Richard Innes considers some of the more stressful decisions critical care consultants have to take and laments the lack of training in these areas.
When was the last time you sat with colleagues worried about how to treat someone with septic shock or ARDS?
A long time ago I suspect.
Much more likely they will be stressed about managing beds: who should have a bed, who should be discharged to let the next patient in,what to do about the patients waiting in recovery or ED who urgently, or not so urgently, needs a critical care bed? The latter may require you to be pragmatic and decide that a patient can be managed outside of ICU as beds are short. If this is the case then you shoulder some, or all, of the responsibility should the patient deteriorate. After all, you said they were OK to go!
The other thing I find very difficult is deciding who’s care is inappropriate and when I should stop treatment. This decision rightly takes time and requires working out in some subjective / objective way what is in the patients best interests; not always obvious and potentially a source of great conflict. And in reality, more difficult when beds are in short supply.
I find very difficult is deciding who’s care is inappropriate and when I should stop treatment
So why is this so important?
Well the Bawa-Garba case, with which we have all become very familiar, suggests to me that if you make a series of wrong decisions, particularly now we have the relatively new duty of candour, you may well end up having to justify your decision making, not only to the family, but a coroner , the GMC or even a judge. And none of them may be very sympathetic!
So if I find this type of decision making the most stressful part of my job why doesn’t ICM training focus heavily on this? How can we hope to staff ICU in the future if a third of consultants quit early, burnt out because of all this “unexpected”, but not really unexpected, stress?
I spend ages ticking boxes for trainees to say they know how to assess various conditions, can put various lines in competently etc.
However what will really catch trainees transitioning to the consultant role is working out who to withdraw on, who not to admit and who to discharge early.
However what will really catch trainees transitioning to the consultant role is working out who to withdraw on, who not to admit and who to discharge early when you’re not totally happy about it? Not to mention how to deal with an over full intensive care unit when your mobile is on overdrive coping with all the referrals?
These issues will cause consultants now and in the future to burn out.
We ran a seminar last year providing expert practical guidance on the complex medico-legal ethical issues that we all face day to day in our practice and we hope to run another in September.
In the mean-time ICM training urgently needs to catch up with what really stresses consultants out in intensive care, and it’s not the management of ARDS or inserting a vascath!