WEBVTT

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Thank you Suparna. Thank you so much for inviting me for this

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talk. Can you see my screen now? Yes sir, it is visible.

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So good evening everyone. Can we start now or should we wait

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for some more participants? So we can Okay

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fine. So we'll start on time right now. So basically this concept

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this patient centric model in critical care. So when the topic was

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allotted to me, I was just thinking why this vague topic has

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been given to critical care specialist. I mean like you know there

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are so many other topics directly related to the medical, but this

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topic which is a patient centric model in critical care especially in

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medicine or critical care whatever you think of. So then I go

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back and have researched so many things. So in fact I will

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learn many things which we do on a general routine day-to-day basis,

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but I don't know that I am doing this patient centric model

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only in my critical practice also. Okay, thank you so much Suparna

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for the introduction. Without further delay, I'd like to go ahead and

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see what I'm going to present now. So as we all know

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that everyone has got two minds. One is an intuitive mind, the

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other one is the other one is a rational mind. Okay, the

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intuitive mind is something that you learn things without any reason. So

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you you know that water flows down. You know that air will

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be can be seen. So that's an intuitive mind. So that's a

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sacred gift given to the human body. And the rational mind is

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there wherein you only believe the things with a proof. Okay. So

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as Einstein said no intuitive mind is a sacred gift for all

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the humanity and the rational mind is a servant. But we humans

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have created a society that we respect always the servant and forget

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the intuitive mind itself. The same thing, the same quotation goes back

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to my practice also. So without knowing I am practicing the patient

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centric critical care only in all these days since my last 10

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years of critical care practice here. So let's see what is this

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patient centric models. So different centric models here when it comes to

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medicine or critical care here. So go back, going back to the

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history, what are the various models were there and how they got

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developed. Starting from 1950 Michael

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Balint is a person who coined the term illness centered medicine. So

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it's a conventional method. Everyone of us know those type of don't

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know the type of medicine wherein in the olden days we used

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to practice illness centered medicine. So we'll not understand the patient's

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perspective. We'll not understand anything related to the patient's illness. So when

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is diagnosed the patient is having cancer, yes that is then the

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treatment part we'll explain to the patient and patient whether he follows

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or not it's his will. So that we called as illness centered

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medicine in 1964. Then the physicians came out and then they came

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out that there should be a concept of attentive listening and we

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should respond to the patient offers to it. It's not like you

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dictating all the treatment to the patient. There are something the request

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from the patients, request from the patient attendees. You need to give

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an ear to those requests. So without that I don't think you

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can develop a bond between the patient and the patient attendees and

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the outcomes also here. So in 1964 Balint Dev came forward the

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concepts of attentive listening. Later in 1970 Mike Vinnie.

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So he is the one who coined this patient centric care medical

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model in 1970 wherein he came forward so many concepts how

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to do a patient centric model, how to do a patient centric

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model. And Levinstein he formulated a patient centric model as a clinical

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method. So everyone of us should practice this patient centric model as

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a routine clinical problem. So let us see what are the various

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things that are there inside this model here. So as I'm quoting

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there are two basic models. One is a medical model or illness

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model. The second one is a patient centric model. So what are

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the basic differences here? In the illness model, patient is only a

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listener for you. He's not going to ask any questions. Patient is

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quiet. You will say them yes you got typhoid. You need to

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use the medication for seven days. Come back after seven days, then

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I'll see. But in a patient centric model, the patient role is

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active. So patient can ask questions here. So you allow the patient

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to shoot up all his questions. Okay. So once you ask him

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to shoot up his questions, he'll comfort so many questions. So in

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a patient centric model, you'll ask the patient to ask his questions.

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Patient is only the recipient end, but in the patient centric model,

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patient is a partner of the plan. So you need to explain

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what is the diagnosis, what is the plan here. If at all

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if the plan A goes on, what is the plan B? So

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patient is given the options here and patient should be the part

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of the plan here. Physician dominates the conversation in a medical model

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wherein he does not offer any options and physician collaborates with the

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patient. So understanding the patient needs, understanding the family needs, understanding the

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community needs. We offer various options, discuss pros and cons of various

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options and then you go ahead with the patient treatment. The care

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is only the disease centered. So whatever might be the patient is

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the side effects the patient is experiencing. Yes, he is supposed to

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take care of the medicine for seven days which was prescribed to

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him. But here the care in patient centric model is towards the

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quality of life centered. So it focuses on the family and his

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day-to-day day-to-day activities. How much you can give his return of functional

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activities. Those that is the major advantage in a patient centric model.

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And physician does most of the talking and physician listens here and

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he talks less in a patient centric model. So most of the

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times in a medical model because of the side effects, because of

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the treatment plan, whatever might be, patient may or may not adhere

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to the treatment plan. Once you discuss all the plans, once you

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discuss with the outcomes, once you discussing the pros and cons, so

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he's more likely to adhere to the treatment plan. So these are

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the basic differences of that. Coming to the definition part, it's a

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practice of caring the patients. Not only the patients, it's a practice

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of caring the patients and their families too in ways that are

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meaningful and valuable to the patient. So you need to care for

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the family, you need to care for the patient, you need to

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care for the whole society also. So the Medicine Institute of Medicine

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defines as providing care that is respectful, responsive

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based upon the individual patient preferences, needs and values that is

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ensuring the patient's values guide in all your clinical decisions. So

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whatever it is, the definition says that you need to respect and

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you need to respond to the individual preferences of the patient. So

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guiding them for going ahead with the clinical decisions here. So that's

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the basic concept of a patient centric care here. So if you

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see the diagram so what do we have in a patient centric

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care model? You have a patient at the center. You need to

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have the healthcare team on the one end like the doctors, the

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treatment treating doctors, whether it might be a critical care physician or

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whether be a primary physician under whom the patient is admitted. The

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other end should be the patient's family and one more wing will

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be your healthcare instructions. So what are the instructors who are there?

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What are the instructions you're giving to the patient? So this should

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happen in a closer loop communication between the patient, patient family, healthcare

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team. So everyone comes into your patient centric model. So what is

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the science behind? So what is the science? It's nothing but you

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are explaining the disease. So we are explaining the disease, we are

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explaining the experience of illness to the patient, whereas psychological issues, whereas

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social issues and a sharing decision, coming to a common sharing decision

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with the patient and his family is the basic science behind the

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patient centric care. So this believes with the background that the process

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of healing depends on knowing the patient as a person in addition

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to accurately diagnosing. So once you once you gain their will or

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once you gain the trust of the patient and patient attendees. So

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even diagnosing becomes very much easy for you. So you need to

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explain them in detail about your thought process, about your diagnostic plan,

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about your treatment process. So in a way not only helps in

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communicating the disease to the patient, it also helps in healing him

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helping us to get a better diagnosis or an accurate diagnosis. That's

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the basic science behind the a patient centric model of any any

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any healthcare system. Coming to especially critical care. So what are the

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various principles of patient centric care in critical care? So if you

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see the diagram here one is the access to the care. So

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everyone should be given access to the care and that access should

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have a continuity and transition from one place to another place or

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one treatment to another treatment. It should involve the family and friends

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because ultimately end of the day it's an emotional support to the

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patient, providing the physical comfort for him, informing and educating the patient

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regarding the treatment plan outcomes. You need to coordinate and integrate the

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care also. You need to have coordination proper and then integration of

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the care and then respecting the patient preferences. So every steps.

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So this is called as Pickers eight principles of patient centric care

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in critical care. So you need to respect each and every step

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when it comes to patient centric models here. So by by respecting

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each and every step, what you're going to achieve? You're going to

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achieve a good outcome. You are going to achieve a good patient

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doctor relationship here. So let us see one by one, one by

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one in critical care especially because I'm a critical care physician here.

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So respect for the patient values, preferences and needs. What does it

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mean when it comes to providing care? So when I'm giving treatment,

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why do I why do I need to respect the patient needs

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here? It's just like involving the patients in decision making, recognizing that

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they're individuals with their own unique values and preferences. So you should

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always treat the patients with dignity, respect, sensitive to his or her

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cultural values and autonomy. Some patients like Jehovah Witness, they don't want

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other patients blood transfused to them. So you need to get you

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need to respect their cultural values. Based upon their cultural values, you

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need to treat them. Otherwise, if you say that I'm going to

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transfuse blood to a Jehovah Witness patient, he's not going to get

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admit and ultimately you're not going to treat that patient and the

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patient is going to succumb to death and something might happen here.

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So you need to give respect to the patient. You need to

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understand his values and preferences and need to give respect, get the

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respect in back from the patient it's here. So by doing this

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in critical care, what happens? For example, in critical care, I'll quote

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some examples here respecting the patient values and preferences. If I if

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I receive a patient who is a grade three or grade four

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carcinoma with a distant mets so the patient asks me, come on

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doctor, don't do all these things like the high end critical care,

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like placing me on a ventilator things and all if he's conscious

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enough or if the patient attendees gives me the concern that don't

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do all those things. I have to give respect for their decisions.

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Just because I know how to save a life and I cannot

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jump onto the patient and do all the procedures what I know

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for him. So you need to understand the patient needs to understand

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what is a going on for him, what is the treatment plan

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for him. And then he needs to give consent especially when it

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comes to the conscious patients. So in a way you are giving

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respect and getting respect is the first model of a patient centric

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care. Second thing is how a doctor coordinates and coordinates the treatment

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plan, the wholeness, the whole integration of the care. So you need

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to focus on groups. So when I divide my planning and strategy,

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what is my planning strategy here? I need to involve the person

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who is getting the disease, the patient. I need to involve the

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family caregivers too in my whole like the communication process. If he's

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particularly from a community, there are some community constraints too and then

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the healthcare team. So everyone sit together should have a coordination between

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the whole team here. So once the patient expresses feelings like he's

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feeling vulnerable and powerness and powerlessness in the face of illness. So

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then your family caregivers, your healthcare team, everyone will come forward for

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him, coordinate among themselves. So what is happening to him? And then

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once they do a proper coordination, yes we can properly integrate the

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care and you can counsel the patient in person here. So we

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need to have a coordination of clinical care or a critical care

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here. So you need to have coordination between the the different treating

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doctors. Say for example a pulmonologist and an oncologist and an orthopedician

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combinedly treating together a bone sarcoma with the distant mets. You

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need to have a coordination between the all the three clinical teams.

