Life in the Balance: The Intensivist

Critical care is one of the most stressful of medical specialties. It takes a unique individual to navigate the challenges of an ICU.
In this episode, we meet Christina Bastin DeJong  of Duluth, Minnesota, who is a veteran ICU physician and even under the intense pressure of the COVID-19 pandemic, can't think of a better job to have. 

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Transcript

Episode #2 Dr Christina Bastin De Jong/ICU doctor/Essentia Health-Duluth

 Support for Conversations of the Heart: Prescriptions for Healing is made possible by the Richard M. Schultze Family Foundation and donors to the End in Mind Project.  

Prerecorded disclaimer: The producers of this podcast and their partners are careful to ensure that all stories protect patient confidentiality. The views of providers heard in these conversations are their own and not their employer. 

 Theme music: Bittersweet

 You’re listening to Conversations of the Heart: Prescriptions for Healing.  This is a glimpse behind the scenes of medicine, focusing on the very human stories in every patient and provider interaction. I’m CW. 

Ever heard of an intensivist? I’m not surprised if you haven’t. The word was added to the Merriam-Webster dictionary just a few years ago, in 2020. Intensivists are better known as ICU doctors.  It’s a physician who specializes in the care of critically ill patients. TV shows and movies don’t often accurately portray what they or their colleagues do in an ICU. 

For instance, after watching the TV shows ER or Chicago Med, you might think critical care doctors and nurses spend entire shifts making dramatic attempts to resuscitate patients…

In reality, intensive care units with their beeping monitors overlaid with the rhythmic hiss of air from ventilators…aren’t as chaotic as seen on TV and for the guest we’ll meet in today’s episode, there are few places she’d rather be…

Dr De Jong:

For me walking into the ICU every day. This is definitely where I want to be every day, which is kind of lucky, right? Like, not too many people get to do their dream job every day. So it's pretty cool. 

 Dr. Christina Bastin De Jong works in the ICU at Essentia-St. Mary’s Medical Center in Duluth, Minnesota. When she entered medical school, she at first thought she wanted to work in pediatrics.

It was really hard to see really sick kids. The parents were really sad and kind of angry sometimes because their kids were sick. And I didn't understand that till I had my own kids, which was not until fellowship. And so at the time, I'm like, well, maybe this isn't for me, we'll look at different things. And then I did medicine, for internal medicine, and I loved it in the hospital. And, and then when I was doing that training was when I decided I wanted to do critical care.

Critical care doctors are a special breed of physician who must work well under pressure, making quick decisions to help very sick patients who are suffering from complex, life threatening illnesses and injuries. 

 Intensivists are said to be the one of medicine’s ultimate multi-taskers who know about every organ system in the body, the latest procedures and technology as well as ethical and social issues…plus they need to communicate well with their ICU team members and families. 

 It’s an honor and a privilege to be part of people's lives during this time. So usually, it's the sickest, their mom, dad, sister, brother, kid, you know, has ever been, and they're critically ill. And so during this time, it's really a privilege to be part of their of that family's life for this and then being the person that helps explain, like, this is why they're really sick. This is what's going on. And on a daily basis, we work kind of a week at a time. So we usually keep our patients for that whole week. And we see them evolve throughout the week, and then we switch and have time off, which is really important too. But during that week, we you know, spent a lot of time explaining what the disease process is, what the treatment plans are, and what their prognosis is if they can get better. This is what it looks like if they can't get better than we need to talk about. You know what that looks like to some. Yeah, so that's why I love it. It can be draining, but I actually I find energy from doing it.

Host:  What do you see as your role or your obligation to the ICU team?

 Dr. DeJong: It's a multidisciplinary team. So on a daily basis, a patient that's critically ill has, you know, the pharmacist that we're working with at least one bedside nurse, if not more, respiratory therapists, occupational therapists, physical therapists, diet dietitians, and so that whole team, so we're the leaders of the team. And but I always say the most important person is the bedside nurse, because they have they, they're responsible for telling us if a patient's deteriorating quickly, and getting us to the bedside, we're seeing multiple patients throughout the day, and working with this team, but but really, really dependent on them knowing exactly, you know when to call us, oh, this person's changing, come to the bedside. Okay, let's look at this and working with that team. And it's my favorite part of working in the ICU actually is working with the team and that working with the families, on sort of my, I think in medicine, there's a lot of things that you I mean, in the clinic, they people work with their clinic team, but like radiologists work a lot of times by themselves in their reading in the dark room. And one of the things that really drew me to critical care was the team, for sure.

 Host: You mentioned the families. There are lives hanging in the balance so often in an ICU. How do you support families? When you see a very different trajectory for the patient, they see the they see it, they see it one way you see it, maybe another way? How do you support the family?

