The book – Clinical Intensive Care Medicine is intended as an authoritative guide to practical intensive care medicine written by acknowledged specialist practitioners from the UK, Europe and North America, most of whom are also internationally acclaimed authors. Target audiences are medical students, trainees in intensive care medicine and other acute specialties, consultants wishing to remain up to date on all branches of this vast specialty and other allied professionals practising in intensive care, including nurses and physiotherapists. The book – Clinical Intensive Care Medicine therefore has a practical and educational common thread rather than an encyclopaedic approach.
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Intensive care patients are the sickest and most challenging in any hospital and use up a disproportionate amount of resources. The specialty is relatively young, only about 40 years old, and expanding worldwide as patients grow older, harbour greater expectations and present increased demands on already stretched health systems.
The older generation of intensivists is approaching retirement. The middle generation trained in various medical and surgical specialties and then subspecialised in intensive care. These doctors now lead the way in clinical practice, research, management and training. The younger generation of intensivists includes an ever increasing number of doctors who, for the first time, enjoy a structured training programme with clinical rotations, courses and exam qualifications.
This book – Clinical Intensive Care Medicine is aimed at this younger generation. My vision is for this book to become a useful resource for those wishing to study, practice and excel in intensive care medicine
While conceiving this book – Clinical Intensive Care Medicine I have reflected on the true challenges which face the intensive care clinician. They are of three types: clinical, managerial and life challenges.
On the clinical front there are several crucial decisions to be made and revisited for every patient, every day. What is acceptable physiology, what is achievable and at what price? The clinician may, for example, decide that intravascular volume is the priority. He/she must therefore be prepared to accept as a trade-off an increase in unwanted fluid in the form of pulmonary (capillary), peripheral and cerebral oedema. Equally, given a different scenario — or a different clinician — perfusion pressure may become the prime goal. This will of necessity be at the expense of increased cardiac work and also of peripheral vasoconstriction, the combination of these two potentially giving rise to tissue hypoxia and acidaemia. Finally, normalisation of acid-base chemistry may be the utmost priority. Strategies targeted to achieve this can lead to raised intrathoracic pressure (through increased ventilatory settings), increased cardiac work and peripheral oedema.
Also worth reflecting upon is the challenge of blending in with other intensive care colleagues who might have somewhat different clinical philosophies. Changing treatment plans for the sake of change or in order to prove a point seldom benefits the patient, often has a negative effect on team morale and frequently causes undesirable confusion. When taking over the care of a human being who is making satisfactory clinical progress but is perhaps being weaned differently, on inotropes which one would not necessarily have chosen or on antibiotics not amongst one’s favourites, the challenge facing the clinician is this: is it really necessary to change these when they are being effective? Some of us refer to this phenomenon as the ‘Monday syndrome’
Perhaps the most important decision facing the intensive care team is to decide which patient requires immediate intervention and which patient can and will benefit from masterful inactivity and close observation. Which patient should be left alone? When should resident doctors be encouraged to do nothing but just observe? One of the eminent contributors to this book – Clinical Intensive Care Medicine once told me that it is just as important to do something which causes benefit as it is to stop others from doing something which may cause harm.
On a philosophical note the reader will agree with me that there is always the possibility of being wrong. The problem here is not necessarily the wrong itself but the consequence of not realising it. The wise, humble clinician is mindful of the possibility of being wrong, however knowledgeable and experienced, and therefore is likely to recognise a wrong decision early and thereby be better positioned to rectify it. The less wise and perhaps less humble intensivist displays an inability to entertain being wrong, which can lead to catastrophe.
The managerial front requires quite a different mind-set. Gifted administrators have an almost innate ability to get the most out of the resources available to them. Perhaps the greatest resource is time and I am always admiring of colleagues who excel in time management. The ability, desire and vision to delegate the right task to the right individual seems inextricably linked to that of successful time management. One of the hallmarks of good management is the creation of efficient and robust systems to ensure clinical safety and governance. The ideal system practically runs itself, accepts newcomers, is understood and appreciated by all and can be modified as new standards develop. For any system to function to a high standard there must be good communication within its members as well as with other clinical groups.
Intensive care specialists are of course members of the human race with a multitude of complex personal, professional and family interactions which clearly are constantly undergoing evolution. We bring children, partners, wives, husbands, holidays, parties, funerals, weddings, deaths, illness, injuries, rota difficulties and an endless list of life events to the table of intensive care medicine. The management of these individually and collectively and the support we give to but also draw from our colleagues constitutes an important challenge in our life as a member of an intensive care department.
Life has thrown a couple of curve balls in my direction while editing this book – Clinical Intensive Care Medicine and I must forever thank Neville, David, Robert and Claire. They know how much they have helped.
An endeavour of this kind requires a lot of activity behind the stage. My wonderful colleagues have challenged, criticised, amused, assisted and supported me throughout. Our nurses, physiotherapists and all members of the wider team make it possible for care to be administered and have over the years provided much clinical advice and feedback; many regularly provide support and some have become friends. Our residents no longer live in the hospital but provide constant care and vigilance, vibrant energy, an inquisitive and stimulating approach as well as a valuable source of criticism and advice; with the nurses, they are an important gateway to the outside world.
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