齊魯醫(yī)學(xué)ICU醫(yī)師的背景與專業(yè)優(yōu)勢

1、ICU醫(yī)師的背景與專業(yè)優(yōu)勢上海復(fù)旦大學(xué)附屬中山醫(yī)院外科監(jiān)護(hù)病房 諸杜明12021/10/23 星期六了 解ICU的模式和發(fā)展背景ICU常用的診療手段ICU需要什么樣的醫(yī)師22021/10/23 星期六ICU的模式和發(fā)展背景最早的ICU其實不是醫(yī)生發(fā)明的，其用途也僅僅是用于手術(shù)后恢復(fù)，時間是十九世紀(jì)中葉 Florence Nightingale wrote about the advantages of establishing a separate area of the hospital for patients recovering from surgery32021/10/23 星期六早

2、在一個多世紀(jì)以前，人們即已認(rèn)識到了給予外科手術(shù)病人特別管理的重要性。 1863年偉大的護(hù)理事業(yè)的先驅(qū)者南丁格爾就曾撰文提到，其時“在小的鄉(xiāng)村醫(yī)院里，把病人安置在一間由手術(shù)室通出的小房間內(nèi)，直至病人恢復(fù)或至少從手術(shù)的即時影響中解脫的情況已不鮮見”。這種專門為術(shù)后病人，以后又進(jìn)一步擴(kuò)大到為失血、休克等危重外科病人開僻的“小房間”存在相當(dāng)長的時間，直至本世紀(jì)20年代被正式命以“術(shù)后恢復(fù)室”(recovery room)。 42021/10/23 星期六南 丁 格 爾 最 后 的 照 片52021/10/23 星期六提燈女神南丁格爾62021/10/23 星期六ICU在美國的初創(chuàng)監(jiān)護(hù)單元的出現(xiàn)時間、地

3、點1923、 Johns Hopkins Hospital 床位 three-bed unit 負(fù)責(zé)人 Dr. W.E. Dandy 性質(zhì)neurosurgical patients for postoperative 72021/10/23 星期六早 期 發(fā) 展1927年，芝加哥的 Sarah Morris Hospital 出現(xiàn)了第一個屬于醫(yī)院管理的早產(chǎn)兒監(jiān)護(hù)中心.二戰(zhàn)時針對士兵的戰(zhàn)傷和隨后的手術(shù)，出現(xiàn)了用于休克復(fù)蘇和監(jiān)護(hù)的病房82021/10/23 星期六發(fā)生于1947的流行性脊髓灰質(zhì)炎席卷歐美 治療所用的方法已現(xiàn)呼吸治療的雛形（manual ventilation was accomp

4、lished through a tube placed in the trachea of polio patients） with respiratory paralysis and/or suffering from acute circulatory failure required intensive nursing care. 92021/10/23 星期六鐵 肺102021/10/23 星期六112021/10/23 星期六上世紀(jì)五十年代，機械通氣技術(shù)進(jìn)一步發(fā)展，在歐美國家出現(xiàn)了集中治療呼吸系統(tǒng)疾病的呼吸ICU，病人的呼吸治療得以更有效的進(jìn)行，同時，針對各種衰竭病人和術(shù)后病人的普

5、通ICU也應(yīng)運而生。122021/10/23 星期六ICU的模式和發(fā)展背景（開放和封閉之爭）Dr. Liolios: There is a lot of discussion on the topic of open versus closed ICUs . While many ICUs are closed in Europe, there are still many open ICUs in the United States, with the subspecialists often running the show. How do you respond to that? Do

6、you think it has an impact on outcome? Dr. Vincent: I think it is very important to place critically ill patients in the hands of a properly trained, experienced doctor who is part of a team available 24 hours a day. The open ICU design has clearly been shown to provide lower-quality management. In

7、Europe, it is also not uncommon for an ICU physician to have important duties elsewhere in the hospital (usually as an anesthesiologist in the operating room, but also as an internist in the outpatient clinic). This is acceptable only in ICUs with a relatively light patient load. In any case, a doct

8、or should be immediately reachable in case of problems. By the way, there are recent data from the IMPACT program suggesting that the closed ICU model may not be better, but it is too early to discuss this new information.132021/10/23 星期六在那些科室內(nèi)部的ICU和部分?？艻CU而言，以開放型模式或封閉型管理病人為主。在那些綜合型ICU而言，以半開放型為主管理病人