 Well, I think that's where education comes in, and try it can take many days, but trying to help people kind of wrap their heads around, everything that's going on with their loved one is really a big part of that. Because, you know, I've been doing this long enough that I sometimes I'm like, Okay, well, this is what I've seen happen with the same patient, this is what the data tells me from all of the, you know, from what we know. And so I tried to share that with the families like this is the diagnosis.

  This is the treatment plan right now, this is what we see, when we follow people who have had the same disease over time or the same age with the same comorbidities. So a lot of people have a lot of things going on. And then they end up on life support machines, and this is what we see happen. So just talking through that, and, and making sure they understand the medical side of it, what what we know. And then I think, you know, over time and understanding a lot of people go okay, and now I get where we're at. And I think for us, it's super important to be, you know, compassionate and realistic at the same time, you know, like we sometimes we end up hoping for different things. And then beginning we're hoping that the patient can get better, but sometimes they can't, their bodies are just at a point where they can't. And then sometimes we hope for other things we hope for comfort or, you know, things like that. And so I think coming together, you know, and I really see my role as as, you know, communicating and working with the families so that they can come to an understanding.

Host: We hear about the importance of advanced care directives. And we most people agree they're a good thing. Often people don't have them, you know, and when you're in a situation, you are left as the provider to figure out with family input, what should we do, right? Do you run into this at all, where a patient a patient's family says, Well, what would you do if this was your dad or mom? And if you do, how do you navigate that?

 Yeah, so I, we I get that question quite often. But what I do is, you know, when I'm having those conversations, I really try to focus on that patient and holding that patient kind of as front and center kind of as our North Star is it but um, so like, so I do try to say you know, this what did your mom or dad or sister brother would your loved one What did they, you know, who were they as a person who are they as a person, and what did they what do they enjoy on a daily basis, you know, what, what are the things that they really care about? And then can we, you know, get them back to where they could enjoy those things? Or can we not? And then where where does that go? So really trying to keep people focused on that person and who they are not. I think it's hard though, because I think people, you know, they, they don't want to lose their their person, but they also know that their person wouldn't want to live not being able to do the things that they love. And so those are the tough conversations, but really important conversations. So try not really steer away from Hey, you know, if this was your, and it's usually if this was your dad, you know, what would you do? And I'm like, Well, my dad would probably choose, you know, to do this and the situation because I know him, well, you know, or my dad would, you know, has, you know, certain things that he understands and doesn't quite understand. So we'd have to talk through it and work it out. And you have a sense for who that person is. So that's where we, I usually go with that was trying to figure out who their loved one is and what they would choose for themselves. Because it's different. Every, there's no right or wrong answers. There's no, this isn't, you know, cookie cutter situations in any way. These are like, everyone is individual, everyone who would choose slightly different things. And every disease is slightly different. And so where people get to, you know, depends on all those all those factors.

 Host: That's a lot that you're shouldering and these are very difficult conversations. How do you how do you take care of yourself during something like this? I mean, I'm sure you have these conversations almost every week.

 Yeah. So every time I'm on, we have these conversations, there are serious illness conversations and things. And so I mean, I just so for me, I exercise, and I spend time with my family, go sailing. So all the things that feed your cup, I go skiing in the winter, you know, so staying really active. And also, you know, just making sure that we have protected time away. I think, for a student in medicine, critical care has the highest burnout rates, we do these burnout surveys and things like that. And, and it's pretty well documented that, that because of I think these conversations being around critically ill patients and life support every day, that if you don't take good breaks from it, then you have a very short career, because it's hard to it's hard to feed back if you get behind and you start to feel burned out. And then you have another week where you know, it's just can be very draining. So making sure that everyone has protected time away is is one of our high priorities here. For sure.

HOST: It’s no surprise, given the intensity of their specialty, that surveys show critical care doctors experience the highest rates of burnout among physicians. Critical care providers’ work is done against a backdrop of stress, trauma and death. 

 Covid-19 increased the pressure. Some research showed that health care workers displayed similar post traumatic stress disorder symptoms seen in veterans who’ve served in combat.  

Dr. Bastin Dey-Young got through it, but now wants to put the pandemic in a rear-view mirror. 

 I don't know if this is a coping skill or not, but I think I'm starting to, like, put it in a to kind of a place that's a little bit further away because I almost like putting it in a box a little bit because we, we did it, it was really challenging. And now I think now I'm like okay, and we we got through that there probably will be another bad respiratory virus again. 10 years ago, there was H1N1 and we lost a lot of young people during that. During COVID there was so much loss. I mean, there's so much death and so much loss, and it was people of all ages. 

