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Wednesday, March 19, 2014

Principles of Critical Care Medicine for Non-Intensive Care Specialists: Harvard Medical Education at its best


I just got back from Boston where I visited friends and went to a really good and useful Harvard Medical school continuing medical education course. Harvard is one of the few institutions that I have found to have consistently good classes for practicing physicians, with a few exceptions. This Spring I wanted to get myself to Boston and so I went to the online list of Harvard CME courses, which is more exciting than a candy store. In the time block that I had available they offered two delicious options. One was a week long course on everything anyone ever wanted to know about internal medicine which would have earned me over 60 hours of credit while crushing my soul with 10 hour days of densely packed information mainly intended to help practicing physicians pass their board exams. The other was the course that I chose which delivered almost 20 hours over 2 1/2 days, leaving me time to walk along the waterfront and eat a little lobster and even frolic with my friends.

The course, the 2nd Annual Principles of Critical Care Medicine for Non-Intensive Care Specialists was designed with the knowledge that much of the intensive care delivered in the United States is by physicians who don't do intensive care medicine as their main thing, and haven't received fellowship training in it. Many of us have become pretty good at it, but we sure can benefit from hearing what highly intelligent and rigorously educated intensivists have to say. Three intensive care and pulmonary medicine specialists from Harvard's Beth Israel-Deaconess, Drs. J. Woodrow Weiss, Jeremy Richards and Peter Clardy, along with guest speakers, shared information that was geared to what I really needed to learn. They gave us "evidence based" recommendations, but more importantly they told us how things worked in their hospital's intensive care unit, what they had done to improve patient care and outcomes and what that actually looked like. They focused on some of the most deadly diseases, sepsis and acute respiratory distress syndrome, and about some relatively dismal long term outcome information for the patients who are saved from their dread diseases in intensive care units, often to be faced with long term physical and mental disability. They taught us to manage ventilators more skillfully and to actually engage our brains by remembering how human physiology is reflected in some of the data which is presented to us so copiously in critically ill patients. They taught us how we might prevent delirium in patients who frequently become confused and have a very hard time coming out of it. We were gently encouraged to give blood products only to patients who could really benefit from them, which is still a bit of a moving target.

In skills workshops which were wound into the lecture and small group problem solving sessions we had a chance to use ultrasound to practice procedures and image the hearts of a few live volunteers. We were taught the standard bedside echocardiographic views and used "phantoms" to practice placing central venous catheters and sampling fluid in the abdomen and chest.  Having attended many specific ultrasound training workshops I was a little disappointed in the cursory nature of these workshops, but the course was short and there truly was not enough time to cover everything that people should learn. The fact that bedside ultrasound was a part of the course means that the organizers not only feel that it is part of what should be done in intensive care units, but also that it is at the core of what anyone who practices intensive care medicine should be able to do, even (or maybe especially) at small community hospitals. This is a good message.

The course was small enough that it was possible to talk to all of the speakers and ask individual questions. The folks who attended were an interesting mix: we were primarily physicians who managed patients in hospitals where there were no intensivists, but we were also emergency physicians and advanced nurse practitioners and physician's assistants. It is unusual to run into many of these people at conferences because they are often too busy to attend, and we are a small minority of physicians in the US.

There was a feeling in the course of trying to make sure every recommendation was based on some kind of reputable research. Since only a minority of interesting questions have been addressed adequately by reputable researchers, this approach was impractical, and as the course wore on we more often treated to experience, deduction, good sense and critical questioning. There was a nice mix of research results and practical recommendations.

The course was held in the World Trade Center on the water in South Boston, where not too long ago only warehouses and fishing boats lived. It is near a beautiful museum of contemporary art, is served by $3 ferries to all sorts of destinations on the Boston Harbor, and has easy walking access to excellent restaurants. There is a very long foot path called the Harbor Walk which makes it easy to get exercise at the edge of the water. The Seaport Hotel where conference attendees stayed was large, well appointed, expensive but not ridiculously so. The World Trade Center was also hosting the Boston Flower and Garden Show, so parking would have been terrible, but renting a car was superfluous so it didn't matter. The show was really interesting, if you like that sort of thing, and it was possible to walk in from the conference without paying the $20 entrance fee, which was probably not intentional, but did not appear to be forbidden.

What I learned is readily usable. I look forward to treating my next intensive care patients to what is presently the cutting edge at one of America's best hospitals and sharing some really great ideas with my doctor colleagues.

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