So the ICU physician,
the Intensivist. The training for intensivists
varies in different countries.
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.
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.
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.
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.
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.
So the admitting examination by the Intensivist
takes about 30 minutes.
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.
They learn constant assessments of hemodynamics
and how to adjust the drugs
as necessary, to maintain a stable
hemodynamic situation as possible.
They provide a constant assessment of ventilation.
They have to know how to manage transducers.
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.
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.