9、因為：病人來自不同科室。142021/10/23 星期六美國的第一個1958年，美國第一個綜合性、多學(xué)科ICU在Johns Hopkins Bayview Medical Center at Baltimore City Hospitals成立, 也是第一個由麻醉科住院醫(yī)生擔(dān)任全天候?qū)Ｂ氠t(yī)生的ICU。152021/10/23 星期六六十年代，大多數(shù)美國醫(yī)院有了至少一個以上的ICU. 1970, 28 名志同道合的從事危重病專業(yè)的內(nèi)科醫(yī)生相聚洛杉磯，發(fā)起成立了美國重癥醫(yī)學(xué)會（the Society of Critical Care Medicine ，SCCM). 1986,美國醫(yī)師委員會開始了

10、針對以下四個專業(yè)的危重病專業(yè)資格認(rèn)證：麻醉、內(nèi)科、兒科和外科 162021/10/23 星期六發(fā) 展新世紀(jì)以來，各種移植手術(shù)的開展，促使重癥醫(yī)學(xué)在移植領(lǐng)域的進(jìn)步各種無創(chuàng)技術(shù)、微創(chuàng)技術(shù)的運用，降低了費用和使用風(fēng)險（如機械通氣、心功能監(jiān)測、微創(chuàng)氣切）對各種藥代動力學(xué)的研究，各種針對某一特定器官的治療措施的使用，使得病人的花費和住院天數(shù)大大下降。172021/10/23 星期六賀國外醫(yī)學(xué)麻醉與復(fù)蘇分冊創(chuàng)刊 吳玨麻醉專業(yè)百齡過，祖國推遲十年又，世界期刊卅余種，卓著優(yōu)質(zhì)實難數(shù)。學(xué)術(shù)登攀廣交流，動態(tài)進(jìn)展新貌多，麻醉復(fù)蘇有分冊，綜述文摘具規(guī)模。編纂印刷事務(wù)煩，徐州附院敢承擔(dān)，舉國群英襄盛舉，眾志成城事不難。

11、全麻伊始驚駭慘，功過莫論后人判，新藥爭勝年年異，評比參照朝朝喚。局麻普魯*世紀(jì)初，硬外阻滯宜稱賀，穿刺敏捷巧妙手，熟練觀摩思路寬。靜吸復(fù)合日月奇，誘導(dǎo)快速效應(yīng)冀，解痛肌松另用藥，鎮(zhèn)靜安寧全憑依。體外低溫心病醫(yī)，控制降壓可顯微，監(jiān)測描記多變革，電子自控莫猜疑。機械呼吸性能好，血氣酸堿共信號，扶傷搶救成專職，垂危醫(yī)學(xué)有功勞。邊緣學(xué)科憶念時，試驗探測動物試，閱讀思維圖書室，猷懷往年辛酸事。事業(yè)成長青藍(lán)*共，指引輔導(dǎo)有舵工。182021/10/23 星期六不同背景醫(yī)生的優(yōu)勢麻醉科醫(yī)師優(yōu)勢最坐得住，最善于觀察生命體征，最多也許還是最早使用監(jiān)護(hù)儀器對各種呼吸、循環(huán)監(jiān)測方法都已掌握或早有所聞熟練掌握各種搶救

12、技能中心靜脈穿刺、氣管插管各種搶救、鎮(zhèn)痛所需藥物的藥理、器官生理功能都有涉獵 吳玨教授言：麻醉科醫(yī)生是半 個外科醫(yī)生、半個內(nèi)科醫(yī)生熟悉外科手術(shù)的主要步驟，十分理解將要處理的外科并發(fā)癥的難點所在十分關(guān)切病人術(shù)后疼痛問題并有能力解決之多與外科醫(yī)師保持良好的溝通能力192021/10/23 星期六不同背景醫(yī)生的劣勢麻醉科醫(yī)師少與病人家屬打交道，缺乏相應(yīng)經(jīng)驗善于處理問題，但缺少發(fā)現(xiàn)問題的能力(檢驗結(jié)果的研判、對影像學(xué)結(jié)果的研讀)全局觀念、全身觀念有待提高 人無完人 金無足赤202021/10/23 星期六不同背景醫(yī)生的優(yōu)勢內(nèi)科醫(yī)師天然的耐心、細(xì)致印象。注重分析、注重檢查、注重檢驗、注重鑒別診斷在處理下

