ICU Rule #8: Treat The Patient

In the Intensive Care Unit, we are surrounded by numbers: heart rate, blood pressure, respiratory rate, oxygen saturation, and a whole host of laboratory values. Any or all of them can be abnormal, and they are frequently abnormal all at once. It can be difficult to decipher which abnormal number is significant, and this skill comes with time and experience caring for critically ill patients.

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.