Table Of Contents

First Impressions ICU Types The ICU Team The Patients The Equipment Rounds, Rounds, Rounds Ethical Issues in the ICU What Makes a Career in Critical Care Medicine So Satisfying 3 4 6 8 12 14 19

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First Impressions
The medical student's first encounter with the intensive care unit (ICU) can be overwhelming. The life-support systems, monitors, data management tools, patient care providers, potent drugs, and complex ethical issues stirred by round-the-clock admissions and discharges easily obscure the most important element of the ICU: the patient. To the novice, the busy unit seems hectic, the humming unit seems noisy, the caring unit seems chaotic. The professionals seem to be in constant motion around the patient, often appearing to care more for data than for the patient. Small wonder that many medical students (and even some physicians!) find the ICU a confusing, intimidating, and challenging place. The reality is that the ICU is a place where skilled professionals of diverse backgrounds provide highly structured, and often highly technological, care to the sickest patients in the hospital. Their efforts are rewarding: more than 96% of patients admitted to intensive care units are discharged alive. This introductory guide to the critical care environment is written with you, the medical student, in mind. It describes the ICU and the caregivers who staff it; the patients and how they are admitted, monitored, and treated; and some of the common life-support equipment. It includes a strategy for presenting your patient to your team and prepares you for the ethical issues that might confront you in the ICU. We want to share our excitement with you during this, your first, encounter with the ICU in the hope that you will consider a career in critical care medicine. This guide describes some of the career paths that culminate in leadership positions in critical care medicine. Now is the time to introduce yourself to the ICU team leader as the new student on the service. On behalf of the entire ICU team and its multidisciplinary professional organization, the Society of Critical Care Medicine, welcome to the ICU!

ICU TYPES
Whats in a Name?
The hospital you are training in today is different from the hospital your attending physician claimed as his or her learning environment. Lengths of stay are down, patient acuity is rising, and critical care units are proliferating. Although the health care system is changing, hospitals will always need an area to care for their sickest patients--a critical care center. The need for these units is growing as patients at all extremes of life--the most premature infants, adults with cardiovascular disease, the severely injured--are growing, both in absolute numbers and in proportion to the general population. Citizens of developed nations around the world are living--and staying active--into the ninth and tenth decades of life. When they become ill, they often require aggressive intervention to stabilize their delicate physiologic balance so they can heal. The interventions required to manage life-threatening illnesses generally include both core supports--intensive nursing care and cardiopulmonary monitoring--as well as

supports focused on the patient's particular illness. While nearly all ICUs are capable of providing a spectrum of care, many have developed a focused area of excellence: care of critically ill and injured children in the pediatric ICU (PICU); adult cardiac diseases in the coronary care unit (CCU); perioperative care, trauma care, and care of multiple organ dysfunction in the surgical ICU (SICU); care of neurological and neurosurgical patients in the neuroscience ICU; and so on. Many teaching hospitals also have graded critical care centers such as intermediate care units and telemetry units where patients who require more than ward care can benefit from specific monitoring and intervention. One of your first questions to your team leader should be: what sorts of patients are typically cared for in this ICU? What sorts of patients are typically sent to other critical care centers? This will guide your study and help you focus your reading and thinking on the patients for whom you will be providing care.

The ICU Team

The more things get busy, the more you will appreciate that each team member in the ICU has a specific role. This section of the guide reviews the roles of the team and gives you an idea of the role you, the student, will play on the team. Make no mistake-you are very much a part of this team! The team leader is a physician. Students typically are assigned to train in intensive care units where the team leader is an intensivist physician who has received advanced training in the art and science of critical care medicine. In North America,

