齐鲁医学ICU医师的背景与专业优势

1、ICU医师的背景与专业优势上海复旦大学附属中山医院外科监护病房 诸杜明12021/10/23 星期六了 解ICU的模式和发展背景ICU常用的诊疗手段ICU需要什么样的医师22021/10/23 星期六ICU的模式和发展背景最早的ICU其实不是医生发明的，其用途也仅仅是用于手术后恢复，时间是十九世纪中叶 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、在一个多世纪以前，人们即已认识到了给予外科手术病人特别管理的重要性。 1863年伟大的护理事业的先驱者南丁格尔就曾撰文提到，其时“在小的乡村医院里，把病人安置在一间由手术室通出的小房间内，直至病人恢复或至少从手术的即时影响中解脱的情况已不鲜见”。这种专门为术后病人，以后又进一步扩大到为失血、休克等危重外科病人开僻的“小房间”存在相当长的时间，直至本世纪20年代被正式命以“术后恢复室”(recovery room)。 42021/10/23 星期六南 丁 格 尔 最 后 的 照 片52021/10/23 星期六提灯女神南丁格尔62021/10/23 星期六ICU在美国的初创监护单元的出现时间、地

3、点1923、 Johns Hopkins Hospital 床位 three-bed unit 负责人 Dr. W.E. Dandy 性质neurosurgical patients for postoperative 72021/10/23 星期六早 期 发 展1927年，芝加哥的 Sarah Morris Hospital 出现了第一个属于医院管理的早产儿监护中心.二战时针对士兵的战伤和随后的手术，出现了用于休克复苏和监护的病房82021/10/23 星期六发生于1947的流行性脊髓灰质炎席卷欧美 治疗所用的方法已现呼吸治疗的雏形（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 星期六铁 肺102021/10/23 星期六112021/10/23 星期六上世纪五十年代，机械通气技术进一步发展，在欧美国家出现了集中治疗呼吸系统疾病的呼吸ICU，病人的呼吸治疗得以更有效的进行，同时，针对各种衰竭病人和术后病人的普

5、通ICU也应运而生。122021/10/23 星期六ICU的模式和发展背景（开放和封闭之争）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 星期六在那些科室内部的ICU和部分专科ICU而言，以开放型模式或封闭型管理病人为主。在那些综合型ICU而言，以半开放型为主管理病人

9、因为：病人来自不同科室。142021/10/23 星期六美国的第一个1958年，美国第一个综合性、多学科ICU在Johns Hopkins Bayview Medical Center at Baltimore City Hospitals成立, 也是第一个由麻醉科住院医生担任全天候专职医生的ICU。152021/10/23 星期六六十年代，大多数美国医院有了至少一个以上的ICU. 1970, 28 名志同道合的从事危重病专业的内科医生相聚洛杉矶，发起成立了美国重症医学会（the Society of Critical Care Medicine ，SCCM). 1986,美国医师委员会开始了

10、针对以下四个专业的危重病专业资格认证：麻醉、内科、儿科和外科 162021/10/23 星期六发 展新世纪以来，各种移植手术的开展，促使重症医学在移植领域的进步各种无创技术、微创技术的运用，降低了费用和使用风险（如机械通气、心功能监测、微创气切）对各种药代动力学的研究，各种针对某一特定器官的治疗措施的使用，使得病人的花费和住院天数大大下降。172021/10/23 星期六贺国外医学麻醉与复苏分册创刊 吴珏麻醉专业百龄过，祖国推迟十年又，世界期刊卅余种，卓著优质实难数。学术登攀广交流，动态进展新貌多，麻醉复苏有分册，综述文摘具规模。编纂印刷事务烦，徐州附院敢承担，举国群英襄盛举，众志成城事不难。

11、全麻伊始惊骇惨，功过莫论后人判，新药争胜年年异，评比参照朝朝唤。局麻普鲁*世纪初，硬外阻滞宜称贺，穿刺敏捷巧妙手，熟练观摩思路宽。静吸复合日月奇，诱导快速效应冀，解痛肌松另用药，镇静安宁全凭依。体外低温心病医，控制降压可显微，监测描记多变革，电子自控莫猜疑。机械呼吸性能好，血气酸碱共信号，扶伤抢救成专职，垂危医学有功劳。边缘学科忆念时，试验探测动物试，阅读思维图书室，猷怀往年辛酸事。事业成长青蓝*共，指引辅导有舵工。182021/10/23 星期六不同背景医生的优势麻醉科医师优势最坐得住，最善于观察生命体征，最多也许还是最早使用监护仪器对各种呼吸、循环监测方法都已掌握或早有所闻熟练掌握各种抢救

