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FREQUENTLY ASKED QUESTIONS

What is an ICU?

Intensive care unit is a place in the hospital where those patients are admitted who need intensive treatment and monitoring which can’t be delivered in the ward.

In the ICU, patients are closely monitored with high-tech invasive and non-invasive monitor 24X7. ICU provides organ support for the failing organ at one place e.g. ventilator for respiratory failure, dialysis of renal failure, inotropic support for the low blood pressure.

Patients are being looked after by doctors and sisters trained in care of sick patients. ICU Doctors are called intensivist, who manages the ICU 24X7.

ICU is a multidisciplinary care area, where most of the patients are being look after by various specialist and the care is coordinated by the intensivist.

Why in the ICU?

Patients are admitted to the ICU for intensive care and monitoring. Patients come either directly from Casualty, ward or after surgery or procedure.

Those patients who have organ dysfunction or organ failure which requires monitoring and/or treatment are usually admitted to the ICU.

Why patient gets infection in the ICU?

ICU is the place in the hospital where sickest patients are admitted. They harbor infection since they are most susceptible to get infection due to illness and poor immunity. The infective organisms like; bacterial, viruses, fungus etc. enter the body either through nose, mouth, ear, urine and blood. There is a natural barrier to protect body from such foreign invaders. When these barriers are disrupted the body gets infected by such micro-organisms.

When multiple infected patients share common environment in the ICU, the ICU becomes the source of infection.

Why ICU is restricted area and why there are visiting hours?

ICU caters sickest patients in the hospital. These patients require intensive care and monitoring continuously. ICU patients are being managed by dedicated nursing staff and multi specialist doctors and paramedical staff. Presence of every individual carries risk of infection for the patient in the ICU. So, to reduce the traffic & eventually infection risk to the patients there are visiting hours and ICU is kept as a restricted area. If there is continuous movement of relatives in the ICU, there will be interruption in the patient care.

Why it is so much costly?

Everything costs in the ICU. To treat the patient, it requires diagnosis, maintenance of organ function, monitoring, prevention of complications and definite therapy. And most importantly, everything at appropriate time. And once time is lost, it is difficult to restore the biological functions of the body. So, goal is to control the disease as early as possible to save the patients by providing the therapy at earliest.

Why patient develops bedsore in the ICU?

Bedsore develops due to continuous pressure on the blood vessels supplying blood to the skin, during prolonged immobilization. All the patients in the ICU are always mobilized except during sleep. There are situations when patients can’t be mobilized due to critical illness e.g. multiple invasive devices, very low blood pressure, advanced respiratory failure, multiple trauma, postoperative status with multiple catheters, prone ventilation, continuous loose motions, prolonged immobilization due to stroke…

In spite of utmost care, patient develops complications of immobilization when the period of immobilization is prolonged. Longer the period of immobilization, higher the chances of developing bedsore.

Why many patients die in spite of being in the ICU?

Appropriate treatment given on appropriate time in a salvageable patient result in good recovery. Many a times, patient get admitted late and once already disease process has done irreversible damage its usually a futile effort. There are certain conditions in which even appropriate treatment on appropriate time does not result in recovery e.g. massive intracranial hemorrhage, refractory ARDS, Refractory cardiogenic shock, massive bleeding, severe sepsis etc. Even many patients who shows initially recovery may deteriorate later on due to various complications of prolonged hospitalization and advanced diseases.

Why patient can’t be survived even when money and expertise is in abundance?

Many a times patient can’t be survived because of unavailability of expertise and lack of money for the treatment on time. If patient receives the appropriate treatment on time, the chances of recovery are good. There are stages of organ damage. One is a reversible stage of injury, where if treated on time the tissues can recover. But once the injury to the organ is irreversible than in spite of the best treatment patient can’t be survived. The tissues don’t regenerate once there is a permanent damage. That’s why, even if the money and expertise is unlimited, patient can’t be saved.

Why so many doctors are involved in the patient care?

ICU patients have frequently multi-organ failure. Each organ is managed by specialist doctor, expert in the particular field along with the intensivist. Brain, lungs, heart, kidney and liver each of which require special expert for treatment. Most of the patient in ICU are being looked after by multiple doctors and sometime second opinion is also taken if the case is complicated or treatment resistant.

Why ICU needs consent for each and every procedure?

In the ICU various procedures are performed for various kind of monitoring and treatment like Intubation, central line insertion, arterial line insertion, pleural and ascetic tapping, lumbar puncture…

Every procedure has its own benefits and risk. And procedures are being performed when the benefit is more than risk involved in the procedure.

Example…Central line insertion, it has benefit of giving multiple access through one channel, blood sample collection, CVP monitoring, Blood pressure drugs and hypertonic fluid can be given through it.

The risk involved is, arterial puncture, infection, pneumothorax, malposition, thrombus formation etc.

Since the benefit outweigh the risk involved, the central line is a most common procedure in the ICU.

So, consent is taken to inform regarding the benefit and risk involved in the procedure which intent to benefit the patient. If consent is not given, procedures can’t be performed.

Emergency like arrest situation is an exception where first priority is given to the patient care and consent may be taken later on.

Why doctors don’t answer in black and white?