13、列危重癥時，應(yīng)有相當(dāng)?shù)墓Φ? 急性呼吸功能不全、急性心功能不全 、急性心肌梗死、嚴(yán)重心率失常 、高血壓危象、急性腎功能不全 、嚴(yán)重水、電解質(zhì)紊亂，酸堿平衡失調(diào) 、急性中毒 、DIC、甲亢危象、非酮癥性昏迷等 RICU/CCU/EICU/NICU212021/10/23 星期六不同背景醫(yī)生的劣勢內(nèi)科醫(yī)師對外科并發(fā)癥、創(chuàng)傷缺乏深入的理解動手能力稍弱222021/10/23 星期六不同背景醫(yī)生的優(yōu)勢外科醫(yī)師有極強的臨床動手能力，在收治外科病人為主的ICU工作，其操作能力游刃有余對下列疾病和相應(yīng)并發(fā)癥的處理有相當(dāng)?shù)墓α?急性重癥胰腺炎、大血管病變、嚴(yán)重創(chuàng)傷、燒傷、和外科相關(guān)的膿毒癥等等缺陷：診療病情直

14、奔主題，缺少分析232021/10/23 星期六Pulmonary medicine and (adult) critical care medicine in Europe Eur Respir J 2002; 19: 12021206There has been growing concern within theEuropean Respiratory Society (ERS) that pulmonary physicians are becoming less involved in the practise of intensive care medicine Thoracic

15、Society (ATS) expanded its mission statement to include CCM and changed the name of its journal to the American Journal of Respiratory and Critical Care Medicine in 1994intermediate dependency areas intermediate level of care between the general ward and the ICU, patients with chronic and acute on c

16、hronic pulmonary insufficiency and those requiring prolonged mechanical ventilatory support can be managed effectively， support patients with single organ (i.e. pulmonary) failure, providing an intermediate level of care242021/10/23 星期六Pulmonary medicine and (adult) critical care medicine in Europe

17、Eur Respir J 2002; 19: 12021206In some countries (e.g. Scandinavia, UK), anaesthesiology has dominated ICM from its birth, whereas in others (e.g. the Netherlands), the picture is changing. ICM can only be practised legally by anaesthesiologistsAs of March 2001, of the 2,332 members of the European

18、Society of Intensive Care Medicine(ESICM), 50.6% counted anaesthesiology and 20.9% internal medicine.Approximately 53% of Society members spend 100% of their time practising ICM; 24% spend 5075% of their time thus occupied.252021/10/23 星期六不同國家的培訓(xùn)時間In Spain, 5 yrs training is required to achieve spec

19、ialist status, 3 yrs of which is in ICM.In France, Germany, Greece and the UK, 2 yrs training in ICM is required in addition to that needed for base specialty (usually anaesthesiology, pulmonology or general internal medicine). In Italy, only anaesthesiologists may legally practise ICM.Pulmonary med

20、icine and (adult) critical care medicine in Europe Eur Respir J 2002; 19: 12021206262021/10/23 星期六Spanish model Dr. Vincent Spanish model : a mixture of internal medicine, anesthesiology, surgery, and emergency medicine. It should be 5 years like the other specialties - that is, 1 year less than in

21、the present curriculum (which is 1 primary specialty plus 2 years of additional training, but 1 year is possibly included in the primary specialty).272021/10/23 星期六 The pulmonary physician in intensive care: practical difficulties Eur Respir J 2002; 19: 12021206歐盟內(nèi)部對ICM的發(fā)展政策的制定并不包含肺科學(xué) 主流學(xué)術(shù)組織ESICM其著眼

22、點是在ICM中的多學(xué)科建設(shè)，而這種多學(xué)科建設(shè)卻不包括對肺科醫(yī)師的專業(yè)培訓(xùn)在大多數(shù)歐盟國家需要至少兩年的專業(yè)訓(xùn)練時間這兩年的時間對一個初級臨床醫(yī)生的培訓(xùn)來說是相當(dāng)困難或者是不可能的在一些國家如西班牙，ICM傾向于獨立成為學(xué)科，讓一個醫(yī)師既接受ICM訓(xùn)練又接受肺科訓(xùn)練并不現(xiàn)實，在意大利，法律禁止肺科醫(yī)師從事ICM 282021/10/23 星期六加拿大的情況最復(fù)雜的病例在ICU中得到治療，過去，這里的醫(yī)生來源于麻醉科、外科、內(nèi)科，但是，現(xiàn)在重癥監(jiān)護(hù)成為了一個多學(xué)科專業(yè)（multidisciplinary specialty ），大約30以上的醫(yī)生是麻醉醫(yī)師 （About thirty percen

