Never talk to a resuscitator. In what cases are hospitalized in the intensive care unit Why are they in intensive care

What happens to a person in the intensive care unit

A person who is in intensive care may be conscious, or may be in a coma, including medication. With severe traumatic brain injury and increased intracranial pressure the patient is usually given barbiturates (that is, they are put into a state of barbituric coma) so that the brain finds resources for recovery - it takes too much energy to stay conscious.

Usually in the intensive care unit, patients lie without clothes. If a person is able to stand up, then they can give him a shirt. “In the intensive care unit, patients are connected to life support systems and tracking equipment (various monitors), - explains Elena Aleshchenko, head of the intensive care unit of the European Medical Center. - For medicines in one of the central blood vessels a catheter is placed. If the patient is not very heavy, then the catheter is placed in peripheral vein(for example, in a vein of the arm. - Note. ed.). If artificial ventilation of the lungs is required, then a tube is installed in the trachea, which is connected through a hose system to the apparatus. For feeding, a thin tube is inserted into the stomach - a probe. A catheter is inserted into the bladder to collect urine and record its amount. The patient can be tied to the bed with special soft ties so that he does not remove the catheters and sensors when excited.

The body is treated with fluid to prevent bedsores daily. They treat their ears, wash their hair, cut their nails - everything is as in normal life, except that hygiene procedures doing medical worker". But if the patient is conscious, they may be allowed to do it on their own.

To prevent bedsores, patients are regularly turned in bed. This is done every two hours. According to the Ministry of Health, in public hospitals, there should be two patients per nurse. However, this is almost never the case: there are usually more patients and fewer nurses. “Most often, nurses are overwhelmed,” says Olga Germanenko, director of the SMA Families charity foundation (spinal muscular atrophy), Alina's mother, who was diagnosed with this disease. - But even if they are not overloaded, sisterly hands are still always lacking. And if one of the patients becomes destabilized, then he will receive more attention at the expense of another patient. This means that the other one will be turned later, fed later, etc.”

Why are relatives not allowed into intensive care?

According to the law, both parents should be allowed to see children (it is generally allowed to stay together here), and relatives to adults (Article 6 323-FZ). This possibility in pediatric ICUs (intensive care unit) is also mentioned in two letters from the Ministry of Health (07/09/2014 and 06/21/2013), for some reason duplicating what is approved in federal law. But nevertheless, there is a classic set of reasons why relatives are refused to be allowed into intensive care: special sanitary conditions, lack of space, too much workload for staff, fear that a relative will do harm, start “pulling out the tubes”, “the patient is unconscious - what are you doing there will you do?”, “The internal rules of the hospital forbid.” It has long been clear that if the leadership wishes, none of these circumstances becomes an obstacle to the admission of relatives. All arguments and counterarguments are analyzed in detail in a study conducted by the Children's Palliative Foundation. For example, the story that you can bring terrible bacteria into the department does not look convincing, because the nosocomial flora has seen a lot of antibiotics, acquired resistance to them and has become much more dangerous than what you can bring from the street. Can a doctor be fired for violating hospital rules? "No. Exists Labor Code. It is he, and not local hospital orders, that regulates the interaction between the employer and the employee,” explains Denis Protsenko, chief specialist in anesthesiology and resuscitation of the Moscow Health Department.

“Often, doctors say: you create normal conditions for us, build spacious premises, then we will let them in,” says Karina Vartanova, director of the Children's Palliative Foundation. - But if you look at the departments where there is a permit, it turns out that this is not such a fundamental reason. If there is a management decision, then the conditions do not matter. The most important and difficult reason is mental attitudes, stereotypes, traditions. Neither doctors nor patients have an understanding that the main people in the hospital are the patient and his environment, so everything should be built around them.”

All uncomfortable moments that can actually interfere are removed by a clear formulation of the rules. “If you let everyone in at once, of course, it will be chaos,” says Denis Protsenko. - Therefore, in any case, you need to regulate. We in Pervaya Gradskaya start one by one, let us down and tell at the same time. If the relative is adequate, we leave him under the control of the nursing staff, we go for the next one. On the third or fourth day, you perfectly understand what kind of person this is, contact is established with him. Even then, you can leave them with the patient, because you have already explained everything to them about the tubes and devices for connecting the life support system.”

“Abroad, talk about admission to intensive care began about 60 years ago,” says Karina Vartanova. - So do not count on the fact that our healthcare will be inspired together and will do everything tomorrow. A forceful decision, an order, can spoil a lot. The decisions that are made in each hospital about whether or not to let in, as a rule, are a reflection of management's attitudes. There is a law. But the fact that it is not being implemented en masse is an indicator that both individual doctors and the system as a whole are not ready yet.”

Why is the presence of relatives 24 hours a day impossible even in the most democratic intensive care units? In the morning, various manipulations and hygiene procedures are actively carried out in the department. At this time the presence stranger highly undesirable. During the rounds and during the transfer of the shift, relatives should also not be present: this will at least violate medical secrecy. During resuscitation, relatives are asked to leave in any country in the world.

A resuscitator at one of the US university clinics, who did not want to be named, says that their patient is left without visitors only in rare cases: “In exceptional cases anyone’s access to the patient is limited - for example, if there is a danger to the patient’s life from visitors (usually these are situations of a criminal nature), if the patient is a prisoner and the state prohibits visits (for seriously ill patients, an exception is often made at the request of a doctor or nurse), if the patient has a suspected/confirmed diagnosis of a particularly dangerous infectious disease (the Ebola virus, for example) and, of course, if the patient himself asks that no one be allowed in.”

They try not to let children into adult intensive care either here or abroad.

