The tickbox revolution in intensive care

The New Yorker has a completely gripping article on intensive care medicine that while fascinating in its own right, is also interesting as it contains an amazing account of a how a three year old girl was resuscitated and recovered brain function after near drowning, and stresses the importance of behavioural interventions in high-tech medicine.

The article is essentially about an incredibly simple idea that is vastly reducing infection rates and improving survival rates in intensive care – using checklists to make sure that each step of complex procedures are completed.

It’s been championed by physician Dr Peter Pronovost and is simple but effective way of reducing cognitive error in high pressure situations.

It’s interesting that the idea has found a fair amount of resistance among some doctors, who think that it somehow diminishes their expertise if they have to check against a list, despite the fact that common slips affect even the most competent of people.

One illustration of how complex the intensive care process has become is given near the beginning of the article when it describes a case of a three-year-old girl saved from drowning with what has become a hugely complex, multi-expertise, high-tech medical effort.

Consider a case report in The Annals of Thoracic Surgery of a three-year-old girl who fell into an icy fishpond in a small Austrian town in the Alps. She was lost beneath the surface for thirty minutes before her parents found her on the pond bottom and pulled her up. Following instructions from an emergency physician on the phone, they began cardiopulmonary resuscitation. A rescue team arrived eight minutes later. The girl had a body temperature of sixty-six degrees, and no pulse. Her pupils were dilated and did not react to light, indicating that her brain was no longer working.

But the emergency technicians continued CPR anyway. A helicopter took her to a nearby hospital, where she was wheeled directly to an operating room. A surgical team put her on a heart-lung bypass machine. Between the transport time and the time it took to plug the inflow and outflow lines into the femoral vessels of her right leg, she had been lifeless for an hour and a half. By the two-hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.

After six hours, her core temperature reached 98.6 degrees. The team tried to put her on a breathing machine, but the pond water had damaged her lungs too severely for oxygen to reach her blood. So they switched her to an artificial-lung system known as ECMO—extracorporeal membrane oxygenation. The surgeons opened her chest down the middle with a power saw and sewed lines to and from the ECMO unit into her aorta and her beating heart. The team moved the girl into intensive care, with her chest still open and covered with plastic foil. A day later, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator and close her chest. Over the next two days, all her organs recovered except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team drilled a hole into the girl’s skull, threaded in a probe to monitor her cerebral pressure, and kept that pressure tightly controlled by constantly adjusting her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.

First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But by age five, after extensive outpatient therapy, she had recovered her faculties completely. She was like any little girl again.

It’s a wonderful article that speaks to a number of important issues in medicine, including the self-perception and culture of clinicians, the importance and power of simple changes in behaviour, and why low-tech capital-free solutions are often the hardest to implement.

Link to New Yorker on checklists and intensive care medicine.

2 thoughts on “The tickbox revolution in intensive care”

  1. they don’t seem to, but stories like this must challenge our notion of what being “dead” means. if one could solve the problem of freeze-damage over time, who’s to say how long she could have remained dead before being brought back?

  2. It’s the brain’s ability to compensate that allowed her to regain all of her motor functions, and the use of her limbs. It’s fascinating the way we’ve evolved.

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