When the time finally came, I came to the ICU thinking I knew all that there was to know about Critical Care Medicine. I came to the ICU fully confident in my abilities to crush critical illness and save every patient I saw. I came to the ICU roaring like a lion…until I met the ICU nurses.

They whipped me into shape real, real quick. They showed me, in short order, what I didn’t know, and they showed me how to be properly behave in the ICU. I came to the ICU roaring like a lion…and the ICU nurses left me meowing like a kitten. And that experience taught me very early on to NEVER cross an ICU nurse.

The nurses in the ICU are among the best nurses around. They are highly skilled, highly educated, highly motivated to do what is right for the patient, and they do not back down easily. They will keep fighting for the patient with all their might, all their passion, and all their soul. I am not saying that other nurses do not do this. I am saying that ICU nurses do this par excellence.

I was witness to their selfless care during the COVID-19 pandemic. They spent hours at the bedside of countless very, very sick people with COVID-19. They gave them everything they had, and if the patient was not going to make it, they made absolutely sure the patient did not die alone, holding their hand in the room while the family was mourning on an iPad or cell phone.

They are such an important component of the care of the patient in the ICU. I was – and continue to be – in awe of their excellent patient care, and I am grateful to be their partner in the ICU.

As I said before, when I first came to the ICU, they whipped me into shape real, real quick. I learned to NEVER cross an ICU nurse, and their tough love made me a much better critical care doctor. I am forever better because of those ICU nurses with whom I worked my very first month in the ICU as a doctor. And to them – along with every other ICU nurse – I am forever grateful.

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That said, there is a general principle when it comes to treating patients – anywhere, actually – but especially the ICU: treat the patient and not necessarily just the number.

The heart rate may be fast at 125 beats per minutes. How does the patient look? Is she anxious? Does he have pain? Is there a fever? Is this an arrhythmia (abnormal heart rhythm) that needs treatment? Or, is there something else that is behind the abnormal heart rate?

The same can go for blood pressure. The number is low. But, once again, how does the patient look? Are they awake, alert, pink, and warm? Is the blood pressure reading truly accurate? What is their blood pressure normally? All of these factors need to be considered before prescribing potentially toxic medications to correct the low blood pressure.

The point is this: we need to take a holistic look at each of our patients and assess how the patient’s clinical appearance relates to whatever abnormal vital sign or laboratory value is present at that current time.

Now, of course, there are caveats to this general principle. There are some numbers, regardless of how the patient looks, that need immediate treatment. A serum potassium level of 7 – which is dangerously high – needs to be immediately treated no matter how the patient looks clinically.

The same goes with an abnormally low oxygen level: even if the patient looks “fine,” we need to give oxygen to someone who has a dangerously low oxygen level. Covid patients, in fact, routinely presented with oxygen levels previously thought to be incompatible with life but looked completely comfortable. I had never seen that before in my career. We still gave them oxygen, no matter how comfortable they appeared.

Still, in general, we need to treat the patient and not necessarily just a number. Yes, the numbers mean something, and we need to look at the entire clinical picture to figure out what is really wrong with the patient and fix that underlying problem.

In the ICU, I can make the abnormal numbers go away. I can give medications to “fix the number.” But that does not mean that I have treated the patient. Sometimes, “fixing the number” may make the patient worse.

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