What to do to get you into intensive care

“The very first step is to ask if it is possible to go to the intensive care unit,” says Olga Germanenko. A lot of people don't really ask. Most likely, it’s in their head that they can’t go to intensive care.” If you asked, and the doctor says that it’s impossible, that the department is closed, then you definitely shouldn’t make a fuss. “Conflict is always useless,” explains Karina Vartanova. “If you immediately start stomping your feet and shouting that I will rot you all here, I will complain, there will be no result.” And money doesn't solve the problem. “No matter how much we interview relatives, money does not change the situation at all,” says Karina Vartanova.

“It makes no sense to talk about admission with nurses or the doctor on duty. If the attending physician takes the position “not allowed”, you must behave calmly and confidently, try to negotiate, - says Olga Germanenko. - No need to threaten to appeal to the Ministry of Health. You calmly explain your position: “It will be easier for the child if I am there. I will help. Pipes don't scare me. You said that with the child - I can roughly imagine what I will see. I know the situation is difficult.' The doctor will not think that this is a hysterical mother who can pull out her tubes and yell at the nurses.

If you are denied at this level, where do you go next? “If the department is closed to relatives, communication with the head will not give anything,” says Denis Protsenko. - Therefore, it is necessary to go to the deputy chief physician for medical work. If he does not give the opportunity to visit, then go to the head doctor. In fact, that's where it ends." Olga Germanenko adds: “You need to ask the head physician for a written explanation of the reasons why they are not allowed in, and with this explanation go to the local health authorities, Insurance companies, the prosecutor's office, supervisory authorities - anywhere. But imagine how long it will take. It's a bureaucracy."

However, Lida Moniava, so to speak, is reassuring: “When a child lies in bed for a long time, mothers are already being let in. In almost all intensive care units, a couple of weeks after hospitalization, they begin to let in, gradually increasing the duration of the visit.

Director of the Department of Public Health and Communications of the Ministry of Health Oleg Salagay contact his insurance, which, in theory, is responsible for the quality of medical care and respect for the rights of the patient. However, as it turned out, companies do not have experience in solving similar situations. Moreover, not everyone is ready to support relatives (“Resuscitation is not created for dates, here they are fighting for human life, as long as there is at least some hope left. And no one should distract either doctors or patients from this struggle, who need to mobilize everything their strength in order to survive," one of the insurance companies told the Afisha Daily correspondent). The responses of some companies are full of confusion due to supposedly conflicting legislation, but nonetheless, someone is ready to "respond quickly."

When are there objective reasons not to let a relative into the ICU? If you are frankly ill and can infect others, if you are in a state of alcoholic or drug intoxication - in these cases you will rightly not be allowed into the department, no matter how hard you try.

“If there is quarantine in the hospital, then no certificate will help you get to the department,” explains Denis Protsenko.

How to understand that everything is in order

“If you are not allowed into intensive care, you will never know if everything is being done for your relative,” says Olga Germanenko. - A doctor can just give little information, but actually do everything that is needed. And someone, on the contrary, will paint the smallest details of your relative's treatment - what they did, what they are going to do, but in fact the patient will receive less treatment. Perhaps you can ask for a discharge epicrisis. But they won’t give it just like that - you need to say that you want to show it to a specific doctor.

It is generally accepted that the admission of relatives to the intensive care unit will complicate the life of the staff. However, in reality, this reduces the number of conflicts precisely on the basis of the quality of medical care. “Of course, parental presence is an additional quality control,” says Karina Vartanova. - If we take a situation when the child had no chance to survive (for example, he fell from the 12th floor), the parents were not allowed, and he died, then, of course, they will think that the doctors left something unfinished, overlooked. If they were allowed in, there would be no such thoughts, they would also thank the doctors for fighting to the end.”

“If you suspect that your relative is being treated poorly, invite a consultant,” suggests Denis Protsenko. “For a self-respecting, self-confident doctor, a second opinion is absolutely normal.”

"At rare diseases only narrow specialists know that some drugs cannot be prescribed, some can, but you need to control such and such indicators, so sometimes resuscitators themselves actually need consultants, explains Olga Germanenko. - True, the choice of a specialist must be approached carefully so that he does not talk down to local doctors and does not intimidate you: “You will be killed here. There are such stupid things here.

“When you tell your doctor that you want a second opinion, it often sounds something like this: you are treating the wrong way, we see that the condition is getting worse, so we want to bring a consultant who will teach you how to treat you properly,” says the psychiatrist, head of the Clinic of Psychiatry and psychotherapy at the European Medical Center Natalia Rivkina. - It is better to convey such an idea: it is very important for us to understand all the possibilities that exist. We are ready to use all our resources to help. We would like to ask you to get a second opinion. We know that you are our main doctor, we have no plan to go elsewhere. But it is important for us to understand that we are doing everything that is necessary. We have an idea who we would like to contact. Maybe you have other suggestions. This kind of conversation can be more comfortable for the doctor. You just need to rehearse, write down the wording. No need to go with the fear that you are breaking some rules. It is your right to get a second opinion.

How to help

“Doctors are forbidden to say that they do not have any drugs, consumables,” explains Lida Moniava, deputy director of the Children's Hospice House with a Lighthouse. - And out of fear they can convince you that they have everything, although in reality it will not be so. If the doctor voices the needs, thank him very much. Relatives are not required to bring everything, but thanks to those doctors who are not afraid to speak.” The problem is that it is considered: if something is missing in the hospital, then the management does not know how to allocate resources. And relatives do not always understand the position of the doctor, so they can complain to the Department of Health or the Ministry of Health: “We have free medicine, but they force me to buy medicines, return the money, here are the checks.” Fearing such consequences, ICU staff may even use their own money to buy good drugs and consumables. Therefore, try to convince the doctor that you are ready to purchase everything you need, and you have no complaints about this.

Spinal surgeon Alexei Kashcheev also ask the attending physician whether it will be useful for current state the patient to hire an individual nurse.

How to behave in intensive care

If you are allowed into the intensive care unit, it is important to remember that there are rules (whether written or spoken by the doctor) and they are made so that doctors can do their job.