added qualifications in critical care medicine are obtained after board certification in a primary specialty such as pediatrics, internal medicine, surgery, or anesthesiology. Many countries have established critical care medicine as an independent specialty. Irrespective of the training pathway, your team leader embraces the philosophy of critical care medicine, namely that a physician-led, multidisciplinary team can provide optimal care to the critically ill patient. The term "multidisciplinary" refers not only to other physicians who may participate as consultants or coattendings in the ICU, but also to the other health care professionals who work side by side, around the clock in the ICU. The most numerous of these are the critical care nurses, many of whom also have advanced training and certification in critical care and are recognized as CCRNs. Some have achieved even greater recognition and responsibility. They are the acute care nurse practitioners and clinical nurse specialists who complement the physician staff in establishing plans, writing orders, and directing management. Physician assistants also provide care in the ICU. Respiratory therapists are experts in many forms of pulmonary diagnosis and intervention. In addition to operating the mechanical ventilator, therapists often obtain and analyze arterial blood for blood gases and test patients' breathing strength by obtaining forced vital capacity, negative inspiratory pressure, and other parameters. In some hospitals, respiratory therapists perform endotracheal intubation in addition to supporting ventilation with "bag-and-mask" devices. The ICU team typically includes a pharmacist who helps you review medication profiles and determine if your patient is predisposed to side effects or drug interactions. The pharmacist will help you calculate clearance rates from measured drug levels and plan dosing schedules for many of the medications used in the ICU. The team also typically includes someone who is an expert in nutrition support such as a dietitian who has advanced training in enteral (gut) and parenteral (intravenous) nutritional support strategies and pitfalls. Other important members of the ICU team are the medical social worker, who provides ongoing psychosocial assessments and support; representatives of the chaplaincy staff, who are available on call to offer spiritual support to patients, families, and ICU staff members; and a unit secretary, who manages administrative tasks such as reception, telecommunications, and chart maintenance. In addition, the ICU staff generally includes many other trainees who are there to learn with you such as fellows, residents, nursing students, and dietetics students. Take-home message no. 1: You are not alone! Get to know the people who are there to help you learn, and take advantage of their expertise. Ask them about your specific role and responsibilities. Identify your immediate supervisor and ask for the supervision to which you are entitled. There is no such thing as a "stupid question" in the ICU, and just about everyone you meet will be eager to share his or her knowledge with you. Asking focused, pertinent questions is an important part of being a team member.

The Patients
Pathway to the ICU
Patients are admitted to the intensive care unit either because they require highintensity monitoring and life support by specially trained health care providers or because they require high-intensity nursing care that cannot be provided on a general medical or surgical ward. As noted previously, surgical patients are admitted to the surgical intensive care unit and medical patients to the medical or coronary intensive care units. Many surgical patients are admitted with medical problems such as pneumonia or sepsis. Patients come to the ICU from several areas: Operating room (OR) or post-anesthesia care unit (PACU)--Surgical patients who require invasive monitoring, mechanical ventilation, or resuscitation after surgery may be transported directly to the ICU from the OR or the PACU after a period of observation. Such direct transport is considered a transfer from one critical care area to another. Therefore, their ICU management is a continuation of care that they received from the anesthesiology team in the operating room or PACU.

Emergent care center (ECC) or emergency room--Medical, surgical, trauma, or burn patients can be admitted to the ICU from the ECC or emergency room. These patients typically undergo a series of diagnostic tests prior to their transfer, and the etiology of their illness may or may not be known by the time they come to the ICU. They are admitted to manage their acute illness. Medical or surgical ward--Patients may be admitted to the ICU from a general medical or surgical ward. These are patients who were initially stable but who developed respiratory distress, low blood pressure, shock, cardiopulmonary arrest, or other physiologic instabilities on the ward. They require aggressive resuscitation, treatment, and invasive monitoring and are transferred to the ICU for closer observation, more frequent measurement of vital signs, invasive monitoring, or mechanical ventilation. Other facilities--Patients may also be transferred from another facility that does not have the resources to provide the level or type of care they require.

Common Reasons for Admission to the ICU

Respiratory compromise--Patients with respiratory distress, manifested either as an inability to oxygenate or an inability to ventilate, are transferred to the ICU for supplemental oxygen and mechanical ventilation. Etiologies of respiratory distress are numerous and include pneumonia, acute respiratory distress syndrome, pulmonary embolism, and exacerbations of chronic obstructive lung disease. Hemodynamic compromise--Patients with hemodynamic instability are admitted for management of arrhythmias, hypotension, or hypertension. Patients with hypotension are typically resuscitated with fluid or medications (e.g., vasopressors or inotropes) to increase vascular tone. If a predetermined minimal mean blood pressure cannot be maintained, or if the patient has signs of inadequate oxygen delivery to the tissues (i.e., altered mental status, decreased urine output, cool skin, and lactic acidosis), a pulmonary artery catheter (PAC) may be inserted to monitor cardiac output. Measurements obtained from the PAC aid the clinician in deciding, for example, whether to treat the patient with more fluids to improve preloadthe filling pressure of the left ventricle--or to initiate inotropes to improve contractility. In these instances, an arterial catheter is often inserted to monitor systemic blood pressure continuously. Patients with severe hypertension are generally managed with titratable intravenous medications.

