The ICU is a super dynamic environment. The learning part is very challenging here for novices. With lots of things going on simultaneously, it is sometimes difficult to focus on important things. Many a times crucial things are missed, cognitive errors occur and failure to address important issues happens. The current scenario of medical profession in India is very complicated in view of increasing litigation against doctors, media apathy, yellow journalism, violence against doctors1, VIP cultures, so called medical terrorism etc. So at this difficult hour how to make patients as well as doctors safe and how to prepare our upcoming doctors for all these.? Now question is whether this can be addressed and the learning process can be improved? The answer is probably yes. The “4B strategy” should really be helpful in this. The 4B strategy consists of four B’s e.g. Basics, Because, Beware and Backup. Now let’s elaborate a little.
This is the first “B” of “4B Concept” .Basics means basics. We should always be focused on basics. Sometimes it happens, in the process of knowing the advanced things and more updated things we used to forget those basics of medical sciences. Sometimes you tend to get lost in this all chaotic and distractible environment. Sometimes there are lots of information’s in front of you but you are confused and unable to link those information and pointing towards a logical diagnosis. Like for example when there is a patient in front of you who is visibly breathless you should first give oxygen rather than trying to take history and taking vitals. When a patient presented to you in ED , you should always start with ABC except in cardiac arrest situation when you start with CAB. While in round in ICU you should not miss FASTHUG (Feeding, Analgesia, Sedation, Thrombosisprophylaxis, Head of the bed elevation,Stress ulcer prophylaxis, Glycemic control), because these are basics. Addressing a patient system wise like CNS, CVS, Respiratory etc. is always good , because you are very unlikely to miss anything. When you see tachycardia you should not ignore , always address. You should know all normal ranges be it hemodynamics , biochemical or microbiological and try to address if something is not in normal range. Always believe common things are always common. Believe your “GUT FEELING”. If you feel something is not right in a patient , always address. If anything bothering you or not understanding , always take help from seniors. Another important thing is if you are using a drug or intervention, there must be a target or desired goal/result. And don’t forget to measure the target and result. Then only you can first know whether it is working or not , or you need to do something about it. Like, as for example you have used noradrenaline in patientin septic shock, you must know the target BP/MAP for the same, Say you target 65mmhg MAP for that patient. Then if the patients MAP is exceeding that you will reduce the dose or if the MAP is lower than that , you will increase the dose. This information must be clearly communicated to the assigned nurse who looking after the patient continuously. And you should know the maximum amount of drug that can be given in 24 hrs time and you should not exceed that. If you don’t do that you will probably be giving overdose of a drug and the result will be that the patient will suffer those unwanted side effects and which sometimes may lead to a very serious consequences including preventable death. Next for example if you have done a Ryles tube insertion and forget to confirm it by radiology (Chest x-ray). Many a time there will not be any problem if you have confirmed it by auscultation method. But some cases you will miss it. So you should ideally do a CXR to confirm the position. If you assess a patient systematically these al problems will show up to you and you can address it. Now if you find a blood sugar of 190 mg% in a non-diabetic patient , you just cant ignore as its not normal , you must address. Now for example if a ventilator is giving alarm, you should address or call your senior if you are in need of help. Moreover the nurses at bedside must be made aware that they should not ignore an alarm. So overall these are all basics things you should always address never and never ignore these. This is actually the basics of critical care. So we can say in other words BASIC is Basics of critical care medicine.
The second “B” of the “4B concept” is Because. Now in Basics we emphasized on knowing what is normal and that we should always address if something is abnormal. We should always make a habit of asking questions to ourself regarding why this is this a deviation from normal.Like for example if you see a patient having Tachycardia you should ask yourself “why this tachycardia” and this will lead you to try to find an answer. Now how will you find an answer that’s the question. I proposed an “ARD approach” to find the answer.
Ask– Yourself, your colleagues, your seniors, Expert, Forum
Read– Established Textbook, Established online websites
Discuss– discussed in a good Forum
Always remember “No Question is small”, so don’t feel embarrassed to ask. It will help you in future. Sometimes it may open a new world to you. Next important point is always be convinced by yourself. Third don’t believe ANYONE if you are not convinced. And always try to find out and realize what you don’t know. Then only you will try to know. Learn to frame a question properly so that it will give you the answer you desired. Be a member of good society, journal, body so that you will find help in knowing things. Read latest guidelines from reputed society. Most importantly open your mind and senses it will make you more receptive.
Finally, this quest for knowing why things are happening will translate to learning and this learning will lead to knowledge and this knowledge will lead to good clinical patient care which will lead to improved outcome and give you professional satisfaction.