Even in those intensive care units where you can come even in outerwear, there is a rule: treat your hands with an antiseptic before visiting a patient. In other hospitals (including those in the West) they may be asked to wear shoe covers, a gown, not to wear woolen clothes and not to walk with loose hair. By the way, remember that visiting the intensive care unit, you expose yourself to certain risks. First of all, the risk of infection with local bacteria resistant to many antibiotics.

You must imagine where you are going and what you will see

If you have a tantrum, faint or feel sick, you will attract the attention of the intensive care unit staff, which is potentially dangerous. There are other subtle moments that Denis Protsenko talks about: “I know cases when a guy came to his girlfriend, saw her disfigured face and never returned. It happened the other way around: the girls could not cope with such a spectacle. In my experience, it is not uncommon for relatives who volunteer to help quickly disappear. Just imagine: you turn your husband on his side, and he has gases or a bowel movement. Patients have vomiting, involuntary urination - are you sure you will react normally to this?

You can't cry in the ICU

“Usually, the first visits to the department by relatives are the most difficult,” says Elena Aleshchenko. “It is very difficult to prepare and not cry,” says Karina Vartanova. - It helps someone to take a deep breath, someone is better off crying on the sidelines, you need to talk to someone, someone should not even be touched. You can learn to be calm in the intensive care unit if you remember that the patient's condition largely depends on your calmness. Some hospitals employ clinical psychologists to help manage emotions.

Ask how you can help and don't be selfish

“A mother can change a diaper, turn it over, wash it, give a massage - all this is especially necessary for heavy children,” says Olga Germanenko. “It is clear that nurses, with the current workload, cannot do all this to the extent that is needed.”

Being in the intensive care unit around the clock is not only pointless, but also harmful

“You can visit us at any time, you can stay with the patient for 24 hours in a row,” says Elena Aleshchenko. Whether it is necessary is another matter. People then themselves understand that this is useless, that they are doing it more for themselves. When a person is in intensive care, he is sick, he also needs to rest. Olga Germanenko confirms this idea: “Sleeping in the intensive care unit does not make much sense. In fact, no one will sit for more than four hours in a row (unless, of course, we are talking about a dying child). After all, everyone has their own things to do." A day in intensive care is hard not only physically, but also mentally: “What will happen to a relative after 24 hours in the intensive care unit? - says Denis Protsenko. - Corpses will be taken out several times past him, he will become a witness cardiopulmonary resuscitation, suddenly developed psychosis in another patient. I'm not sure that the relative will survive this calmly.

Negotiate with other relatives

“In one of the intensive care units where I ended up with my daughter, the children were in boxes for two,” says Olga Germanenko. - That is, if a nurse comes, and there are two more parents, then do not turn around. And her presence may be needed at any time. So we agreed to come to different time. And the children were always supervised.

Respect the wishes of the patient

“When a person regains consciousness, the first question we ask him is: do you want to see relatives? There are situations when the answer is “no,” says Denis Protsenko. “Many clinics around the world have such programs for natural dying, when a patient and his family discuss how he will die,” says Natalia Rivkina. - This happens a month and a half before his death. The task is for a person to die with dignity and in the way he would like. There are parents who do not want their children to see the process of dying. There are wives who do not want their husbands to see the process of dying. Perhaps they will look ugly. There are those who want to be with their loved ones at the time of death. We must respect all these decisions. If a person wants to make the transition himself, this does not mean that he does not want to see loved ones. It means he wants to protect you. You shouldn't force your choice on him."

Respect other patients

“Speak to your child as quietly as possible, do not turn on loud music, do not use a mobile phone in the department. If your child is conscious, then he can watch cartoons or listen to music using a tablet and headphones so as not to disturb others. Do not use strong-smelling perfume, ”writes Nadezhda Pashchenko in, published by the Children's Palliative Foundation,“ Together with Mom.

Do not conflict with doctors and nurses

“The work of the ICU staff is quite difficult, very intensive, energy-consuming,” Yulia Logunova writes in the same brochure. - This must be understood. And in no case should you conflict with someone, even if you see a negative attitude, it’s better to keep silent, it’s better to take a break in communicating with this person. And if the conversation turns to raised voices, the following phrase always works: I thought that you and I had one goal - to save my child, to help him, so let's act together. I have not had a single case when it did not work and did not transfer the conversation to another plane.

How to talk to a doctor

Firstly, it is advisable to talk with the attending physician, and not with the person on duty, who changes every day. He will definitely have more information. That is why in those intensive care units in which the time for visiting and communicating with the doctor is limited, it falls on uncomfortable hours - from 14.00 to 16.00: at 15.45 the shift of the attending physician ends, and until 14.00 he will most likely be busy with patients. It is not worth discussing treatment and prognosis with nurses. “Nurses carry out doctor's orders,” writes Nadezhda Pashchenko in the booklet Together with Mom. “It’s pointless to ask them about what exactly they give your child, since the nurse cannot say anything about the child’s condition and the essence of medical prescriptions without the doctor’s permission.”

Abroad and in paid medical centers, you can get information by phone: when processing papers, you will approve a code word for this. In public hospitals, in rare cases, doctors can give their mobile.

“In a situation where someone close is in intensive care, especially when it is associated with a sudden onset of the disease, relatives may be in a state of acute reaction to stress. In these states people
experiencing confusion, difficulty concentrating, forgetfulness - it is difficult for them to get together, ask the right question, - explains Natalia Rivkina. - But doctors may simply not physically have time to build a dialogue with relatives who have such difficulties. I encourage family members to write down questions throughout the day to prepare for their appointment with the doctor.

If you ask "How is he/she?", the doctor may give two responses: "Everything is good" or "Everything is bad." This is unproductive. Therefore, it is necessary to formulate clearer questions: what is the patient's condition at this moment, what symptoms does he have, what are his plans for treatment. Unfortunately, in Russia there is still a paternalistic approach to communication with the patient and relatives. It is believed that they do not need to have information about the treatment. “You are not a doctor”, “You still will not understand anything.” Relatives should always be aware that by law they must be informed about the treatment being carried out. They have the right to insist on it.