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So who are going to treat the patient? Apart from all the

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three clinical teams, we need to have the coordination between the ancillary

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and support services. Who are the support services here for the patient?

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The family caregivers are the support services or the community is the

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support service for him. So involve them, coordinate with them. Don't try

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to confuse them with all the options available. You need you need

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to give them the basic options, understand the patient's mindset and throw

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the options onto the patients or the patient attendees. So someone from

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the healthcare team should be coordinating the whole process and coordination of

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the front line patient. So ultimately what you're doing? So you're keeping

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the patient in front of you and then coordinating everything behind the

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patient. Where is the treatment or it's a family in family interests

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or the community interests, everything should have a proper coordination. So you

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cannot confuse the patient with different options available here. So you need

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so to prevent that you need to have the coordination. Coming to

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the next principle of patient centric care, information and education. So what

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is meant by information and what is meant by education here? So

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informing the patient about his disease process. Okay, in any interview, sit

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with the patient, let the patient express all their worries and all.

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So you need to focus on three types of communication with the

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patient. So you need to inform him based upon his clinical status.

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So he got a so and so disease. So so and so

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disease when you came here and then once the treatment is started,

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we are progressing in a good way. So focus upon the clinical

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disease or the patient is happening and focus upon the progress of

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the disease, whether the patient is improving or deteriorating, is the patient

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is clinically conscious and prognosis of the disease. So based upon

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different prognostic scores, whether it might be sofa or a individual diagnostic

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based prognostic scores give the information properly to the patient his

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disease condition, how is it progressing and what is the prognosis in

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this? So an information regarding the process of care. So what is

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the process you're going to do for the present disease? So in

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this disease, the initial my step one should be I'll admit you

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in under my care. The step two should be I'll start some

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IV antibiotics. Step three should be after the antibiotics. If it is

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not responding, then I'll send some more tests. So the whole the

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process of care which you are planning need to be informed to

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the patient in a clearly understandable language, in a clearly mother tongue

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of the patient. It should be informed to the patient, the process

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of the care. And then we need to give them or we

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need to make them understand regarding autonomy, self care and health promotion.

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So they have some rights. Right to reject the treatment is also

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one of the right of the patient. So we need to make

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them understand that what are the various options available in the options,

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how to choose an option and which option to be chosen. And

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because if then an individual is conscious enough, he can take a

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self care of about himself. So everything should be informed to the

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patient such a way that you need to get all the all

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the three information processes which you are planning here. So that is

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regarding the information and education part. Coming to providing physical

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comfort. So what is meant by physical comfort in a patient centric

252
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care? So every patient we see them with physical comfort, right? When

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it comes to critically ill ICU. Sorry, when it comes to critically

254
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ill and ICU patients, providing physical comfort is one of our responsibilities.

255
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Okay, but it was separately told in a patient centric care because

256
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it has a significant impact on their experience. Okay, once they come

257
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to the hospital, so they need to have a fairly good experience.

258
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So in this particular I mean like how to get a good

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00:16:26.000 --> 00:16:29.300
experience or how to provide a proper physical comfort for the patient

260
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is focus upon three major areas of the patient. One is a

261
00:16:32.700 --> 00:16:37.800
pain management. So no patient should suffer with pain especially

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if it is treatable conditions. If it is a condition which is

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reversible also. So you need to properly treat the patient and in

264
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terms of pain management, you need to give them assistance with daily

265
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living needs and activities. In critical care, we generally mobilize the patient

266
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since make sure they feel comfortable in the ICU stay. Make sure

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they flex their limbs, they make sure they they have a fresh

268
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breath of air. Make sure they have they have come out or

269
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stepped out of the bed so that they can feel alive. Keeping

270
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them always on the bed sedated is not going to help in

271
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the outcomes and recoveries. Even the protocol says you need to have

272
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a daily sedation interruption if the patient is on any ventilator tubes.

273
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So make them comfortable to the hospital surroundings and environment. So they

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need to understand which place they are and what is this place

275
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is capable of and why is she there with us in this

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particular hospital ICU or in the ward and all. They need to

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understand the attendees need to understand the patient needs to understand this.

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So once you're able to address all these three major concerns of

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the patient, I think you're going provide going to provide a very

280
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good comfort care or a very good physical comfort for the patient

281
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in your hospital here. Next important thing is emotional

282
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support and elevation of fear and anxiety. So any patient who steps

283
00:17:52.700 --> 00:17:55.900
into the hospital, they come with the background of fear and anxiety.

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If you don't have the fear and anxiety, you should seriously doubt

285
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the diagnosis of the patient. So they might be thinking of what

286
00:18:02.600 --> 00:18:05.200
might be my diagnosis, what might be the doctor might going to

287
00:18:05.200 --> 00:18:08.200
tell us. So they'll have a lot of anxiety in their mind.

288
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They come into the hospital, they step into your hospital with a

289
00:18:10.700 --> 00:18:14.900
lot of elevation and fear and especially critical care. They'll be deadly

290
00:18:14.900 --> 00:18:18.100
scared to life. Once the minute we say we're going to shift

291
00:18:18.100 --> 00:18:21.500
you to the ICU then the next minute they'll think that why

292
00:18:21.500 --> 00:18:24.000
is their shifting me to ICU? That means am I so critical?

293
00:18:24.600 --> 00:18:27.800
The the the the proper funda or the proper thinking of all

294
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the humans is once I say critical, they say it's 50 50

295
00:18:30.200 --> 00:18:35.200
chances. So caregivers, the critical care physicians I mean in this

296
00:18:35.200 --> 00:18:40.700
particular construct should pay attention to anxiety or the physical status, treatment

297
00:18:40.700 --> 00:18:44.700
and prognosis. Whatever the treatment that's going on but the patient attendees

298
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or patients will have a lot of anxiety towards that. That should

299
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be addressed. Patient attendees or patients should be addressed or the impact

300
00:18:51.400 --> 00:18:54.900
of illness. So how it is going to affect him? How it

301
00:18:54.900 --> 00:18:57.900
is going to affect the family? If it is a stroke, how

302
00:18:57.900 --> 00:18:59.900
it is going to affect the family? If it is a Guillain

303
00:18:59.900 --> 00:19:02.700
Barre syndrome, how it is going to affect the family? If it

304
00:19:02.700 --> 00:19:05.200
is a bed sore, how it is going to affect the family

305
00:19:05.200 --> 00:19:08.700
and the patient? If the patient is a tracheostomized patient who is

306
00:19:08.700 --> 00:19:11.500
having a difficulty weaning, how it is going to affect the family?

307
00:19:11.500 --> 00:19:15.700
Everything needs to be discussed in detail with the family members and

308
00:19:15.700 --> 00:19:20.700
provided if required with the patient also. And finally because in India

309
00:19:20.700 --> 00:19:24.200
the financial impact or the Indians or the guys who think of

310
00:19:24.200 --> 00:19:29.000
finances even though they were inside the hospital or even though even

311
00:19:29.000 --> 00:19:34.300
they're very critical conditions. So in those basic situations, yes anxiety

312
00:19:34.300 --> 00:19:38.400
or the financial impact should also be taken care of the taken

313
00:19:38.400 --> 00:19:41.100
care by the critical care physicians or any physician who is treating

314
00:19:41.100 --> 00:19:48.300
the patient especially. Continue.

315
00:19:49.600 --> 00:19:53.500
Yes, next is continuity and transition. So what is meant by continuity

316
00:19:53.500 --> 00:19:57.700
and transition of care? So patients express concern about ability to care

317
00:19:57.700 --> 00:20:01.500
for themselves after discharge. So once you're done everything to the patient,

318
00:20:01.500 --> 00:20:04.700
you made the patient comfortable, you extend the whole disease process for

319
00:20:04.700 --> 00:20:08.000
the patient. You made the attendees understand that this stroke patient is

320
00:20:08.000 --> 00:20:11.400
not going to come out. Everything has happened now. Next step is

321
00:20:11.400 --> 00:20:15.200
to keep the patient in continuity with the treatment and then how

322
00:20:15.200 --> 00:20:18.900
to make them a transitional into a normal phenomena. So you need

323
00:20:18.900 --> 00:20:23.100
to understand the patient needs in this criteria. The patient should understand

324
00:20:23.100 --> 00:20:27.000
that the disease which the patient is suffering. So patient should have

325
00:20:27.000 --> 00:20:32.400
an understandable ability based upon the disease. Detailed information regarding the medications,

326
00:20:32.800 --> 00:20:36.800
physical limitations. If there's a color blind person, we need to address

327
00:20:36.800 --> 00:20:40.900
them saying that you are not supposed to drive in traffic or

328
00:20:40.900 --> 00:20:44.400
you're not supposed to do high risk jobs. If the patient is

329
00:20:44.400 --> 00:20:48.000
an alcohol withdrawal patient, you're not supposed to drive motorcycle for the

330
00:20:48.000 --> 00:20:52.100
next few days. So these physical limitations what two patient attendees or

331
00:20:52.100 --> 00:20:55.800
patients have should be addressed. Dietary needs as we all know now

332
00:20:55.800 --> 00:20:59.300
every time day in and day out any diabetic patients comes to

333
00:20:59.300 --> 00:21:02.900
us, we say diabetic diet, a thyroid diet, a hypothyroid diet and

334
00:21:02.900 --> 00:21:06.100
all those things. So diabetic needs and dietary needs should also be

335
00:21:06.100 --> 00:21:10.100
addressed for the patients. Coordinate and plan the ongoing treatment and after

336
00:21:10.100 --> 00:21:13.900
discharge services too. So once the patient gets discharged, so what are

337
00:21:13.900 --> 00:21:17.900
the services you can provide for the patient? And provide the informations

338
00:21:18.000 --> 00:21:22.200
regarding access to the clinical. So they need to understand to have

339
00:21:22.200 --> 00:21:25.600
a proper continuity of treatment, when to come back to hospital. So

340
00:21:25.600 --> 00:21:27.800
what are the various issues? I think everyone of us might be

341
00:21:27.800 --> 00:21:31.000
dealing with the same things, same diseases. So once they go out

342
00:21:31.000 --> 00:21:33.600
from the hospital, you need to make them understand that when they

343
00:21:33.600 --> 00:21:36.400
have to come back again for the help when the when the

344
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when when when they should come back to you again saying that

345
00:21:38.800 --> 00:21:42.200
my treatment or my disease is not I mean like not getting

346
00:21:42.200 --> 00:21:46.300
treated and all. So you need to support them physically, financially on

347
00:21:46.300 --> 00:21:52.400
an accounting basis and a continuing basis also. Sorry.

