Medicina intensiva na graduação médica: perspectiva do estudante / Intensive care medicine on medical undergraduation: student's perspective

JUSTIFICATIVA E OBJETIVOS: Acredita-se que existe uma deficiência no ensino de Medicina Intensiva (MI) na graduação da maioria das escolas médicas, levando a um prejuízo na formação acadêmica de futuros médicos. O objetivo deste estudo foi analisar o ensino e o grau de interesse em MI por estudantes de Medicina de Salvador-BA. MÉTODO: Estudo transversal realizado em 2005 entre estudantes do 6º ao 12º semestres de duas escolas médicas baianas. Utilizou-se um questionário auto-aplicável composto de questões objetivas sobre interesse, habilidades e conhecimentos dos estudantes sobre MI, bem como a sua opinião sobre o ensino dessa especialidade em sua faculdade. RESULTADOS: Foram entrevistados 570 estudantes. A maioria (57,5 por cento) nunca realizou estágio em unidades de terapia intensiva (UTI). Contudo, a utilidade deste para o futuro profissional de um médico foi classificada como alta (média de 4,14 ± 1,05, numa escala de 1 a 5) pelos entrevistados. O interesse em MI foi considerado alto ou muito alto por 53,7 por cento da amostra. Quase todos os alunos (97 por cento) acreditam que tópicos de MI devam ser mais explorados em seus currículos. Apenas 42,1 por cento sentiam-se seguros em avaliar um paciente gravemente enfermo, sendo essa segurança maior entre aqueles que já realizaram estágios em UTI (p < 0,001). Os tópicos de MI de maior interesse foram choque, reanimação cardiopulmonar e sepse. CONCLUSÕES: O presente estudo revelou um alto interesse em Medicina Intensiva entre estudantes de Medicina da Bahia. Contudo, a maioria nunca realizou estágio em UTI, o que demonstrou ser importante fator na segurança do médico em formação frente ao paciente gravemente enfermo.

BACKGROUND AND OBJECTIVES: There are deficiencies on Intensive Medicine (IM) teaching in most of medical undergraduate schools. Those deficiencies may imply damages on their clinical competence. The objective of this study was to analyze current status of IM teaching and the medical undergraduate student interest in this speciality. METHODS: A cross-sectional study was performed in 2005. We applied a self-reported questionnaire to enrolled students between the sixth and the last semesters of two medical schools from Salvador-Bahia. The questionnaire contained questions about students' interest and knowledge on IM, and opinion on IM teaching in their schools. RESULTS: We studied 570 students. Most of them (57.5 percent) had never realized a clerkship in intensive care unit (ICU) despite classifying its usefulness as high (mean of 4.14 ± 1.05, in a scale from 1 to 5). IM interest was high or very high in 53.7 percent of sample. Almost all students (97 percent) thought that IM topics should be more explored at their curriculum. Only 42.1 percent reported to be able to assess a critical care patient and this assurance was higher among students with previous clerkship in ICU (p < 0.001). Shock, cardiopulmonary resuscitation and sepsis were the most interesting topics in ICU for students' opinion. CONCLUSIONS: This study revealed a high interest in IM among medical undergraduate students. However, most had never practice a clerkship in ICU, demonstrating to be an important factor on undergraduate student performance faced to a critical care patient.

Condutas de limitação terapêutica em pacientes internados em Unidade de Terapia Intensiva / Therapeutic limitation conducts in intensive care unit patients