Myocardial ischemia or infarction--Patients with inadequate oxygen delivery to their myocardium are admitted for the management of angina and myocardial infarction. They may require titration of nitroglycerin, beta blockers, and morphine. Each medication can result in further complications such as hypotension, decreased heart rate, bronchospasm, or decreased respiratory drive, respectively. These patients are often candidates for thrombolytic agents and cardiac catheterization. The goal of admission, to reverse ischemia and minimize myocardial injury, requires close monitoring and rapid intervention. Neurological compromise--Patients with alterations in mental status are admitted to the ICU for frequent neurologic checks. If their condition deteriorates, they may need to have an endotracheal tube placed to protect their airway. Gastrointestinal--Patients with life-threatening gastrointestinal bleeding are admitted to treat hypotension with IV fluids, blood and blood products. Diagnostic tests such as endoscopy will likely be performed to locate and treat the source of bleeding in unstable patients in the ICU. Renal and metabolic--Patients may be admitted for treatment of the complications of renal failure, including acidosis, volume overload, and electrolyte abnormalities. More often, patients develop renal failure in the ICU secondary to hypotension and sepsis. Treatment with careful attention to acid-base balance, electrolytes, and volume status is provided in the ICU. Other metabolic crises, such as hypercalcemia, unrelated to renal failure, may result in a patient's admission to the ICU. Postoperative--There are many reasons for admitting patients to the ICU. They may still be on a ventilator, or they may have other invasive monitoring. They may have a history of coronary artery disease and therefore be at risk for a perioperative MI. They may have had extensive bleeding and require frequent observation. They may have had an extensive surgical procedure, including open-heart surgery, organ transplantation, vascular surgery, or general abdominal surgery. Each surgical intervention has specific perioperative issues that require observation and treatment in the ICU. Patients with trauma, orthopedic injuries, and extensive thermal injuries are also admitted to ICUs.

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Transporting the Patient to the ICU

Once it is clear that a patient requires management in the intensive care unit, the ICU personnel should be notified. An attending, fellow, or resident should call the ICU charge nurse and indicate the patient's name, illness, reason for transfer to the ICU, and immediate plans for treatment. Alerting the staff in the ICU prior to patient transport allows them to prepare for the patient's arrival. Advance communication with the ICU physician ensures that the appropriate support is available when the patient arrives. It is essential that the appropriate personnel, equipment, and monitors are available for all transfers to the ICU. Take-home message no. 2: When transferring a patient to the ICU, try to anticipate all complications that can occur in transit. Patients may have worsening respiratory or hemodynamic compromise during transport. Ensure that the appropriate personnel and equipment accompany them. All adult patients should be transported with a large-bore intravenous access that runs well and will permit the rapid administration of at least 500 ml of fluid resuscitation. Trainees often ask the nursing personnel if an IV is present, but they don't think to check if it is running properly. Verify that a large-bore IV is present and functional. The patient's heart rate and rhythm should be monitored with a transport

