Archive for category Clinical Pearls

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.

Ileus and SBO Strategies

Discussion of ileus and SBO. More general surgery topics coming

MCIs and Disasters

Further discussion of handling MCIs and preparation for disasters. Happy Holidays. JY

Discussion of MCI from Alt Right Rally

My first hand description of our preparation and process that helped us manage the MCI this past Saturday. I want to thank everyone for their professionalism, knowledge, and skills that helped us manage this incident. JY

Kobiyashi Maru (for the Star Trek fans)

I present a no-win scenario. No matter what you do the patient is going to get sicker. Spans the time from 911 call to the ICU. Guest spot from Chewbacca and music from an album I made in the 90’s. Thanks for listening. JY

Introduction to Patient Safety

Part 1 of a discussion of patient safety. Thanks for listening. JY

Obtaining Proficiency in Low Frequency High Stress Situations

Discussion of the positives and negatives of experience, and the various tools to use to gain clinical proficiency when actual clinical experience is lacking. A tune I wrote and recorded at the beginning and end. Thanks for listening.

Complex Trauma

Discussion of some complex trauma resuscitation and evaluation situations. Hope you find it useful. JY

Situational Decision Making: Chest-Pelvis-Head

Sorry its been so long. I will do new podcasts talking about complex ICU and trauma clinical situations and my algorithms and beliefs on how you should handle them. Me on sax trying to do justice to My One and Only Love. Happy New Year!