published, High Care Unit (HCU) of PAPDI, which includes 58 emergency conditions5, and incorporation of emergency medicine development of IDI, are basic.
SPECIAL ARTICLE
Emergency Medicine and High Critical Care Unit in Internal Medicine: a Commentary Cosphiadi Irawan, A Azis Rani, Zulkifli Amin
INTRODUCTION
Our clinical experience of patient care as an internist indicates that occasionally, the conventional method, approach and care is not an ideal approach for acute or chronic patients with acute exacerbation, which is life-threatening, either in emergency room or the common medicine ward. The “fixed dose” management and standard diagnostic approach occasionally fail to decline morbidity and mortality rates of those patients. The data, which are quite longstanding, but still appropriate, demonstrated 1216 hospitalized patients in IRNA B, 5th floor in 1988: 250 patients (20.56 %) were dead and 40 death patients (16% of 250 patients) were caused by pulmonary system failure. The other causes were distributed for 18 different clinical causes such as 16% septic shock, 11.20% heart failure, 11.20% chronic renal failure, 9.6% liver failure, 5.20% hematemesis/ melena and etc. These rates indicate a quite high morbidity rate in medicine ward, which if it is evaluated, it may be caused by limited accommodation capacity and different perception about the criteria of ICU care in Cipto Mangunkusumo Hospital and limited infrastructure and laboratory facility in common medicine ward. Therefore, the considerations; that correlate the above condition and immediately-measured necessity sparked the “emergency medicine” or “critical ill care” term. We admit that even there has not any uniformity about the term of “emergency medicine”/EM (—unimpeded translation: emergency of internal medicine —) or about its scope, but all of us could except that this field includes patients with severe condition (“critical ill patients”) and emergency medicine or another field,
Department of Internal Medicine, Cipto Mangunkusumo Hospital/ Faculty of Medicine, University of Indonesia, Jakarta 110
which is related to management priority in medicine. Therefore, is there something special in this field? Then, the answer is: When we compare it to “conventional” approach, which is very ideal because it is comprehensive by history, physical examination, routine laboratory, special diagnostic procedure and it is formulated on problem oriented medical record, and therefore each of them make a rational therapy. Then in emergency medicine, the question that has to be answered is: what is the life-threatening cause? “Conventional” approach does not guarantee an express answer for that, besides there is time limitation, which obscures immediate management based on “titration dose” in order to prevent advanced morbidity, which in turn could prevent mortality of that patient.2 DEFINITION
The term of EM in several health centers of some countries (Canada, Australia and America) is related to pre-hospital services, before patient is brought to emergency room, i.e. pick-up service, stabilization and evacuation to the nearest emergency room. The dispatched team may constitute a unity of paramedic and “fire and rescue” service division, who consult with medical team of emergency unit at local hospital.3, 4 It was preceded by informal discussion at Department of Internal Medicine, Faculty of Medicine, University of Indonesia/Cipto Mangunkusumo Hospital; that observe such necessity above. Standard Profession of Emergency Medicine (in ER) that has been published, High Care Unit (HCU) of PAPDI, which includes 58 emergency conditions5, and incorporation of emergency medicine development of IDI, are basic law-principles of this unit development. Furthermore it could be understood that “emergency medicine/high critical care” is: a work team/association under protection of Department of Internal Medicine/ Head of Department, who evaluate the management of
Vol 37 • Number 2 • April-June 2005
emergency-patients either acute or chronic in internal medicine or other elated fields; in order to save life and improve related organ functional reservoir to extend time for medical treatment of its primary disease. As an organization, this team aims to develop fast diagnosis in order to specially manage, either acute or chronic condition, which is life threatening in short time or few days, to suppress the patient’s morbidity and mortality rate. Hence, in order to achieve those aims, some action of that program should be measurable, i.e.: 1. Carry out an effort to improve quality of internist and define about what is meant by emergency medicine, so that they are able to diagnose and manage it in fast and effective manner. 2. Prepare a “life support” room and infra structure or replacement of vital organ function on specific management. 3. Prepare an evaluation of vital organ function as complication of basic/primary disease either by laboratory, biology and mechanics. 4. Prepare an effort and care facility, and intensive and continuous treatment, which are evaluated by “titrating dose” in order to prevent further complication of severe primary disease. 5. Maintain further homeostasis, prevention, diagnosis and trauma prevention, either simultaneously or by priority scale.6 In order to achieve the above objectives, there is some principle philosophy that should be fully comprehended, i.e.: 1. The implementation of “emergency medicine and high critical care” services, depends on internist and nurse that understand and can give professional service. 2. Diagnostic approach and its management are holistic and multidisciplinary, which avoid compartmentalized specialist or sub specialist practice. 3. One or multi organ failure and complication should be evaluated causatively either through: metabolic, “milieu interior” and tissue perfusion/oxygen transportation, so that we are able to carry out specific intervention and other medical procedures. 4. The service target/patient population in “emergency medicine & high critical care” (EM / HCC) unit is internal medicine patient, either coming from ER, ward or consulted by other discipline, who needs intensive treatment/EM priority in medicine field.