Doctors react very nervously when frightened relatives come and say: “What are you doing? We read on the internet that this drug kills.” It is better to ask this question like this: “Tell me, please, what side effects have you seen from this medicine?” If the doctor does not want to answer this question, ask: “What do you think about this side effect? That way you don't attack or criticize. Any criticism causes resistance in people.

A common question in intensive care, especially when it comes to cancer patients: "Is that all?" or “How long does he/she have to live?” This is a question that has no answer. A properly trained doctor will answer it. A doctor who has no time will say, "God only knows." Therefore, I always teach relatives to ask this question in this way: “What is the worst and best prognosis?” or “What is the minimum and maximum life expectancy according to the statistics of such conditions?”.

Sometimes I insist that people leave and rest. No matter how wild and cynical it may be. If it is obvious that they cannot do anything for the patient now, they will not be allowed in one hundred percent, they cannot make any decisions, influence the process, then you can be distracted. Many people are sure that at this moment they should grieve. Going out to drink tea with friends in a cafe is to break the whole logic of the universe. They are so fixated on the mountain that they reject any resources that could support them. When it comes to a child, any mother will say, “How can I afford this?” or "I'll sit there and think about the baby." Sit and think. At least you will do it in a cafe, and not in the intensive care corridor.

Very often, in situations where one of the relatives is in intensive care, people become isolated and stop sharing their experiences. They try so hard to protect each other that at some point they just lose each other. People should speak openly. This is a very important step for the future. Children are a special category. Unfortunately, very often they hide from children that one of the parents is in intensive care. This situation is very bad for their future. Proven fact: the later children learn the truth, the higher the risk of severe post-stress disorders. If we want to protect a child, we must talk to him. This should be done by relatives, not a psychologist. But it is better that they get professional support first. Communicate in a comfortable environment. It should be understood that children of 4-6 years old are much more adequate to the issues of death and dying than adults. They at this time have a fairly clear philosophy regarding what death and dying are. Later, many different stigmas and myths are superimposed on this, and we are already starting to relate to this in a different way. There is another problem: adults try not to show their emotions, while children feel and experience this experience as a rejection.

It is also important to understand that different family members different variants adaptation to stress and different need for support. We react the way we react. This is a very individual thing. There is no one correct response to such an event. There are people who need to be stroked on the head, and there are people who get together and say: "Everything will be fine." Now imagine that they are husband and wife. The wife understands that a catastrophe is happening, and the husband is sure that you need to clench your teeth and not cry. As a result, when the wife starts crying, he says, "Stop crying." And she is sure that he is soulless. We often see family conflicts related to this. In this case, the woman becomes isolated, and it seems to the man that she simply does not want to fight. Or vice versa. And it is very important to explain to family members that everyone needs different support in such a situation, and to encourage them to give each other the support that everyone needs.

When people do not allow themselves to cry and kind of squeeze their emotions, this is called dissociation. Many relatives described this to me: in intensive care, they seem to see themselves from the outside, and they are horrified by the fact that they do not experience any emotions - no love, no fear, no tenderness. They are like robots doing what needs to be done. And it scares them. It is important to explain to them that it is absolutely normal reaction. But we must remember that these people have a higher risk of delayed reactions. Expect that after 3-4 weeks you will have disturbed sleep, there will be anxiety attacks, maybe even panic.

Where to look for information

“I always strongly advise relatives and patients to go to the official websites of clinics,” says Natalya Rivkina. - But if you speak English, it's much easier for you. For example, the Mayo Clinic website has great text across the board. There are very few such texts in Russian. I ask relatives not to enter the Russian-language patient forums. Sometimes there you can get misleading information that is not always related to reality.

Basic information in English about what happens in the intensive care unit can be found here:.

What to expect

“Within a few days after the patient is in intensive care, the doctor will tell you how long the person will stay in the ICU,” says Denis Protsenko.

After resuscitation, as soon as the need for intensive observation is no longer necessary and the patient can breathe on his own, he will most likely be transferred to a regular ward. If it is known for sure that a person needs lifelong artificial ventilation lungs (ventilator), but in general he does not require the help of resuscitators, he can be discharged home with a ventilator. You can buy it only at your own expense or at the expense of philanthropists (from the state

Photo from pmd74.ru

I'll tell you like a doctor

The story of Tatyana Listova, published in Novye Izvestia under a catchy cap, is really impressive. It implements all the fears that haunt everyone who thinks about the possibility of being in intensive care: here are just angry nurses and doctors who hate their job; and killer nurses injecting the wrong medicine; and lying naked patients; and screaming patients with various diseases... Well, here, except that no one was gutted for organs, and so - Horror! Horror! Horror!, as they say in a well-known anecdote.

Of course, one can recall that it is in the Botkin hospital that patients with strokes are kept separately from others. That is, for example, a schizophrenic can, in principle, get into this department - they also have strokes, and a patient with vascular dementia against the background of dyscirculatory encephalopathy (the same “screaming old woman”), but the guy after the accident is unlikely. And the fact that the guy is conscious, but silent - it is possible that he has not purely motor, but sensorimotor aphasia, and he still does not understand the doctor's words about his lack of prospects.

Yes, and the transient ischemic attack that Tatyana had is not a harmless condition, but what was previously called a “microstroke”. Those. such a breach cerebral circulation, which quickly recovered during treatment (with these same killer doctors, by the way), but very often changes the psyche - for example, the patient notices only the bad and is constantly irritated ...

However, the discussion of the text showed that people actually saw this in many intensive care units.

Let not everywhere in such quantity, but a lot - yes, it occurs, and at all “not in some places with us sometimes”, but very often. Therefore, it would be nice to understand what is really going on behind closed doors of intensive care units.