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monitor. Oxygen saturation should be monitored with a pulse oximeter. Communication with the patient during transport provides measures of mental status and, indirectly, blood flow to the central nervous system. Supplemental oxygen should be available and supplied as needed, based on oxygen saturation. If the patient demonstrates respiratory difficulty, such as low oxygen saturation or a labored respiratory pattern, the appropriate equipment must be available, including a bag-and-mask ventilator to provide artificial ventilatory support, suctioning equipment, airway equipment, as well as personnel such as respiratory therapists or physicians who can ventilate the patient if he or she stops breathing en route. If the patient demonstrates any cardiac arrhythmias on the monitor, a monitor with defibrillator capability must be included. Medications such as lidocaine, atropine, and epinephrine must accompany the patient. If the patient is transferred to a unit on another floor, the elevator should be called in advance to minimize the time involved in transport. When a patient is transferred to the ICU, the first 30 to 40 minutes are often devoted to resuscitation and stabilization rather than diagnosis. Take-home message no. 3: It is not uncommon to resuscitate a patient before the underlying problem is determined. In every instance, managing the Airway, ensuring appropriate Breathing, and stabilizing Circulation take priority (ABCs). Novice intern and resident trainees are frequently paralyzed in crisis situations. They attempt to determine the cause of the patient's instability and forget the fact that the patient needs to be resuscitated. Once the patient has been resuscitated, a number of carefully designed diagnostic algorithms can be implemented depending on the history and laboratory data; however, the rule is to ensure the ABCs first: secure the airway, ensure breathing, and stabilize blood pressure and circulation.

The Equipment
The vast array of technology present in an average patient's room can be overwhelming. Even the beds have become incredibly complex, costing tens of thousands of dollars and requiring detailed operating instructions. It is stressful enough just to be in the room of a patient who is critically ill, let alone to cope with the anxiety that the equipment might alarm or malfunction and require an intervention. In reality, the machines in the ICU have many fail-safe backup systems so that mechanical failure is rare. Furthermore, devices that require more supervision are usually accompanied by an individual with expertise, such as a cardiac technician for an intra-aortic balloon pump or a hemodialysis technician for a hemodialysis machine. Respiratory therapists are in close proximity to patients' rooms and intervene quickly if a mechanical ventilator alarms or malfunctions. The best way to resolve anxiety is to become familiar with all of the different devices. This section introduces the equipment routinely found in an ICU. Bedside monitors--All patients are connected to a bedside monitor whose screen displays several parameters. Channels I and II typically display two EKG leads providing continuous monitoring of the patient's heart rhythm. The patient's blood

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pressure is displayed either continuously from a catheter in the patient's arterial system or intermittently from an automatically inflating blood pressure cuff on channel III. The arterial line allows beat-to-beat measurement of blood pressure. An A-line is also inserted in patients who require numerous arterial blood gases in order to avoid repeated punctures. Patients may have a central venous cathe ter placed in the superior vena cava through the internal jugular or subclavian vein. A central venous catheter allows measurement of right heart central venous pressure (CVP). The CVP serves as an estimate of the patient's volume status. Central lines are also used to rapidly infuse fluid and to administer substances that cannot be infused into a peripheral vein such as hypertonic parenteral fluids and medications such as vasopressors. When more data about a patient's hemodynamic physiology is required, a pulmonary artery catheter can be inserted and advanced through the right ventricle into the pulmonary artery. The PAC allows continuous display of pulmonary artery pressure, and variables such as cardiac output and pulmonary artery occlusion pressure, or wedge pressure, can be intermittently obtained. The "wedge pressure" is a measurement that reflects the patient's preload. The catheter is used to diagnose and manage hemodynamic instability. The respiratory rate and the pulse oximeter reading, which indicates the patient's oxygen saturation, are also displayed on the monitor. The pulse oximeter is a noninvasive monitor attached to the patient's finger or earlobe to measure oxygen saturation continuously. Bedside monitors can be set to alarm for bradycardia or tachycardia, hypotension or hypertension, tachypnea, and/or oxygen desaturation. Mechanical ventilators--Patients are mechanically ventilated for several reasons. If they are unable to protect their airway due to encephalopathy or massive stroke, they may be intubated (have an endotracheal tube placed through their mouth or nose into the trachea) to minimize the possibility of aspiration. If they have refractory hypoxemia (low oxygen saturation that does not respond to oxygen delivered by face mask), the ventilator will allow higher concentrations of FIO 2 to be delivered to the alveoli, and pressure can be delivered through the ventilator to open alveoli that have collapsed. If they have respiratory failure and are unable to take adequate tidal volume, the ventilator can deliver a preselected tidal volume and respiratory rate. Patients remain on the ventilator until the underlying disease is resolved. When this occurs, the doctors and respiratory therapists begin the process of decreasing, or "weaning," ventilator support until the endotracheal tube can be removed, a process known as extubation. Other common devices--Intravenous medication pumps allow the nursing staff to titrate medications; Foley catheters and urine collection bags aid in monitoring urine output; sequential compression devices squeeze the lower extremities and reduce the incidence of deep venous thrombosis; transvenous pacemakers stimulate the patient's heart to beat; dialysis machines remove fluid and correct electrolyte and acid-base disturbances; intraaortic balloon pumps assist the heart's contractility; and neurologic monitoring systems measure intracranial pressure.

