Page 36 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 1: An Approach to Critical Care 5

produce a cure. Third, understanding that comfort care is extensive TABLE 1-3 Critical Care Curriculum: The Pathophysiology of Critical Illness
and effective allows the ICU to become a safe place for grieving and
dying. This is a distinctly different approach from that of many phy- 1. O delivery and the management of life-threatening hypoxia
2
sicians who feel they have failed their dying patients by not provid- 2. Pulmonary exchange of CO , dead space (V /V), and ventilatory (type II) failure
2
d
t
ing cure; all too often this fear of failure leads to abandoning dying 3. Pulmonary exchange of O , shunt, and acute hypoxemic (type I) respiratory failure
2
patients without providing effective comfort care. Since death is not 4. Respiratory mechanics and ventilator-lung model demonstration
an option but an inevitability for all of us, critical care physicians can 5. Perioperative (type III) respiratory failure and liberation of the patient from mechanical
bring their expertise and understanding to help patients decide when ventilation
to forego life-sustaining therapy and to replace it with effective com- 6. Right heart catheter, central hemodynamics, and lung liquid flux
fort care, making the ICU a safe and supporting space for the dying 7. Cardiovascular management of acute hypoxemic respiratory failure
patient and his or her significant others. 8. Ventilatory management of acute hypoxemic respiratory failure, including ventilator-
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Note that the ministerial skills and attitudes required to implement induced lung injury
this approach are more in the province and curriculum of social work- 9. Ventilator waveforms to guide clinical management
ers, psychologists, and clerical pastoral associates than critical care 10. Status asthmaticus and acute-on-chronic respiratory failure
physicians. To the extent that experienced intensivists find this approach 11. Control of the cardiac output and bedside differential diagnosis of shock
helpful, teaching it to students of critical care becomes an important 12. Volume and vasoactive drug therapy for septic, hypovolemic, and cardiogenic shock
contribution to a curriculum of critical care. 13. Left ventricular mechanics and dysfunction in critical illness—systolic versus diastolic
14. Acute right heart syndromes and pulmonary embolism
THE SCHOLARSHIP OF TEACHING AND 15. Acid-base abnormalities
16. Severe electrolyte abnormalities
DISCOVERY IN CRITICAL CARE 17. Dialytic therapy
The process of providing exemplary critical care is magnified and refined 18. Nutrition in critical illness
by learning interactions with students of critical care at all levels—from 19. Sedation, analgesia, and muscle relaxation in critical illness
freshmen to senior medical students through residents in anesthesia, 20. Evaluation and management of CNS dysfunction in critical illness
medicine, and surgery to critical care fellows and practicing intensivists 21. The physician on the other end of the ET tube—audiotape and discussion
seeking continuing medical education. In such teaching sessions, these 22. Managing death and dying in the ICU—videotape and discussion
students always question the principles of critical care and how best to 23. Ultrasound in the ICU
impart them, thereby helping direct a search for better teaching meth- 24. Miscellaneous additional topics: noninvasive ventilation, heat shock, rhabdomyolysis,
ods. Of course, any active ICU is a classroom for learning the principles acute renal failure, hypothermia, and critical illness in pregnancy
of critical care. Yet teachers of critical care need to avoid the pitfalls to
learning when there is little time for the student to process the reasons
for the formulations of differential diagnostic and treatment plans in each the pathophysiology of critical illness is to provide students with an
patient. There can develop a “shoot-from-the-hip” pattern recognition of
critical illness that often misses the mark and perpetuates a habit of erro- informed practical approach to integrating established concepts of organ
system dysfunction with conventional clinical skills. New duty-hour
neous interventions that delay a more rational, mechanistic, questioning
approach to each patient’s problem. regulations for US house officers have made it difficult to include all
members of the team in these teaching sessions, an issue we have not
■ IMPLEMENT A CRITICAL CARE CURRICULUM been able to fully solve. A syllabus of reading material and videos dem-
IN THE INTENSIVE CARE UNIT onstrating procedures and diagnostic techniques such as ultrasound that
follows the seminar topics closely is helpful to students.
One helpful teaching technique is to implement a schedule providing
ity provides a counterpoint to the work rounds and clinical problem- ■ ENCOURAGE INDEPENDENT INTERPRETING OF IMAGING
students of critical care with the luxury of time to think. This prior-
solving activities that, unfettered, tend to dominate the daily activities of TECHNIQUES, BIOPSIES, AND OTHER INTERVENTIONS
the unit. A good start is to ritualize a curriculum for critical care learn- A second forum for teaching critical care is to review essential imaging
ing. In many academic centers, house staff and fellows rotate through the procedures. Accordingly, we incorporate the diagnostic radiology imag-
ICU on monthly intervals. Accordingly, a monthly series of well-planned ing procedures, ultrasound studies, and echocardiograms conducted
seminars addressing the essential topics that house staff and fellows need in the last 24 hours on each of our patients on daily rounds, allowing
to know can incorporate medical students and nursing staff, and lay learners to interpret these studies and to not rely only on written or
the foundations of conceptual understanding necessary to approach the verbally transmitted reports. This incorporation of studies into daily
critically ill patient effectively. In our teaching program, we emphasize rounds has been greatly facilitated by the digital medical record, which
a conceptual framework based on the pathophysiology of organ system allows this review in an efficient manner. We also find it useful to bring
dysfunction shared by most types of critical illness (Table 1-3). an ultrasound machine on rounds for purposes of both diagnosis and
This approach complements the specific etiology and therapy of education. Encouraging students of critical care to be active participants
individual illnesses, because the opportunity for favorably treating many in bedside diagnostic and therapeutic procedures such as endoscopy
concurrent organ system failures in each patient occurs early in the and to follow-up on all biopsy specimens by direct observation with the
critical illness, when the specific diagnosis and focused therapy are less pathologist are other ways to encourage active learning concerning the
important than resuscitation and stabilization according to principles interpretation of ICU procedures and their integration with the patient’s
of organ system pathophysiology. Critically ill patients present many clinical evaluation in a timely manner.
diagnostic and therapeutic problems to their attending physicians and
management and monitoring technology facilitate early detection of ■ TEACH HOW TO TEACH
so to the students of critical care. Recent advances in intensive care
pathophysiology of vital functions, allowing the potential for preven- An essential component of the critical care fellowship is learning how
tion and early treatment. However, this greater volume of diagnostic to teach. It is common in academic medical environments to assume
data and possible therapeutic interventions occasionally can create that completing medical school and residency confers the ability to
“information overload” for students of critical care, confounding rather teach, but most critical care fellows value the opportunity for super-
than complementing clinical skills. The purpose of a syllabus addressing vised and guided enhancement of their teaching abilities by effective

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