 Host: Here’s some context. Essentia Health, based in Duluth, Minnesota is one of the largest health care providers serving rural northern Minnesota and parts of Wisconsin and North Dakota. Before the pandemic, critical care doctors at Essentia/St. Mary's Medical Center in Duluth typically saw about 15 patients a day. During the height of the pandemic, they had more than 30 patients at any time in their ICU. 

  Dr. DeJong: The first year was mostly as we know, was driven by fear, there was no vaccine. 

We were, you know, I would come to work. And then I was in my garage, I would literally undress, run in the shower, put my stuff in the laundry run in the shower, take a complete shower, because I was living with my elderly parents moved in during that time, which I'm sure a lot of people had things going on. And so I was like, I am not going to be the one that gets my parents, or my kids sick, and we don't have vaccines. And so, so first year was fear, lots of fear, lots of stress. And it was inundated because media had grabbed on to this, this pandemic, like no other respiratory virus we had had before. In fact, even when, you know, 10 years ago, when we were losing lots of younger people and things. It wasn't in the news, whereas this was, this was every time you put the TV on every time you opened a newspaper, every time you went to Target like every it was everywhere, and it was a lot to talk about, you know, initially wearing masks and then and then to talk about making sure everybody got vaccinated and and then after the vaccines, I mean, I honestly remember the day I got vaccinated It was December 17. Like, it's like a day where I was like, oh, yeah, I mean, I kind of had tears come to my eyes. I was like, oh, yeah, now there's some kind of relief that's coming. And so that was huge. And that was the first year. And a lot of people, a lot of people died. But it felt like we were doing everything we could, there wasn't conflicts with patients and families. And physicians, we were all on the same page, we were all doing the same thing. And then it was the following year, that actually was much, I think, much harder on my entire group. I know it was much harder on me personally, just because they all of a sudden, there was this created out of fear, created politicizing of the disease and the vaccinations. And people were so passionate about things that didn't have any data behind them. And it was really hard. Because we most of the patients are second year, and we had a lot of death. Again, most of them were patients that didn't have any vaccinations. And so that was much harder, because there was already because it had kind of selected out for patients that didn't have their vaccines, there was already a lot of mistrust of medicine. And I think that it just fed into a lot of that. And it was, it was a tough time, because we were taking the best care of of the patients just like we did the first year. But you know, there was just a lot more anger from patients and families a lot more already. Like I don't think medicine’s doing the right thing for us. And we're, you know, we're trying to convince people we're trying to do the right thing. This is what we'd recommend. There was a lot of Yeah, it was much more difficult that second year. Sure.

 Host: Sounds like you got a lot of pushback from some folks who disagreed with your decision. So it has to be hard.

 Yeah, I think and like no, there was no other time when in my career that I've ever had that. And it wasn't just it wasn't just pushed back. It was an like, in a true like an anchor, like, you know, and it was every little thing it was you know, we always feed people next to you. They wanted different, like nutrition stuff, and it was even antibiotics, people would argue about watching antibiotic and I mean, it was just every little detail. And I was like, wow, that's it was, like I said, not like any other time in my career that, that that's happened. And it was and we of course, as I said from the beginning, that's part of what I enjoy is educating and going through things. But even after education and discussion, there was just it, it was kind of some fixed beliefs that couldn't, that we couldn't work through.

 Host:  You could have quit but you did not, you kept going. Is that because you love your work, the obligation you have to your patients that kept you going.

 You don't, you know, there are there are people who quit actually, I don't know, if you looked at some of the data, there are people who were like, That's it, I am not going to do critical care anymore. That is, you know, that's the I'm gonna go some people left medicine just a lot of nurses left medicine, we have had a ton of staffing shortages, because of all of this, you know, this type these types of things happening. And so. But for me, I think it's probably because I was driven from my young age to want to do this. And then I knew that, like, we've been through hard flu seasons and things like that before, I'm like, we will get through this. It's just, it would never even crossed my mind to quit. I think I you know, for me medicine, what I do with critical care is something that it's kind of like, I don't know, it's, it's part of me and who I am. And so it didn't, it never crossed my mind to quit. Although, you know, I did have partners who were like, Listen, I'm really burnt out, I need to take, you know, a few weeks off, what can we do? You know, things like that? And I'm like, yeah, absolutely. So, understanding that I actually, for me, I almost wanted to lean in more and be like, okay, you know, like, we've got to figure this out, how can be so education is not working, what else can we do?

Host: A longtime doctor, friend of mine says that, in every physicians mind, there's like, there are patients that you just never forget. Right? So keeping, you know, HIPAA in mind, is there a patient in your career who is who, who comes to mind that taught you something that you'll never forget, or, again, will always kind of stay in your heart?

