Introduction - Sunderland ICCU Medical Education - Home



What is critical care?IntroductionMy research led me to an article written by a doctor working out in an Ebola centre in Western Africa. In this article, the doctor described the treatment that he had given some of his sickest patients; it was based on two elements: antibiotics and hope. Although critical care centres, also known as intensive care units, are more technically advanced than those in West Africa, it struck me that in many ways, approaches to critical care highlight a number of similarities. Many of the sickest patients in hospitals are assessed and/or treated by critical care staff. It seems that often the role of critical care is not to make the patient ‘better’ but to give them the best chance possible to let their body do the healing itself. Much like the cases described in West Africa, professional medical treatment is inherently limited; the rest relies on providing support to the body so that it may have additional time to recover. Who comes to critical care units?Critical care units are confronted by a variety of patients. Unlike other wards in the hospital which primarily focus on one organ or one system in the body, most critical care units across the country accept patients with multiple problems, occurring across a variety of organ systems. Some patients arrive through the main part of the hospital, due to acute illness, trauma from accident and emergency, or deterioration on the wards. Others enter from the operating theatre following complications arising from surgery.Some critical care units across the country, for example at the Freeman hospital in Newcastle, have dedicated beds for specific organ systems e.g. cardiothoracic beds, which allow complicated surgery to take place and provide the post-operative support needed.Previously, critical care units have been divided into the two terms ‘intensive care units’ and ‘high dependency units’. There is now a four-tiered grading system used in the UK to categorise the level of care needed by a patient. Level 0Needs met with regular ward careLevel 1At risk of deterioration. Advice from critical care, but on a normal ward.Level 2Requiring more support. Single organ failure or post-op.Level 3Respiratory support or support for at least two organ failures.Some patients may be slow to wean off their ventilator and require longer stays on an intensive care unit, staying for months before being discharged to a normal ward.Over three-quarters of patients survive their intensive care stay, and are discharged to other wards to complete their recovery CITATION Dav \l 2057 [1].What happens on critical care units?Care on a critical care unit differs from general ward care in many ways. On arrival to critical care, patients may often require intubation and ventilation along with other equipment and lines inserting. This is for both monitoring and support purposes.Patients are monitored ideally one-to-one by nurses around the clock in the event of any changes that require attention. Doctors are involved in deciding what treatment is appropriate that will allow the body to mend itself as best as possible and appropriate. Although many of the same diseases are seen amongst general wards too, patients on intensive care units require close supervision and an even more specific management plan. This often entails multiple organ responses to certain treatments or medications. Whilst on a critical care unit, medical professionals also have a role in communicating with families and other health care professionals, firstly in order to gain a better picture of what the patient is normally like and secondly to inform relatives of probable prognosis.The Intensive Care Society’s introduction to UK adult critical care services CITATION Dav \l 2057 [1] discusses the evolution of evidence based practice in critical care over the last number of years. The new sepsis definitions published in the Journal of the American Medical Association CITATION Mer16 \l 2057 [2] are an example of how an advancing scientific knowledge and understanding of the disease pathophysiology is changing medical practice, particularly in a critical care setting. The bigger pictureCritical care does not just involve treatment of illness and injury. It is a place where ethical dilemmas are often encountered – both pre-admission and during admissions onto a critical care unit. Sometimes medical professionals, and family members, must decide what would be in the patient’s best interests. This may involve tough decisions on whether to withdraw treatment, or not to commence intensivist treatment in the first place.Despite from the outset appearing to be a very fast paced, quick thinking speciality, almost all decisions made in critical care can have massive long-term impacts. These decisions are a hugely important part of what critical care doctors do daily.Outside of the critical care unitThe critical care team do not only work inside the unit. There is an outreach team led by nurses along with the doctors on the unit who attend calls from wards and accident and emergency departments regarding patients who are deteriorating and may need admission to intensive care. This team also covers some of the cardiac arrest or peri-arrest calls from the hospital. Whilst on my placement with critical care, we were called to a paediatric case who was critically ill in the emergency department. Here, I was able to observe the role of the critical care team out of the unit and how the patient was managed