It all seems like an “out-of-the-world” place: buzzers and pagers bleeping, strange sound of the ventilator machines and sudden unpredictable rushes to tackle the coded patient. That’s the scenario in the intensive care unit. Amidst all these chaos, there seems to be a direction of certainty as to who performs what. This managerial prowess aids the unstable patients to recover and go back to the floor. The lead man in this complex scenario of the ICU is the new generation “intensivist”.
Sreerupa Patranobish recently caught up with Dr. Penchala Swamy Mittadodla, Medical Director of the ICU at Mercy Hospital Rogers in Arkansas, USA, discussing the key challenges surmounted by the director round the clock in the ICU. The discussion elaborates the discipline brought in by the intensivist in the face of uncertain outcomes in the ICU.
SP: Welcome Dr. Mittadodla
PSM: Thanking for having me.
SP: Intensivist is a new field of medicine?
PSM: Not really. Nearly 80% of the hospitals in the US have ICUs; so is the case in
India as well. When patients get very sick and unstable, they need care, constant
attention and titration of their management, which can vary by minutes. The
Intensive Care Unit or ICU provides that secluded, high-action environment, with a
constant motivation of salvaging the patient’s life.
SP: What kind of patients are admitted in the ICU?
PSM: Any patient in the hospital who decompensate and become physiologically
unstable are the main candidates for ICU admission. These patients may have heart
rhythm abnormalities, heart attack or an acute stroke. Some of these patients may
have cardiopulmonary arrest and needs resuscitation. Other patients may have
suffered road traffic accident, drug overdose, serious infections or poisoning.
SP: Who then is an intensivist?
PSM: An intensivist is a physician who is trained and certified through a primary
care speciality and has completed additional training in critical care medicine.
For the most part, pulmonary physicians or emergency room physicians train in
critical care because airway management of unstable patient is a key issue in the
ICU. All pulmonary physicians in the US, such as myself, are Board Certified in
critical care medicine.
SP: Please clarify the role of an intensivist
PSM: The intensivist is like the Ennio Morricone of the ICU. We take a top-down
view and our main role is in coordinating the different individuals in optimization
of care of a such a busy environment. The attending physician of the sick patient,
the pharmacist consulting on the medicines, the nursing staff and the respiratory
therapist all act in tandem to bring success to the ICU. It is a great team work.
Tension runs high, but it is the intensivist who knows where to draw the line.
Often times, difficult decisions have to be taken. With aging America, and even in
India and across the globe, the ICU shall remain a busy place in years to come.
SP: Can you tell us a little bit of your career and how did you get motivated of
becoming an intensivist?
PSM: From early on in my career, I liked the challenge of stabilising patients who
were otherwise on the edge. I served as an Emergency room physician for several
years while I was accomplishing my MRCS in the UK. Based on my original research
findings of judicious use of CTPA (CT Pulmonary Angiography), national guidelines
have been drafted by the American College of Physicians of how to reduce
unnecessary imaging for patients with blood clots in the lungs. Some of these
patients can die suddenly but not all patients in the hospital suspected of
pulmonary embolism needs to be imaged. I have encountered scores of cases in which
patients suddenly became very ill, but we stabilize and recovered their health.
SP: What is the key aspect of an excellent intensivist?
PSM: I am still evolving in my role but in my opinion, keeping a cool head is the
key to obtaining success in the ICU. The ICU is like a vortex, not only from
disease complications but also serious emotional issues of family members with an
intending sense of doom due to dying of there near and dear ones. Compounded with
these are opposing viewpoints, ethics issues and divergent philosophy. I try to
keep it simple by the concept of “Hope for the best and prepare for the worst”.
However, I ensure open communication, which enhances satisfaction for both the
providers and brings the sense of closure to the family members, who are coping
with the end-of-life issues. I also respect the knowledge and decision making
across the team, seldom making medical hegemony as a factor in decision making and
keep the tides of tension low.
SP: What is your advice for young physicians who wants to become intensivists?
PSM: I recommend learning the natural course of illness and being on task. Every
illness carries a legacy, and it is erroneous to think that severe illnesses such
as respiratory failure and sepsis are zero sum games. For example, patients who
suffers from delirium in the ICU can have residual psychological issues many months
after their discharge. Young physicians need to track the recovery trajectories of
these diseases more, so the tools of digital medicine should be utilised. I have
extensively used the app “Know Delirium” to keep family members posted why their
near and dear ones behaved “differently” when they were in the ICU. Above all, the
intensivist graduates as a “physician extraordinaire” when he becomes the patients’
advocate. Using tools of digital medicine, the new physicians should feel the drive
to empower their patients on the path to wellness. I motivate my own students in my
capacity of Assistant Professor of Medicine at the NorthWest Arkansas Campus of
University of Arkansas for Medical Sciences (UAMS). In my humble ways, I have used
simple educational tools to motivate for smoking cessation (www.yougain.co.in).
Smoking cessation is at the heart of improving lung conditions, though it is very
difficult to achieve it. You may be surprised to learn that many patients in the
ICU smoke. Understanding social norms remains a major avenue for the intensivist to
succeed in their daily missions.