I once saw a podcast where Dr. Thomas Scalia said: “Critical care is not a place, it is a mindset.” Prior to this, while I certainly subscribed to that mindset, I had never really thought about it in such terms.
Having started my career in the Fire and EMS service I have a diametrically opposed experience of the more traditional medical provider. The traditional education focuses on most common or “likely” diagnosis and treatments, followed by a career of working your way up to the most severe and complicated patient encounters. There is always somebody around to consult or call for help. Only in the most extreme circumstances are you left to your own devices. Even then, many times there is a set of instructions which clearly detail the steps to be taken for a specific patient population.
Critical Care is just the opposite. In the emergent setting, the patient could be anyone, have anything wrong with them, and communication or effective communication, may not even be possible. In the intensive care environment, the patient has multiple things wrong, all of which have complex interactions on other systems and functions, and often treatments that regularly conflict. In the surgical critical care environment, the patients are not prequalified, again could be anyone, with comorbid conditions, and require surgical intervention which is the very antithesis of how most surgeons are trained and prefer to operate.
The “mindset” of this environment necessitates first considering, diagnosing, and treating the worst case scenario. In both EMS and medicine. It is common to find the newest provider, without benefit of definitive help or counsel, deciding and acting in these extreme conditions.
This appeals to certain personality types. (You can pick your favorite description of the many available terms) But generally speaking, these people work hard and play hard, and in many cases are defined by their professional position. They also develop a “dark” sense of humor that makes them seem very cold and displeasurable for the uninitiated.
I must admit, sometimes I have very little tolerance for people who do not share the mindset, but I do try to remember their point of view.
The Critical Care mindset extends beyond this much further. Some have described providers as “cowboys who shoot from the hip.” I think that while this is what it appears like to the uninitiated, it isn’t very accurate.
One of my First teachers in the fire service once asked my class during a lecture, “Who read the chapter on rescue last night?” To which many people, myself included, raised our hands. He simply laughed and stated “The book tells you how to rescue people in the perfect circumstances. If the circumstances were perfect, nobody would need rescued…” That statement has had a profound effect on my career. It didn’t take long for me to discover how accurate that statement was. In the emergency environment, the protocols, treatments, etc. have to be tailored to the patient. The patient will almost never “fit” into the rules, and improvisation becomes the norm.
Said very well in one of my favorite movies “The code is more like guidelines, than actual rules.” But this is where the “cowboy” image loses its accuracy. In dealing with such patients, the mastery of the details of medicine is a must in order to be successful. The question of “why” is never answered to satisfaction, and constantly challenged. Without knowing why you are doing something, you will never know what to do. The constant learning required between patients along with the need to incorporate a broad based understanding when treating the patients creates more of a sniper-like precision than a wild shot from the hip. It has been my experience, the more you know and experience, the more accurate that “first shot” becomes every time.
It is also why it seems critical care practitioners are excellent “zebra hunters” (reference to the book “The House of God for those who have not heard the term) The knowledge of “why” permits more than accuracy in treatment, but also unmasks seemingly disconnected presentations.
So I think this insight should conclude my first blog post, it seems long and deep enough already and I should save something to write more on later, but I will leave with one final quote if you are deciding whether or not this form of medicine is for you, for the old hands to nod their heads to, and for those not in the club trying to grasp our madness.
Bilbo Baggins: “Can you promise that I will come back?”
Gandalf: “No…and if you do, you will not be the same…”