348
00:21:53.200 --> 00:21:56.600
So by doing this, what you're effectively doing? You're effectively treating the

349
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patients by your medications and then not only by treating the patients,

350
00:22:00.300 --> 00:22:04.300
you're confronting them from a patient to your normal human being. To

351
00:22:04.300 --> 00:22:07.800
summarize again all the treatment plans and then they should have proper

352
00:22:07.800 --> 00:22:11.900
access to the care also. So they need to know when they

353
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I mean like they can where they can access the care when

354
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it is needed. So it should be an ambulatory care. So the

355
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following areas these areas should be what is it thoroughly stressed to

356
00:22:23.100 --> 00:22:26.200
the patients like access to the location of hospital. So which is

357
00:22:26.200 --> 00:22:29.600
the nearest hospital for you in case of emergency? What should be

358
00:22:29.600 --> 00:22:34.800
done to the nearest hospital? Availability of transportation, ease of scheduling appointments.

359
00:22:35.200 --> 00:22:37.900
So if it is a role patients, they should have an access

360
00:22:37.900 --> 00:22:42.200
for you. They need to be accessibility for you and so that

361
00:22:42.200 --> 00:22:47.200
you can easily schedule their appointments. Accessibility to specialist or specialist services

362
00:22:47.200 --> 00:22:50.300
when a referral is made. If your center is only a primary

363
00:22:50.300 --> 00:22:53.800
care center or secondary care center, if you're discharging the patient, you

364
00:22:53.800 --> 00:22:56.800
need to make them understand that next time if a complications happens,

365
00:22:56.800 --> 00:23:00.000
they need to go for a a specialty center. Okay, then only

366
00:23:00.500 --> 00:23:02.700
the the disease or the illness can be cured and you're going

367
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to live for those patients. Clear instructions should be provided for all

368
00:23:06.400 --> 00:23:09.500
the patients on on how on to get these referrals. So if

369
00:23:09.500 --> 00:23:13.200
you see each and every point in a row, I think every

370
00:23:13.500 --> 00:23:17.200
point being followed by all the critical care physicians are properly trained.

371
00:23:17.700 --> 00:23:20.800
So they'll be counseling the patients on a daily basis, on a

372
00:23:20.800 --> 00:23:24.600
regular basis, on a patient attendees, on a frequent basis making them

373
00:23:24.600 --> 00:23:28.400
understand the disease process of the patient, making them understand how we

374
00:23:28.400 --> 00:23:31.500
are going to tackle the disease of the patient and what is

375
00:23:31.500 --> 00:23:35.000
your plan B for all the complications which are expected. So there

376
00:23:35.000 --> 00:23:39.500
there's always an expected complications and unexpected complications. So generally when I

377
00:23:39.500 --> 00:23:44.000
go on counsel any patient, I need to forward keep forward to

378
00:23:44.000 --> 00:23:47.800
the attendees say that sir these are the expected complications wherein my

379
00:23:47.800 --> 00:23:51.000
plan of action should be like this. If the patient with COPD

380
00:23:51.000 --> 00:23:53.400
comes to you with a multiple Guillain Barre, so you need to

381
00:23:53.400 --> 00:23:57.100
make the patient and attendees understand that if the Guillain Barre ruptures,

382
00:23:57.200 --> 00:24:00.200
yes my plan of action is to keeping an ICD or keeping

383
00:24:00.200 --> 00:24:03.300
a tube that drains the air out of your lungs. So that

384
00:24:03.300 --> 00:24:05.800
should be explained to the attendees in prayer so that you can

385
00:24:05.800 --> 00:24:09.100
gain the confidence of the attendees one step. The second step is

386
00:24:09.100 --> 00:24:12.600
in emergencies in a real time emergencies. They'll not come back and

387
00:24:12.600 --> 00:24:15.400
question you why this has been done and why this has not

388
00:24:15.400 --> 00:24:18.500
been informed to you like informed to me and all those things.

389
00:24:19.100 --> 00:24:21.900
So these things we do in a day in and day out

390
00:24:21.900 --> 00:24:24.800
of our critical care life. But the thing is we don't do

391
00:24:24.800 --> 00:24:27.600
it in a like as as I have presented. We don't have

392
00:24:27.600 --> 00:24:30.200
presentations like this, but we are doing it. I think hope most

393
00:24:30.200 --> 00:24:32.800
of our critical care physicians or most of the clinical physicians are

394
00:24:32.800 --> 00:24:37.100
doing these things. And finally the last step is making the patient

395
00:24:37.200 --> 00:24:40.800
I mean like complaint to your care. So you need to give

396
00:24:40.800 --> 00:24:43.400
them all the services post discharge also so that there will be

397
00:24:43.400 --> 00:24:47.300
complaints to the medications, there will be complaints to your particular care

398
00:24:47.300 --> 00:24:49.800
of the clinic and there will be following it up with you

399
00:24:49.800 --> 00:24:53.500
closely so that the disease will be healed in the situations. So

400
00:08:13.600 --> 00:08:16.900
these are the areas eight principles of patient centric critical care. So

401
00:08:19.600 --> 00:08:20.400
why it is is

402
00:25:00.230 --> 00:25:04.730
required. So once I understand that, patient-centric care is required. These are

403
00:25:04.730 --> 00:25:08.930
the various principles here. We understood the definition of patient-centric care. So

404
00:25:08.930 --> 00:25:11.730
you have learned about what are the various other centric cares like

405
00:25:11.730 --> 00:25:16.830
illness-centric care, disease-centric care. So why, why this patient-centric care is is

406
00:25:16.830 --> 00:25:20.130
required and what is it again? By definition, as I said, it's

407
00:25:20.130 --> 00:25:24.830
not a strictly defined process. It has got various sequential stages starting

408
00:25:24.830 --> 00:25:29.730
from admission through the treatment and starting to the discharge. Everything is

409
00:25:29.730 --> 00:25:34.330
important here in the patient-centric care and standardizing all the procedures. The

410
00:25:34.330 --> 00:25:38.330
minute you say the patient should go to ICU, all the procedures

411
00:25:38.330 --> 00:25:42.630
should be standardized. So it should be either hospital-driven protocols or it

412
00:25:42.630 --> 00:25:46.330
might be ICMR-driven protocols. Whatever might be there, there should be a

413
00:25:46.330 --> 00:25:51.430
standardized protocol in a particular hospitals. Okay, but the reality, as we

414
00:25:51.430 --> 00:25:54.530
all know as I'm quoting earlier, the reality of all these cares,

415
00:25:54.530 --> 00:25:58.430
the patient-centric care at various stages, standardizing the protocols, it's all interwoven

416
00:25:58.430 --> 00:26:01.930
to one each other. So once you make the once you make

417
00:26:01.930 --> 00:26:05.330
the cloth very strong, I think then only your patient-centric care is

418
00:26:05.330 --> 00:26:08.830
going to withstand on the cloth and here. And don't forget it's

419
00:26:08.830 --> 00:26:12.530
not a fixed protocol for everyone. It varies from patient to patient

420
00:26:12.530 --> 00:26:16.230
because here, as I'm quoting here, it's a patient-centric model or a

421
00:26:16.230 --> 00:26:20.430
patient-centric care where patient has given the prior importance, not the doctor

422
00:26:20.430 --> 00:26:23.330
here. So it varies from patient to patient. It is only the

423
00:26:23.330 --> 00:26:26.730
doctors in I mean the illness-centric care, I think anyone of us

424
00:26:26.730 --> 00:26:29.930
can treat the patient with the medications which we all know. But

425
00:26:29.930 --> 00:26:34.330
the patient-centric care part, it varies from patient to patient. So learning

426
00:26:34.330 --> 00:26:37.930
is different from acquiring the process. So in a patient-centric care, we

427
00:26:37.930 --> 00:26:42.730
do learn things differently. Sometimes as DNR patient comes to you unable

428
00:26:42.730 --> 00:26:47.630
to express his thought process. So he might be indirectly asking you

429
00:26:47.830 --> 00:26:50.830
what are the various options available for the peaceful pass away or

430
00:26:50.830 --> 00:26:54.230
peaceful death of my father. So you need to make them understand.

431
00:26:54.230 --> 00:26:57.530
You need to first listen to them, make them make you first

432
00:26:57.530 --> 00:27:00.130
make sure understand about the thought process of the patient or the

433
00:27:00.130 --> 00:27:04.830
patient family, then give about the options. So you need to aware

434
00:27:04.830 --> 00:27:07.230
by while you are giving the options, you need to aware of

435
00:27:07.230 --> 00:27:10.830
the whole process itself. It's not like simple components 1 2 3

436
00:27:10.830 --> 00:27:14.230
4 and all. While performing this task, you need to understand the

437
00:27:14.230 --> 00:27:18.030
whole process also. Once you access the whole process, then only this

438
00:27:18.030 --> 00:27:22.030
patient-centric care is possible. Let us take an example, especially in critical

439
00:27:22.030 --> 00:27:25.430
care. There's an dialysis patient in my unit. So what are the

440
00:27:25.430 --> 00:27:30.530
various healthcare workers and what are the various domains that

441
00:27:30.530 --> 00:27:33.930
work together to bring out the best outcome in my dialysis patient?

