This document provides advice for how to be an ICU physician. It discusses topics like professional journals to read, common rules for critical care, case studies, and other advice. Some key points include treating the patient not just the numbers, starting with basic assessments, keeping treatments simple, and never forgetting the importance of physical examination.

1. 如何做一名ICU医生 北京协和医院 杜斌

3. Professional Journals to be Read

4. Physician vs. Surgeon vs. Film Star (n = 12) (n = 12) (n = 6) Height (cm) 179.4 (175.1 to 184.0) 172.6 (170.2 to 175.4) Good looking score 4.39 3.65 5.96 Trilla A, Aymerich M, Lacy AM, et al. Phenotypic differences between male physicians, surgeons, and film stars: comparative study. BMJ 2006; 333: 1291-1293.

5. Marik’s Evidence-Based Commonsense Critical Care Rules Don’t assume the obvious. Common diseases occur commonly. When doing a procedure, remember nature always sides with the hidden flaw. Corollary: If something can go wrong, it will. Just when you thought things couldn’t get any worse, they will.

6. 病例: 现病史 GT, F/30, C845169 2005年11月25日 间断腹泻发热1年余, 呼吸困难3天 2004年10月腹泻, 低热 嗜酸细胞性肠炎? 肠结核? 2004年12月高热 FUO

7. 病例: 现病史 2005年3月入住外院 经空肠营养管行胃肠营养 经中心静脉插管行肠外营养 2005年4月起 多次血培养: GNB, 真菌 抗生素疗效不佳 类鼻疽假单胞菌抗体强阳性 11月18日血培养: 放射形根瘤菌, 两宫皮肤球菌, 梭杆菌属

8. 病例: 现病史 诊断: 肠源性感染

9. 病例3: 诊治经过 2005年11月25日入ICU 体温40.8C 抗生素: 特治星+甲硝唑 诊断措施: 外周血培养: 产酸克雷白杆菌: ESBL(+) 报警时间: 3.8 h, 4.0 h, 4.7 h 锁骨下静脉插管: 产酸克雷白杆菌 治疗措施 拔除锁骨下静脉插管

10. 病例: 诊治经过 拔除锁骨下静脉插管

11. 病例: 说明 为什么不考虑肠源性感染? 为实验室诊断而非临床诊断 没有特异性治疗措施 为什么考虑中心静脉插管相关性感染? 留置导管> 3天者出现感染表现

12. Marik’s Evidence-Based Commonsense Critical Care Rules Never open a can of worms unless you plan to go fishing. Nothing in medicine stays constant. The law of subspecialty: if you are a hammer, the world looks like a nail. An acute surgical abdomen is when a good surgeon says it’s an acute surgical abdomen. There is no test for it.

13. ARDS: Clinical Diagnosis Acute onset Bilateral infiltrates on CXR PaO2/FiO2 ≤ 200 PAWP ≤ 18 mmHg or absence of clinical evidence of left atrial hypertension Bernard GR, Artigas A, Brigham KL, et al. The American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J RespirCrit Care Med 1994; 149: 818-824.

14. ARDS: CXR Diagnosis Meade MO, Cook RJ, Guyatt GH, et al. Interobserver variation in interpretingchest radiographs for the diagnosis of acute respiratory distresssyndrome. Am J RespirCrit Care Med 2000; 161: 85-90.

15. ARDS: Oxygen Index Aboab J, Louis B, Jonson B, et al. Relation between PaO2/FiO2 ratio and FiO2: a mathematical description. Intensive Care Med 2006; 32: 1494-1497.

16. ARDS: Clinical Diagnosis Esteban A, Fernandez-Segoviano P, Frutos-Vivar F, et al. Comparison of clinical criteria for the Acute Respiratory Distress Syndrome with autopsy findings. Ann Intern Med 2004; 141: 440-445.

17. Marik’s Evidence-Based Commonsense Critical Care Rules Before ordering a test, decide what you will do if it is (a) positive or (b) negative. If both answers are the same, don’t do the test. Corollary: If a test is unlikely to change your management, don’t order it. There is no manifestation that cannot be caused by a given drug. If a drug is not working, stop it.

18. Marik’s Evidence-Based Commonsense Critical Care Rules The quality of patient care is inversely proportional to the number of consultants on any particular case. If it cannot be read, don’t write it. Any order that can be misunderstood, will be misunderstood. Never ignore an ICU nurse’s observation. Be kind to nurses, and they will be kind to you. Be unkind to nurses, and they will make your life miserable.