JUSTIFICATIVA E OBJETIVOS: Atualmente, há uma tendência crescente de se buscar o "morrer com dignidade", mais do que prolongar inutilmente o sofrimento de pacientes terminais em unidades de terapia intensiva (UTI). O objetivo deste estudo foi avaliar a utilização de condutas que sugerem limitação terapêutica (LT) em pacientes que foram a óbito em UTI Adulto. MÉTODO: Trata-se de um estudo exploratório, retrospectivo, que avaliou prontuários médicos de pacientes que foram a óbito na UTI geral de um hospital privado de Salvador-BA, entre janeiro e agosto de 2003, com internação superior a 24 horas na unidade. Os pacientes foram classificados, em relação ao óbito, em "não resposta a medidas de reanimação", "morte encefálica", "decisão de não reanimar" (DNR), "não adoção ou retirada de medidas de suporte de vida", sendo estas duas últimas consideradas medidas sugestivas de limitação terapêutica. RESULTADOS: Foram incluídos dados referentes a 67 pacientes, correspondendo a 90,4 por cento dos pacientes falecidos na unidade durante o período. Destes, 56,7 por cento eram mulheres e a idade média dos pacientes foi de 66,58 ± 17,86 anos. Medidas sugestivas de LT foram encontradas em 59,7 por cento dos pacientes, sendo a mais importante "não adoção de medidas de suporte" (35,8 por cento), seguida de DNR (17,9 por cento) e "retirada de medidas de suporte" (6 por cento). A utilização de fármacos vasoativos e métodos dialíticos foram as medidas de suporte mais omitidas, enquanto antibioticoterapia foi a mais retirada. A utilização de medidas de LT foi mais freqüente nos pacientes clínicos. CONCLUSÕES: Os dados do presente estudo sugerem altas freqüências de condutas médicas sugestivas de LT em UTI geral no Nordeste do Brasil. Métodos terapêuticos que possam causar desconforto ou sofrimento aos pacientes terminais, como nutrição, sedação e analgesia, raramente foram omitidos ou retirados.

BACKGROUND AND OBJECTIVES: There is a growing tendency of looking for "dying with dignity", rather than to prolong death and suffering of terminal patients on intensive care units (ICU). This study aims to evaluate medical practices that suggest therapeutic limitation (TL) in patients who died in an adult ICU. METHODS: A retrospective exploratory study was carried out to evaluate medical records of patients who died in a general adult ICU of a private hospital in Salvador-BA, between January and August of 2003, after at least 24 hours from the admission. The patients were classified, in relation to their deaths, in: "not responding to cardiopulmonary resuscitation", "brain death", "decision not to resuscitate" (DNR) and "withhold or withdrawal life-support measures". RESULTS: Sixty seven patients were included, corresponding to 90.4 percent of the deaths occurred in this ICU during the referred period. The most of them (56.7 percent) were women and the patientsÆ mean age was 66.58 ± 17.86 years. Suggestive measures of TL were found in 59.7 percent of the patients, being "withhold of life-support measures" the most important (35.8 percent), followed by DNR (17.9 percent) and "withdrawal of life-support measures" (6 percent). The procedures most commonly omitted were use of vasoactive drugs and dialysis, while antibiotics were the most discontinued. The use of TL measures was more frequent in clinical patients. CONCLUSIONS: The results of the present study suggest high frequencies of medical conducts suggestive of TL in a general ICU in Northeast of Brazil. Therapeutic methods that could cause discomfort or suffering to the patients, as nutrition, sedation and analgesia, were rarely omitted or discontinued.

Análise de estressores para o paciente em Unidade de Terapia Intensiva / Analysis of stressors for the patient in Intensive Care Unit

JUSTIFICATIVA E OBJETIVOS: O ambiente hospitalar, especialmente o de uma Unidade de Terapia Intensiva (UTI), devido à complexidade do atendimento prestado, bem como a estrutura física, o barulho, os equipamentos e a movimentação das pessoas, é tido como gerador de estresse para os pacientes. O objetivo deste estudo foi identificar e estratificar os estressores para pacientes internados em UTI, na perspectiva do próprio paciente, familiares e profissionais de saúde. MÉTODO: Estudo de corte transversal realizado entre junho e novembro de 2004, na UTI geral de hospital privado. A amostra foi composta por três grupos: pacientes (G1), familiares (G2) e um membro da equipe da UTI responsável pelo atendimento do paciente incluído (G3). Para identificação e estratificação dos fatores estressantes, utilizou-se a Escala de Estressores em UTI (Intensive Care Unit Environmental Stressor Scale - ICUESS). Para cada paciente e participante, foi calculado um escore total de estresse (ETE) pela soma de todas as respostas da escala. RESULTADOS: Foram incluídos 30 pacientes e participantes em cada grupo. A média de idade foi de: 57,30 ± 17,61 anos para o G1; 41,43 ± 12,19 anos para o G2; e 40,82 ± 20,20 anos para o G3. A média do ETS foi: 62,63 ± 14,01 para os pacientes; 91,10 ± 30,91 para os familiares; e 99,30 ± 21,60 para os profissionais. A média do ETS dos pacientes foi estatisticamente inferior à encontrada nos familiares e nos profissionais de saúde (p < 0,01). Os principais estressores para os pacientes foram: ver a família e amigos por apenas alguns minutos do dia; tubos no nariz e/ou boca; e não ter controle de si mesmo. CONCLUSÕES: A percepção sobre os principais estressores foi diferente entre os três grupos. A identificação destes fatores é importante para a implementação de medidas que possam facilitar a humanização do ambiente da UTI.

