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Thu Sep 23 16:02:23 BST 2004

 '>'-- Mensagem Original --
 '>'Date: Thu, 23 Sep 2004 11:37:36 -0300
 '>'From: "Claudia Teles" <cvteles at globo.com>
 '>'Subject: RE: screening on ICU
 '>'Reply-To: cvteles at globo.com
 '>'To: thomas.marx at medizin.uni-ulm.de
 '>'
 '>'
 '>'Thomas,
 '>'
 '>'You haven?t get my point. Of course not...Each unit has it?s own unique
 '>'profile of patients.
 '>'I dislike, in fact, the term "screening" when it comes to ICU treatment.Ken
 '>'posted it as a form of provoking a deep discussion on underdiagnosing
patients
 '>'in the ICU, and I extend it for medicine as a whole...
 '>'Intensivists are seen by most of primary care and internal medicine
doctors
 '>'as the "guys who solve everything".I don?t know how it comes in your
hospital,
 '>'it?s very different and with a much higher care standards than the average
 '>'throughout the world,
 '>'but in mine, they just lower the level of attention and care when a
patient
 '>'comes out from the ICU to the floor...and only continue the measures
taken
 '>'in the ICU, without going any further..they relax, and think:"well,
they
 '>'were very
 '>'well taken care of in the ICU - so there?s nothing left to do, only
put
 '>'the patient on his/her feet and make him walk home asap" .
 '>'And things like  pelvic exams, rectal exams, a good cardiac auscultation
 '>'and abdominal palpation, ear & throat inspections, thyroid palpation,
etc
 '>'are simply not done anymore inside the hospital. We expect this should
be
 '>'done else where, uh? OK, the patient is then
 '>'referred to the primary care. Our health plans remmunerate very badly
office
 '>'physicians. Public facillities are overburdened too...So to earn  a
bit
 '>'more, or to attend more people in a shorter time, appointments are made
 '>'in average offices every 15 minutes - each attendance won?t get over
15
 '>'minutes,
 '>'Thomas. Many attendances last less than this..In only 15 minutes you
certainly
 '>'agree with me that we can?t address
 '>'the average "screening" for common diseases, and at the most, only vital
 '>'signs and the main complaint is recorded, a quick interview and a bunch
 '>'of lab, imaging and
 '>'other tests are asked, WITHOUT even touching the patient.
 '>'The teeth won?t be pulled out, because they won?t even notice they are
rotten.
 '>'I?ve been taking care of helpless patients with multiple hospital admissions,
 '>'with "subclinical" methastatic melanomas/breast and prostate cancers,
unrecognized
 '>'diabetes target organ lesions, multiple embolic episodes without prophylaxis/diagnosis,
 '>'and severe adverse reactions to long term prescribed meds that no one
managed
 '>'to change
 '>'in a much more frequent basis than I did in the past - and all of them
HAVE
 '>'a primary care physician taking care of them, every two or three months
 '>'they go to his/her office...
 '>'What I want is the intensivist not to abdicate from his medical condition
 '>'and duties, and do the possible to get the screened items taken care
of,
 '>'you don?t pull the teeth out, but REPORT it, and at discharge, ask the
nurses
 '>'or someone to fix a dental check for the pt, or tell the pt, if he has
a
 '>'good cognition, that he must see a dentist, a gyn, an ophtalmologist
or
 '>'an endocrinologist whenever indicated.
 '>'I don?t advocate routine PAP smears in the ICU, sure.
 '>'But if it?s indicated in the context of the patient, I wouldn?t hesitate
 '>'to do it.And if the rotten teeth?s owner has an endocarditis, sorry,
but
 '>'I?ll have to call an odontologist before discharge....reinfection might
 '>'become a problem.I need to know if there are any abscesses or periodontitis.
 '>'
 '>'But to discover all that one must look at the opened mouth of the patient,
 '>'agree?
 '>'Many intensivists just don?t do it, only at the time of intubation...they
 '>'depend entirely on nursing personnel...
 '>'Not to mention clinical history...most of our patients don?t inform,
but
 '>'one should ask family/friends about key problems like allergies, transfusions,smoking,
 '>'etc. If nurses fail to do it, it?s not done here. Many missed info has
led
 '>'to severe mistakes here.
 '>'I know your village is quite different from ours, but I think these
observations
 '>'are valid for many places around the world.
 '>'
 '>'claudia
 '>'
 '>'
 '>' '>'-- Mensagem Original --
 '>' '>'Date: Thu, 23 Sep 2004 15:18:14 +0200
 '>' '>'From: thomas.marx at medizin.uni-ulm.de
 '>' '>'To: cvteles at globo.com
 '>' '>'Cc: Trauma & Critical Care mailing list <trauma-list at trauma.org>,
 '>' '>'	ccm-l at list.pitt.edu
 '>' '>'Subject: screening on ICU
 '>' '>'
 '>' '>'
 '>' '>'It once happened that (at that time I was in the ICU of the Urology)
 '>'a patient
 '>' '>'came from their diagnostics with the diagnose "postrenal renal failure"
 '>'(in
 '>' '>'fact he was anuric and an urolithiasis was detected). On first glimpse
 '>'the
 '>' '>'patient was not only anuric, but in addition circulatory insufficient,
 '>' '>'hypoxic and desorientated. In one word, one look: septic. We very
quickly
 '>' '>'"cabled" him,replaced fluids, catecholamines etc., the standard
programme.
 '>' '>'The
 '>' '>'x-ray control of
 '>' '>'the central venous line revealed subdiaphragmatic free air which
lead
 '>'to
 '>' '>'the
 '>' '>'diagnosis of a bowel perforation.
 '>' '>'What I want to say is that a sophisticated physical examination
leads
 '>'to
 '>' '>'many
 '>' '>'diagnosis and the ones, leading to the fact that the patient was
sent
 '>'to
 '>' '>'ICU care should be diagnosed, treated and the patient removed from
the
 '>'ICU
 '>' '>'as
 '>' '>'soon as possible. Additional findings could be reported to the patient
 '>'as
 '>' '>'soon
 '>' '>'as he or she is able for consent (!!!). "Screening" to my opinion
is
 '>'obsolete,
 '>' '>'"therapy" of accompagnying diseases even more as most of our patient
 '>'are
 '>' '>'not
 '>' '>'able to give consent. Not to think about the fact who
 '>' '>'in the end pays for all the diagnostic and therapeutic procedures.
During
 '>' '>'the
 '>' '>'Bosnian/Jugoslavian war 66% of all refugees and some victims were
treated
 '>' '>'here.
 '>' '>'Some of them I saw on ICU (one who had a handgranate exploded close
 '>'to his
 '>' '>'face), but old grandmas with cardiac failures etc. too. Guess how
many
 '>' '>'"side-diagnosis" they had.  What should we have done? Where do you
want
 '>'to
 '>' '>'start your "screening" and where do you want to end?  Some of our
patients
 '>' '>'have
 '>' '>'a ruinious dental status. Do you want to pluck their teeth out before
 '>'they
 '>' '>'wake
 '>' '>'up?
 '>' '>'
 '>' '>'Thomas
 '>' '>'Ulm
 '>'
 '>'
 '>'
 '>'
 '>'

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