The ten laws of critical care

One occasionally encounters lists of specialty-specific dictums, such as “Uncle Joe’s 6 Rules for Carpentry” or Michael McGonigal’s Laws of Trauma. Many of these are throwaway chaff, little more than checkout line folderol, but the best are worth remembering, internalizing, and perhaps hanging on your office wall.

To be useful, such “laws” need to fulfill a few criteria. They should be mostly true, and apply broadly to one’s practice, rather than being isolated to specific or rare situations. They should reveal and reinforce what the work—i.e. critical care—is really about. Most importantly, they should be concrete and useful, not just nebulous platitudes. Like ethical principles, we establish these guidelines in times of clarity, so they can assist our thinking when it’s 3 AM and the way ahead is unclear. “What should I do?” you might ask, then remembering one of your commandments, say: “Now I see.”

Here are the ten laws of critical care that guide my own practice. These should not be confused with the rules for practicing medicine like an adult, more “advanced” goals towards which we might aspire. These are the fundamentals.

First law: Do everything right away.

As we’ve discussed before, everything in the ICU is best done promptly. This is sometimes life-saving. More often, the benefits of early action are more subtle. Yet it’s always true. Delays are often inevitable, but never embraced. They accumulate, undermine our efforts, and throw sand in the machinery of healing. They are the enemy.

This applies to everything, including intentional inaction (do that immediately too) and deresuscitation. Do as much as you should, as fast as you can, for as little time as possible. Resuscitate aggressively; deescalate aggressively; do it all now.

Second law: Excellence will save some lives, but diligence will prevent many deaths. Be pretty good at your worst.

In medicine, we may dream of the unlikely save, the clutch diagnosis, the heroic victory while the music crescendos. Those come along sometimes.

They are not nearly as common as the mundane successes. The electrolytes you replaced, the scrupulous DVT prophylaxis, the pre-procedure hand hygiene. Boxes checked, T’s crossed—the boring stuff. The yield of any one of these actions is low, but hundreds of them occur every day, and the impact adds up. Taken in net, the error-free, consistently competent provider saves far more lives than the occasionally brilliant one. Strive to be both.

Third law: Own the patient, their problems, and your opinions. The buck starts and stops with you.

This is part of adulthood, but is important enough to reiterate. Most ICU patients have a laundry list of consultants, specialists, proceduralists, and opinions following them around. Yet there’s only one person with the task of integrating it all, making a decision, and standing by it. That’s you.

If you don’t accept that onus, the reigns aren’t taken up by anybody else; they’re simply left in the wind. And modern medicine is too rough a road without anybody to steer.

Fourth law: When there’s evidence, follow it. When there’s none, turn to physiology and clinical judgment. When there’s none, guess. Follow this order.

We should all embrace the science behind our practice, while also acknowledging its inevitable gaps and shortcomings. If we make ten decisions, one may be in an area supported by good evidence, two may be evidence-free zones, and the rest are likely a morass of vague, conflicting data. It’s easy to give up and just wing it.

Don’t. Accept that the science is imperfect, but use it to the bounds of its strength. Do everything you can to practice the most current, evidence-based medicine possible. Then when it all changes next month, switch gears and start over. Despite its flaws, it’s still the best game in town.

Fifth law: There are enough hard things. Don’t make the easy things hard.

Overthinking is an inherent risk of being smart and detail-oriented, and perhaps that’s why it’s common in critical care. Don’t succumb to it. When simple things simply need to get done, do them simply. Use minimal effort and rote habit-execution to minimize decision fatigue, bunt the easy pitches, and save your mental energy for the tough diagnoses, gray areas, and difficult choices.

Sixth law: Everything is multifactorial.

It’s right and good to ask why disease and derangement occurs in the ICU, but often it’s difficult to determine. It’s not a cop-out to acknowledge the reality: in almost every case, pathology has multiple causes.

Our patients are complex, and things rarely occur in isolation. If you think you’ve found the culprit, look again: there’s probably a score of supporting players lurking in the shadows. Elegant answers are the exception. Most problems are a mess.

Seventh law: Understand everything you order.

As a busy provider directing care, it’s easy to view yourself as a general commanding troops: in charge of the big decisions, but far removed from their execution.

This is a mistake. Yes, you can delegate much of your care, and indeed you must. But it shouldn’t be a menu of things you request but don’t understand. Ideally, you should be able to personally describe the pharmacokinetics, set up the device, adjust the ventilator, ambulate the patient, or perform the procedure. You just choose not to.

Strive to keep black boxes out of your practice. Aim to fully comprehend everything you’re doing, down to the cogs and wheels, even if you generally delegate or simplify it. If you lack this top-to-bottom understanding, you cannot troubleshoot, prioritize, customize, or analyze what’s happening; all you can do is click orders.

Eighth law: Remember the human in the bed

Critical care is a highly invasive specialty, whose patients are often sedated, non-verbal, and very ill. There’s a fine line between such a human being and a mere object, and it’s easy to slip over it.

Avoid that. You’re still taking care of a person, even if they can’t declare it or remind you of their humanity. Before they rolled into your unit, they lived, laughed, cooked meals and ate them, cracked jokes, enjoyed good days and survived bad ones, loved and were loved and spread love. Much of that has been taken from them by illness and by medicalization, and some of it they may never get back. But they’re still a person.

Leave them with that identity. Don’t strip it away, even if you strip away everything else. They deserve it, but more importantly, you need it. Once you start seeing your patients as objects, you become nothing more than a people mechanic, and that’s not a rewarding job.

Ninth law: Being an asshole is a character flaw, not a right or a charming quirk.

Many of the people involved in medicine are brilliant, forceful, and dedicated. The process of medical recruitment and training specifically selects for these traits.

Not so for kindness, collegiality, or in the worst cases, mere professionalism. This unfortunate oversight has led some to the incorrect conclusion that bad behavior is actually an asset. (Maybe we learned that from watching Drs. House, Cox, or McSteamy.)

Jerks can be good at medicine, but not because they’re jerks. It’s the opposite: all things being equal, jerks do it worse. They alienate their colleagues, they’re unable to collaborate, they don’t hear what they don’t want to hear.

Plus… they’re jerks. They make the hospital (and the world) a worse place for everyone.

We all have off days, and that’s okay. Just keep recognizing bad behavior as bad, not as acceptable, and certainly not as laudable.

Tenth law: Strive to give people another chance.

Sometimes it’s not obvious what, exactly, we’re doing for our patients. In many cases, we’re not curing their underlying diseases, which are chronic. In some cases, their own decisions may lead them inexorably back to our care. In all cases, they’re not getting any younger, and age eventually humbles everyone.

Every success in medicine is ultimately temporary, and there’s no sense in bewailing that. Rather, accept our role: to swoop in and catch people who fall. To return them to their former dignity, such as it was, or at least give them that option. What happens next is up to the dice, or the gods, or their genes, not to us. If they do come back, we’ll be waiting, and we’ll do it again.

Recap

  1. Do everything right away.
  2. Excellence will save some lives, but diligence will prevent many deaths. Be pretty good at your worst.
  3. Own the patient, their problems, and your opinions. The buck starts and stops with you.
  4. When there’s evidence, follow it. When there’s none, turn to physiology and clinical judgment. When there’s none, guess. Follow this order.
  5. There are enough hard things. Don’t make the easy things hard.
  6. Everything is multifactorial.
  7. Understand everything you order.
  8. Remember the human in the bed.
  9. Being an asshole is a character flaw, not a right or a charming quirk.
  10. Strive to give people another chance.

More reading: See also the Laws of EMS, circa many years ago.

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