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Rounds, Rounds, Rounds

As an experienced medical student, you have already developed substantial roundsmanship skills. Why devote a section of this guide to presentations on rounds? Rounds in the ICU differ from rounds on the ward in several important respects. First, substantially more information is exchanged. Second, substantially more critical information is exchanged. Third, the focus in the ICU is on physiologic systems as opposed to the ward focus on specific problems. Fourth, the care is goal-oriented: when the goals have been met, the patient is well enough to be transferred to a less intense level of care. In addition to their educational value, rounds in the ICU serve two purposes. The first is to communicate the patient's present status to the entire team, and the second is to establish goals and plans for each patient. To accomplish these purposes efficiently and thus have time for lectures, tutorials, and hands-on skill development, the student must be familiar with--and utilize--the ICU's method of communication and goal setting. Every ICU has its own unique communication and goal-setting methods, but the core of these methods is universal. Communication is system-based. In order to ensure that each patient undergoes a comprehensive evaluation each day, intensivists think--and communicate--in terms of systems. These typically include: neurological (including pain and sedation management); pulmonary; cardiovascular; renal, fluid, and electrolytes; GI, nutrition and metabolic; hematologic and infection issues; and immunosuppression. Your team anticipates a system-based presentation and anticipates hearing about each system in the same order on every patient. Do not try to make up your own method or revise the order. Rather, adopt and adapt the method used in your ICU. Rounds will move along more efficiently because every member of the team will know what to listen for in your presentation.

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Systems are analyzed according to outcome and process variables. While systems overlap in both outcome and process variables (for example, cardiac function, pulmonary status, and fluid and electrolyte balance may all be influenced by the administration of a diuretic), the most relevant variables are reported for each system. In renal, fluid, and electrolytes, the outcome variables will typically include the net intake/output balance for the past 24 hours and the most recent set of electrolytes and serum creatinine. The process variables will typically include the rate and composition of intravenous fluids administered, supplemental electrolytes administered, and whether or not diuretics (or other drugs with secondary diuretic action such as dopamine or theophylline) were administered. By presenting the outcome and process variables, the intensivist sets the stage for the other important component of rounds--establishing physiologic goals. The table shows outcome and process variables pertinent to particular systems.

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System Neurologic

Pulmonary

Cardiovascular

Outcome variables Functional examination Pain level Sedation level Glasgow coma score Intracranial pressure Occurrence of seizures Presence of rales or wheezes Appearance of chest x-ray Oxygen saturation End-tidal CO2 concentration Arterial blood gas data Spontaneous ventilation rate Forced vital capacity Negative inspiratory pressure Blood pressure Heart rate Abnormal rhythm Presence of rales Peripheral pulses and extremity warmth Cardiac output Evidence of ischemia

Process Variables Type/route of analgesic Type/route of sedative antiseizure meds Intracranial pressure monitors

Ventilator settings Administration of nebulized bronchodilators Administration of supplemental gases such as nitric oxide

Renal/Fluid/ Electrolytes

GI/Metabolic/ Nutrition

Heme/ID

Weight Net intake and output balance Current electrolytes BUN, creatinine Bowel sounds, function Absorption of enteral feedings Fraction of caloric goal attained Nitrogen balance Metabolic data Hyper or hypoglycemia New findings on physical exam suggestive of bleeding Hematocrit, platelet count and coagulation parameters Temperature, findings suggestive of infection on physical exam, gram stain and culture data, including antimicrobial sensitivity Leukocyte count and differential