19. Marik’s Evidence-Based Commonsense Critical Care Rules When you don’t know what to do, do nothing. Corollary: Doing something harmful is not better than doing nothing. No organ ever fails in isolation. Empty vessels make the most noise. He who thinks he knows everything knows nothing. A committee is the only life form that has twelve rectums and no brain.

20. Thalidomide: SAE

21. More is Less, Less is More Primum Non Nocere (First Do No Harm)

22. Keep Treatment Simple 男性，45岁，病历号1612296 入院日期 2010/02/21 入ICU日期 2010/02/24 既往史 24年前因感冒后颈部淋巴结肿大行左颈部淋巴结活检术，自述病理阴性 8年前阑尾切除术 1年前行鼻中隔弯曲矫正术

23. Keep Treatment Simple 2009/12/30 大量饮酒后头昏、恶心，右胁肋部及后背部胀痛 胃镜：糜烂性胃炎伴胆汁返流 2010/01/18 生化检查：ALT、AST、LDH、HBDH进行性升高 血淀粉酶237 – 588 U/L，尿淀粉酶839 – 3330 U/L 腹部超声检查提示胆囊炎

24. Keep Treatment Simple 2010/01/24 静滴脂肪乳过程中出现气促、胸闷 抗过敏、改善循环、补液及对症处理后缓解 2010/01/28 胸闷、气促，深大呼吸伴酸碱平衡紊乱 无创通气

25. Keep Treatment Simple ABG 7.435 / 6.2 / 116 / 4.1 / -19.2 AG 20 – 27 血乳酸 14.8 – 16.0 mmol/L 血丙酮酸 6.62 mg/dL (0.3 - 0.9) 0.83 mmol/L L/P 17.8 – 19.3

26. Keep Treatment Simple 诊断：重症胰腺炎? 治疗 按胰腺炎治疗，恶心、呕吐症状缓解 输血浆及冷沉淀纠正DIC 亚甲蓝中和乳酸 呼吸困难（深大呼吸）合并代谢性酸中毒 2010/02/12 血液透析 乳酸可短暂下降至7 mmol/L

27. Keep Treatment Simple

28. Keep Treatment Simple: Examples Cerebral resuscitation Yes: therapeutic hypothermia, maintain adequate CPP No: neuroprotective agents, agrynotics Non-renal indication of CRRT Yes: severe electrolyte/acid-base disorders, refractory congestive heart failure No: intoxication/poisoning, cytokine removal Immunomodulation No: thymosin, immunoglobulin, …

29. Begin with BASICs Ohm’s law R = U / I Hemodynamics: SVR = (MAP – CVP) / CO Respiratory mechanics: Raw = (PIP – Pplat) / flow

30. Know Why and Know How Antifungal agent for Candida pneumonia Who: immunocompromised vs. immunocompetent When: ETA +ve for Candida vs. β-1,3-D-glucan What: Fluconazole vs. Caspofungin

31. Other Advices Always ask what to treat Always ask what is still unknown Never prescribe antibiotics just for positive cultures Treat the patients, not the numbers Never forget physical examination Learn how to tell a story

32. What Else… When reading a paper, read the method and materials carefully Patient population: inclusion & exclusion Treatment protocol Endpoints

33. Salary by Specialty Critical care medicine $234,503 Intensivisit $245,293 Pediatric intensive care $201,901 Orthopedic surgery – spine $554,054 Geriatrics $162,541 Physician salary data. Available at http://www.physiciansalary.net/physician-salary-data.php. Accessed June 13, 2010

34. Salary & US Residency Fill Rate Ebell MH. Future salary and US residency fill rate revisited. JAMA 2008; 300: 1131-1132

35. BMJ 2005;331:1529 (24 December), doi:10.1136/bmj.331.7531.1529

36. When Doctors Marry Doctors Sobecks NW, Justice AC, Hinze S, et al. When doctors marry doctors: a survey exploring the professional and family lives of young physicians. Ann Intern Med 1999; 130: 312-319

37. When Doctors Marry Doctors Sobecks NW, Justice AC, Hinze S, et al. When doctors marry doctors: a survey exploring the professional and family lives of young physicians. Ann Intern Med 1999; 130: 312-319

38. In Summary…