Why is everyone naked?

So, the first thing that actually exists is that people in intensive care are naked and, in most cases, without division into men and women. And this is not only in Russia, it is the same everywhere. Why naked - I thought at first, and there is no need to explain. It turned out that not everyone understands, I explain: a number of patients have various stitches, stoma, wounds, catheters and drains, etc., and clothing will interfere with manipulations with them, and in some cases - and be a hotbed of infection (on it secretions will accumulate). In addition, if you need to carry out urgent resuscitation, the clothes will interfere, and there is no time to take them off. Therefore, sheets, which, of course, should not be on the floor.

But being in the wards of both sexes together is connected with something else. Resuscitation - the department is not planned, but emergency; Admissions there are quite spontaneous, and the number of beds is limited.

And if we divide the wards in half in a standard 12-bed department, then it may well be that 11 men and 1 woman will enter. And how to be?

And in ordinary (non-departmental and non-commercial institutions - yes, in the same Botkinskaya, for example) it can be like this: 12 men and 8 women - our departments almost officially work with 80% overload. And it happens that with 120% ...

Of course, in departments such as cardioreanimation, where the bulk of patients need not so much resuscitation treatment as observation, if the department is relatively new and has many wards, then men and women are tried to be placed separately. But - alas! Such an opportunity is not always and everywhere.

Previously, screens were widely used, but due to the fact that the number of equipment per patient has increased, and the number of patients entering intensive care has also increased (for example, in my youth, patients with stroke were usually not placed in intensive care, but now they are placed in 6 almost all hours), then there is simply nowhere to put the screens - they will interfere with the staff and move around and observe the patients.

Why doctors "bark"

The second is the human factor. Yes, the staff in intensive care units are not fluffy bunnies. These are the people who work in the most difficult field of medicine- and with the most severe (not only by the nature of the disease, but also physically) sick, and they constantly see death (and this does not go away without a trace - a person needs psychological protection), and they work for a small salary.

Of course, the hospital is not the ratio of the hospital, but the dental assistant nurse in the commercial office (whose duties include give-and-fetch) gets more than the intensive care nurse.

At the same time, I do not believe Tatyana Listova that the staff told her (a stroke patient) how much they hate their job. I have been working as a resuscitator for more than 30 years, but I have met only a few of them. They get very tired - yes.

The question of mobile phones and other gadgets always comes up, but in most departments they are not allowed to be kept.

And not only because you can make a video, although this is also - not everyone will be happy when a neighbor posts on YouTube how he was given an enema.

And also because in the process of moving the patient everything can be lost (and valuables too, so it’s better not to try to carry them into the intensive care unit). And besides, the patient himself may have a temporary mental disorder, and he, for example, will eat his phone. So, first of all, it is about taking care of patients.

Of course, among doctors there are boors, and unscrupulous workers, and just fools - but they are in any specialty.

However, of course, the main problem of intensive care units is the staff and salary.

In the West (in different countries in different ways, but the trend is exactly the same) for each patient in the intensive care unit, there are one or two actually ward sisters, plus an older shift nurse, plus various narrow specialists with a secondary education (respiratory technician, postural drainage massage therapist, etc.) plus a care specialist (our nurse), plus porters, plus a room cleaner ..

And we even have current order- 1 sister for 3 patients (Order of the Ministry of Health of the Russian Federation dated November 15, 2012 No. 919n “On approval of the Procedure for providing medical care to the adult population in the profile “anesthesiology and resuscitation”, reducing the burden on the sister to two patients did not come into force) , but in reality - the load is much greater. The salary, which is already low, practically does not depend on the load. This is where nurses and doctors come in. This is bad. But, unfortunately, this is provoked by our healthcare system.

What about the patient and his relatives?

Now there is an order of the Ministry of Health on the admission of relatives to intensive care. In Moscow, under the leadership of the Chief Anesthesiologist-Resuscitator of the city D.N. Protsenko, intensive care units are becoming more and more “patient-oriented”, although, of course, in different hospitals this process is different.

And, of course, relatives should try to establish contact with nurses, doctors, and the head of the department.

The main thing is for the staff to understand that the patient is needed by their loved ones - even if he is 100 years old.

Of course, it is necessary to raise questions before the authorities about increasing allocations for healthcare, reducing the burden on staff and raising the salaries of doctors - then the demand will be higher.

I will add as a priest

Hieromonk Feodorit Senchukov, resuscitator. Photo from pmd74.ru

Well, and most importantly, what should not be forgotten is the help of God. Both the patients themselves and their relatives should prayerfully turn to the Lord, do not forget about the saving sacraments - then the inevitable hardships of being in intensive care will be endured much easier.

Intensive (emergency) therapy is a way to treat diseases that threaten life. Resuscitation is the process of restoring functions that are partially lost or blocked as a result of an illness. These types of treatment allow you to establish constant control over the restoration of functions and intervene in the process in case of rapid disturbances in the functioning of organs and systems. In general, resuscitation and intensive care are the most effective and the last methods available today to prevent the development of a fatal outcome in severe (life-threatening) diseases, their complications, and injuries.

Basic concepts

Intensive care is a round-the-clock treatment that requires fluid infusions or detoxification methods with constant monitoring of vital signs. They are determined through blood tests and biological fluids, which are often repeated to quickly track the deterioration and improvement of the somatic functions of the patient's body. The second method of control is monitoring, which is implemented in hardware by using heart monitors, gas analyzers, an electroencephalograph and other standard equipment.

Resuscitation is the process of using medical and hardware methods to bring the body back to life if it occurs. If the patient is in a state that implies a threat to life arising from a disease or its complication, then intensive therapy is carried out to stabilize it. If the patient is in a state clinical death and will not live without an early restoration of lost functions, then the process of their compensation and return is called resuscitation.