Estimates of, and interventions to adjust preload such as CVP or pulmonary artery occlusion pressure Estimates of and interventions to adjust afterload such as vasodilator therapy Estimates of and interventions to adjust contractility such as inotropic therapy Estimates of (e.g. drug level) and interventions to adjust antiarrhythmic therapy Intravenous fluid composition and rate Supplemental electrolytes Sites of unusual loss of volume Sites of unexpected loss of specific electrolytes Route/rate/composition of nutritional support Use of prokinetic or antiemetic agents Prophylaxis against GI bleeding Insulin requirements Hormone replacement therapy (such as thyroid) Transfusion requirements DVT prophylaxis Procedures to diagnose and/or control infection Antimicrobial prescription including drug levels where appropriate

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Using these categories, a student presentation might go something like this: "Good morning, Mr. Smith. We're going to talk about how well you have done overnight and we'll be happy to answer your questions as soon as we're through with our discussion. "Mr. Smith is 64 years old, one-day status post-repair of an infrarenal abdominal aortic aneurysm. His medical history includes insulindependent diabetes and hypertension treated with a beta blocker and an ACE inhibitor. His preop cardiac stress test was normal and he has never had cardiac symptoms. He was admitted to the ICU intubated and mechanically ventilated after the operation required an unexpectedly long cross-clamping of the aorta, loss of 2 liters of blood, transfusion of 4 units of packed cells in the operating room, and a diminished urine output. "Neurologically, Mr. Smith is sleepy but arousable and moves all four extremities. We've controlled his pain with a morphine drip at 2 mg/hr overnight and are weaning off the midazolam drip we used to sedate him. "From a pulmonary standpoint, he has crackles at the lung base and the chest x-ray suggests that he is a little fluid overloaded. His oxygenation is nevertheless good, with O2 saturations greater than 95%. His CO2 clearance is also good, with end-tidal CO2 about 33 torr, all of this breathing on his own with minimal ventilatory support including a pressure support of 8 torr, a PEEP of 5 torr with an FIO 2 of 40%. "From a cardiovascular standpoint, we weren't sure where he stood after the blood loss and transfusion in the context of a blood pressure that was normal but low for him, so we inserted a pulmonary artery catheter. The initial pulmonary artery occlusion pressure or wedge pressure reading was 6 mmHg, suggesting that he was still behind on fluids, so we administered additional crystalloid overnight. Presently, he has a wedge pressure of 14 mmHg, a cardiac index of 3.5 liters per minute per meter squared on low doses of beta blocker and the ACE inhibitor. Heart rate is 80 and his blood pressure is now normal for him, 150/90 torr in both arms. There's no bleeding at the wound site, and peripheral pulses are full with no mottling of the feet. "Regarding his fluids and electrolytes, he's net positive about 9 liters over the past 24 hours, presently voiding about 5.0 ml/hr clear urine with a sodium of 138, potassium of 3.8, a creatinine of 1.4, and a glucose of 250 on IV fluids of 5% dextrose in half normal saline supplemented with 20 mEq of potassium chloride per liter running at 125 ml/hr, having received an additional 40 milliequivalents of potassium chloride overnight. His GI/metabolic status is that he's NPO with an NG tube in place, losing about 40 ml per hour of NG drainage that is not being replaced. We've

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been chasing his blood sugars all night with subcutaneously administered insulin, a total of 24 units administered over the past 8 hours. He's being prophylaxed against stress bleeding with intravenous cimetidine. From a heme/ID standpoint, his last hematocrit was 28% after receiving an additional 2 units of packed red blood cells here in the unit, with a platelet count of 104,000 and coagulation parameters normal. He has had no fever spikes and received one dose of antibiotic postoperatively." What's impressive about this presentation is the amount of data communicated within a very short span. The system's organization, using system-specific outcome and process variables in a predictable order, is what makes the communication work. Goals and approaches to achieving those goals are also system-based. The reason for this approach is that deliberate interventions in one system are likely to affect several others, and those secondary effects need to be explicitly accounted for as plans are formulated. The intent, of course, is to have the patient move from one physiologic state to another using the minimum intervention necessary to accomplish the transition. The way this is typically approached on rounds is running through the systems once more, this time focusing on "where we want the patient to be and how we're going to get him there." Returning to our example patient, Mr. Smith: "Mr. Smith's morphine has controlled his pain well, and I think the only change necessary is to switch him to a PCA device. We need to extubate him, but I don't want to do that until we've managed to mobilize some of the fluid that is visible on the chest x-ray and audible in his lungs. His heart appears to be working well and, other than checking an EKG, I plan to leave him on his present meds. "From a fluid standpoint, the first thing we need to do is shut off his IV fluids and watch his wedge pressure. If his wedge pressure doesn't fall and his urine output doesn't pick up, I'd like to initiate diuresis with a loop diuretic. That will tend to make him hypokalemic, so we will need to augment his potassium replacement. I think his sodium is higher than the 138 due to the high glucose levels, so if we need to give him supplemental fluid in the next 24 hours, we might want to make it relatively sodiumpoor. "Regarding his glucose, his sugars are still high. Rather than take the dextrose out of his IVs, I'd like to get enough insulin in to do the job. We may need to switch to an IV insulin infusion if higher doses of subcutaneous insulin fail to correct the sugars. Either way, the supplemental insulin will drive his potassium down further, reinforcing the need to get some additional potassium started right now. He'll tolerate another day without nutrition support, but not much more, so we need to revisit the nutrition issue tomorrow. His bleeding appears to have ceased, although I'd like to check another hematocrit later on this afternoon.

