Choosing the Right Tool for the Job

The Role of Blood Gas Tests in Intensive Care

In the intensive care unit, one of the most common and useful tests that differentiates it from most other areas in the hospital is the blood gas. It consists of taking a sample of blood from an artery, vein, or capillary bed and measuring carbon dioxide, oxygen, and the acid/base status. The blood sample is obtained in a myriad of critical care situations, such as respiratory distress, shock, and sepsis, to name a few. The results help assess a person’s breathing, lung function, oxygen transport to cells, and electrolyte disturbances as they affect the acid/base balance in the blood. It helps inform the clinical team of the severity of the illness of a patient and what actions to take. From an intensive care physician’s standpoint, it offers a detailed insight into a patient’s physiological state.

As a pediatric intensivist, I spent years reviewing blood gas results in a wide variety of situations. It was very routine and not considered something out of the ordinary. So, when my wife and I opened a pediatric urgent care, I had to have a blood gas machine of my own. It was something that I was familiar with. I could use the machine to assess how severely dehydrated a child was or how much trouble they were having with their breathing. I was so excited at the prospect of its usefulness.

Realizing the Inappropriateness

Little did I realize, when I transitioned from the intensive care unit to the urgent care clinic, a blood gas machine would not fit into my new clinical setting. Children come to an urgent care for a wide variety of clinical conditions, but critical illness is usually not one of them. Don’t get me wrong, we would see some infants and children who were quite ill. However, the clinical appearance and scenario would often dictate when we called an ambulance to take them to the emergency room or not. If their clinical exam reflected that their illness was very severe or the amount of care was too much for the urgent clinic to provide, they didn’t belong in the urgent care. They needed to go someplace with a higher level of care, like the emergency room. So, it came to pass that I realized that if I thought that I needed to perform a blood gas on a patient, they shouldn’t really be in the urgent care in the first place. An emergency room visit was more appropriate. My coveted blood gas machine never got used.

Initially, I was a little disappointed that I didn’t find a use for my machine. However, as time progressed, I realized it was for the best. An urgent care wasn’t the place to practice critical care. It was a different type of medicine, and it required a different set of skills. While both environments cared for infants and children with acute illnesses, the systems of medical care were not transferable from one to the other. My expectations of the level and type of care that could be provided in an urgent care needed to be adjusted.

Adjusting Expectations

Expectations and reality can often be misaligned. Whether it is in medicine or any other aspect of life, a conscious assessment needs to be made to see if expectations match reality. This is sometimes not so easy, as one may lack the initial experience to provide proper insight into a situation. However, as one gains knowledge and exposure in a new scenario, such as a pediatric intensivist working in an urgent care setting, review and assessment are required to establish realistic expectations in that different setting.

Without decisions, plans, or systems rooted in realistic expectations, one may find oneself in an uncomfortable situation. In medicine, this may put someone’s life at risk. If I was to use the blood gas machine to obtain information about an infant or child to gauge the severity of illness in the urgent care, I would run into two problems. If the blood gas was normal, the patient likely did not need to have the test performed in the first place. If the blood gas was abnormal, one could argue that the patient should have been in the emergency room already and I delayed proper delivery of care. In one scenario, I overtreated and, in the other scenario, I undertreated. I didn’t need a blood gas machine to tell me what to do.

The Right Tool for the Right Environment

The blood gas machine is uniquely suited to the intensive care unit because the patients are already critically ill and there is a very narrow therapeutic window to work within. It helps fine-tune the evaluation and management where a routine clinical assessment may not provide the same information, as the patient is already quite ill. The expectations of the use of the machine are aligned with the reality of the situation in the ICU. The reality of an urgent care is different. It's a reminder that tools and strategies must be contextually appropriate to be effective. It's like using a chainsaw to open a letter – the tool isn't flawed, but its usefulness is entirely dependent on the circumstances. In the end, deciding not to use the blood gas machine in the urgent care setting was an important lesson in realizing that aligning expectations to reality is more important than forcing expectations on reality. The essence of effectiveness is not in the tool itself, but in its appropriate use.

 

Have you ever encountered a situation where a tool or strategy you relied on was not suitable for a new environment? How did you adapt?