The resuscitator deals with these issues. This is a narrow specialist, whose place of work is the intensive care unit and intensive care unit. Most often, there are no doctors with the only profession of an resuscitator, since a specialist receives a diploma in an anesthesiologist and resuscitator. At the place of work, depending on the profile of the institution, he can hold three types of positions: "anaesthesiologist-resuscitator", as well as separately "resuscitator" or "anesthesiologist".

Doctor in intensive care unit

An intensive care physician is an anesthesiologist-resuscitator. He deals with the choice of the type of anesthesia in preoperative patients and monitoring their condition after surgery. Such a specialist works in any multidisciplinary medical center(more often regional or district), and the department is called OITR. There may be patients whose functions are compensated, but monitoring of vital signs is required. In addition, patients with life threatening injuries and diseases, as well as their complications. Postoperative patients can similarly be observed in the intensive care unit by an anesthesiologist-resuscitator.

Resuscitator

The resuscitator deals only with the restoration of vital functions, and often his place of work is an ambulance station or substation. With access to the equipment that comes with a resuscitation ambulance, he can resuscitate a patient on the road, which is useful in all situations related to disaster medicine. Most often, the resuscitator does not deal with intensive care in the intensive care unit, but establishes control of the patient's vital functions in the ambulance. That is, it is engaged in drug treatment and hardware control of the functions of a patient with a threat

Anesthesiologist

An anesthesiologist is an example of a specialist position in a narrow-profile medical center, for example, in an oncology dispensary or in a perinatal center. Here, the main work of a specialist is planning the type of anesthesia for patients who are to be transferred. surgical interventions. In the case of a perinatal center, the task of the anesthesiologist is to select the type of anesthesia for patients who will undergo C-section. It is important that intensive care for children is also carried out in this center. However, the intensive care and intensive care units for patients and for newborns are structurally separated. Neonatologists work in the intensive care unit for children (newborns), and an anesthesiologist-resuscitator serves adults.

OITR of surgical hospitals

The resuscitation and intensive care unit in hospitals with a surgical bias is planned depending on the number of patients who require intervention and the severity of operations. With interventions in oncological dispensaries, the average time spent by a patient in the ICU is higher than in general surgical ones. Intensive care here takes more time, since important anatomical structures are inevitably damaged during operations.

If we consider oncosurgery, then the vast majority of interventions are characterized by high trauma and a large volume of resected structures. This requires a long time for the recovery of the patient, since after the operation there is still a risk of deterioration in health and even death from a number of factors. Here, prevention of complications of anesthesia or intervention, life support and replenishment of blood volume, part of which is inevitably lost during the intervention, are important. These tasks are most important during any postoperative rehabilitation.

OITR of cardiological hospitals

Cardiology and therapeutic hospitals are distinguished by the fact that there are both compensated patients without threats to life, and unstable patients. They need to be monitored and maintained. In the case of diseases cardiology profile Myocardial infarction with its complications in the form of cardiogenic shock or sudden cardiac death requires the closest attention. Intensive therapy for myocardial infarction can reduce the risk of death in the short term, limit the extent of the lesion by restoring the patency of the infarct-related artery, and improve the prognosis for the patient.

According to the protocols of the Ministry of Health and international recommendations, in acute coronary pathology requires the patient to be admitted to the intensive care unit for urgent action. Assistance is provided by an ambulance officer at the stage of delivery, after which restoration of patency is required coronary arteries that are occluded by a thrombus. Then the resuscitator is engaged in the treatment of the patient until stabilization: intensive therapy, drug treatment, hardware and laboratory monitoring of the condition are carried out.

In the CITR of a cardiological profile, where surgical operations on the vessels or valves of the heart, the task of separation is early postoperative rehabilitation and status tracking. These operations are highly traumatic, which are accompanied by a long period of recovery and adaptation. At the same time, there is always a high probability of thrombosis of a vascular shunt or stand, an implanted artificial or natural valve.

RITR equipment

Resuscitation and intensive care are branches of practical medicine that are aimed at eliminating threats to a patient's life. These events are held in a specialized department, which is well equipped. It is considered the most technologically advanced, because the functions of the patient's body always need hardware and laboratory control. Moreover, intensive care implies the establishment of a constant or frequent

Principles of treatment in the NICU

In traditional departments, where patients are not threatened with death from the disease or its complications in the short term, an infusion drip system is used for this purpose. In RITR, it is often replaced by infusion pumps. This equipment allows you to continuously administer a certain dose of a substance without having to puncture a vein every time a drug is required. Also, the infusomat allows you to enter medicines continuously for a day or more.

Modern principles of intensive care of diseases and emergency conditions already established and are as follows:

the first goal of treatment is to stabilize the patient and attempt a detailed diagnostic search;
determination of the underlying disease, which provokes deterioration and affects well-being, bringing a probable lethal outcome closer;
treatment of the underlying disease, stabilization of the condition through symptomatic therapy;
elimination of life-threatening conditions and symptoms;
implementation of laboratory and instrumental control of the patient's condition;
transfer of the patient to the specialized department after stabilization of the condition and elimination of life-threatening factors.

Laboratory and instrumental control

Monitoring the patient's condition is based on the evaluation of three information sources. The first one is a questioning of the patient, the establishment of complaints, the clarification of the dynamics of well-being. The second is data laboratory research performed before admission and during treatment, comparison of test results. The third source is information obtained through instrumental research. Also, this type of source of information about the well-being and condition of the patient includes systems for monitoring the pulse, oxygenation of blood, frequency and rhythm of cardiac activity, indicator blood pressure, brain activity.

Anesthesia and special equipment

Such branches of practical medicine as anesthesiology and intensive care are inextricably linked. Specialists who work in these areas have diplomas with the wording "anesthesiologist-resuscitator". This means that the same specialist can deal with issues of anesthesiology, resuscitation and intensive care. Moreover, this means that in order to meet the needs of multidisciplinary healthcare institutions, including inpatient departments surgical and therapeutic bias, one OITR is enough. It is equipped with equipment for resuscitation, treatment and anesthesia before surgery.