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There are no infectious disease issues except to consider getting the invasive lines out as soon as possible. "In summary, I want to diurese Mr. Smith, treat the glucose and electrolytes, and, when we have taken off a couple liters of fluid, extubate him." At this juncture, the student will have the opportunity to ask and be asked questions by other members of the team. If the plan is generally sound, the team will adopt it. Good work! And on to the next patient. Again, there is a lot of information and planning being communicated. It works because the format is highly stylized. Students are typically assigned just one patient until they get their bearings in the unit. They may pick up more as the rotation goes on, but students rarely carry more than three or four patients. The house staff, fellow, and attending intensivist are responsible for all of the patients, and for this reason it is important that rounds proceed efficiently.

Ethical Issues in the ICU

Ethical issues in the ICU often entail decisions to implement "do not resuscitate" (DNR) orders or to withdraw life support. These are emotional issues in the best of circumstances. In order to unravel the religious, social, and personal aspects of an individual case it is important to follow some concrete guidelines. First, determine the patient's goals of therapy. The clinician must be able to describe the patient's illness, prognosis, treatment options, and risks and benefits of treatment. Patients and families cannot outline treatment plans without this information. Second, compare the patient's goals with what can be medically achieved. For example, a patient with leukemia has completed a course of chemotherapy; he has stated that if his heart stops he doesn't want chest compressions during hospitalization. A DNR order is entered in the chart. During the hospitalization the patient develops severe pneumonia, requiring admission to the ICU. The goal of therapy is to treat the

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pneumonia and support the patient until he can recover. To that end, the patient should be supported with antibiotics and mechanical ventilation if needed. This is not inconsistent with the DNR order. On the other hand, had the patient failed all chemotherapy and reached the end of life, with no hope for survival, admission to the unit would not be appropriate. In this instance, patients frequently request that the goal of therapy be directed toward comfort and that when their cardiac or respiratory system fails they not be resuscitated. A "comfort care only" order should be entered into the chart. Decisions to admit patients and treat them aggressively with invasive equipment must be based on an understanding of the underlying illness and the patient's treatment goals. Third, don't be confused by the concept of medical futility. In actuality, very few treatments are truly medically futile (i.e., they don't work). Most treatments work; however, one must consider if the quality of life they afford is worth it to the patient. Again, the clinician and patient must have established a goal. Consider a patient with severe end-stage heart failure and respiratory distress due to pulmonary edema. If the goal is to return home to a normal life, all treatment is futile, and the patient may elect for comfort care when he or she develops respiratory failure. If the goal is to return home with limited function and be with family for as long as possible, admission to the ICU to support with diuretics and inotropes may be appropriate. If the goal is to support until family can arrive from out of town to be at the bedside, aggressive support with vasopressors may be appropriate. Fourth, when patients are unable to make decisions, who speaks for them? Someone has to outline a patient's goal of therapy. Traditionally, family members in order of legal recognition are the spouse, the children, and the siblings. If a family member has had a specific conversation concerning treatment goals, this is called "substituted judgment." If they have not had such a conversation, families may make decisions using a "best interest" model. To minimize the distress to families, Congress passed an act that lets patients decide for themselves in advance by completing advance directives. There are several kinds of advance directives such as a living will or a durable power of attorney. Living wills allow a competent patient to document his or her preferences for future treatment in writing. However, ambiguities in predicting all future circumstances may limit their usefulness. A durable power of attorney designates another individual to speak for the patient and to make decisions for health care. A family member who has had a prior conversation with the patient and can make decisions using substituted judgment is a valid form of advance directive. When it is clear tha t the goals of therapy are unachievable, therapy can be discontinued. However, be very careful. To know that treatment is futile, the clinician must know what the problem is. For example, when an emergency response team discovered an unresponsive patient with widely metastatic breast carcinoma, there was a debate concerning treatment. Option A: If the patient wanted comfort care only, no intervention should be provided. Option B: If the care directives are unclear, the patient should be supported until the etiology of unresponsiveness is discovered.