12、技能中心静脉穿刺、气管插管各种抢救、镇痛所需药物的药理、器官生理功能都有涉猎 吴珏教授言：麻醉科医生是半 个外科医生、半个内科医生熟悉外科手术的主要步骤，十分理解将要处理的外科并发症的难点所在十分关切病人术后疼痛问题并有能力解决之多与外科医师保持良好的沟通能力192021/10/23 星期六不同背景医生的劣势麻醉科医师少与病人家属打交道，缺乏相应经验善于处理问题，但缺少发现问题的能力(检验结果的研判、对影像学结果的研读)全局观念、全身观念有待提高 人无完人 金无足赤202021/10/23 星期六不同背景医生的优势内科医师天然的耐心、细致印象。注重分析、注重检查、注重检验、注重鉴别诊断在处理下

13、列危重症时，应有相当的功底: 急性呼吸功能不全、急性心功能不全 、急性心肌梗死、严重心率失常 、高血压危象、急性肾功能不全 、严重水、电解质紊乱，酸碱平衡失调 、急性中毒 、DIC、甲亢危象、非酮症性昏迷等 RICU/CCU/EICU/NICU212021/10/23 星期六不同背景医生的劣势内科医师对外科并发症、创伤缺乏深入的理解动手能力稍弱222021/10/23 星期六不同背景医生的优势外科医师有极强的临床动手能力，在收治外科病人为主的ICU工作，其操作能力游刃有余对下列疾病和相应并发症的处理有相当的功力 急性重症胰腺炎、大血管病变、严重创伤、烧伤、和外科相关的脓毒症等等缺陷：诊疗病情直

14、奔主题，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 星期六不同国家的培训时间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欧盟内部对ICM的发展政策的制定并不包含肺科学 主流学术组织ESICM其着眼

22、点是在ICM中的多学科建设，而这种多学科建设却不包括对肺科医师的专业培训在大多数欧盟国家需要至少两年的专业训练时间这两年的时间对一个初级临床医生的培训来说是相当困难或者是不可能的在一些国家如西班牙，ICM倾向于独立成为学科，让一个医师既接受ICM训练又接受肺科训练并不现实，在意大利，法律禁止肺科医师从事ICM 282021/10/23 星期六加拿大的情况最复杂的病例在ICU中得到治疗，过去，这里的医生来源于麻醉科、外科、内科，但是，现在重症监护成为了一个多学科专业（multidisciplinary specialty ），大约30以上的医生是麻醉医师 （About thirty percen

23、t of intensivists in Canada are anesthesiologists）,这个比例在英国和澳洲还要高292021/10/23 星期六展 望302021/10/23 星期六美 国1985年到2000年间，美国医院总数下降了8.9% (6,032 to 5,494) 内设危重医学科（CCM）的医院，总床位数下降了26.4% (889,600 to 654,400). 相反 CCM 床位总数上升了 26.2% (69,300 to 87,400)CCM 床位占用率是65%. CCM 每床每天使用价格上涨了126% ($1,185 to $2,674)，尽管CCM总的花费增

24、加了190.4% ($19.1 billion to $55.5 billion), 但是健康保险部门给CCM的费用配额却下降了5.4%（说明整体医疗费用的上扬更快更多）2000年, CCM 占医院总费用的13.3%, 国家健康费用预算的4.2% 和国内生产总值的 0.56%结论：CCM在医院持续萎缩的情况下床位总数仍在增加，CCM花费比预想的要低，其占GDP的总量也相应比预想的要低 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 星期六国 内一份最新的调查结果显示，目前我国71.40的医院设立了独立的ICU科室，ICU总床位数已达5424张。2006年全国16631（似乎少了点）人次入住ICU，而仅一年后的2007年,这一数据就翻了一番，达到34344（似乎少了点）人次。急遽的发展也带来了问题。一些医疗机构盲目购置昂贵的先进医疗设备，忽视了专业人员的培训，造成高技术装备与低素质专业人员的尖锐矛盾 医师报2008.11.27322021/10/23 星期六Dr. Vincent:怎样的态度面对挑战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，危重病人的数量在接下来的数年里将显著增加，但是ICU医生不可能平行增加，我们要为此做好准备，我相信我们会适应这种变化，危重医学是十分有趣的专业，我相信还将有许多有趣点被发现，其重要性也将在将来不断被发掘，我们应该为此自豪332021/10/23 星期六一种

28、新的职业hospitalists医院里工作的家庭医生 另一种挑战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