BACKGROUND AND OBJECTIVES: The hospital environment, especially in Intensive Care Units (ICU), due to the complexity of the assistance, as well as the physical structure, the noise, the equipments and people's movement, is considered as stress generator for the patients. The aim of this study was to identify and stratify the stressful factors for patients at an ICU, in the perspective of the own patient, relatives and health care professionals. METHODS: A cross-sectional study was carried out between June and November 2004 in a general ICU of a private hospital. The sample was composed of three groups: patients (G1), relatives (G2) and a member of the ICU health care team responsible for the included patient (G3). In order to identify and stratify the stressful factors, we used the Intensive Care Unit Environmental Stressor Scale (ICUESS). For each individual, a total stress score (TSS) was calculated from the sum of all the answers of the scale. RESULTS: Thirty individuals were included in each group. The mean age of the three groups was: 57.30 ± 17.61 years for G1; 41.43 ± 12.19 for G2; and 40.82 ± 20.20 for G3. The mean TSS was 62.63 ± 14.01 for the patients; 91.10 ± 30.91 for the relatives; and 99.30 ± 21.60 for the health care professionals. The patients' mean TSS was statistically lower than mean TSS of relatives and professionals (p < 0.01). The most stressful factors for the patients were: seeing family and friends only a few minutes a day; having tubes in their nose and/or mouth; and having no control on oneself. CONCLUSIONS: The perception of the main stressful factors was different among the three groups. The identification of these factors is important to the implementation of changes that can make the humanization of the ICU environment easier.

[Intensive care medicine on medical undergraduation: student's perspective]. / Medicina intensiva na graduação médica: perspectiva do estudante.

BACKGROUND AND OBJECTIVES: There are deficiencies on Intensive Medicine (IM) teaching in most of medical undergraduate schools. Those deficiencies may imply damages on their clinical competence. The objective of this study was to analyze current status of IM teaching and the medical undergraduate student interest in this speciality. METHODS: A cross-sectional study was performed in 2005. We applied a self-reported questionnaire to enrolled students between the sixth and the last semesters of two medical schools from Salvador-Bahia. The questionnaire contained questions about students' interest and knowledge on IM, and opinion on IM teaching in their schools. RESULTS: We studied 570 students. Most of them (57.5%) had never realized a clerkship in intensive care unit (ICU) despite classifying its usefulness as high (mean of 4.14 ± 1.05, in a scale from 1 to 5). IM interest was high or very high in 53.7% of sample. Almost all students (97%) thought that IM topics should be more explored at their curriculum. Only 42.1% reported to be able to assess a critical care patient and this assurance was higher among students with previous clerkship in ICU (p < 0.001). Shock, cardiopulmonary resuscitation and sepsis were the most interesting topics in ICU for students' opinion. CONCLUSIONS: This study revealed a high interest in IM among medical undergraduate students. However, most had never practice a clerkship in ICU, demonstrating to be an important factor on undergraduate student performance faced to a critical care patient.

[Analysis of stressors for the patient in Intensive Care Unit]. / Análise de estressores para o paciente em Unidade de Terapia Intensiva.

