Learning Critical Care Medicine

“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant. Here is a hypothetical illustration. Mr. X. has a sore throat. He buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails. Mrs. X dies. Who is primarily responsible for Mrs. X’s death?” Above statement has been borrowed from the Alexander Fleming’s noble lecture delivered on December 11, 1945. [1] Fleming’s serendipitous discovery of penicillin and its therapeutic potential in treating bacterial infection was a boon to mankind. However, shortly thereafter resistance to penicillin as well other discoverd antibiotics was observed. Scie...

“Ethics is knowing the difference between what you have a right to do, and what is right to do.”  -  Potter Stewart, Associate Justice, United States Supreme Court, 1958-1981 . Before the evolution of modern medicine, death had been a well-accepted inevitability of life, wished to happen at home surrounded by family members. This inescapable truth had become an integral component of every religion, culture and society with defined rites and rituals. With the advent of cardiopulmonary resuscitation and organ support technologies in the second half of last century, this integrated approach to end of life started receding towards denial, altering the trajectory of the process of dying. [2] Now ordinary people want and demand everything to be done to prolong the life of their loved ones, as it gives a virtual satisfaction to them and answer to others. Chest compression, defibrillation, escalating vasopressors, mechanical ventilation, dialysis, artificial nutrition in the loneli...

  From respirator lung to ventilator induced lung injury, we have travelled a long distance from the concept of barotrauma-volutrauma to stress-strain. Stress is defined as equal and opposite force developed in a material, when exposed to external force, while strain is change in the area or volume from baseline, brought about in this process. Stress-strain relationship is a function of material property, solid, viscous or viscoelastic. Current strategy of mechanical ventilation as endorsed by ARDS net, is limiting the tidal volume and plateau airway pressure to 6 ml per kg of predicted body weight and 30 cmH 2 O. Baby lung volume in ARDS is variable with severity of disease, worse is the ARDS, smaller is the baby lung. As baby lung has normal compliance, setting tidal volume according to predicted body weight, may be safe to unsafe depending upon baby lung volume. Lung behaves like viscoelastic material, which makes pulmonary mechanics time dependent. For a constant...

“Education is a progressive discovery of our own ignorance” Will Durant Since the inception of human society, people have been intrigued about the mystery of human behavior and emotions. Scholars came up with different explanations based on existing belief system, knowledge and evidences. Greek philosopher Aristotle believed heart as center of intelligence and emotions. Few centuries later, another Greek philosopher Galen explained that animal spirit originates in the heart and travels via the circulatory system to brain. Galen described his assumptions based on dissection of corpse, and further elaborated that cerebral ventricles are the epicenter of reasons and emotions. In the medieval period, accurate reproduction of images by artists like Da Vinci, Michelangelo and Rembrandt as well as rapid dissemination of knowledge by printing press, led to better understanding of human neuroanatomy and neurophysiology. As a result, by the end of eighteenth century, knowledge of huma...

"The difficulty lies, not in new ideas  but escaping old ones,  which ramifies,  for those brought up with them,  as most of us has been,  into every corner of our minds" - John Maynard Keynes  Hyponatremia is defined as serum sodium concentration less than 135 mmol/L. Biochemical severity of hyponatremia has been described as mild (S. Na of 130-135 mmol/L), moderate (125- 129 mmol/L) and Severe/ profound (125 mmol/L). Clinical severity of hyponatremia is recognized based on urgency of treatment. Severe symptoms are the result of cerebral edema and increased intracranial pressure with risk herniation. It manifests as vomiting, seizures, obtundation and cardiorespiratory distress.                                Moderately severe symptoms of hyponatremia are due to mild cerebral edema but no ris...