I have many, many of those, I always think, so for me, the patients that, you know, even and we learned from our patients all the way through medical school and residency. And I remember the first patient that I did certain procedures on or that taught, you know, the made it through when I didn't think they could, I mean, the patients over time have really taught me about like resiliency, like you think there's no way where you're throwing the kitchen sink, and this person's young, they have to make it through, but I don't know the path that that's going to happen, we can only do so much. And then the rest has to kind of it takes time and the body takes time to heal. And you just hope that there's time for that to happen. And and so those are the patients that in that's happened many times, it's many different patients that I mean, when you said that I'm like, oh, yeah, and there's some so and there sounds. During COVID, we had one patient that I still that I that came to mind right away that was in the hospital for months, I think four months total, something like that. But you know, somebody who didn't, you know, didn't know they had any lung disease, but when they came in, were very sick with COVID. And on the CT scan, we could see, you know, there was some lung disease, probably that he had long standing and then, you know, got the all the protocols we had this was before vaccinations. So it was that, you know, that fall. And, you know, and so there was no family members that could come visit and so we're updating his, the wife and every day and talking through this, and there was multiple days where I'm like, I don't know if, if he's gonna make it through the night. We're doing everything we can or proning and steroids and antibiotics and doing all the stuff we can do. But I don't know if he's gonna make it through the night and, and then he would make it through the night. Then, you know, and this happens, like, and then he'd get a little better and then the week after, Oh, nope, take another dip. And this was it was typical of COVID. It just was such a long inflammatory disease that people would kind of even out and then they take a dip down and then they you know, and then they'd even out again And then in the question was always can we get them through this and, and resiliency is definitely something that that that patient taught me. I was like, I don't know. And then months later he, they ended up with their birthday in the he was out of the ICU at that point. But I was like, Oh, I didn't know if you'd make this birthday. You know. So those types of you know, that, that's one of the things I've learned. The other thing from patients, I think it's always important to like, you know, if they, as I'm looking through patients, and diagnosing and treating and things, just, I teach my students as to just staying curious about stuff, making sure because there was things we didn't know, like, if we put somebody on all of these medications, and all of these steroids, and we're treating one disease, what can happen, what can come up, because we've done this because we've suppressed their immune system so much. And then I remember during this, we would have patients that hadn't knew, like, we wouldn't normally see an infection from like a fungus. And we saw Aspergillus, coming up, and then we started to check in with other people around the country. Are you seeing this? Are you seeing this? And everybody was starting to see it? So there's, you know, to staying curious. And from the medical side to just like, oh, what else could be going on? Why is this patient taking a turn? You know, and, you know, what, what, are we missing? Anything? You know, those types of things? So, yeah, so resiliency and curious and staying curious, I think those are the two big things that I've learned from patients over the years.

HOST:: I know that you deal with science, and you're very focused on what data says, around certain cases, but as you say, every person is different. Right? So then do you leave yourself open? For want of a better word to miracles? Do you allow that to enter your thinking? Have you seen that? Does that happen? Yeah, I think

by miracles, meaning, kind of, like I was talking about, like a, you, you're throwing the kitchen sink any ears, like, by the numbers, there's no way this person's, you know, going to, you know, start to turn around. And then sometimes they do, you know, so and whether it's, you know, their body just had enough to start to fight the infection and turn around, or, you know, like, what, what was it that did it? Or, you know, but yeah, I never, there are unexpected, unexpected people who, who turn around and get better. So there's outcomes that I'm like, huh, my guess would be that this wouldn't be how it goes. But. And that's kind of why we do this, right, we, we put, you know, we offer these things, because there is small chances that sometimes people can get better, sometimes the chance is very large. And we reckon, you know, like, hey, you know, what, this shouldn't be what comes next? Because this has a high chance of getting this person better. But in COVID, that's not how it was. I mean, the chances of people getting better, without vaccines. In the beginning, were just terrible. And yet, we did get some people through it. And, and, yeah, and so are those miracles, I don't know if they're miracles, but I look at them as small miracles along with lots of effort. 

HOST: The ICU can be a place of frightening uncertainty and unpredictability for patients and their families. It’s where lives are saved and lost. 

While it’s demanding work with an incredible amount of responsibility in caring for patients in life threatening situations, intensivists say the work is rewarding because often times, in the midst of despair, their team is the glimmer of hope for patients and families. 

Special thanks to Dr. Christina Bastin De Jong  an intensivist at Essentia-St. Mary’s Medical Center in Duluth, Minnesota for telling her story.

Thanks to you for listening to Conversations of the Heart: Prescriptions for Healing, made possible with support from the Richard M. Schultze Family Foundation and donors to the End in Mind Project.  

If you liked this, share the episode or tell a friend about us. 

Our next episode promises to be a memorable one. While members of the medical team try to fix the body, we’ll meet other members of the care team who work on a far deeper level where hope, meaning and transcendence meet. Until then, I’m Cathy Wurzer. Be well.