PGY 39, Day 178
The Christmas Holiday Vortex was pulling hard this past week, but despite that and the skeleton crew, we were able to stay on TARGET and on task in the ICU. Patients and families were well cared for, and they always appreciate the good care. How can we do it? Focus on the mission ... mission integrity and mission adhesion, facilitated by our team development tools. The message to the team is simple, Sick Patients Take no holidays and there is no room to cut corners on the Critical Care Mission ... EVER ... not for one second of any day ... NEVER cut corners on patient care or patient safety!
A message for PATIENTS & FAMILIES and INEXPERIENCED CARE GIVERS ... before I get into the meat of our work discussion ...
Please, I beg PATIENTS and FAMILIES to make sure their wishes are known, because this work is very intense ... and it requires our dedication to PRESERVATION of LIFE and limb. It is shameful to waste resources on people who do not want us to do our best to fix what we can fix. If you don't want critical care ... PLEASE don't let yourself, get to the ICU. Make sure your family knows you DON'T WANT the hospital and especially ICU care. There is nothing worse from THIS experienced intensivist's point of view than to have families start to waffle on a care plan before a proper therapeutic trial has been carried out. Advanced directives are useful, but they are rare, and they are VERY RARELY SPECIFIC. IF in our best judgment we are carrying out the patient's wishes, let us carry on until we are sure ... absolutely certain that we are doing what is in accordance with our Critical Care Mission. Please don't undermine our mission.
And ... as for inexperienced care givers ... plaese stay out of it. In other words, please leave these decisions to the EXPERIENCED MEMBERS OF THE TEAM. Let the Experienced Providers determine what is a proper trial of care. If you don't know what you are doing, do nothing and get help. If you don't know what you are talking about, say nothing and get help.
This is a reiteration of my big picture teaching this week.
What is the Critical Care Mission?
Preservation of Life, Limb, Organ and Vital Human Functions in accordance with the wishes of the patient, and with the intent to serve the best interest of the patient at all times.
In that context, and in the context of the family, the Intensivist and his team of care givers, must include the family in the team, and should relentlessly strive to achieve the following Goals and Objectives as soon as is possible:
A. GOALS: NOW = UPON ARRIVAL
SIMULTANEOUS and RAPID (within seconds to minutes)
-Resuscitation,
-Preservation and Restoration of
-Perfusion, Oxygenation and Ventilation to
-Optimize preservation of Life, Limb and Organ function
-Recognize and treat coexisting diseases, precipitating illnesses and/or injuries
B. OBJECTIVES:
SIMULTANEOUS and RAPID (within seconds to minutes) EVALUATION & TREATMENT to
1. Optimize cardiac output and end organ perfusion
2. Oxygenate the blood
3. Remove carbon dioxide from the blood
4. Deliver oxygen to Tissues, Organs/cells
5. Remove carbon dioxide, metabolites and toxins from Tissues, Organs/Cells
(organ priorites are a. Heart, Brain/CNS, Lung b. Kidneys c. All others)
6. Diagnose and Treat the Precipitating Illness/Injury
7. Restore Vital Functions and Optimal Physiology (total organism) ASAP (within minutes to hours) to Prevent and Limit Limb and Organ Damage As Much as is possible and as rapidly as possible (minutes to hours)
8. Prevent complications of Illness, Injury and Treatment as much as is possible (from start to finish)
9. Promote optimal recovery and restoration of normal function through rapid mobilization and rehabilitation as soon as is possible.
10. Restore patient to normal, productive and creative life, as much as is possible (To srart As soon as is possible ... and to continue as long as is necessary for days to weeks to months to years), and to help the family throughout this process.
Toward these ends, we have developed a comprehensive set of check lists designed to help facilitate team care of the sickest patients in the care of teams with varying levels of knowledge, skill and experience. Our Check Lists, all part of the StepWisely(R) System include STOMPP(TM) & STOMPPIT(TM) The Strategic Targeted Operations Management for Patient Protection Integration Tools to promote Optimal Patient Care Through Teamwork. This
Comprehensive checklists includes:
TARGETS and GUIDELINES to Promote
1. Family Integrity, Participation, and Protection - FIPPs(TM)
2. Patient Integrity Protection & Preservation - PIPPs(TM)
3. Patient Organ Specific Protection & Preservation Guidelines POPPs(TM)
4. Targets for Organ Specific Protection, Preservation & Treatment Strategies (Generic and Disease Specific) - TOPPs(TM)
5. General for ALL Pateints Prophylaxis - GAPPs(TM)
I have been using these check lists to help keep the care teams on Target for the last few years. The less experienced find them particularly helpful in light of the many distractions that are rampant and increasingly complex. Focus on the patient and on patient safety. When in doubt go see the patient ... don't rely on the record, or the documentation for decision making, but rely on reevaluation of the patient. The less stable the patient, the more time you should spend at the patient's bedside.
If you have questions, or want more details, respond to this blog, or email me @ Dr.Mike@ihealsolutions.com and I will get back to you as soon as I can.
Buona Fortuna!
Enjoy!
Dr. Mike
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