The third “B” is very important in present context. With the emerging consumer protection law which was enacted in 1986 in India and revised recently in 2018 and passed in Loksabha as consumer protection bill , doctors are now liable legally more than anything. The current scenario is totally bizarre. With increasing litigation, violence, media and social media hyper phobia is creating an environment where peaceful and free minded medical care is getting very difficult. At the same time, we need to protect our patients’ safety and continue giving recommended care. So we should train ourself in patient safety guidelines and also medico legal aspects. The biggest arms given by law to doctors in india are consent, necessity and good faith2. There are lots of things going on regarding patients safety in the world especially by WHO (world health organization), AHRQ (agency for healthcare research and quality), JCI (joint commission international) , NABH (national accreditation board foe hospitals and healthcare providers), ISO (international organization for standardization) etc. So we should be well versed with these norms. This will safeguard us from preventable harm to patients. We should also be familiar wth medico legal aspect so that our and as well as patient’s rights can be safeguarded.Some IPC codes doctors should know like, Indian Penal Code 1860 (IPC) any act of commission or omission is not a crime unless it is accompanied by a guilty mind (MENS REA)3. There are other sections like Sec. 29: Deals with documents, Sec. 52: Describes “good faith”, Sec. 90: Related to consent, Sec. 176: Failure to inform police whenever essential, Sec. 269-271: Related to spread of infectious disease and disobedience of a quarantine rule, etc. 272-273: Related to adulteration of food and drinks, Sec. 274-276: Related to adulteration of drugs, Sec. 304-A: Deals with death caused by a negligent act, Sec. 306-309: Related with abatement of suicide, 307. Attempt to murder, Attempts by life-convicts, Sec. 312-314: Related to causing mis-carriage, abortion and hiding such facts, Sec. 315-316: Deals with act to prevent child being born alive or to cause it to die after birth, Sec. 319-322: Related to causing hurt, grievous hurt, loss of vision, loss of hearing or disfigurement, Sec. 336-338: Deals with causing hurt by rash or negligent act, Sec. 340-342: Related to wrongful confinement, etc. 491: Related to breach of contract, Sec. 499: Related to defamation, Section 304 and 304-A (304-A is bailable as it is not intentional, but many times police used to put 304 causing serious hardship to a doctor as it is a non bailable offense). Doctors should also be trained in good communication skill as this can decrease the conflict with patients and attendants to a great extent. Good documentation must be followed at all cost. One should not compromise in this.There must be proper knowledge in identifying patients or attendants at risk of causing nuisance so that proactive measures can be initiated to diffuse the tension. During our communication with patients they should be aware about these so that the society as a whole can be sensitize about the bad impact of this conflict.
The fourth “B” is all about making a backup. During management of a patient we should always have a plan B in place. This is also called reassessment, reevaluation, follow up and changing your management line if it is not working. Say for example if you are treating a patient with a diagnosis of acute left ventricular failure and patient is not improving expectedly, rather than sticking to the same treatment plan you should reassess the patient. May be you can come up with underlying pneumonia or a pulmonary infarct which is complicating the disease process and addressing these issues will give you a better outcome. So the line of management here can go like this
Another back up doctors should know about the laboratory, medicine, diagnostic backup and specialist back up. In the event of unavailability or technical problem of equipements , there must be a back up plan exists. This should be discussed thoroughly discussed and a plan which is doable must be in place to face any shorts of problems. Doctors should be also aware about the manpower requirement and back up available in case of need. As ultimately these everything matters when it comes to patient care.
Another thing which is very important is making a financial backup. Every doctor should have a indemnity insurance in place with sufficient cover. Apart from indemnity we should have medical insurance policy ( you have to pay for YOUR TREATMENT also, so is a must) which should cover you along with your family. Doctors should be also encourage to to take Term insurance policy (for death and disability). Doctors should be advised to be a member of some professional body who can support its right like IMA ( Indian Medical Association), Human rights etc. We should also learn to mix with the society and be involved. This will decrease the differences with other non-medical people.
Doctors should be taught about the disaster management like fire, earthquake, mass casuality etc. We should encourage training in these areas also.
To conclude fellow doctors should be trained and aware about lots of things. These are not only the management of patients but also other hosts of things they should know to face the new world. The “4B Concept” should be good strategy to address this and prepare our fellow resident in a better way so that the medical care can be delivered in a more efficient way and we can work in an environment where there will be “safe patient, safe doctor and safe society”.
- Paurush Ambesh,Violence against doctors in the Indian subcontinent: A rising bane,Indian Heart Journal,Volume 68, Issue , Science Direct 5,2016.
- Singh MM, Garg US, Arora p. Laws applicable to medical practice and hospitals in India- Int J Res foundation Hosp Healthc Adm;2013
Dr Apurba Kumar Borah
HOD & In-charge Emergency and Critical Care Medicine
Narayana Superspeciality Hospital, Guwahati