23、t of intensivists in Canada are anesthesiologists）,這個比例在英國和澳洲還要高292021/10/23 星期六展 望302021/10/23 星期六美 國1985年到2000年間，美國醫(yī)院總數(shù)下降了8.9% (6,032 to 5,494) 內(nèi)設(shè)危重醫(yī)學(xué)科（CCM）的醫(yī)院，總床位數(shù)下降了26.4% (889,600 to 654,400). 相反 CCM 床位總數(shù)上升了 26.2% (69,300 to 87,400)CCM 床位占用率是65%. CCM 每床每天使用價格上漲了126% ($1,185 to $2,674)，盡管CCM總的花費增

24、加了190.4% ($19.1 billion to $55.5 billion), 但是健康保險部門給CCM的費用配額卻下降了5.4%（說明整體醫(yī)療費用的上揚更快更多）2000年, CCM 占醫(yī)院總費用的13.3%, 國家健康費用預(yù)算的4.2% 和國內(nèi)生產(chǎn)總值的 0.56%結(jié)論：CCM在醫(yī)院持續(xù)萎縮的情況下床位總數(shù)仍在增加，CCM花費比預(yù)想的要低，其占GDP的總量也相應(yīng)比預(yù)想的要低 Critical Care Medicine. 32(6):1254-1259, June 2004.Halpern, Neil A. MD, FCCM; Pastores, Stephen M. MD, FCC

25、M; Greenstein, Robert J. MD 312021/10/23 星期六國 內(nèi)一份最新的調(diào)查結(jié)果顯示，目前我國71.40的醫(yī)院設(shè)立了獨立的ICU科室，ICU總床位數(shù)已達(dá)5424張。2006年全國16631（似乎少了點）人次入住ICU，而僅一年后的2007年,這一數(shù)據(jù)就翻了一番，達(dá)到34344（似乎少了點）人次。急遽的發(fā)展也帶來了問題。一些醫(yī)療機構(gòu)盲目購置昂貴的先進(jìn)醫(yī)療設(shè)備，忽視了專業(yè)人員的培訓(xùn)，造成高技術(shù)裝備與低素質(zhì)專業(yè)人員的尖銳矛盾 醫(yī)師報2008.11.27322021/10/23 星期六Dr. Vincent:怎樣的態(tài)度面對挑戰(zhàn)It is clear that the n

26、umber of critically ill patients will increase significantly in the years to come, and the number of ICU doctors may not follow in parallel. We should indeed prepare for this, but as it is a progressive phenomenon, I am sure we will adapt to it. Critical care medicine is the most interesting special

27、ty: I am sure it will continue to raise a lot of interest. The importance of the specialty will also increase in the future - we should all be proud to be a part of it.很清楚，危重病人的數(shù)量在接下來的數(shù)年里將顯著增加，但是ICU醫(yī)生不可能平行增加，我們要為此做好準(zhǔn)備，我相信我們會適應(yīng)這種變化，危重醫(yī)學(xué)是十分有趣的專業(yè)，我相信還將有許多有趣點被發(fā)現(xiàn)，其重要性也將在將來不斷被發(fā)掘，我們應(yīng)該為此自豪332021/10/23 星期六一種

28、新的職業(yè)hospitalists醫(yī)院里工作的家庭醫(yī)生 另一種挑戰(zhàn)The hospital, which began tracking data, found that the hospitalists were able to decrease the number of code blues by almost 80%. Data also showed that they improved length of stay, cost per case and the rate of ICU bed diversions.“Hospitalists could take care of man

29、y ICU patients, with intensivists taking care of the sickest ones,” said Derek C. Angus, MD, chair of critical care medicine at the University of Pittsburgh, during an SCCM presentation. “Its threatening to intensivists, but frankly I think its the only way if we think we need to keep the same number of ICUs.” Theres another factor: “On any given day, only a fraction of patients cared for in the nations ICUs require primary care delivered by physicians with specialized, a