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One outcome may be that the patient will be found to have inoperable metastasis to the brain. Therapy can be withdrawn when futility of care is determined. However, the patient could also have decreased mental status secondary to inadvertent overadministration of narcotics or secondary to hypercalcemia, both medically reversible. Take-home message no. 4: Unless the patient has distinct directives and you are clear on the directives and goals of therapy, support until the etiology is established. Once the etiology is determined, and outcome established, treatment can be tailored to the patient's goals of therapy.

What Makes a Career in Critical Care Medicine So Satisfying

The issues that overwhelm the student are the very ones that make critical care an immensely satisfying career choice. The effective critical care medicine (CCM) attending is like an orchestra conductor, directing various staff to integrate their diverse talents toward one goal. It is very gratifying to resuscitate an unstable patient, initiate appropriate therapy, evaluate outcome, and ultimately discharge the patient to a nonacute area. However, not all interventions and resuscitations are successful. The ICU is often an environment where patients die. While death may not be a satisfactory outcome, it is reality. The CCM attending uses personnel, monitors, and equipment to support patients during treatment in hopes of achieving the goals of therapy. When it is clear that these resources are prolonging life without achieving the patient's goals, the therapy is futile and the patient should be allowed to die. There is an art to bringing a family through this decision-making process. A skilled CCM physician will ensure that the family has been informed, has not been overwhelmed by issues they don't understand, and has come to the realization that the patient's goals are not achievable. Providing comfort then becomes the primary objective. The process for both successful and unsuccessful outcomes is unique to the ICU. Nowhere else do so many individuals--physicians, special consultants, nurses, respiratory therapists, technicians, pharmacists--pool their cognitive and technical skills. It is an environment rich in continued educational opportunity, with the CCM physician directing it all. Unlike some specialists, the CCM physician is a generalist in a specialized environment. The CCM physician must be an expert in cardiology, pulmonary, renal, neurology, and infectious disease and must be able to integrate these disciplines into the care of a patient with multiple organ failure. In addition, the CCM attending must be able to communicate with specialists in these areas. The specialized equipment in the ICU also provides a unique opportunity to observe physiology in real time. Nowhere else can the physician evaluate hypotension, measure inadequate filling of the left ventricle, administer a bolus of fluid, repeat the cardiac output, and measure the effect of increased output on organ perfusion. No other environment provides an opportunity to demonstrate the effect of ventilator support or changing ventilator parameters on reducing the work of breathing. Many of the interventions have immediate consequences that are predictable and measurable. The rewards of a treatment intervention are obvious to patient and clinician.

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Should you decide to pursue a career in critical care medicine, you can take an elective as a fourth-year student in the ICU. You can also join the Society of Critical Care Medicine to learn about career opportunities and the people in the ICU. For a career in critical care medicine, you will have to obtain training in a primary field such as anesthesiology, internal medicine, pediatrics, or surgery. Fellowship training requirements are different for each primary specialty. For example, individuals who have trained in anesthesiology and surgery require only one additional year of training in critical care, whereas individuals who have trained in internal medicine require at least two years of critical care training. In pediatrics, three years of fellowship training are required. During your fellowship training you will have an opportunity to decide whether you wish to practice in a community setting or in an academic institution such as a university. We at the Society of Critical Care Medicine hope that this brief introduction has piqued your interest in critical care and alerted you to the exciting career opportunities in this arena.

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