CHAPTER 1: An Approach to Critical Care

KEY POINTS

• Thoughtful clinical decision making often contributes more to the patient's outcome than dramatic and innovative interventions or cutting-edge technology.

• While protocols and checklists inform general care of patient populations in the ICU, for individual patients it is equally important to formulate clinical hypotheses based on an understanding of pathophysiology, then test them.

• Define therapeutic goals and seek the least intensive intervention that achieves each.

• Novel treatments require objective clinical trials before they are implemented, and traditional therapies require clarification of goals and adverse effects in each patient before their use can be optimized.

• Determine daily whether the appropriate therapeutic goal is treatment for cure or treatment for palliation.

• Critical care is invigorated by a scholarly approach, involving teaching, learning, and performing research.

INTRODUCTION

Intensive care has its roots in the resuscitation of dying patients. Exemplary critical care provides rapid therapeutic responses to failure of vital organ systems, utilizing standardized and effective protocols such as advanced cardiac life support and advanced trauma life support. Other critically ill patients in less urgent need of resuscitation remain vulnerable to multiple organ system failure, and benefit from prevention or titrated care of each organ system dysfunction according to principles for ultimately reestablishing normal physiology. This critical care tempo differs from the time-honored rounding and prescription practiced by most internists and primary care physicians. Furthermore, the critical care physicians providing resuscitation and titrated care often have little firsthand familiarity with their patients' chronic health history, but extraordinary tools for noninvasive and invasive description and correction of their current pathophysiology. Though well prepared for providing cure of the acute life-threatening problems, the intensivist is frequently tasked with the responsibility of being the bearer of bad news when recovery is impossible, and must regularly use compassionate pastoral skills to help comfort dying patients and their significant others, using clinical judgment to help them decide to forego further life-sustaining treatment. Accordingly, experienced intensivists develop ways to curb their inclination toward action in order to minimize complications of critical care, while organizing the delivery of critical care to integrate and coordinate the efforts of many team members to help minimize the intrinsic tendency toward fragmented care. In academic critical care units, teaching and investigation of critical care are energized by the clinical practice; in turn, the practice is informed, animated, and balanced by the information and environment arising from and around teaching and research programs. Yet the vast majority of critical care is delivered in community-based ICUs not affiliated with universities,^1,2 where critical care physicians rely on their penchant for lifelong learning to update their knowledge and skills through informed reading and participating in continuing medical education. These activities provide a means for all critical care physicians to maintain career-long learning and access to new understandings of the management of critical illness.

PROVIDING EXEMPLARY CARE

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