Resuscitation and intensive care require a monophasic (or biphasic) defibrillator or cardioverter-defibrillator, an electrocardiograph, a heart-lung machine system (if required by a particular healthcare facility), sensors and analyzer systems necessary to monitor heart and brain activity. It is also important to have infusion pumps necessary for setting up systems for continuous infusion of drugs.

Anesthesiology requires the availability of equipment for the delivery of inhalation anesthesia. These are closed or semi-open systems, through which the anesthetic mixture is delivered to the lungs. This allows you to establish endotracheal or endobronchial anesthesia. It is important that the needs of anesthesiology require laryngoscopes and endotracheal (or endobronchial) tubes, catheters for Bladder and catheters for puncture of central and peripheral veins. The same equipment is required for intensive care.

OITR perinatal centers

Perinatal centers are health care facilities where childbirth takes place, which can potentially lead to complications. Women who suffer from miscarriage or have potentially harmful health in childbirth should be sent here. Also, there should be women with pathologies of pregnancy, requiring early delivery and nursing of the newborn. Neonatal intensive care is one of the tasks of such centers, along with the provision of anesthetic care for patients who will undergo surgery.

Instrumentation for OITR perinatal centers

The intensive care unit of the perinatal center is equipped depending on the planned number of patients. This requires anesthesia systems and resuscitation equipment, the list of which is indicated above. At the same time, OITR perinatal centers They also have neonatology departments. They must have special equipment. First, adult devices artificial respiration and circulation is not suitable for bodies which are minimal.

Today, neonatology departments are engaged in nursing newborns weighing 500 grams, who were born at the 27th week of pregnancy. In addition, a special need is needed because infants born much earlier than the due date require the appointment of surfactant preparations. It's costly medicinal substances, without which nursing is impossible, since the newborn appears with developed lungs, but without surfactant. This substance does not allow the alveoli of the lungs to subside, which underlies the process of effective external respiration.

Features of the organization of the work of the OETR

The CITR works around the clock, and the doctor is on duty seven days a week. This is due to the impossibility of turning off the equipment in the case when it is responsible for the life support of a particular patient. Depending on the number of patients and the load on the department, the bed fund is formed. Each bed must also be equipped with monitors. It is allowed to have less than the number of beds, the number of ventilators, monitors and sensors.

The department, which is designed for 6 patients, employs 2-3 resuscitator-anesthesiologists. They need to change on the second day after 24 hours of duty. This allows you to monitor the patient around the clock and on weekends, when the observation of patients in standard departments is carried out only by the doctor on duty. An anesthesiologist-resuscitator should monitor patients who are in the ICU. He is also obliged to take part in consultations and provide assistance to patients of general somatic departments up to hospitalization in the ICU.

The anesthesiologist-resuscitator is assisted in the work by an intensive care nurse and an orderly. The number of rates is calculated depending on the number of patients. For 6 beds, one doctor, two nurses and one orderly are required. This number of employees must be present at each duty during the day. Then the staff is replaced by another shift, and it, in turn, by the third.

Patients are hospitalized in the intensive care unit and intensive care:

1) with acute hemodynamic disorders ( of cardio-vascular system) of various etiologies (such as acute cardiovascular failure(SSN), traumatic shock, hypovolemic shock- shock with a large loss of body fluid, cardiogenic shock, etc.);

2) with acute respiratory disorders (respiratory failure);

3) with other disorders of vital functions important organs and systems (central nervous system, internal organs and etc.);

4) with acute disorders metabolic processes in the body, etc.;

5) with severe poisoning;

6) in the recovery period after clinical death, after surgical interventions, which entailed dysfunction of vital organs, or with a real threat of their development.

The main methods of treatment in the intensive care unit will be outlined below using the example of the treatment of acute respiratory failure.

Most common causes development of acute respiratory failure are:

1) trauma chest and respiratory organs, which is accompanied by a fracture of the ribs, pneumo- or hemothorax (entry into the pleural cavity of air or blood, respectively) and a violation of the position and mobility of the diaphragm;

2) a disorder of the central (at the level of the brain) regulation of respiration, which occurs when traumatic injury and diseases of the brain (for example, with encephalitis);

3) violation of patency respiratory tract(for example, when foreign bodies get in);

4) a decrease in the working lung surface, the cause of which may be either atelectasis (collapse) of the lung;

5) circulatory disorders in the lungs (due to the development of the so-called shock lung, the ingress of a blood clot into pulmonary arteries, pulmonary edema).

To determine the causes of the development of acute respiratory failure, an x-ray of the chest organs is performed. To determine the degree oxygen starvation and the accumulation of carbon dioxide in the blood by a special apparatus - a gas analyzer - they study the gas composition of the blood. Until the cause of respiratory failure is identified, the patient is strictly forbidden to give sleeping pills or narcotic drugs.

If the patient is diagnosed, then drainage is performed to treat respiratory failure pleural cavity, which is the introduction into the pleural cavity in the region of the II intercostal space of a rubber or silicone tube, which is connected to the suction. When it accumulates a large number of fluid in the pleural cavity (with hemo- or hydrothorax, pleural empyema), it is removed by pleural puncture through a needle (see description above).

In case of violation of the patency of the upper respiratory tract, an urgent examination is performed oral cavity and larynx using a laryngoscope and free them from vomit and foreign bodies. When an obstacle is located below the glottis, to eliminate it, bronchoscopy is performed with a special apparatus - a fibrobronchoscope. With the help of this device, foreign bodies or pathological fluids (blood, pus, food masses) are removed. Then produce bronchial lavage (lavage). It is used when it is impossible to simply suck out the contents of the bronchi due to the presence of dense mucopurulent masses in their lumen (for example, in severe asthmatic conditions).

