Saturday, 3 November 2007

Demystifying the ICU black hole

As a doctor working in general medicine, the intensive care unit (ICU) seemed to be a mystical place. When our patients became very, very sick, we would ask the ICU doctors for help and then they’d swan down onto the ward and point out all the things we hadn’t done. What usually happened next is that they’d then say that they didn’t want to take the patient onto the unit, offer a little advice and swan off again. However, very occasionally, they’d they WOULD take the patient and within minutes, the patient would be whisked off to the intensive care unit. They’d vanish off behind big, locked doors and we never knew what happened to them there. It was like a big black hole that the patients disappeared into. Sometimes, they re-emerged days later, sometimes they never came out.

The bible for junior doctors across the land is the Oxford Handbook of medicine. If you read the sections on treating critically ill people, regardless of the condition, it’ll say something like “do X then Y then Z and if that still doesn’t work, call ICU.” Rarely, do you get any more details and, as a result, I was always more than a little mystified about what went on behind those locked double doors. It’s been a real revelation working on the intensive care unit and seeing things from the other side.

To be honest with you, I was a little underwhelmed when I found out the truth. Aside from mechanical ventilation, nothing particularly special or profound happens in intensive care. Intensive care is based around meticulous attention to detail. It’s based around being focused on every aspect of your patient’s wellbeing. Closely monitoring ALL of their organ systems and intervening quickly and appropriately to try to correct anything that is drifting awry.

I’d say the single biggest difference between ICU and a normal medical or surgical ward is the nursing staff. I’m not saying that the nurses are better on ICU, it’s just that there are many more of them. We get one nurse for every patient. It’s great. It means you have so much more scope to do things. For example, we can confidently put a patient on an infusion of midazolam with the knowledge that they’ll be someone around to turn it off if the patient stops breathing.

It’s also made me realise that it’s often the simplest of things, done early, that make the biggest difference to critically unwell patients. Things like giving oxygen or fluids or adequate pain relief. I honestly believe that every doctor working in an acute specialty should spend some time working in intensive care at some point. Intensive care is based around simple things done well. Good medical care is based around simple things done well, and this is what I’ve seen again and again over the last few months.


Mousie said...

I completely agree. It's why the intensivists are the best doctors in the hospital IMHO.

And I think that every nurse working on acute wards should also spend time working in ICU, because good nursing care is about simple things done well too.

The gold standard of ICU isn't achievable on the wards because of the staffing ratios. We forget, or don't have enough time to pay attention to, the important things like adequate nutrition, regular positional changes and appropriate fluid balance monitoring.

But time spent in ICU would help make those things second nature and bring them to the forefront of nursing care again.

steph said...

I greatly admire your honesty - and Mousie's too.

However, this post really emphasises the 'black hole' that exists for general patient care. ALL patients deserve good medical care and hospital medicine today is more a case of 'pot luck'.

Dr Grumble said...

I quite agree Junior Doctor. I have done 18 months in ICU including a year as a senior registrar but the rest of my many years on the ordinary wards. Never forget how affronted you were by those ICU doctors who occasionally strayed from their place of safety to give you advice. Those intensivists are not necessarily the best doctors in the hospital. It's much easier to do simple things well when you have one nurse per patient and plently of doctors. Spotting the sick patient on the ordinary ward and seeing that everybody is properly treated in the melee of a general medical take is much the greater challenge.

Garth Marenghi said...

I have to agree with Dr G on his point that ITU docs not neccessarily being the best doctors in the hospital, anyone who thinks this is being a tad foolish with this generalisation.

ITU docs are generally very good at what they do, however what they do is intensive care, not medicine or surgery.

All of us have seen problems when ICU doctors don't seek help from the relevant specialist, instead trying to battle on on their own.

Most are excellent and do seek help appropriately, however ICU docs are most certainly not the best surgeons or physicians, they are the best intensivists.

Mousie said...

I didn't say they were the best surgeons, or the best physicians, I said they were, in my opinion, the best doctors in the hospital.

A generalisation it may be. And foolish if you say so. But just my experience, time and time again...