Emergency Medicine and High Critical Care Unit
The Criteria of Patient’s Registration in EM & HCC Unit7
• Based on sub division criteria, collected in conference • Acute Physiology and Chronic Health Evaluation II /APACHE II • Therapeutic Intervention Scoring system / TISS • Miranda II: divides intensive care into three levels. Furthermore, it may be arranged by multi disciplinary medical team, nurses, and hospital director, including the criteria of patient’s registration in EM & HCC unit. Such criteria will be evaluated properly, periodically, and continuously, including: • General principle of patient’s registration (in and out patient) in “EM and HCC“ unit • Determine the categorization priority into I – III class. • Reversibility of clinical problem and expectation of recovery from illness. • Advantage of intensive therapy • Socio-cultural consideration For hesitant patients on criteria of “EM/HCC” registration, then medical director or staff should determine the patient who is given priority for intensive care. The “emergency medicine & high critical care” unit is expected to be able: 1. To give health care services by skilled high care nurse for critical patient or in endangered patient. 2. It is specialist-services unit which cover all of input and support, either technically or consultatively of all internal medicine specialist, under coordination by medical staff of EM/HCC unit 3. Airway management 4. Oxygen therapy, including life-supporting equipment 5. Continuous evaluation of ECG 6. Comprehensive, integrated and fast Laboratory Service (the criteria will be arranged based on all sub-specialist input in internal medicine) 7. Adequate nutritional service based on clinical nutrition and nutritional support 8. Brain, pulmonary and heart resuscitation 9. Parenteral treatment intervention / therapy based on “titrating dose” PATIENT DISCHARGED
Director, medical staff, and nurse discuss about which patient who has met the criteria of moving to common care unit (ward). 111
Cosphiadi Irawan
Patient unable to fulfill intensive care criteria is: a. Patient that in appropriate to brain-stem death b. Terminally-ill patient, who is irreversible and assumed that he will not get any advantage from given therapy (i.e.: Stadium IV malignancy, terminal pulmonary illness and other diseases that will be arranged later) c. Patient who rejects intensive procedure and therapy.
Acta Med Indones-Indones J Intern Med
based on present input and reference, and it is not official judgment of present institution. The author expects that emergency medicine service will be realized soon, and it is not just an expression. REFERENCES 1.
The phase of patient’s management in “EM and HCC“ unit :7, 8 1. Immediate evaluation of vital sign and possibility of life-threatening condition and determine necessary immediate intervention management (resuscitation) 2. Evaluation of tissue perfusion and oxygen transportation, and determine necessary resuscitation to improve above condition. 3. Evaluation of all organ systems which are involved and suspected primary cause as basic pathology and its complication. 4. Advance support of body system and determine laboratory evaluation in order to support therapeutic procedure in accordance to point 1 - 4.
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6. 7. 8.
CONSULTATION AND CORPORATION
A medical staff of EM & CI unit is expected to understand about when he has to consult and realize his limitation on skill and knowledge; without an obligation to consult on all of present disorders based on organ orientation. Therefore this medical team is expected: 1. To have profound and recent knowledge about every disease development so that he knows when he has to have a consult 2. To realize his limitation in giving best health care services. 3. He is able to determine about when and whom he should consult to 4. Disclose to the need of sub-specialist’s input. 5. Have a good communication either with the doctor who has referred to patients and still corporate in patient management. CONCLUSION
Because it is specific, we expect that by the ability to communicate and good relationship with various party, we could avoid overlapping and compartmentalized management, hence one sided/one organ therapy that will exacerbate other system function could be avoided. This brief report is personal opinion of the author, 112
Data rekam medik RSUPN-CM (Tak dipublikasikan): Dikutip dari rancangan unit perawatan khusus penderita di bagian ilmu penyakit dalam. Markovchick VJ. Decision making in emergency medicine. Emergency medicine secrets. 3rd Ed. In: Markovchick VJ,Pons PT, eds. Hanley & Belfus,Inc; 2003. p.1 –4. Emergency medical services. Division of Fire and Rescue services. Montgomery county, Maryland. USA: www.montgomerycuntymd.gov The royal college of physician and surgeon. Curriculum of fellowship. Sept. 1996. Rani A, Pohan HT, Santoso M, et al. Standar profesi kedaruratan medik. Standar profesi penyakit dalam. Jakarta: PB PAPDI; 2004. p.29-31. Rancangan modul pendidikan, Unit medical emergency and critical ill. Departemen ilmu penyakit dalam FKUI / RSUPN-CM. Amin Z. Indikasi, manajemen dan sertifikasi di intensive care. p. 65-74. Panduan program pendidikan dokter spesialis anestesiologi konsultan intensive care. Jakarta, 2003.
