ICUs……….. THE CRITICAL DECISION MAKING UNITS – PSRI

Intensive care units or the critical care units are like a life line not just for hospitals but also for patients. I prefer calling ICUs as critical care units as it is not related just to critical conditions of admitted patients but also to the critical decision making abilities. A good CCU provides intensive care, critical monitoring does critical analysis of diagnosis and treatment and then provides the critical treatment pathway which has to be constantly assessed and reassessed.

The most vital components of critical unit is the critical thinking of the in- house care givers. Based on the monitoring data, analysis and counter analysis is done and a healthy ICU will have a criticism of each diagnosis so that consistently proper diagnosis is arrived at and correct treatment line is chalked and followed, leading to the best possible outcome. To give an example here is a short summary of a difficult case….

A 50 years old female, underwent kidney transplant and on first post-operative day, was found to be breathless, for which she was shifted to medical ICU for monitoring. On examination, she was found to have breathing difficulty and with high breathing and heart rates and low oxygen levels in blood. A clinical diagnosis of clot in the vessels of lungs (Pulmonary Embolism) was most entertained after ruling out a heart problem. An investigation CT scan of lung vessels (pulmonary angiography) confirmed the presence of a large clot in one of the micro vessels of the lungs which was blocking it and thus producing the symptoms by causing increased pressures of the vessel. The patient also developed low blood pressure further lowering of oxygen levels for which the needed Non-mechanical ventilator  support to support worsening lung parameters. The ideal treatment of breaking the clot (thrombolysis ) was a great risk due to her post operative (D1) status and failure to manage the large lung clot would also mean a great risk to her life and losing precious post transplant patient. The family was counseled about her rapid deterioration and high risk consent for breaking the clot and risk of massive bleeding and threat to life thereafter as well.

The decision was either not to intervene and let things slip away or to intervene with high risk and hope for miraculous recovery.

An act of commission was favored and patient underwent clot lysis. Within few hours patients showed improved breathing and blood pressure and oxygen level. There was mild bleed as evidenced by the lower, abdominal drain (pelvic) which settled spontaneously. Two days later she was back in her post renal transplant unit producing good urine, stable lung parameters and blood pressure and oxygen levels with hemodynamic parameters. Later she could be discharged on time.

Here is how difficult decisions are taken critically which may make a complete turnaround in some one’s life. That is the magic of ICUs.

Name : Dr. Anurag Mahajan
Qualification : MBBS, MD (Internal Medicine)
Designation : Senior Consultant Physician, Head Intensive Care
Department : Critical Care
Webpage : Dr. Anurag Mahajan | Internal Medicine Doctor in Delhi | PSRI (psrihospital.com)