Employees – Special Employees and Conditions in the ICU

by Brian Warriner, MD, FRCPC

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    00:00 So the ICU physician, the Intensivist. The training for intensivists varies in different countries.

    00:07 And in rural communities it's usually an anesthesiologist who takes on this role. In my country, Canada, there is a three pronged approach to intensive care medicine qualifications.

    00:19 One must complete either their Anesthesiology training, their Internal Medicine training, their General Surgical training, or their Emergency Medicine training before applying for an Intensive Care Residency.

    00:37 This is a further two years of training in which they learn how to deal with all kinds of ICU patients. This is, varies from country to country how this is managed.

    00:49 But in Canada takes, on average, 7 years to 9 years after completion of medical school, before one completes their Intensive Care Residency and is classified as an Intensivist. So what happens to a patient that enters the ICU? Well, the first thing it happens is they have a very complete physical exam. Much more complete than we see in most areas in the hospital. But it's done quickly and with great efficiency.

    01:19 It's a head to toe assessment, with special focus on gross neurological exam and the level of consciousness. It's very important to know what your patient's level of consciousness is at the beginning of their stay in the ICU and to keep an eye on that throughout their stay. There's obviously a pulmonary exam with emphasis on ruling out pneumothorax and observing the respiratory pattern of breathing. Determining whether the patient may have pneumonia or some other major problem with ventilation. There's a cardiovascular assessment with emphasis on the patient's volume status. This is often included with a cardiac ultrasound, transthoracic ultrasound down through the chest wall and assessment of central venous pressure, which can be done by reading the jugular veins on the side of the neck, or by placing a catheter in the jugular vein down into the heart and actually measuring the pressure. There's a daily abdominal exam, and there may be ultrasound done on the abdomen as well. And a careful assessment of bowel function on a daily basis. There's almost a continuous assessment of skin lesions, swelling edema, and a focused exam on areas of greatest concern.

    02:43 So the admitting examination by the Intensivist takes about 30 minutes.

    02:49 But every day there's a follow up examination by the Intensivist that takes between 5 and 7 minutes. The ICU Nurse is also a highly qualified health care provider. A Critical Care nurse has to complete nursing training and work for a number of years as a general duty nurse, or a subspecialist nurse in a place like the emergency or the operating room, before they attempt to qualify as a Critical Care Nurse. They must show the ability to assess patients, react quickly to changing conditions, make decisions quickly and know how to manage many high potent drugs, highly potent drugs, dangerous drugs and operate complex equipment. It's often up to the nurses to manage the patient's changing condition for sometime before a physician becomes available. So nursing aspects of care include a complete reevaluation of the patient at each change of shift. So that can be 2-3 times a day. The ability to infuse very potent drugs safely, and they have to spend a significant length of time learning how to do this.

    04:01 They learn constant assessments of hemodynamics and how to adjust the drugs as necessary, to maintain a stable hemodynamic situation as possible.

    04:13 They provide a constant assessment of ventilation. They have to know how to manage transducers.

    04:19 There's a constant assessment of the level of consciousness. There has to be management of sedation, pain, and muscle relaxation. They may have to manage continuous renal dialysis. And they may have to manage end of life care.

    04:37 They are the ones who provide most of the communication to the patient and family, in collaboration with the physician, but the nurses role is vital in all of this.

    About the Lecture

    The lecture Employees – Special Employees and Conditions in the ICU by Brian Warriner, MD, FRCPC is from the course The ICU.

    Included Quiz Questions

    1. Pneumothorax
    2. Pulmonary tuberculosis
    3. Atelectasis
    4. Bronchitis
    5. Emphysema
    1. Daily
    2. During admission
    3. Upon discharge
    4. Every 3 days
    5. Only as needed
    1. Ordering the administration of potent drugs to patients
    2. Completing evaluation of patients at the change of shift
    3. Performing constant assessment of ventilation
    4. Managing continuous renal dialysis
    5. Managing end-of-life care

    Author of lecture Employees – Special Employees and Conditions in the ICU

     Brian Warriner, MD, FRCPC

    Brian Warriner, MD, FRCPC

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