other surgeons who do ERCP, where they can go in and actually remove the gall stone with a lighted scope placed down through the mouth to get that stone out of the bile duct.

Ellen Beth Levitt: So you don't need a big incision and surgery and that sort of thing?

Steven Johnson, M.D.: No. Oftentimes we can get by with very small incisions if necessary at all. The first step is to get the stone out of the bile duct. We leave that obstruction, and when the patient gets better, we'll come back with a laparoscopic cholecystectomy and keep any further stones from going down.

Ellen Beth Levitt: The cholecystectomy is a gallbladder removal?

Steven Johnson, M.D.: That's correct.

Ellen Beth Levitt: You mentioned some medicines can cause pancreatitis. Are they common? Or kind of rare ones?

Steven Johnson, M.D.: There are both. The common ones that we see associated with pancreatitis are things such as a water pill commonly prescribed. Other medications used for different auto immune diseases.

Ellen Beth Levitt: If you have a family member who has had pancreatitis are you at higher risk?

Steven Johnson, M.D.: If there is a very small percentage of pancreatitis that is related to genetic transmission. But most of it has to do with if you have gall stones, if a family member of yours has gall stones; you probably are going to have gall stones, too. Alcoholism runs in families as well. Those are some of the common ways that families will see groups of bank creteitis occur.

Ellen Beth Levitt: We only have about a minute left. I want you to talk a little bit about the research you are doing in surgical critical care.

Steven Johnson, M.D.: Yes. We currently have got a couple of projects going. Looking at pre dom naply managing severe infections in sepsis and how we can make that diagnosis earlier. We do that looking at some of the genes that get changed. And looking at how that makes a difference in our ability to diagnose earlier. Before people show all the signs of being septic, can we find out when the genes change? Does that make it easier?

Ellen Beth Levitt: That would be an early warning sign.

Steven Johnson, M.D.: Looks like we can tell somebody is going septic about two days before they look like they are clinically infected.

Ellen Beth Levitt: Would that be a blood test?

Steven Johnson, M.D.: That would be a blood test obtained on a daily basis looking for changes. It also helps us in differentiating patients that are in the intensive care unit looking lake they are septic, but aren't infected, due to their critical illness.

Ellen Beth Levitt: In the few seconds we have left, do you have any other advice for anyone whether or not might have a family member in critical care? Is there hope? Should people actually have hope that a lot of patients do survive and come out of it?

Steven Johnson, M.D.: Yes, I think we have made a lot of advances in critical care over the past 20 years. We are allowing more things in the operating room and getting patients over critical illness ask injuries and getting them back to their usual livelihood.

Ellen Beth Levitt: Thank you so much. My guest has been Dr. Steven Johnson, chief of surgical critical care at the University of Maryland Medical Center, which includes the R Adams Cowley Shock Trauma Center. Dr. Johnson is also a professor of surgery at the University of Maryland School of Medicine. If you have any comments or questions about this program, please contact me by email at eblevitt@umm.edu. If you’d like to reach Dr. Johnson or any other University of Maryland physician, call 1-800-492-5538. Or visit the website, where you’ll find a great amount of health information and be able to see other Maryland Health Today programs: the address is www.umm.edu.

Ellen Beth Levitt: Take good care of yourself, and we'll see you next time, from Maryland’s health today.

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This page was last updated on: June 25, 2009.

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