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Patient Care Vignette
A 34-year-old woman, AB, was involved in a motor vehicle crash. She was transported by Emergency Medical Services (EMS) to a Level 1 trauma facility. Due to a very low blood pressure and obvious signs of abdominal injury, she was taken to the Operating Room (OR). After operative repair of multiple organ injuries using a damage control approach (fixing only life-threatening injuries), she was transported to the surgical ICU (SICU) for ongoing care. In the SICU she was cared for by a multiprofessional team led by a surgeon trained in surgical critical care. The damage control surgeon also has additional training in surgical critical care, and acted as the intensivist for nearly half of her SICU stay. After SICU admission, the surgeon updated her husband on what was found, what was done, what remained to be accomplished, and what was likely to happen over the next few days.
During her several weeks in the SICU, her husband participated in daily morning rounds as well as afternoon rounds. He had many questions that were regularly answered by the intensivist. The intensivist explained what other specialty surgeons including orthopedic, urologic, and gynecologic surgeons needed to do to help his wife. As a result of regular contact, the husband identified the initial surgeon as his wife’s doctor—despite the surgeon’s practice being one that functions as a team. Accordingly, even after SICU survival and hospital discharge the patient and her husband both maintained contact with the surgeon. They specifically solicited the surgeon’s opinion about care-related decision-making. The durable contact with the surgeon-intensivist helped to identify that the patient demonstrated PICS. She was referred for cognitive and psychologic therapy with benefit.
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ROLE OF THE PHYSICIAN IN THE ICU
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Regardless of setting, the physician serves in a leadership role within the ICU. This is true in facilities where there is an intensivist as well as in the nearly 50% of US facilities that do not have an intensivist on staff. The physician is responsible for patient care as their top priority. Part of that responsibility is to coordinate care when there are other specialists involved in patient care. Regardless of setting (critical access vs community vs tertiary vs quaternary care center) there are three broadly different roles for physicians within the ICU that impact direct care decision-making as well as care coordination (Fig. 2-1). When there is no intensivist, the admitting physician also serves as the Attending of Record. In facilities where there is an intensivist in the ICU, the intensivist can serve as the Attending of Record—a process common within the medical ICU. Most medical ICUs function as “closed ICUs” where only the critical care team may write orders, render care decisions (in conjunction with the patient or family or surrogate), and embrace or reject consultant recommendations. Alternatively, the intensivist may serve as a consultant—a process more common in the surgical ICU. Most ...