A call comes from the ICU Registrar and the Intensivist wanders up from the sanctuary of the ICU to attend the tail end of the latest MET (Medical Emergency Team) call.
The tension is palpable entering the room – there is a clear division of opinions. The experienced ward Nurses are worried about the patient, having looked after her for several days. The ICU Registrar feels there is no objective reason to admit the patient currently.
The attention shifts to the Intensivist for a decision as both parties put their cards on the table. The Intensivist scans the room, conducting an ‘end-of-bedogram’ in moments – too fast to be the result of pure conscious thinking. The Intensivist greets the patient, simultaneously placing a hand on her cool clammy extremities, noticing slight mottling of an exposed knee, ‘abdominal breathing’ beneath her gown and a drained look in her eye. A blood gas appears from the periphery which completes the picture of someone just compensating. Looking at her, the Intensivist knows that she won’t fare well when she falls off that cliff she’s precariously balancing on, especially if we only find that out when the next set of observations is done by the already thinly stretched ward Nurses.
“Let’s bring her down”, proclaims the Intensivist.
“But her obs are all within the normal ranges, what are we going to do that can’t be done up here?”, asks the ICU Registrar.
“We’ll be able to catch her before it’s too late”, says the Intensivist.
Degrees of concern
Assessing a critically ill patient and determining disposition is a core part of MET teams and ICU Liaison services. Whilst this patient was assessed as needing to come to the High Dependency Unit, there are many patients seemingly like her ‘on paper’ in the hospital who can be managed safely on the ward. How the heck do we tell the difference?
1) Experience
– The ability to make quick and effective decisions is a function of seeing thousands of patients in similar situations and knowing the subtle warning signs. The human brain is phenomenal at pattern recognition and subconscious processing. This comes to the surface of our conscious brain as a ‘gut feeling’ or intuition. In reality, there is a huge amount of data being crunched in the background to come to these conclusions. The conscious brain really is the tip of a huge iceberg.
2) Staying calm
– Keeping your cool in potentially stressful situations is not only an important attribute of a good leader but it also allows the brain to think smarter! When the ‘fight or flight’ response is triggered and the sympathetic nervous system is in overdrive, we can no longer think logically and clearly. We revert to more primitive instincts and patterns rather than situation specific reasoning.
3) Trajectory
– A snapshot in time is certainly insightful but trajectories over time are infinitely more useful. How was the patient 2 hours ago, how were they yesterday and how were they when they were ‘well’ at home? The speed of deterioration and the particular signs that have developed guide our diagnosis and therapy. This is why sometimes we need to see how patients go over the next 24-48 hours before being able to offer a prognosis or diagnosis.
4) Nurse concern
– As Doctors and even more so as Specialists, we have many patients to look after and are only at the bedside for short periods of time. The experienced bedside Nurse who has been looking after the patient for some time will know what is ‘normal’ for the patient, give insight into the trajectory as above and have a highly tuned ‘gut feeling’.
We don’t always get it right!
We are imperfect and give our best estimates which are generally correct but not always. That is why we may errr on the side of caution by bringing a patient to the HDU/ICU or asking our ICU Liaison Nurse/ICU Registrar to check up on a patient we decide to leave on the ward.
Most importantly, the good Intensivist takes on feedback and opinions from their team and realizes that pattern recognition is powerful but can also be an alluring trap. We must not lose the ability to think creatively and broadly because the human body loves to throw us curve balls!