Table Of Contents

First Impressions 3

ICU Types 4

The ICU Team 6

The Patients 8

The Equipment 12

Rounds, Rounds, Rounds 14

Ethical Issues in the ICU 19

What Makes a Career in Critical Care

Medicine So Satisfying 21

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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!

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 ICU TYPES
What’s 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

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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.

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 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,

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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.

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 The Patients
Pathway to the ICU
Patients are admitted to the intensive care unit either because they require high-
intensity 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.

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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 preload—the 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.

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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; intra-
aortic 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 Outcome variables Process Variables
Neurologic âFunctional examination âType/route of analgesic
âPain level âType/route of sedative antiseizure meds
âSedation level âIntracranial pressure monitors
âGlasgow coma score
âIntracranial pressure
âOccurrence of seizures
Pulmonary âPresence of rales or wheezes âVentilator settings
âAppearance of chest x-ray âAdministration of nebulized bronchodilators
âOxygen saturation âAdministration of supplemental gases such as
âEnd-tidal CO2 concentration nitric oxide
âArterial blood gas data
âSpontaneous ventilation rate
âForced vital capacity
âNegative inspiratory pressure
Cardiovascular âBlood pressure âEstimates of, and interventions to adjust preload
âHeart rate such
âAbnormal rhythm as CVP or pulmonary artery occlusion pressure
âPresence of rales âEstimates of and interventions to adjust afterload
âPeripheral pulses and extremity warmth such
âCardiac output as vasodilator therapy
âEvidence of ischemia âEstimates of and interventions to adjust
contractility
such as inotropic therapy
âEstimates of (e.g. drug level) and interventions to
adjust antiarrhythmic therapy
Renal/Fluid/ Electrolytes âWeight âIntravenous fluid composition and rate
âNet intake and output balance âSupplemental electrolytes
âCurrent electrolytes âSites of unusual loss of volume
âBUN, creatinine âSites of unexpected loss of specific electrolytes
GI/Metabolic/ Nutrition âBowel sounds, function âRoute/rate/composition of nutritional support
âAbsorption of enteral feedings âUse of prokinetic or antiemetic agents
âFraction of caloric goal attained âProphylaxis against GI bleeding
âNitrogen balance âInsulin requirements
âMetabolic data âHormone replacement therapy (such as thyroid)
âHyper or hypoglycemia
Heme/ID âNew findings on physical exam âTransfusion requirements
suggestive of âDVT prophylaxis
bleeding âProcedures to diagnose and/or control infection
âHematocrit, platelet count and âAntimicrobial prescription including drug levels
coagulation where
parameters appropriate
âTemperature, findings suggestive of
infection on
physical exam, gram stain and culture
data,
including antimicrobial sensitivity
âLeukocyte count and differential

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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 insulin-
dependent 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 sodium-
poor.”

"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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