442
00:27:34.330 --> 00:27:37.630
The first one is nephrologist, no doubt. So he'll prescribe like how

443
00:27:37.630 --> 00:27:40.630
many dialysis should be done, what are the frequency and duration of

444
00:27:40.630 --> 00:27:45.830
dialysis? And what is the sorry,

445
00:27:46.030 --> 00:27:48.830
and what is the outcomes of the patient? So the nephrologist is

446
00:27:48.830 --> 00:27:51.430
the key or nephrologist is the I mean like the pilot here

447
00:27:51.430 --> 00:27:54.730
for the all the patient-centric care. Depending upon the institute, sometimes a

448
00:27:54.730 --> 00:27:57.630
critical care physician might be the pilot for your dialysis patient because

449
00:27:57.630 --> 00:28:02.130
things will go dynamically change. So once the things are dynamically changing,

450
00:28:02.430 --> 00:28:06.730
the critical care physician is the is the key or the pilot

451
00:28:06.730 --> 00:28:10.830
here. And then the dietician. So kidney patients are supposed to have

452
00:28:10.830 --> 00:28:15.130
a separate dietician, separate diet mentioned for them. You need to have

453
00:28:15.130 --> 00:28:18.630
a nurse who can handle over all your lines, the perma catheter

454
00:28:18.630 --> 00:28:22.430
or the dialysis catheter or any surgical site that has been placed.

455
00:28:22.430 --> 00:28:25.430
So nurse should take care of these patients. Apart from that, the

456
00:28:25.430 --> 00:28:29.030
patient care technician like the dialysis technician, he also should have an

457
00:28:29.030 --> 00:28:33.830
equal responsibility or he also should share the equal equal responsibility in

458
00:28:33.830 --> 00:28:37.530
saving a patient's life, especially when it comes to dialysis. And then

459
00:28:37.530 --> 00:28:41.830
next one is the administrator part. So yes, don't forget this part

460
00:28:41.830 --> 00:28:45.430
of the job which is being done by all the administrators because

461
00:28:45.430 --> 00:28:47.930
we will be in the ground level working at different stages like

462
00:28:47.930 --> 00:28:51.830
the dietician, the nursing, the patient care technicians and all. These people

463
00:28:51.830 --> 00:28:56.230
said these people will be on behind us, supporting us. These administrators

464
00:28:56.230 --> 00:28:59.130
will be supporting us based upon either it may be finances or

465
00:28:59.130 --> 00:29:01.930
whether it might be the equipment that is required to save the

466
00:29:01.930 --> 00:29:06.530
life of the patient or whether it might be concession when it

467
00:29:06.530 --> 00:29:09.530
comes to the financial bill or whether it might be various services

468
00:29:09.530 --> 00:29:11.630
they're going to provide for the patient. So you need to have

469
00:29:11.630 --> 00:29:16.630
an administrator also, who is an able administrator. I preferably think

470
00:29:16.630 --> 00:29:18.930
that a clinician will be a good administrator when it comes to

471
00:29:18.930 --> 00:29:23.430
hospitals and involving the social workers also. So these are the various

472
00:29:23.830 --> 00:29:27.430
a typical example of a patient-centric care here for the dialysis patient

473
00:29:27.430 --> 00:29:31.330
who is undergoing a routine dialysis here. So nephrologist or a critical

474
00:29:31.330 --> 00:29:34.630
care physician can be the pilot of all this care here. So

475
00:29:34.630 --> 00:29:38.030
generally my boss during my PG days, he used to say that

476
00:29:38.830 --> 00:29:44.130
post-graduation days that anesthesiologist, I'm from anesthesia background, anesthesiologist and then surgeon

477
00:29:44.130 --> 00:29:46.930
will be there inside the operation theater. So once you're trying to

478
00:29:46.930 --> 00:29:51.530
operate the patient, if things are fine, okay. So surgeon is the

479
00:29:51.630 --> 00:29:54.330
in charge. If the things are not fine, anesthesiologist they used to

480
00:29:54.330 --> 00:29:57.030
they used to say that when the ship is in sale, the

481
00:29:57.030 --> 00:29:59.430
surgeon is the captain of the ship. But when the ship is

482
00:29:59.430 --> 00:30:03.230
in storm, anesthesiologist is the captain of the ship. So whoever might

483
00:30:03.230 --> 00:30:07.530
be, they need to follow a patient-centric care model protocol so that

484
00:30:07.930 --> 00:30:11.030
once you follow this protocol, there not be any chances of missing

485
00:30:11.030 --> 00:30:14.630
or there not be any chances of mistrust between the patient and

486
00:30:14.630 --> 00:30:19.130
the attendants. There not be any conflicts between the patients and the

487
00:30:19.130 --> 00:30:23.230
patient's family along with the patient and patient's family here. So yes,

488
00:30:23.230 --> 00:30:27.730
the information to be very much clear, documented in detail in any

489
00:30:27.730 --> 00:30:31.230
understandable language of the patient here. Why are going to do that?

490
00:30:32.330 --> 00:30:35.130
I think if you can recognize this gentleman, Dr. Martanda Varma, who

491
00:30:35.130 --> 00:30:39.930
is the founder of Nimens Bangalore. So he he quoted in his

492
00:30:39.930 --> 00:30:43.630
regime that human achievement which you're doing is very much high, but

493
00:30:43.730 --> 00:30:47.530
what you're lagging is the humanness. Okay, we must have an integrated

494
00:30:47.530 --> 00:30:52.730
approach. The integrated approach is twice blessed. So it blesses the healer

495
00:30:52.830 --> 00:30:55.930
as well as the healed also. So once you have an integrated

496
00:30:55.930 --> 00:30:59.030
approach, at the end of the day, you also feel blessed. Yes,

497
00:30:59.030 --> 00:31:01.730
I have taken a good care of this patient again. Once I

498
00:31:01.730 --> 00:31:04.730
took a good care of this patient, I feel so much blessed

499
00:31:05.130 --> 00:31:08.830
for the patients and the patient's family here. So not not not

500
00:31:08.830 --> 00:31:13.230
always something has gone wrong with the patient. It's not something that

501
00:31:13.230 --> 00:31:17.030
has gone wrong with the patient always. The important thing is that

502
00:31:17.330 --> 00:31:20.630
one person has to examine the whole patient from top to bottom,

503
00:31:20.630 --> 00:31:24.030
where it might be nephro, euro, critical care, whatever might be the

504
00:31:24.030 --> 00:31:28.030
specialties. One doctor who is leading the team for that particular patient,

505
00:31:28.230 --> 00:31:32.130
he should be examining the patient from top to bottom. So then

506
00:31:32.130 --> 00:31:36.530
only you're going to find the diagnosis also here. So coming to

507
00:31:36.530 --> 00:31:41.830
other advantages of why to practice a patient-centric care here. Improved satisfaction

508
00:31:41.830 --> 00:31:44.830
will be there for the patient and service provided. So I think

509
00:31:44.830 --> 00:31:47.030
most of us will agree with that if you are going for

510
00:31:47.030 --> 00:31:51.130
a patient-centric approach, there is always a positive relationship with the patient's

511
00:31:51.130 --> 00:31:56.330
recovery, emotional health of the patient, physical functioning and physician physiological

512
00:31:56.330 --> 00:32:00.030
outcome of the patient and treatment satisfaction. The most important one is

513
00:32:00.030 --> 00:32:03.830
the treatment satisfaction. So no matter what you do, no matter how

514
00:32:03.830 --> 00:32:07.030
good you treat the patients, no matter how good you followed the

515
00:32:07.030 --> 00:32:11.130
protocols, no matter how good you are you're a master in your

516
00:32:11.130 --> 00:32:14.530
clinical knowledge and the theoretical knowledge. If you are not going to

517
00:32:14.530 --> 00:32:18.530
address the emotional health, if you're not going to address the physical

518
00:32:18.530 --> 00:32:23.830
functioning and physiological outcome of the patients, then ultimately the patients

519
00:32:23.830 --> 00:32:27.130
will not be satisfied with your treatment. The treatment will not change

520
00:32:27.130 --> 00:32:29.730
from India to US, it's not change from US to USA to

521
00:32:29.730 --> 00:32:32.930
UK when it comes to pharmacy, yeah. When it comes to pharmacy,

522
00:32:33.230 --> 00:32:36.730
I think treatment is always the same, but only thing that makes

523
00:32:36.730 --> 00:32:41.330
you unique compared to your fellow clinician is maintaining a positive relationship

524
00:32:41.330 --> 00:32:46.030
with the patient in terms of his recovery, emotional health, physical functioning

525
00:32:46.030 --> 00:32:49.330
and outcomes. So this will lead to improved adherence to you. So

526
00:32:49.330 --> 00:32:53.330
whatever happens to patient or their family and along with that improve

527
00:32:53.330 --> 00:32:56.530
adherence to the treatment plan. Once you explain them this is going

528
00:32:56.530 --> 00:33:00.730
to happen, then they're more likely that patients are going to adhere

529
00:33:00.730 --> 00:33:05.830
for a treatment plan. Okay. So they have

530
00:33:05.830 --> 00:33:08.730
they they show for you for appointments. So there will be always

531
00:33:08.730 --> 00:33:12.930
a better patient adherence if you're going to follow patient-centric care. Even

532
00:33:12.930 --> 00:33:16.630
in critical care too, so the patient is getting discharged from the

533
00:33:16.630 --> 00:33:20.230
ICU or discharged from the hospital. So you need to maintain that

534
00:33:20.230 --> 00:33:23.630
physical I mean like you need to maintain that relationship. You need

535
00:33:23.630 --> 00:33:26.030
to maintain the physical functioning of the patient. You need to think

536
00:33:26.030 --> 00:33:29.130
of the physiological outcomes of the patient and then maintaining a good

537
00:33:29.130 --> 00:33:31.830
positive relationship so that they will come back again to the critical

538
00:33:31.830 --> 00:33:35.730
care people and then they'll have an appointment with us. So that

539
00:33:35.730 --> 00:33:40.130
in that way you can improve your patient adherence also. So there

540
00:33:40.130 --> 00:33:43.830
are a lot of evidences saying that patient-centric model of communication if

541
00:33:43.830 --> 00:33:47.130
you promote the patient adherence to the doctor so the physicians here.