Purification of the respiratory tract from mucus and pus is also carried out by sucking them with a sterile catheter, which is inserted in turn into the right and left bronchus through an endotracheal tube through the mouth or nose. If it is impossible to apply the listed methods, then a tracheostomy is done to restore the patency of the airways and cleanse the bronchi.

Treatment of acute respiratory failure with paresis or paralysis of the intestine, when the position and mobility of the diaphragm are disturbed as a result, consists in inserting a probe into the stomach to remove its contents, while the patient is given an elevated position.

Of course, in addition to the above, the patient undergoes drug therapy. To achieve a quick effect, drugs are injected into the subclavian vein, for which it is catheterized (see above). In addition to drug treatment, the patient must undergo oxygen therapy, in which a constant high blood pressure and increased end-expiratory resistance. For this purpose, various devices are used for an oxygen inhaler or an anesthetic-respiratory apparatus.

When acute respiratory failure is caused or exacerbated by severe pain when breathing (for example, with chest trauma or acute surgical diseases of the organs abdominal cavity), painkillers are used only after finding out the cause of the pathology. With an anesthetic purpose, a blockade of the intercostal nerves is performed. If there is a fracture of the ribs, then perform novocaine blockade at the site of the fracture or near the spine.

When breathing stops or in very severe forms of respiratory failure, the patient is given mechanical ventilation.

The most effective way to carry out mechanical ventilation is with the help of special devices, which can be both imported and domestically produced.

Tracheal intubation is used to transfer to machine breathing, as well as to maintain airway patency during mechanical ventilation. For this purpose, special devices are used - a laryngoscope with a lighting device, a set of plastic tubes for intubation with inflatable cuffs and a special adapter (connector) for connecting the endotracheal tube to the ventilator.

During tracheal intubation, the patient is placed on his back, then, having brought the blade of the laryngoscope into his mouth and lifting the epiglottis with it, an endotracheal tube is inserted into the glottis. After making sure that the tube is in the correct position, it is attached with adhesive tape to the skin of the cheek, after which the tube is connected to the ventilator through the connector.

In the absence of ventilators, the procedure is carried out using an Ambu bag or by mouth-to-tube method.

Resuscitation is one of the most mysterious departments in the hospital. You can drive through the whole city to end up in front of a closed door, and even if you insist, they will not let you into the department. “The condition is stable. You can't go inside. We do all the care ourselves. Goodbye". All. What's going on behind this door? Why can you not be allowed into the department, although you are required to? Here are a few reasons (and life situations).

The patient has just arrived

The patient was admitted by ambulance, surrounded by two doctors, three nurses, a nurse. It is necessary to shift it from the wheelchair to the bed, connect the sensors for pulse, pressure, saturation. Organize venous access, collect blood and urine for analysis. Someone collects droppers and prepares preparations for injection. Someone assists the doctor - tracheal intubation is performed, because the patient cannot breathe on his own.

At this time, the doorbell rings. The resuscitation workers have keys, so this is a relative. It is impossible to let him in now, the doctor cannot talk to him, because helping the patient is more important. But relatives can insist on a visit, besides, they immediately want to know the diagnosis, get information about the condition and “how long he will lie here,” although, let me remind you, the person has just been delivered and nothing is really known yet.

New patients arrived

This is the most common reason. The fact is that resuscitation is not just a department. There is no strict visiting schedule. Rather, he is. But if in the interval, say, from twelve to one, when it is allowed to visit patients, a seriously ill patient arrives - no one, alas, will allow you to enter the ward. During the admission of patients, manipulations, etc., it is forbidden for outsiders to be present in the ward.

Other patients in the room

Yes, you need to remember that apart from your loved one Other patients may also be in the room. Lie down, as it should be in intensive care, without clothes. And not everyone will be pleased if strangers walk past them. In the United States - this country is often cited as an example when they talk about organizing visits to intensive care units - there are separate wards for patients, and there are even sleeping places for relatives. It is not so in Russia - there are several people in one ward.

The patient is recovering after a planned operation

Moreover, some patients, being in an unpresentable form, do not even want to see their relatives. For example, after planned operation The patient lies on the first day in intensive care. Lying naked. He has a sore throat after a ventilator tube. I have a stomachache. The bed is stained with blood, because the bandage is leaking a little. It hurts, but now they have given an injection and he is falling asleep. Two days later he will be transferred to general department, soon he will cheerfully run along the corridor and discuss his health with his family, and now he only wants to sleep. And he doesn't need any visits.

The relative of the patient himself is not ready to visit

Another situation. The person lies down for a long time. The diagnosis is serious. A relative is coming and wants to see you. He is skipped. After talking, the relative goes out of the ward into the corridor, goes to the door, but, before reaching, he faints right into the hands of the nurse on duty. Well, if it is not very tall and large, and there is a trestle bed nearby, on which they will have time to lay it ...

Unaccustomed people are afraid of foreign objects sticking out of the patient: catheters, probes, drains. Often the departments smell bad, and any visitor can feel bad. Especially if doctors see a relative in a clearly unbalanced state - such a visit can be denied with a high probability.

If there are no objective reasons preventing the visit, the relative will be admitted to the ward. Sometimes relatives help a lot - wash, process, re-lay. It's real and needed help because there is never enough staff. Such people are always allowed to see patients. And such people always wait patiently outside the door if manipulation is carried out in the hall and outsiders cannot enter.

You need to be prepared to visit the intensive care unit. Do not be afraid of the sight of your relative or his neighbors in the ward. Don't wrinkle your nose bad smell. Do not cry with pity - this can be done outside the door, but here, next to the patient, you must support him, not he you. Do not interfere with the staff and leave the room at the first request. If you were not allowed in, it is best to calmly wait outside the door until the doctor is free and you can ask him all your questions. The intensive care unit is an emergency department, and in emergencies there is not always time for talking.

Anastasia Larina

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