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Critical Care: Presentations and Some Concepts

It can be very difficult for third year medical students, and NP/PAs new to critical care to learn how to present patients. I have done several podcasts on this and I direct you to the “critical care podcasts” page of this site and the “ICU presentations” podcasts. But I think a written primer can be helpful.

Presentations in general are done to bring people up to speed on new or current patients. The purpose is to advise the team coming on shift of the patients current condition and warn them of potential problems. I have always had a problem with the totally scripted presentation, in that it does not highlight what is important for the new team to know which is:

  • Why is the patient here?
  • What are their critical problems?
  • What happened since previous presentation (24 hours, or 12 hours depending on service)?
  • What are their ongoing concerns?
  • What are we doing today?

I realize that novices cant present exactly like this, because they don’t have the ability to synthesize a large amount of data and turn it into a coherent presentation. Therefore they are taught to go through either a data-based or a system-based presentation format. What usually happens is that the experience people on the team have to take this scripted format and turn them into something useful. I often find it very hard to pick out those critical pieces of information from a system based presentation because all data is presented similarly and it is difficult to know what is absolutely essential for the next shift. For instance in a typical system based presentation you will talk about what happened in the past 24 hours hopefully after talking about why the patient is in the intensive care unit, and then go through neuro, cardiovascular, pulmonary, renal, infectious disease, endocrine, and musculoskeletal. Usually the laboratory data is sprinkled in amongst this system presentation or non-laboratory data is presented amongst the systems and then the data is presented in one bolus at the end.

It is difficult to find common ground between a presentation that two attending physicians would make to each other, and a presentation that two medical students would make to each other. If it is the only presentation the team is getting, then critical information has to be relayed. In my opinion the critical information is:

  • What threats to life exist?
    • Is the patient on a ventilator?
    • Is the patient on pressor agents?
    • Is the patient septic?
    • Is there evidence of any organ failure?
    • Is there evidence of impending organ failure?
  • Is the patient getting surgery today?

The other concept I’ve tried to get across (with minimum success) is the inter-relation between organ systems. If the patient’s respiratory status is worse, what’s their renal status? If they’re septic, what going on with their kidneys and lungs? Will treating one system hurt another system?

This is why its essential to think through your proposed actions. Do you wean the vent on a patient who’s renal function is plummeting? Maybe, but you need to consider if they’ll need dialysis to maintain extubation.

There are also several things that I do, more religion than science, that has served me well over the years:

  • Every patient on a ventilator gets a CXR and ABG every day. Reason – physical exam is inaccurate in assessing pulmonary status, and if you are trying to wean someone, or are augmenting vent support, if you’re only looking at the oxygen saturations, you’re seeing the situation through a keyhole. I believe getting these two things every day helps you make better progress than guessing
  • In the acute ICU phase I need these labs to “screen” the status of the patient’s condition and gain situational awareness
    • Lactic acid
    • HCO3
    • WBC
    • HCT
    • Cr
  • Run toward problems, not away from them
    • If the patient may have pneumonia, look for it
    • If the patient may be leaking from an anastomosis, or may have a problem in their abdomen, find out (usually with CT)
    • If a patient has become hypotensive, treat it, then figure out why so it doesn’t happen again. Pressors can mask problems so if the BP is good on 10 of Levo, you definitely should not be relaxing

All I have for now.

Critical Care Podcasts

As July 1 approaches I went ahead and put a group of useful critical care related podcasts on their own page. Go to top of this page under picture and click on “Critical Care Podcasts”. Hope you find them useful. JY.

Optimaltraumacare.com

Optimaltraumacare.com

For several months I’ve been putting together a book on how to run a trauma center. I have created a new website optimaltraumacare.com where I will post writings on trauma center operations, PI, site visit preparation, etc. For those of you working in trauma centers, I hope that you will visit the site.

Thanks.

JY

Podcasts now listed along right side of page

People have told me that iTunes limits the number of my podcasts it shows, limiting access to old files.

There is now a widget along the right side of this page that lists and provides access to the last 100 podcasts.

Thanks for listening.

JY

Ileus and SBO

A discussion of ileus and SBO. Thanks for listening. JY

Hierarchies in Medicine and Surgery

A discussion of the key role hierarchies play in high risk fields. Thanks for listening. JY

Change in Podcast Format (after all, it’s been four years)

After 110 podcasts and 57,000 downloads, I think it’s time for a change in format. Loyal listeners have noticed a drop in my productivity. This is mostly due to the fact that it is tough to think of something to talk about for 25-30 minutes, that we have not already discussed, and that I can stand talking about again.
So I am going to decrease the duration of the podcasts, and increase their frequency. The podcasts will less often be about global topics (resuscitation, respiratory failure, etc.) and will be about cases or incidents that I have lived through (possibly recently) that I feel can be instructive to the listeners. I would like to spend some time talking about the decision making, and the psychology of evaluating situations and coming up with solutions, rather than telling you things you can read on Wikipedia. I will also talk about situations and incidents that have come to bother me, and where I think we can do better.
Hope you find it worthwhile to listen to. The podcasts will be as long as it takes for me to get the point across, may be 5 minutes (bathroom break) or 20 minutes (ride into work).
Thanks for listening.
JY

Clinical Red Teaming

A discussion of Red Teaming and its possible application to clinical medicine. The music is a flute and sax solo I played live with Green Eggs and Sam on the Dave Matthews Tune #41. Thanks for listening and have a Happy Holiday. JY.

Risk Assessment and Aggressiveness

Discussion of risk assessment and aggressiveness. Also an audio clip from a live performance by me on tenor and Green Eggs and Sam at Trax with Ken Leone on vocals from 10 years ago. Some sax work I’m most proud of. Thanks for listening. JY

Improving Care and Performance

Discussion of steps you can take to improve performance in your organization. A little from a flute quintet I put together at home. Thanks for listening. JY