Week 7 – Question of the Week: What critical care may be accomplished at home?
Week 7 – 2011-04-21
Today I’m asking our professionals to weigh in on the question:
- What critical care may be accomplished at home?
We have a number of ICU nurses, EMTs, and physicians on board, whose opinions should be quite interesting.
You, too, are welcome to post your responses and questions below.
Check back soon and see what our panel of over 100 professionals has to say.
– Doc Cindy
About Cynthia J. Koelker, MD
CYNTHIA J KOELKER , MD is a board-certified family physician with over twenty years of clinical experience. A member of American Mensa, Dr. Koelker holds degrees in biology, humanities, medicine, and music from M.I.T., Case Western Reserve University School of Medicine, and the University of Akron. She served in the National Health Service Corps to finance her medical education.
Sounds like you’ve “been there, done that.” Doc Cindy has asked me to write on doing basic labs in the field or austere setting. Looks like you have done some. Care to share your knowledge? It would be much appreciated. Drop me a line in this space or via Doc Cindy. Thanks!
I have been offline for a bit, just got back, a little swamped right now. Check out these resources on my sky drive.
lets try that again
Just about all critical care is capable of being accomplished at home IF you have the logistics of energy sources, material resources, and manpower available.
The critical issue here to consider is that once you start the critical care, you had better be well-prepared to see it through to an acceptable outcome. What would be an acceptable outcome in this situation? It would depend on the diagnosis and the likely prognosis for its treatment.
In a TEOTWAWKI situation, with hospital transfers not being a possibility, the initial triage performed by a competent and trained medical professional is crucial. Medical and surgical care protocol decisions regarding what triage methodology will be utilized needs to be discussed and followed strictly according to the availability of your actual on-site prep logistics and the actual number of skilled persons available who will be devoted to provide medical duty.
Let’s face reality here: if the scenario is that severe, and if it is a catastrophic or prolonged emergent event, issues of supply and medication replenishment and personnel replacement are going to impose an astringent triage that will dictate no critical care for a few, when many more lives, or lesser injuries or illnesses, will benefit from those same logistics, over an extended time frame for the future needs of an entire group.
Fellowship-trained PICU doc here. Easiest answer is: depends on the situation. Any ICU-type care is going to be incredibly resource intensive, and if there is no reasonable expectation of access to a fully-equipped medical center, you are going to use up scant resources on a lost cause. ICU medicine is not complicated. Basically, 1) air goes in and out; 2) blood goes round and round; 3) oxygen is good. Catch is, that what you need to do to maintain these functions may mean that another (or multlple others) die due to lack of manpower or supplies used up on this case. Worst part? We will be the ones tasked with making that call. It gives me nightmares.
I have a well-developed kit. An overview question does not get into the details, so OK, so here goes an outline answer.
10 yrs ago I was a CVICU nurse.
5yrs ago I had to do a bunch of austere, critical care transport out of a rucksack in a combat zone getting patients from remote hospitals to central ones. Briefly, I’m describing the preps I have made and the capabilities I think I have at my home with my kits. Some are battle proven and others not so much.
Airway/Breathing: rescue position, suction (hand, foot, power) combitube, O2 concentrator, ET tube, crich, draw over anesthesia, ketamine, ether, nebs (albuterol & epi,), humidity, crossfire vent, (want an eagle), chest tubes, basic thoracotomy (this is a discussion all by itself). I will run out of paralytics prior to tetanus recovery so get vaccinated, chest percussion, bronch lavage, need a rhinoscope, have colonoscope and light source. Peep, improvised peep.
Circ: IV NS, non invasive and invasive cvp, whole blood, type and match, ligation, hemostatic gauze, I need a few heparin shunts to do temp periph arterial bypass, I have yet to research how to make them in austere settings. short term IV meds as they go out of date so I only have leftovers from the prior trip. right now I have small amounts of lasix, dopamine, dobutamine, ntg, my field MI kit is ASA, MSO4, NTG patch and SL, metoprolol po. lifepack 12 with EKG, pacing, defib (high mortality) etc… mine needs newer batteries. acls drugs (going out of date), art line using aneroid gauge from bp cuff.
Neuro: burr holes, skull flap
GI/GU: gastric lavage, ice water lavage, blakemore tube, foley, tube feeding with homemade nutrition, peritoneal dialysis
Lab: microscope, millipore field portable battery operated incubator, manual CBC, BG, K+, spec grav, urea, NaCl, need reagents for Ca+ and Mg+, ua micro, dipsticks, dextrostix
Burns: homemade silvadine, simple skin grafts, home made vac dressings, Vaseline gauze
care of the critically ill patient in the tropics and sub tropics by watters 0-333-53799-8
neurosurgery in the tropics rosenfeld 0-333-68412-5
village medical manual by vanderkooi 978-0-87808-748-8
primary anaesthesia by king 019562617-6
primary surgery by king 0-19-567786-2 (AND not or) 0-19-567785-4
and a bunch of articles from tropical doctor, etc…..