542
00:33:47.730 --> 00:33:51.730
Also there will be functional outcome that gets improved when there is

543
00:33:51.730 --> 00:33:56.530
a patient-centric care. The research done in various studies they show pure

544
00:33:56.530 --> 00:34:00.130
limitations only imposed by the disease and the functioning ability if you're

545
00:34:00.130 --> 00:34:05.130
following a patient-centric care. Most important thing is decreased litigations.

546
00:34:05.530 --> 00:34:11.030
The minute you convey the attendance regarding the disease process. So the

547
00:34:11.030 --> 00:34:15.530
minute you convey the attendance regarding the anticipated and unanticipated complications, the

548
00:34:15.530 --> 00:34:19.530
minute you convey the information properly, the minute you convey the information

549
00:34:19.530 --> 00:34:23.930
properly and properly plan B of your action. If everything has been

550
00:34:23.930 --> 00:34:29.330
conveyed properly, so many studies have demonstrated that physicians okay,

551
00:34:30.230 --> 00:34:34.030
who are delivering poor information are more likely to have litigations. So

552
00:34:34.030 --> 00:34:36.830
if you if you properly provide the information to the patient in

553
00:34:36.830 --> 00:34:40.130
terms of all what are discussed till now, there are less chance

554
00:34:40.130 --> 00:34:43.830
of litigation. So less chances of you being attending the court and

555
00:34:43.830 --> 00:34:47.030
then giving the explanation. So instead of attending the court and giving

556
00:34:47.030 --> 00:34:50.830
explanation why you have done this, you can better give the explanation

557
00:34:50.830 --> 00:34:54.130
on the bedside to the patient I in a counseling room to

558
00:34:54.130 --> 00:34:57.630
the patient attendants. So in a way you can decrease the litigation

559
00:34:57.630 --> 00:35:02.630
of your clinical practice, okay. So these are the various advantages. These

560
00:35:02.630 --> 00:35:07.030
are the various principles of patient-centric care which should be followed and

561
00:35:07.030 --> 00:35:10.130
these are the various advantages here. And coming to the what are

562
00:35:10.130 --> 00:35:15.230
the common questions? So what are the common doubts we generally generally

563
00:35:15.230 --> 00:35:17.630
think when you say when you say when comes someone comes and

564
00:35:17.630 --> 00:35:22.730
says kindly provide a patient-centric care. The thing is common questions is

565
00:35:22.730 --> 00:35:27.730
conflict between the patient's expectations and medical assessment. So whenever there's a

566
00:35:27.730 --> 00:35:31.830
conflict between the patient expectations and medical assessment, you need to have

567
00:35:31.830 --> 00:35:34.930
a patient-centric care. You have to sit down with the patient, what

568
00:35:34.930 --> 00:35:38.130
is his expectation? So what is he expecting to do now after

569
00:35:38.130 --> 00:35:44.030
the treatment? So once the patient expectations has been clearly communicated,

570
00:35:44.430 --> 00:35:47.830
then give them the medical assessment plan and then give them the

571
00:35:47.830 --> 00:35:52.330
chances of recovery here. So if there is a quadriplegic patient comes

572
00:35:52.330 --> 00:35:56.730
to you with a if you see spine patient, she's traumatic cervical

573
00:35:56.730 --> 00:36:00.930
spine patient with a quadriplegia. So his expectation might be he'll be

574
00:36:00.930 --> 00:36:05.130
walking normally and talking normally like a normal routine patient. But as

575
00:36:05.130 --> 00:36:08.330
per the medical assessment, our expectation that he's going to be bed

576
00:36:08.330 --> 00:36:12.230
bound for his life because a traumatic quadriplegia, the chances of recovery

577
00:36:12.230 --> 00:36:15.930
are going to pretty pretty less. So we need to reconcile on

578
00:36:15.930 --> 00:36:20.130
the conflicting views. Being a physician, you need to understand the expectation

579
00:36:20.130 --> 00:36:23.730
of the patient. If the expectations are very much high, once your

580
00:36:23.730 --> 00:36:26.330
medical assessment is done, you need to give the option to the

581
00:36:26.330 --> 00:36:30.430
patient saying that sir, this is the treatment plan, but in spite

582
00:36:30.430 --> 00:36:34.130
of treatment, he might be bed bound. The chances of him getting

583
00:36:34.130 --> 00:36:39.130
recovery might be less. That's the important thing. Does it risk your

584
00:36:39.130 --> 00:36:43.430
invading privacy of the doctor? Okay. So in this competitive world, generally

585
00:36:43.430 --> 00:36:46.630
everyone of us were talking to the patient attendants, shifting the patients

586
00:36:46.630 --> 00:36:50.230
here and there to maintain the integrity and all those things. But

587
00:36:50.230 --> 00:36:54.130
compared to that, this patient-centric care is not going to risk the

588
00:36:54.430 --> 00:36:58.230
privacy of the treating in privacy of the treating doctors here. In

589
00:36:58.230 --> 00:37:02.130
spite the other way around, it allows and encourages expression without forcing.

590
00:37:02.530 --> 00:37:04.430
So no one is going to trouble you at the middle of

591
00:37:04.630 --> 00:37:07.830
of a night. But in the daytime, once you give them the

592
00:37:07.830 --> 00:37:11.830
reconcile and the consolidation what they want from you. So what will

593
00:37:11.830 --> 00:37:15.730
happen now? So you can make the patient, you can make the

594
00:37:15.730 --> 00:37:20.730
patient understand and accept the disease without forcing him. And their

595
00:37:20.730 --> 00:37:25.230
privacy will also be respected when it comes to doctor-patient relationships. Does

596
00:37:25.230 --> 00:37:28.330
you always use this method is one more question? I don't think

597
00:37:28.330 --> 00:37:33.230
we'll use this method unless unless the patient attendants or we are

598
00:37:33.430 --> 00:37:36.330
what are you say determined to start this off in a particular

599
00:37:36.330 --> 00:37:39.830
ICUs or in a particular set of patients here. So it's not

600
00:37:39.830 --> 00:37:43.230
always, but always you need to ask. Is it time consuming is

601
00:37:43.230 --> 00:37:46.530
one more thing? Average length, if you can take an average length

602
00:37:46.530 --> 00:37:50.930
in India of and a physician's official visit plus physical examination, whatever

603
00:37:50.930 --> 00:37:54.030
might be the model, so it's around 21 minutes. The minute the

604
00:37:54.030 --> 00:37:57.630
phone call comes to the physicians, the average length of the office

605
00:37:57.630 --> 00:38:02.830
visit plus examination everything together is 21 minutes. So it's not that

606
00:38:02.830 --> 00:38:06.630
much time consuming here, but lot of times gets wasted in doctor-centric

607
00:38:06.630 --> 00:38:10.730
visits. Why? Because in a doctor-centric whistle, what happens? Doctor goes on

608
00:38:10.730 --> 00:38:14.230
to the particular patient's home. He'll get information about the medicines that

609
00:38:14.230 --> 00:38:19.230
he's using and sometimes patient or patient attendance might not be

610
00:38:19.230 --> 00:38:23.630
knowing that that they are using some particular medicine. They're using some

611
00:38:23.630 --> 00:38:28.630
alternate medicine instead of a required medication and all. So remember guys,

612
00:38:28.630 --> 00:38:32.130
in patient-centric visits, the doctor talks less and the patient says more.

613
00:38:32.130 --> 00:38:35.430
It's only you listening to the patient and regarding his outcomes and

614
00:38:35.430 --> 00:38:40.230
all. So to summarize the patient-centric care here, so what are the

615
00:38:40.230 --> 00:38:43.330
qualities a physician should have or whatever the qualities a critical care

616
00:38:43.330 --> 00:38:47.030
physician or treating physician should have? So it should be a comprehensive

617
00:38:47.030 --> 00:38:50.430
for them. So no need to explain them all the disease process,

618
00:38:50.630 --> 00:38:54.230
how the clock, how the like the diabetic keto, how the ketones

619
00:38:54.230 --> 00:38:56.630
forms, what are the metabolism of ketones inside the one. No need

620
00:38:56.630 --> 00:39:01.630
to explain everything. Let's be comprehensive. Just tell them that his sugar

621
00:39:01.630 --> 00:39:04.030
levels are should up leading to the acids in the body. That's

622
00:39:04.030 --> 00:39:07.630
it. And it should be a continuous note. Always counsel the patients

623
00:39:07.630 --> 00:39:12.130
on a regular basis daily in a continuous note. Be accessible for

624
00:39:12.130 --> 00:39:14.830
your patients so in a way you can trust or in a

625
00:39:14.830 --> 00:39:17.730
way you can gain the trust of the patient or attendants or

626
00:39:17.730 --> 00:39:22.030
also you can have a better better adherence policy compared to other

627
00:39:22.030 --> 00:39:27.030
physicians here. And then be your mind, keep your mind patient

628
00:39:27.030 --> 00:39:32.130
and family-centric always. Sometimes even though I'm an echo physicians,

629
00:39:32.430 --> 00:39:35.030
sometimes I know how to place an echo on a patient who

