Darrell Raikes waved sleepily to his wife as they wheeled him down to the operating room for a routine knee replacement last May. He woke up in the Critical Care Unit four weeks later.
Raikes had an adverse reaction to his anesthesia and began bleeding into his lungs post-operatively. Ashley Montgomery, MD, Raikes’ critical care physician, had to navigate tricky territory: the drugs that are standard care to prevent blood clots post-knee replacement would also contribute to Raikes’ bleeding.
“We like to think that medicine is an exact science, but there often isn’t a ‘yes or no’ answer to a patient’s medical problems, particularly in an ICU situation where multiple organ systems are involved and the treatment for one problem is contraindicated for the patient’s other problems,” Montgomery said. “We talk to the patient, use the best data available and make an informed decision about how to best care for them.”
Montgomery and her team in the UK HealthCare ICU were able to stabilize Raikes without compromising his knee replacement by inserting an IVC filter in his inferior vena cava. This umbrella-like device catches circulating clots and prevents them from travelling to the lung. Raikes was discharged from the ICU on June 29th and felt well enough to run (although he admits it was more of a walk) his first 5K in his hometown of Lebanon, Ky., this past September.
A New Journey
Raikes’ journey — or “scenic tour,” as he says jokingly — didn’t end with his hospital discharge. He now attends Montgomery’s Critical Care Survivors Clinic (CCSC) at UK. One of only a handful in the country, the CCSC’s purpose is to help patients navigate the complicated and often confusing decision matrix that follows a high-maintenance hospital stay.
Solving one problem often uncovers a new problem, and critical care is no exception. As advances in medicine have reduced mortality rates, critically ill patients fortunate enough to recover and be discharged are suffering cognitive impairment, depression and/or ongoing physical disabilities. These conditions, particularly when in concert with complex post-discharge care, often lead to hospital readmission. Patients with co-morbidities and those from rural areas are even more vulnerable when their hometown primary care specialist is overwhelmed by their patient’s challenging care requirements.
“Most doctors are trained to handle one organ system at a time, whereas in ICU we handle multiple organ systems simultaneously, and our patients often have co-morbidities, which complicates things even further,” said Montgomery. “Their post-discharge care can be so complicated and disjointed that these patients often end up back in the hospital.”
This, in turn, runs afoul of one of the major tenets of the Affordable Care Act, where hospitals are penalized for patient readmissions within a certain timeframe.
Improving Outcomes
The first CCSC was established in Indiana in 2011 with the goal to improve long-term outcomes, decrease hospital readmission rates and improve quality of life for critical care survivors. Montgomery, who was then in her fellowship here at UK, immediately recognized the value of a similar program in Lexington.
“The population we serve is strongly rural and has a high rate of co-morbidities,” Montgomery said. “These people struggle to balance their follow-up care, because they typically have a lot of it to keep track of and a long way to travel to get it.”
Furthermore, Montgomery explained, rural physicians and other providers who care for these patients back home often are uncomfortable making decisions on how to move forward with aftercare. In addition to seeing the patients face to face, Montgomery frequently talks with a patient’s hometown providers, advising them and facilitating services that keep the patient as close to home as possible.
“It doesn’t hurt that the CCSC is a fiscally sound proposition, but in the end for me it’s about providing quality of life for these people,” Montgomery said.
Originally, the clinic met once a month but is now several times a week. Montgomery typically sees patients for one to six months post-discharge, but some are followed longer term if necessary.
Being able to see these patients in a non-crisis situation often provides opportunity to ask important quality of life questions.
“Remember,” Montgomery said, “that these people were recently very sick, and for many of them chronic illness is a fact of life. To be able to sit down with them when they aren’t in a hospital bed opens up all sorts of opportunities to ask important quality of life questions, which then inform our care plan.”
Examples include life goals (Do you want to be able to drive again? To work again?) and end-of-life goals (How can we make you comfortable?)
A Detour
While a career path is rarely a straight line, Montgomery’s earlier training clearly influences her work today. Before medical school, she had her own business coordinating services for families with autistic children. “It’s perhaps overly simplistic, and really obvious, but I learned then that if you support people, they do better,” said Montgomery.
It’s especially true in healthcare, she continues. Even with a medical degree, Montgomery felt lost as she helped a family member navigate her care when she was diagnosed with breast cancer.
Raikes has been back to the CCSC twice so that Montgomery could chat with him face to face about his progress with physical therapy and assess whether the time was right to remove the IVC filter. At his second follow-up there was a snafu with his CAT scan scheduling, and Montgomery’s staff helped resolve the issue.
Eventually, Raikes will be discharged from the CCSC, but he and his wife will still keep Montgomery and her staff in their hearts.
“We come to Lexington often, and every time we come we visit the ICU and Dr. Montgomery,” said Raikes. “What these people did — not just the big things, but all the little things that kept our spirits up during a horrible time –is a blessing to us, and we will be thanking them forever.”
-Laura Dawahare is with the University of Kentucky.