BACKGROUND AND OBJECTIVES: The hospital environment, especially in Intensive Care Units (ICU), due to the complexity of the assistance, as well as the physical structure, the noise, the equipments and people's movement, is considered as stress generator for the patients. The aim of this study was to identify and stratify the stressful factors for patients at an ICU, in the perspective of the own patient, relatives and health care professionals. METHODS: A cross-sectional study was carried out between June and November 2004 in a general ICU of a private hospital. The sample was composed of three groups: patients (G1), relatives (G2) and a member of the ICU health care team responsible for the included patient (G3). In order to identify and stratify the stressful factors, we used the Intensive Care Unit Environmental Stressor Scale (ICUESS). For each individual, a total stress score (TSS) was calculated from the sum of all the answers of the scale. RESULTS: Thirty individuals were included in each group. The mean age of the three groups was: 57.30 ± 17.61 years for G1; 41.43 ± 12.19 for G2; and 40.82 ± 20.20 for G3. The mean TSS was 62.63 ± 14.01 for the patients; 91.10 ± 30.91 for the relatives; and 99.30 ± 21.60 for the health care professionals. The patients' mean TSS was statistically lower than mean TSS of relatives and professionals (p < 0.01). The most stressful factors for the patients were: seeing family and friends only a few minutes a day; having tubes in their nose and/or mouth; and having no control on oneself. CONCLUSIONS: The perception of the main stressful factors was different among the three groups. The identification of these factors is important to the implementation of changes that can make the humanization of the ICU environment easier.

[Therapeutic limitation conducts in intensive care unit patients]. / Condutas de limitação terapêutica em pacientes internados em Unidade de Terapia Intensiva.

BACKGROUND AND OBJECTIVES: There is a growing tendency of looking for "dying with dignity", rather than to prolong death and suffering of terminal patients on intensive care units (ICU). This study aims to evaluate medical practices that suggest therapeutic limitation (TL) in patients who died in an adult ICU. METHODS: A retrospective exploratory study was carried out to evaluate medical records of patients who died in a general adult ICU of a private hospital in Salvador-BA, between January and August of 2003, after at least 24 hours from the admission. The patients were classified, in relation to their deaths, in: "not responding to cardiopulmonary resuscitation", "brain death", "decision not to resuscitate" (DNR) and "withhold or withdrawal life-support measures". RESULTS: Sixty seven patients were included, corresponding to 90.4% of the deaths occurred in this ICU during the referred period. The most of them (56.7%) were women and the patients’ mean age was 66.58 ± 17.86 years. Suggestive measures of TL were found in 59.7% of the patients, being "withhold of life-support measures" the most important (35.8%), followed by DNR (17.9%) and "withdrawal of life-support measures" (6%). The procedures most commonly omitted were use of vasoactive drugs and dialysis, while antibiotics were the most discontinued. The use of TL measures was more frequent in clinical patients. CONCLUSIONS: The results of the present study suggest high frequencies of medical conducts suggestive of TL in a general ICU in Northeast of Brazil. Therapeutic methods that could cause discomfort or suffering to the patients, as nutrition, sedation and analgesia, were rarely omitted or discontinued.

Características de pacientes com síndrome da fibromialgia atendidos em hospital de Salvador-BA, Brasil / Characteristics of patients with fibromyalgia syndrome assisted in a hospital of Salvador, BA, Brazil

OBJETIVO: descrever as características demográficas, sócio-econômicas e clínicas de pacientes com síndrome da fibromialgia (SF) atendidos no Hospital Santo Antônio em Salvador, BA, Brasil. MÉTODOS: cento e vinte pacientes com SF foram avaliados prospectivamente por dois reumatologistas, quanto aos dados clínico-epidemiológicos e manifestações clínicas. RESULTADOS: todos os pacientes eram do sexo feminino, com média de idade igual a 29,8 anos. A dor difusa foi encontrada em todas as pacientes e fadiga em 94,2 por cento (n=113). Ansiedade foi referida por 105 pacientes (87,5 por cento) e depressão por 47 (39,2 por cento). O tender-point mais encontrado foi o suboccipital direito, em 40 por cento (n=48) dos pacientes e o menos encontrado foi o glúteo direito, em 26,7 por cento (n=26). A média do número total de tender points foi 13,6 (limites de 11 a 18), sendo a média e a mediana 14. O grupo de pacientes que tiveram número de tender-points superior ou igual à mediana apresentou, significativamente, menor renda familiar (p<0,01), maior presença de tabagismo (p<0,01) e distúrbios do sono (p<0,05), quando comparados com os demais. Conclusões: os pacientes avaliados apresentaram diversas características em comum com pacientes de estudos anteriores, mas diferiram quanto às freqüências total e específica de tender-points. Foi significativa a associação de renda familiar baixa, distúrbios do sono e tabagismo com maior quantidade de tender-points.