The Problem Orientated Systematic Approach Introduction

A core part of critical care training is learning to think like an intensivist. The conventional approach in clinical medicine of taking a history, carefully examining the patient, developing a differential diagnosis, ordering targeted tests and assigning treatment, requires modification in the critical care context. Patients have multisystem disease processes, all of which interact. The diagnosis on admission is often not the problem which keeps the patient in ICU. Intensivists create hierarchical lists of problems. Their primary role is as clinical problem solvers.
Constructing problem lists requires a systematic approach. It is essential that you carefully evaluate each of the body's organs or systems for new or resolved problems. Junior residents frequently miss important problems as hypokalemia, metabolic alkalosis, leukopenia and tachycardia, because of misguided concepts of what is normal and acceptable in intensive care. No physiological abnormality is acceptable. Some are difficult to reverse, but all will be associated with some form of adverse outcome.
As a critical care resident you are expected to behave as a physician. Granted,  the job entails large amounts of clerical, physical, emotional, diplomatic and psychosocial elements, but your main function is to be a clinician. You are there to find out what is wrong with a patient (why they require intensive care), and to develop treatment strategies. Too frequently residents regard themselves as data collecting servants for fellows and consultants,  who make the decisions. This is a rudimentary error. You don't need a medical degree to tell us that the patient has hypernatremia: you are there to determine that this is due to a significant free water deficit arising, for example, from recurrent episodes of diarrhea, which you plan to replace by......

Another mistake frequently made is to take for granted that the patient is in intensive care; this particularly refers to long stay patients. Prolonged admission to intensive care units is unacceptable. Every day when you are rounding on patients, you should ask "why is this patient still in intensive care." For any patient, the story of critical illness reads like an epic: thrown into the most awful place imaginable due to a primary problem, which resolves and then being recurrently beaten down by subsequent complications until the ultimate climax: the romantic ending, where the patient is wheeled out of the ICU (and into the sunset), or the Shakespearean tragedy, when all that is left is a dead shell.
Any good intensivist, on arriving day 1 to round in ICU, will try to determine at what point in the epic each patient lies:

• Why was this patient admitted to intensive care in the first place?
• What happened subsequently? What complications occurred?
• What chronic health problems does the patient have?
• Why is this patient still in intensive care? What are his problems?
• How are we addressing these problems?
• What is this patient’s physiologic reserve? Is this situation futile?

What follows is a detailed method for approaching critically ill patients, during pre-rounds, on rounds and writing clinical update notes.

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