by the multidisciplinary team.Whilst initially the care was provided by the team working in the emergency department, the role of the critical care team was firstly to decide if and when to escalate the care; deciding at what point the treatment became ‘critical’. Following this, the role became to stabilise the patient. What followed was a great example of what I described in my first few paragraphs. The patient that we were looking after was a young girl with a wheeze and difficulties breathing. By herself, with all of the appropriate interventions in the emergency department, she was deteriorating. Critical care interventions allowed her to be put to sleep and her airways to be controlled so that her body had the time that it needed to respond to the various bronchodilators and other medications used. It wasn't necessarily a different medication or magic cure that critical care added to this scenario- it was the ability to wait, and give the body the time to help itself.The disadvantagesDespite offering care that saves lives, critical care is not without its disadvantages.As mentioned before, critical care teams are sometimes involved in hospital cardiac arrest calls, as following these patients may need admission to a critical care unit. One of the disadvantages seen here, in my opinion, is involved in the decision to start CPR. It is not uncommon that CPR is started ‘inappropriately’. Many people may have different ideas and definitions on when CPR is or isn't appropriate, but having watched the sometimes quite brutal nature of CPR, it seems that in the rush to start resuscitation, people don't really stop and think about whether it is appropriate until after it has been started. The problem here is that the conversation about death and patients dying is not had frequently enough among medical professionals and with patients themselves. Often medical professionals enter a situation where they have to start CPR without knowing the patient’s wishes and what the appropriate measures to take.CPR can save lives, but it may lead to a prolonged period in the intensive care ward – one that may have been unavoidable if the CPR was inappropriately given in the first place. This may lead to a withdrawal of treatment at a later stage if the outlook has not improved. It may also leave the patient in a more disabled state than they may have wanted before. When CPR is not successful, which is a high proportion of the time, it does leave you thinking if it was the right thing to do – when it looks extremely unlikely in the first place that you will have any success, the trauma that occurs with CPR may not seem worth it.Another disadvantage incurred through a stay on a critical care unit is the long term physical and psychological impact that a long period like this may have, often with periods of time missing from their memory due to the sedation needed to keep patients asleep. At Sunderland, and many other hospitals around the UK, part of the long term plan is rehabilitation in critical care units with help from the recovery after critical intervention team, aiming to reduce subsequent health issues relating to their critical care stay. This rehabilitation continues after patients have left the unit and allows them to have a diary with entries from staff and their families from their stay – helping them to fill in some of the gaps in their memory.InternationallyCritical care differs across nations in a variety of ways. A clinical review was completed in 2012 summarising some of the main international comparisons in critical care CITATION Mur12 \l 2057 [3]. In the UK, we have relatively fewer beds available with only 3 beds/100,000 population, compared to other developed countries such as Germany who have 25 beds/100,000 population. The impact of this is that patients tend to be sicker when they are admitted on to intensive care units in the UK. In the United States, 8 times more patients are admitted to intensive care units despite similar per capita hospitalisation rates; this is because in the United States many more admissions are for monitoring purposes rather than to treat. It is interesting to see that fewer ICU beds affects the severity of illness and the duration of stay in hospital as well.International differences in critical care are also seen depending on culture, medical insurance and religion.ConclusionCritical care is a highly multidisciplinary practice where some of the sickest patients are given the time and the chance for their bodies to recuperate. Critical care is about much more than treating people, it is about considering what is right for each patient, and what realistically can hope to be achieved in each case. There are also a multitude of international culture-specific sensitivities and approaches to critical care more widely. Clearly, these are all issues that ought to be considered on a more in-depth level as we move forward.Bibliography BIBLIOGRAPHY [1] D. Menon and P. Nightingale, “An intensive care society introduction to UK adult critical care services,” The intensive care society.[2] S. Mervyn, S. D. Clifford, W. S. Christopher, S.-H. Manu, A. Djillali, B. Michael, B. Rinaldo, R. B. Gordon and C. Jean-Daniel, “The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3),” The Journal of the American Medical Association, 2016. [3] S. Murphy and H. Wunsch, “Clinical rewiew: International comparisons in critical care - lessons learned,” Critical Care Journal, 2012. ................
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