630
00:39:35.030 --> 00:39:38.330
is dying in front of me with a lung failure. But still

631
00:39:38.730 --> 00:39:41.330
we just because I know how to place an echo, it doesn't

632
00:39:41.330 --> 00:39:44.830
warrant me to go ahead and place echo on the patient without

633
00:39:44.830 --> 00:39:48.430
taking proper consent from the family or without being family informed about

634
00:39:48.430 --> 00:39:53.730
the treatment. So always keep your mind a patient and family-centric thing

635
00:39:53.930 --> 00:39:57.230
and it should be coordinated. So once you get the patient admitted

636
00:39:57.230 --> 00:40:00.630
under your care, you should coordinate so many things within the lab,

637
00:40:00.630 --> 00:40:04.530
the radiology part and coordinating the treatment part and these things should

638
00:40:04.530 --> 00:40:07.930
be coordinated and be accountable at the end of the day. So

639
00:40:07.930 --> 00:40:11.430
once you do all these things, yes, if something happens, bishop happens

640
00:40:11.430 --> 00:40:14.130
inside ICU, you should be accountable for all that bishops that have

641
00:40:14.230 --> 00:40:18.030
happened. Otherwise that it means that you then didn't develop the protocols

642
00:40:18.030 --> 00:40:23.330
in a particular ICU. So be accountable, accessible, continuously available,

643
00:40:23.730 --> 00:40:28.430
comprehensive treatment plan, patient and family-centric one and it should be properly

644
00:40:28.430 --> 00:40:32.330
coordinated. Everything makes a beautiful house. So once all these things are

645
00:40:32.330 --> 00:40:36.430
being addressed, I think patients will adhere you like like the patient

646
00:40:36.430 --> 00:40:39.230
will adhere you with with you for the treatment plans and all.

647
00:40:40.730 --> 00:40:43.830
So make yourselves decide which side yourself, good side you want to

648
00:40:43.830 --> 00:40:47.930
be, whether it's a patient-centric care or illness-centric care. So I I

649
00:40:47.930 --> 00:40:51.330
need to be unique, so I need to follow both the things

650
00:40:51.530 --> 00:40:54.730
as and when it comes along with the patient-to-patient basis. It's not

651
00:40:54.730 --> 00:40:59.630
going to be a single model applying for everyone. It's a tailored

652
00:40:59.630 --> 00:41:03.630
based model wherein I'll decide with the patient attendants. I 'll sit

653
00:41:03.630 --> 00:41:06.730
down daily with them and then discuss them the pros and cons

654
00:41:06.730 --> 00:41:10.730
of what is happening and to the patient and based upon their

655
00:41:11.130 --> 00:41:15.030
insights, I'll take a decision here. So try to be unique, try

656
00:41:15.030 --> 00:41:18.030
to communicate with the patient attendants all the time that are going

657
00:41:18.030 --> 00:41:21.830
to save you money, time and save you from so many litigations

658
00:41:21.830 --> 00:41:26.930
too. So by this I'll try to conclude this

659
00:41:26.930 --> 00:41:32.630
patient-centric care. So any doubts, I'm so happy to answer guys. Thank

660
00:41:32.630 --> 00:41:38.330
you sir. Thank you so much for such an insightful presentation. So

661
00:41:38.330 --> 00:41:42.430
we have some questions from the attendees. So can we move to

662
00:41:42.430 --> 00:41:47.830
the Q&A? Yes, yes, yes, Suparna. Yes, sir. So

663
00:41:47.830 --> 00:41:52.830
sir, sir one question is

664
00:41:53.630 --> 00:41:58.330
how do you incorporate patient values in the end of life care

665
00:41:58.330 --> 00:42:03.530
discussions? So see end of life care discussions is the pretty important

666
00:42:03.530 --> 00:42:07.730
discussion when it comes to critical care. So a critical care physician,

667
00:42:07.730 --> 00:42:10.730
as I'm quoting earlier, you need to have the whole team with

668
00:42:10.730 --> 00:42:14.430
you while discussing regarding the patient things. So you need to put

669
00:42:14.430 --> 00:42:19.830
forward the diagnosis, the staging of diagnosis, the outcomes of the patient,

670
00:42:20.430 --> 00:42:25.330
what are the chances of survival based upon diseased disease-based prognostic scores

671
00:42:26.130 --> 00:42:30.230
and options available. So in the options available, we'll give him the

672
00:42:30.230 --> 00:42:33.330
options of end of life care. So in the end of life

673
00:42:33.330 --> 00:42:36.230
care again, you need to tell them what you're going to do.

674
00:42:36.830 --> 00:42:40.030
So I'm just going to give this medication for the pain relief.

675
00:42:40.330 --> 00:42:44.830
This medication has a multivitamin. This medication only to decrease the spread

676
00:42:44.830 --> 00:42:48.130
of the disease or decrease the spread of the infection, decrease the

677
00:42:48.130 --> 00:42:52.530
spread of the malignancy, something like that. And make them understand what

678
00:42:52.530 --> 00:42:56.430
you're doing, what you're not doing here. So by saying what you're

679
00:42:56.430 --> 00:42:59.530
not doing, it will be clear-cut communication between you and the family

680
00:42:59.530 --> 00:43:03.430
attendants. And by saying what you're doing, they'll understand that it's a

681
00:43:03.430 --> 00:43:06.530
palliative care what max at the max a doctor can do at

682
00:43:06.530 --> 00:43:10.430
this particular point so that you can you can make the patient

683
00:43:10.430 --> 00:43:15.430
happy at the end of the day avoiding unnecessary

684
00:43:15.830 --> 00:43:19.330
subjecting him to so many invasive procedures and all those things. So

685
00:43:19.330 --> 00:43:25.330
it's only for this we have a spikes protocol. So

686
00:43:25.330 --> 00:43:29.430
in this spikes protocol, you need to understand the situation. You you

687
00:43:29.430 --> 00:43:35.230
need to understand the situation for the spikes pro protocol. S

688
00:43:35.230 --> 00:43:38.730
for spikes, P for the perseverance of the patient's family, I for

689
00:43:38.730 --> 00:43:43.830
the information, K for the knowledge, E for the empathy, okay,

690
00:43:43.830 --> 00:43:48.230
and S for the complete decision funding and all. So follow up

691
00:43:48.230 --> 00:43:51.430
the spikes protocol, try to sit down with the patients, try to

692
00:43:51.430 --> 00:43:56.530
understand the patients of I mean like patients thought process, discuss

693
00:43:56.530 --> 00:43:59.030
with the family, come to a conclusion of end of life care

694
00:43:59.030 --> 00:44:03.230
decisions and clearly document what you're going to do, what you're not

695
00:44:03.230 --> 00:44:08.730
going to do even it's an end of life care. Thank

696
00:44:08.730 --> 00:44:13.830
you sir. Sir, the next question is what to do

697
00:44:13.830 --> 00:44:18.830
sir when patients and their attendees attendees don't listen to reason?

698
00:44:19.330 --> 00:44:22.630
They say they want to shift the patient to other hospital even

699
00:44:22.630 --> 00:44:27.930
when patient is unstable. How to manage such situation? Good

700
00:44:27.930 --> 00:44:32.030
practical question. So most of the critical care physicians will face this

701
00:44:32.030 --> 00:44:37.330
question generally. So the the the the answer for this question

702
00:44:37.330 --> 00:44:41.230
comes from the time of admission itself. The minute the patient gets

703
00:44:41.230 --> 00:44:45.830
admitted into your ICU, so you need to make sure that the

704
00:44:45.830 --> 00:44:49.930
patient attendants has to understand the reason why was he here. So

705
00:44:50.030 --> 00:44:54.130
say for example, an MI patient comes to us with a hypertension

706
00:44:54.130 --> 00:44:58.530
saying chest pain. The minute they enter the ICU, counsel them that

707
00:44:58.530 --> 00:45:00.830
this patient has got a severe heart attack. You need to go

708
00:45:00.830 --> 00:45:04.530
ahead and do the ballooning and then try to save the life

709
00:45:04.530 --> 00:45:08.330
of the patient. So they need to understand the reason first. Once

710
00:45:08.330 --> 00:45:11.430
they understand the reason and once they feel that reason what you're

711
00:45:11.430 --> 00:45:16.830
telling is connected to the patient's clinical status. Okay, for example, most

712
00:45:16.830 --> 00:45:19.330
of them is not going to match, but if it is matching,

713
00:45:19.430 --> 00:45:23.330
they'll definitely understand the first part. Once they say they want to

714
00:45:23.330 --> 00:45:26.230
shift the patient to another hospital, even if the patient is unstable,

715
00:45:26.630 --> 00:45:30.130
the same thing, the same answer is try to sit down, tell

716
00:45:30.130 --> 00:45:32.530
them in the step one itself that this patient is suffering from

717
00:45:32.530 --> 00:45:37.030
massive heart attack and the patient condition is very much unstable. We

718
00:45:37.030 --> 00:45:40.330
do have the facility of keeping a stunting here. If you accept,

719
00:45:40.330 --> 00:45:43.330
I'll go ahead and stunting. If you accept, it's up to your

720
00:45:43.330 --> 00:45:46.830
wish. Even though if you say the patient is unstable, we don't

721
00:45:46.830 --> 00:45:49.630
have I mean like the even if we communicate them that saying

722
00:45:49.630 --> 00:45:52.830
the patient is unstable with the grave diagnosis and then the family

723
00:45:52.830 --> 00:45:55.630
says no sir, I want what to shift the patient to another

724
00:45:55.630 --> 00:45:58.730
hospital. You're not going to stop them. You don't have any right

725
00:45:58.730 --> 00:46:03.430
to stop them. We have only time, we have only right to

726
00:46:03.430 --> 00:46:07.930
make them understand the disease and the criticality of the situation. You

727
00:46:07.930 --> 00:46:11.030
don't have any right to stop them. If they understand you or

728
00:46:11.430 --> 00:46:14.730
the patient condition and if they understand the instability, they'll stay with

729
00:46:14.730 --> 00:46:20.030
us. If they don't understand in those particular situations, try to make

730
00:46:20.030 --> 00:46:23.330
a audio-video counseling that these things has been spoken to the family

731
00:46:23.330 --> 00:46:27.730
in prior point two as the patient is unstable, anything might happen

732
00:46:27.730 --> 00:46:32.930
during the shifting. Point three because you're delaying to shift the patient

733
00:46:32.930 --> 00:46:35.930
to another hospital. So the procedure is not being done. That is

734
00:46:35.930 --> 00:46:40.030
going to add for your outcomes. Point four during the transit process,

735
00:46:40.130 --> 00:46:44.630
if something happens, we are not responsible. So you need to explain

736
00:46:44.630 --> 00:46:49.230
all these things in an audio-video counseling. If possible, try to write

737
00:46:49.230 --> 00:46:52.330
it down in a paper and take the consent of the family

738
00:46:52.830 --> 00:46:55.530
and then send the patients. So no one is going to question

739
00:46:55.530 --> 00:46:58.730
us if these two things were there. If there's a proper audio-video

740
00:46:58.730 --> 00:47:03.830
counseling regarding the disease, instability and criticality of the condition, chances

741
00:47:03.830 --> 00:47:08.230
of death during transport and the same thing has been documented on

742
00:47:08.230 --> 00:47:11.230
paper also. I think we are safe in the court of law.