Every patient behaves differently and respond differently. Treatment and management options are more or less universal but the response depend on multiple factors like, patient immunity, associated comorbidity, disease progression, on-time treatment, antibiotic sensitivity, complication of prolonged ICU stay and immobilization etc. Since the outcome depends on multiple factors which are not always under control of a doctor, it is very difficult to accurately predict the outcome. Many patients recover when the hope of recovery was almost negligible and many patients deteriorate unexpectedly during recovery which keep the prediction of outcome uncertain.

Due to its unpredictable and complicated nature of critical illness many time doctors don’t commit confidently on the outcome.

Why there are so many investigation and test in the ICU?

In the Intensive care unit, those patients are kept who needs intensive care on time.

The patient care includes diagnosis, monitoring and treatment, on the time. The goal of care is to diagnose and treat the disease as early as possible and to prevent the disease complications. To achieve these goal, it requires multiple test, procedures and therapeutic intervention on time. Because time is a tissue in the intensive care.

Why ICU don’t allow DO NOT RESUSCITATION order?

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Why doctors and ICU keep patient on ventilator when the outcome is poor and death definite? Why can’t they pull the plug?

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Why ICU staff don’t get infection and only the patients get infection in the ICU?

ICU staff are at higher risk of infection like HIV, HBV, HCV, TB, H1N1, URTI during patient care in the ICU. ICU patient are at high risk of blood, urine and lung infections. Since their natural immune mechanism is breached due to various invasive catheters. They form the site and source for infection. They become the portal for the infection to enter the body, which is not the case with the ICU staff so only the patient and not the staff in the ICU acquired infection in the ICU.

Why can’t patient have home food in the ICU?

It is always good to have home food. There are two areas of concern when the ICU food is advised for the patient. One is that, it reduces the risk of infection in the hospital when the preparation and disposal of the food is at the designated place. If every relative of the patient begin to bring their own food in the ICU, the storage and discard of wastage is not controlled which can be source of infection. Second is, the ICU patient are sick and their calorie requirement is calculated according to their needs and accordingly the food is prepared. The food preparation is the part of patient care and its integral part of the system. To instruct each and every patient in the ICU regarding the calorie and salt and sugar is practically not feasible.

Lastly, hospital can’t take responsibility of the food not prepared by them.

Why can’t relatives stay in the ICU?

It is always good to have familiar face and desired person with the patient when they are sick. There are visiting hours for such meeting especially in the morning and evening. When relatives will stay with the patient 24X7 in the ICU, they will be more vigilant than the treating staff for sure but they will also have unknowingly try to be part of the patient care and participate in the critical care issue. Which is itself and complicated subject to interpret values and lab reports and clinical scenarios. Ultimately, this practice land up into teaching the relatives regarding medicine and spending more time in explaining the relatives rather than treating the patient.

Why there are holidays for Doctors?

ICU is a place where doctor and staff have to be vigilant 24X7, they have to take critical decision on time promptly. They also suffer patients and relatives pain and discomfort. Every day one or another patient dies whom they have treated very closely at the end of their journey. This takes toll of doctor and sisters emotional nature. There are standards for practicing in such stressful environment. Usually 48 hours in a week is the recommendation which is usually stretched to 60 to 70 hours and sometime 90 hours in a week. This leads to exhaustion and irritability if adequate rest is not taken in due time. Doctors life is always about the patient and diseases which anyhow carries some amount of stress. To break the cycle of stress, Doctor frequently takes break to regenerate themselves. This improves their working efficiency, also.

Why some patient don’t improve and don’t deteriorate, just remain same?

The advancement of the treatment many patients have been saved which would have died otherwise. When the sick patients are admitted to the ICU, they are treated aggressively and promptly. The ICU support the organs when they fail, till there is recovery. The application of treatment is provided equally to all of the patient but the response depends on many factors pertaining to the patient. With advancement of the critical care medicine, most of the care provided are universal standard of care. The recovery depends on patient disease status, immunity, infection, physiological reserve, on time availability of treatment, complications so on and so forth. The aggressive nature of the treatment in the ICU is able to sustain the organ function but when there is no recovery the patient remains in a limbo state. They neither improve nor deteriorate because they are receiving treatment which allows it to function which is suboptimal and the ongoing treatment don’t allow it to deteriorate. The treatment is continued till there is natural deterioration.

Unfortunately, once certain level of damage is already set in, it can’t be reversed. And that is the reason that many patients don’t improve because they are beyond repairable state and don’t deteriorate because they receive treatment. Even after stopping the treatment, patient don’t deteriorate immediately. It’s a natural course of the disease, and the process of death can’t be hastened actively.

Why there are trainee doctors and not the treating consultant 24X7 in the ICU?

ICU has expert doctors 24X7 in the ICU, but not the treating consultant because they plan out the patient care and the junior doctors have to carry forward the orders. When doctors getting training in the ICU, they work for 12-14 hours a day for most of the day of week. The young doctors can work for that long period of time during their training period. After intense training of 7 to 10 years in the intensive care units, the ICU doctors becomes consultant. The expertise comes with time, by that time the senior doctors focus more on the consultation and junior doctors carry forward the orders given by the treating physician. This is the way currently medicine is being practiced in India.

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