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Evidence based chaos in critical care units !

Posted Feb 08 2013 12:00am

Critical  and intensive medical care is meant for supporting  an  individual organ (or multiple organs )  at times of extreme distress ,  till the  healing process  prevails over .Later , the patient  shall be shifted safely out of the unit .

Whatever be the modern technology , the single most important factor that  determines the success of ICU outcome  lies within the  patient body ( One estimate says  patient factor constitutes almost  85-90% -Dukes medical center )

Ironically , the modern gadgets, drugs , devices  threatens  . . .  rather  fights . . . with this  inherent  patient fighting  mechanism . We will  never-ever know how many cellular switches are turned on by our biological high  command ,  that compensates  and tries to restore  body  homeostasis.

critical care unit icu ccu.jpg evidecne based medicine modern medicine

Here is a  personal experience with a patient management scenario in an ICU  . The  patient is none other than my father !

He  is a 82 year old man who has  developed a acute febrile illness which rapidly degenerated into  acute respiratory failure  and  X ray  showing  infective bilateral pneumonia  and  probable ARDS  .He was on ventilator for 4 days  and subsequently weaned  off but still  heavily dependent on oxygen . His lung is wet with crackles and wheeze intermittently . His cardiac function was excellent . In one of the episodes of hypoxia he  developed  , mild shooting of blood pressure and minimal ST changes .  Alarmed  by this he was started on  beta blocker , for the first time  . It  was titrated up to maximum doses for a suspected ischemic  episode .

It is  well-known , ECG changes are extremely common in hypoxia , tachycardiac  stressed individuals .

Sympathetic  blockade  is important , only  if ,  it is an inappropriate surge  . When the body fights a disease it is the only major biological weapon available to him .How is it justified to block it ?

When this was discussed with the  team they said they have no power to deviate from  protocol and there is one article , that says  BBs are  beneficial even in COPD !

The patient  continues to be in ICU dependent on oxygen with extreme  ICU fatigue  definitely worsened by the heavy dose of adrenergic blockers which is in my opinion delaying recovery !

Different   organ specialist are prescribing  drugs  according to their level of understanding  (evidence is always available for them  . . . some where )  and radiology fellows  keep taking  snaps of  distressed  organs  in various angles  in HD quality images . Meanwhile , CT scan  seems to have revealed a chronic  interstitial  process   . . . how to diagnose a chronic lung condition  in a man who is  yet to recover from major acute inflammatory lung Injury ! I do not know ? And the current development is they are considering disseminated tuberculosis !

You may a big physician , the patient  may be a very close family member  , modern health care  system makes you watch  helplessly once you hand over  patient to a   complex care  unit .

We hope for the  best .

Final message

               Medical practice  . . . however intensive the care may be  . . .   the bottom line is  . . . it  should be based on  common sense . Modern medicine  tends  to make  this faculty of our brain  blunted .

The  specialty of Intensivist   is largely  misunderstood  . It goes more with  satisfying scientific egos  and public  perceptions  rather than true patient needs .

We need not react to every changing parameter that emanates  from the modern machines  that  keep sending out live  data from a seriously ill patient ,  on a moment  to moment  basis ! (We simply do  not need that ! If only a pilot  reacts with  jitters to every air pocket turbulence ,  he will  not reach the destination safely  ! )

From a cardiologist perspective ,  the humble  request  to all Intensivists   and critical  care physicians   is ,   avoid being  in  “fire fighting mode”   for all  those subtle ECG changes  that occur  in ICUs ,  especially with multi- system disorder (Caution : Acute coronary syndrome in CCU / post PCI  set up   is different story altogether where even a minor ST shift can be significant ! )

Heaven’s  sake  let us  rely more  in  our  brain rather than  the machines and devices !

Above story is not even a tip of an Iceberg . I come across it  every day  in  many ICUs  I visit  . The  most saddening aspect  is ,  we can not point out these mistakes  to our fellow professionals ,  as it  amounts to   hurting academic egos .They are more important  than patient care at any given point of time !

Counter point

For any system to work  , it  needs  a  strict set of guidelines ,  other wise the system of care will fail. This is a  fundamental basis on which modem medical  care works . The only issue is ,  we  should keep checking for any inadequacies in the evidence base and try to correct it. So do not blame the  EBM . It has come to stay .That is the future ! You are very pessimistic towards  modern science !

Rapid response to counter point

But the real issue is  . . . by the time next evidence base finds a major flaw  in the existing system of care ,  damages are already done . So with your clinical acumen  every learned physician is free to create  his own real world  experience .(That is also called Level 3 evidence now ) ** Protocols are not  sacred sermons . It  may  be (rather must be !)   violated if there is a need for the benefit of patient .

Disclaimer

* This is not an  attempt to disgrace the concept  of intensive  medical care . Please remember ,  finding fault  could be same as finding facts .(At least in   medical care )

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