Transitioning form the world “downstairs” chaotic world of Emergency Medicine to the order and control of Intensive care has been interesting. Here some things I have learnt in the first month.
1/ Time is a better diagnosticians than any test.
Much effort is made to run every serum rhubarobiliarium and scan every conceivable part of our complex patients. However time seems to be a much greater predictor than anything else. “slow to wake up” is a telling phrase. This is a luxury I did not have in the Emergency department.
2/ Positive outcomes are complicated.
Researchers work hard to define these. But for us day to day clinicians this is also difficult. But by definition to be on “the unit” (I don’t think intensivist realise quiet out dystopianly ominous this sounds) you have received a dramatic insult. To survive a week is good, a month, a year and more importantly to be living a life worth living? These outcomes are much harder. Much like seeing a patient in A/E for 10 minutes, we are quite separate for the long term outcomes of our patients.
3/ Time to think is important.
Measured, safe approaches is the way forward. Again, time is a fantastic thing.
4/ Discussion is good, Decision are better
Getting the right number of chefs is a tricky game. Input from many parties adds much. But ultimately, some-one needs to be the person to stamp their name to the many tricky decision that have to be made at the end of medicine which has the least margin for error.
5/ It isn’t magic.
It seems frustrating sometimes what the team “upstairs” would and wouldn’t take. Seeing the non or slow improvement many times in my first month only I get a greater sense of the reasons behind this. Ultimately the patient has to be able to get themselves better. There are some pretty amazing tools to perserve the status quo as they do this. But there is no magic bullet.
6/ There is a finite amount of options.
When starting out in the emergency department it seems amazing what the senior doctors can do. You tell them a few things, they ask a couple of key questions, check one tests and they are happy. As I started to do this myself I realised this is as there is (within a 99 % probability) , considering the infinite variety of presentations, only a finite amount of diagnosis and treatments we can enact.
Intensive care is the same. We can breath for you for a bit, replace you kidneys for a bit, give you antibiotics and optimise some of your numbers. Finite options available unfortunately does not make these choices easy.
7/Frailty not age.
Age is just a number so they say. “Physiological reserve” is what the anaesthetist say. This basic concept is not so easy to judge, however the trend in recent years towards frailty that has broken free form the speciality of geriatrics is a positive one. Discussing this key concept with patient’s and their families is the important next step.
8/Prognostication is difficult
I have had SHOitis (or at the top left of the dunning-kruger curve ) recently with this. The confidence that only comes from minimal knowledge. Knowing who is going to do well and who isn’t is the overlap of art and science that makes medicine so interesting. After seeing many patients prove us wrong already in my short intensive care experience I realise this is no easy task.
It’s been an intense month (pun definitively intended), but enjoyable. Coffee fuelled daily learning, interesting medicine and trying to stop people dying. Fundamentally this is what the day to day life of a junior doctor should be like.