743
00:47:12.130 --> 00:47:15.630
So it starts from the point of admission itself. You cannot leave

744
00:47:15.630 --> 00:47:18.830
the patient whole night. Try to counsel the patient next day when

745
00:47:18.830 --> 00:47:22.230
you come for rounds. The minute the patient gets admitted, they need

746
00:47:22.230 --> 00:47:25.830
to understand the severity of the disease and the critical condition of

747
00:47:25.830 --> 00:47:30.830
the patient. Thank you sir. So as you mentioned

748
00:47:30.830 --> 00:47:37.430
sir, recording the statement is very important with the patient. So

749
00:47:37.930 --> 00:47:42.930
sir, moving on to the next question. Sir, should patient

750
00:47:42.930 --> 00:47:47.230
be told about the option of DNR and when? In India, most

751
00:47:47.230 --> 00:47:51.030
of them don't know about it. Afterwards, when they get to know

752
00:47:51.230 --> 00:47:56.230
about this, they blame us. Yeah, so this is

753
00:47:56.230 --> 00:47:59.930
also practical question, Suparna. So much practical that I think the person

754
00:47:59.930 --> 00:48:02.530
who is asking this question is probably might be an intensivist or

755
00:48:02.830 --> 00:48:07.930
thinking. So so once you give an option of

756
00:48:07.930 --> 00:48:11.330
DNR, no, the minute so if there are multiple connections to answer

757
00:48:11.330 --> 00:48:14.630
this question here, should patient be told about the option of DNR?

758
00:48:14.630 --> 00:48:18.130
When it should be told? Yes, the option of DNR should be

759
00:48:18.130 --> 00:48:22.730
told to the patient. But if the patient condition if you think

760
00:48:22.730 --> 00:48:27.330
the patient condition is irreversible, if you think the patient is not

761
00:48:27.330 --> 00:48:31.330
responding to the treatment, say for example, if the patient comes to

762
00:48:31.330 --> 00:48:35.630
you with a urinary tract infection on day one with some septic

763
00:48:35.630 --> 00:48:39.430
shock without giving him at least at least three to five doses

764
00:48:39.430 --> 00:48:42.930
of antibiotics, you cannot go ahead and counsel the patient for the

765
00:48:42.930 --> 00:48:47.630
DNR. Okay, the minute you say DNR, they might accept. But but

766
00:48:47.630 --> 00:48:50.630
you but the but the but the ethical principle of you as

767
00:48:50.630 --> 00:48:54.130
a physician is not going to get satisfied. So you need to

768
00:48:54.130 --> 00:48:56.830
tell them there is a severe urinary tract infection. We are trying

769
00:48:56.830 --> 00:49:00.830
to treat them with antibiotics. The minute he starts collapsing or the

770
00:49:00.830 --> 00:49:04.830
minute he is not responding to your treatment or whenever you feel

771
00:49:04.830 --> 00:49:09.030
the condition is irreversible or whenever you feel the patient is not

772
00:49:09.030 --> 00:49:12.730
at all responding to your therapy and it's going to be much

773
00:49:12.730 --> 00:49:17.130
much more invasive. There are different prognostic scoring systems, the sofa score,

774
00:49:17.830 --> 00:49:21.330
the Apache two scoring system as I mentioned. It's a generalized scoring

775
00:49:21.330 --> 00:49:26.430
systems for prognosis in ICU. And a disease-based

776
00:49:26.830 --> 00:49:31.230
prognostic scoring systems are also there. So combining all these three things,

777
00:49:31.530 --> 00:49:36.130
if the mortality is exceeding more than 90 percentage, in those situations,

778
00:49:36.130 --> 00:49:39.630
just you can sit back to them, tell them the positive things.

779
00:49:40.530 --> 00:49:43.530
Sir, you came with so and so situation. I tried with all

780
00:49:43.530 --> 00:49:48.130
the high-end antibiotics, but you know because because of the drugs, the

781
00:49:48.130 --> 00:49:51.830
bacteria that is coming out is turned out to be multi-drug resistant.

782
00:49:52.430 --> 00:49:56.230
Your patient is not responding to the antibiotics. So they might ask

783
00:49:56.230 --> 00:49:59.030
us ask us why he is not responding? Are you giving the

784
00:49:59.030 --> 00:50:01.600
correct treatment or not? are they giving antibiotics or not? There are

785
00:50:01.600 --> 00:50:04.200
so many doubts in the patient attendance. So you need to tell

786
00:50:04.200 --> 00:50:08.200
them yes, in spite of giving everything, the bacteria will become drug

787
00:50:08.200 --> 00:50:12.500
resistant because of the exposure, because of the load, amount of bacterial

788
00:50:12.500 --> 00:50:15.200
load or because of the delay by which they have come to

789
00:50:15.200 --> 00:50:18.000
the hospital. So you need to tell them in detail of all

790
00:50:18.000 --> 00:50:23.000
those those things and then say them the chances. Sir, the chances

791
00:50:23.000 --> 00:50:26.300
are pretty low now. So based upon this scoring or no need

792
00:50:26.300 --> 00:50:29.300
to tell them about the scoring system name. You can tell that

793
00:50:29.300 --> 00:50:32.000
based upon my experience, the chance of survival going to be less

794
00:50:32.000 --> 00:50:35.900
than 10 percentage and then give them the options. So in this

795
00:50:35.900 --> 00:50:39.400
situation also, I'm not going to give up, but I'm having three

796
00:50:39.400 --> 00:50:44.400
options now. First option is completely escalating the antibiotics whichever is possible

797
00:50:44.400 --> 00:50:48.500
in the market. Second option is comfort care or DNR which I

798
00:50:48.500 --> 00:50:52.800
mean the the the speaker has spoken like someone is asking it

799
00:50:52.800 --> 00:50:56.400
here. The third option is if you have a doubt, go for

800
00:50:56.400 --> 00:51:00.600
a second opinion on this. Okay, the minute you say second opinion,

801
00:51:00.600 --> 00:51:05.600
most of the attendees will get pacified because before they asking us

802
00:51:05.600 --> 00:51:09.600
about the second opinion, offer them the second opinion from your side.

803
00:51:10.100 --> 00:51:12.700
If you offer them saying that, sir, you can go for a

804
00:51:12.700 --> 00:51:15.000
second opinion and come back to us what else can be done

805
00:51:15.000 --> 00:51:18.700
extra. The minute you say that, yes, they might think that you

806
00:51:18.700 --> 00:51:23.200
are pretty much you are transparent enough so that and you can

807
00:51:23.200 --> 00:51:26.300
also say them that they have equal right of taking the reports

808
00:51:26.300 --> 00:51:30.100
also. So say them that yes, I'm giving you the reports. You

809
00:51:30.100 --> 00:51:32.900
can go to any other doctor you want, get a second opinion

810
00:51:32.900 --> 00:51:35.700
of the doctor and then come back to us and then decide

811
00:51:35.700 --> 00:51:39.000
about the options. Meanwhile, all the treatment will be going on. But

812
00:51:39.000 --> 00:51:42.800
her is given the diagnosis and situation his chances of survival are

813
00:51:42.800 --> 00:51:46.700
going to be less than 10 percentage. So that's how we need

814
00:51:46.700 --> 00:51:50.000
to tell them or break them the option of DNR. If you

815
00:51:50.000 --> 00:51:53.800
say DNR on day one or day two, what will happen now?

