"A service for patients with potentially recoverable diseases who can benefit from more detailed observation and treatment than is generally available in the standard wards and departments."

1. Haemodynamic insufficiency

2. Respiratory insufficiency.

3. Deteriorating level of consciousness or coma.

4. Fluid and electrolyte imbalance

or the anticipation of one of the above.

Observation entails clinical assessment and both non-invasive and invasive monitoring.

Observation also includes data interpretation.

Treatment involves interventions; these have a specific purpose.

The objective of Intensive Care Medicine is to manage the patient in such a way that he/she is in a position to be discharged to an ordinary ward. The therapies instiruted in ICU should see the patient through to discharge from the hospital.

If so, why?

We need to identify the problems and assess what progress has been made to redress them.

"If the patient is not getting better, he is getting worse!"

While internal medicine can often be a specialty of deductive reasoning, taking the patient's history, reading clinical signs, making a differential diagnosis ranging from the blatantly obvious to the weird and wonderful, intensive care is about hard cold facts.

What is the most likely cause? Common things are common.

What can be done to confirm this diagnosis? Best guess reasoning.

Whilst internal medicine is about gathering background information, e.g. Family history, and using deductive reasoning, intensive care is about identifying problems and solving them system by system. The patient is not seen holistically as one body, rather, as a collection of organs, which need to be fixed one by one.

When reviewing a medical patient, it is customary to use the S.O.A.P. routine:

S = Subjective: how the patient himself feels.

O = Objective: what you detect from history and clinical examination.

A = Analysis of data.

P = Plan of management.

This is an excellent system, and useful in a high dependency unit. It is not effective in intensive care.

1. Identify the patient: Name, Age, No of days in ICU, Primary Consultant.

2. Identify the admission problem and developments since admission.

3. Fill in the background problems. Medical history (relevant), ICU history to date.

4. Enumerate current problems.

5. Review the systems on the following basis:

Observation Intervention Impression [stable or unstable]

6. Record your overall clinical impression: improving, disimproving, static.

7. Plan of management for the current day.

1. Central Nervous System
2. Cardiovascular System (including peripheral vascular system)
3. Respiratory System
4. GI tract and Nutritional Status
5. Renal and metabolic (including electrolytes)
6. Peripheries and Skin
7. Endocrine System
8. Haematology
9. Microbiology and Sepsis Status

1. The patient's psychological welfare.

2. The "minor electrolytes": phosphate, magnesium etc.

3. Is the patient tolerating enteral nutrition? If not are we tying promotility agents?

4. Are we using DVT prophylaxis?

5. Does this patient require stress ulcer prophylaxis? Not feeding, renal failure, burns.

6. Physiotherapy and mobilization.

7. Bronchodilation and mucolytics.

8. Pressure areas.

9. Unnecessary drugs, particularly antibiotics.

10. Are we weaning? Could we wean faster?

11. Are we missing anything?

12. How long are the lines in? Are they necessary (if not pull them!)? Do they need to be changed.

13. Do we anticipate a long haul? Is it time for a surgical airway?

14. Is there any prospect of this patient surviving? Are we prolonging suffering?

15. Have the primary care team anything new to offer.

16. Who is coming in to visit the patient?

4. Background: other medical problems - diabetes, hypertension, asthma etc.

1, 2, 3, 4, 5 in order of importance