816
00:51:54.100 --> 00:51:58.800
So unnecessarily the DNR incidence will increase in your ICUs, which is

817
00:51:58.800 --> 00:52:01.900
not a good quality indicator. That means that you are not trying

818
00:52:01.900 --> 00:52:06.600
trying for the patient. So try initially for at least 48 hours

819
00:52:06.600 --> 00:52:09.800
after the arrival of the patient, make them understand. But if you

820
00:52:09.800 --> 00:52:14.500
know the diagnosis prior, say for example, I see a colon patient

821
00:52:14.600 --> 00:52:18.300
with a distant mets presents to you with severe SOB and a

822
00:52:18.300 --> 00:52:22.500
malignant pleural effusion on one side. So you need to sit down

823
00:52:22.500 --> 00:52:25.800
and say I'm going to do a procedure called ICD placement, which

824
00:52:25.800 --> 00:52:29.400
is not a treatment. It's just a symptomatic relief one. But after

825
00:52:29.400 --> 00:52:33.100
placing ICDs, so what is the where is the exit pathway? Where

826
00:52:33.100 --> 00:52:35.900
you're going to remove it or whether you're going to do some

827
00:52:36.800 --> 00:52:40.800
corticotomy or lobectomy, something like that should be discussed. And then you

828
00:52:40.800 --> 00:52:43.400
can say that in spite of doing all these things, you can

829
00:52:43.500 --> 00:52:45.900
you can you can opt a DNR also. If you know the

830
00:52:45.900 --> 00:52:49.700
diagnosis prior and if you know it's irreversible disease, you can give

831
00:52:49.700 --> 00:52:53.900
an option of DNR on day one itself. And if the patient

832
00:52:53.900 --> 00:52:57.100
is deteriorating or the patient comes in a critical condition, try at

833
00:52:57.100 --> 00:53:01.400
least for 48 hours is my suggestion. And my statement might not

834
00:53:01.400 --> 00:53:04.600
hold good in a general way. So it will be it's a

835
00:53:04.600 --> 00:53:08.200
tailored made for every patient to patient. So you can take 48

836
00:53:08.200 --> 00:53:10.700
hours, sometimes you can take 72 hours and then give them an

837
00:53:10.700 --> 00:53:15.800
option of DNR available. You can do this one because all

838
00:53:15.800 --> 00:53:19.100
my treatment is not going to save the patient's life. It's just

839
00:53:19.100 --> 00:53:23.600
postponing the death. I'm not going to prevent the death also. So

840
00:53:23.600 --> 00:53:27.600
that's how you need to communicate your DNR statuses. So it's not

841
00:53:27.600 --> 00:53:31.000
should be on day one. It should be patient to patient based

842
00:53:31.000 --> 00:53:36.200
and it should be done once it should be done once once

843
00:53:36.200 --> 00:53:40.700
you know the prognosis very well and once the patient understands the

844
00:53:40.700 --> 00:53:46.600
disease very well. Thank you, sir. Thank you for your answer. Sir,

845
00:53:46.600 --> 00:53:51.600
we have a last question. What happens if diagnosis is wrong

846
00:53:51.600 --> 00:53:55.700
and treatment has to be changed? How to convey that to patient

847
00:53:55.700 --> 00:54:00.800
family without losing trust? The diagnosis is wrong and then what

848
00:54:00.800 --> 00:54:04.500
happened? What's the next thing? What happens if diagnosis is wrong and

849
00:54:04.500 --> 00:54:08.600
the treatment has to be changed? Okay. How to convey that to

850
00:54:08.600 --> 00:54:13.800
patient family without losing trust? So you yes. So

851
00:54:13.800 --> 00:54:18.900
for this thing, the question is the dynamics changes in

852
00:54:18.900 --> 00:54:23.000
the ICU, the dynamics changes in the patient. It's a dynamic process

853
00:54:23.000 --> 00:54:27.300
that changes. The patient might come with one diagnosis, might land up

854
00:54:27.300 --> 00:54:32.500
in another diagnosis. So in those situations, say for example, the patient

855
00:54:32.500 --> 00:54:37.300
comes with a lung infection, LRTI. What happens after a period of

856
00:54:37.300 --> 00:54:41.800
time? He might land up in a pneumothorax causing an ICD or

857
00:54:41.800 --> 00:54:44.600
he might land up in a septic shock or a bloodstream like

858
00:54:44.600 --> 00:54:49.400
infection and succumbs to death. So now going and talking to the

859
00:54:49.400 --> 00:54:55.000
patient, don't leave your primary diagnosis. So don't forget your LRTI. Try

860
00:54:55.000 --> 00:54:58.900
to convince them that this complication has arrived because of your primary

861
00:54:58.900 --> 00:55:03.600
diagnosis of LRTI. If it's a blunder, yes, we need to admit

862
00:55:03.600 --> 00:55:06.600
in front of them saying that because of this this thing happened.

863
00:55:07.200 --> 00:55:11.300
If it is just a consequence of the primary disease, don't try

864
00:55:11.300 --> 00:55:14.200
to confuse them with all your diagnosis. So there might be an

865
00:55:14.200 --> 00:55:18.600
LRTI. This might turn out to an MI after they come to

866
00:55:18.600 --> 00:55:21.900
the hospital and then the patient may die of MI rather than

867
00:55:21.900 --> 00:55:26.200
dying of LRTI. So in the first instance, you can go and

868
00:55:26.200 --> 00:55:30.100
counsel them saying that patient has got severe lung infection and then

869
00:55:30.300 --> 00:55:33.000
when the patient deteriorates, if you go and say, sir, there is

870
00:55:33.000 --> 00:55:35.600
a heart attack for the patient, then he's not going to believe

871
00:55:35.600 --> 00:55:40.000
you on instantly every human nature is that sir, day one they're

872
00:55:40.000 --> 00:55:42.600
telling it's a lung infection, day two they're telling it's a heart

873
00:55:42.600 --> 00:55:45.600
attack and all. Stick on to the lung infection which is there

874
00:55:45.600 --> 00:55:49.900
for the patient. So because of lung infections, because of decreased oxygen

875
00:55:49.900 --> 00:55:53.500
supply to the heart, what has happened? The patient landed up in

876
00:55:53.500 --> 00:55:57.400
a heart attack. So try to make the link between the initial

877
00:55:57.400 --> 00:56:02.300
disease process and then the complication which has faced and then because

878
00:56:02.300 --> 00:56:05.000
of this complication, the patient has succumbed. In that way, if you

879
00:56:05.000 --> 00:56:08.900
maintain the link, I think patient's trust can be gained very much

880
00:56:08.900 --> 00:56:13.500
easily. But if you confuse as I said, critical care physician goes

881
00:56:13.500 --> 00:56:17.500
and says it's LRTI causing death. The cardiologist goes and says that

882
00:56:17.600 --> 00:56:20.000
it 's not my MI, it's lung that's causing death. And the

883
00:56:20.000 --> 00:56:22.700
pulmonologist goes and says it's not my lung, the heart is causing

884
00:56:22.700 --> 00:56:25.800
the death. So that's why you need to have only one pilot

885
00:56:25.800 --> 00:56:29.800
for the whole for the whole communication part. Preferably if the patient

886
00:56:29.800 --> 00:56:33.600
is in ICU, I want my critical care physician as a communication

887
00:56:33.600 --> 00:56:38.300
leader. So he can take the inputs from different different specialties and

888
00:56:38.300 --> 00:56:41.500
communicate to the patient. So in that way, you can avoid conflicts.

889
00:56:42.800 --> 00:56:48.000
And second part, if you are absolutely wrong in diagnosis, I

890
00:56:48.000 --> 00:56:51.200
think go forward to them, sit down to them, what this has

891
00:56:51.200 --> 00:56:56.100
led to. So these are the confounding factors wherein my diagnosis went

892
00:56:56.100 --> 00:56:58.500
in this direction, but that is not the way. This is the

893
00:56:58.500 --> 00:57:02.400
actual diagnosis. So that option also there, but you need to admit

894
00:57:02.400 --> 00:57:06.100
them in front of the patient directly itself saying that and they

895
00:57:06.100 --> 00:57:08.800
need to understand what are the confounding factors. It might be the

896
00:57:08.800 --> 00:57:12.800
age or whether it may be the presenting symptoms that has completely

897
00:57:12.800 --> 00:57:17.100
changed the diagnosis. The patient comes to you with severe vomiting, SOB.

898
00:57:17.300 --> 00:57:21.000
So you might be thinking that a lung infection. Don't try to

899
00:57:21.000 --> 00:57:24.900
counsel them before you have a evidence. So in the initial diagnosis

900
00:57:25.100 --> 00:57:28.600
counseling, give them the options. It might be lung infection, it might

901
00:57:28.600 --> 00:57:32.800
be gallbladder infection or cholangitis or it might be what do you

902
00:57:32.800 --> 00:57:37.700
say? Kidney urinary tract infection. So give them the options. So once

903
00:57:37.900 --> 00:57:42.600
your radiological, clinical completely mets, then go go to them and talk

904
00:57:42.600 --> 00:57:45.200
them that yes, I have ruled this this this out. So he

905
00:57:45.200 --> 00:57:49.400
is ultimately having a urinary tract infection. The treatment is going. So

906
00:57:49.400 --> 00:57:52.100
you need to tell those in. So immediately the minute you saw

907
00:57:52.300 --> 00:57:54.800
we can go and say patient is having lung infection. Second day,

908
00:57:54.900 --> 00:57:57.800
no no, it's a urinary tract infection, not lung infection. Third day,

909
00:57:58.000 --> 00:58:01.400
no no, it's a gallbladder after the ultrasound. So keep your options

910
00:58:01.400 --> 00:58:05.100
open while counseling. And if it is a complication, don't forget your

911
00:58:05.100 --> 00:58:09.600
primary diagnosis. Try to put in the complication into your primary diagnosis

912
00:58:09.600 --> 00:58:15.000
so that they can also understand what has happened. Thank

913
00:58:15.000 --> 00:58:20.000
you, sir. Thank you so much for clarifying all the doubts and

914
00:58:20.000 --> 00:58:23.400
sharing your knowledge with us. That brings us to the end of

915
00:58:23.400 --> 00:58:27.300
the session. I thank you all for attending our session today. I

916
00:58:27.300 --> 00:58:30.800
hope you enjoyed today's session and learn something new that you can

917
00:58:30.800 --> 00:58:35.200
implement in your daily practice. You can visit Some questions were there

918
00:58:35.200 --> 00:58:40.600
in webinar chat Is that there? No,

919
00:58:40.600 --> 00:58:46.100
sir. Thanking you. Okay, fine. Yeah. Okay.

920
00:58:47.000 --> 00:58:50.500
Okay. And thank you so much, sir, once again for joining us

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00:58:50.500 --> 00:58:53.900
today and thank you one and all. Have a great rest of

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00:58:53.900 --> 00:58:56.700
the day. Thank you. Thank you guys. Have a nice day.