Critical Care

By James G. Cain, M.D.

Millions watch the popular television program House, amazed by the diagnostic prowess of the physicians. This program features a physician and his team in the fictional “Department of Diagnostic Medicine” who diagnose and treat the most ill patients, typically one patient at a time with a multitude of faulty diagnoses along the way.

In reality there is no medical specialty of “Diagnostic Medicine.” The physicians most closely approximating such specialty are Critical Care Medicine specialists, having broad expertise across all areas of medicine and providing care for patients with life-threatening illness.

In contrast to House and his team, the Critical Care Medicine specialist typically diagnoses and treats more than a dozen patients at a time, without the missteps accompanying the television drama. 

History of Critical Medicine
Pennsylvania and the ‘Father of CPR’
Remote Critical Care
What is an Intensivist?

History of Critical Medicine

The United States has been formative in Critical Medicine innovation. American neurosurgeon Walter Dandy established the world’s first hospital Critical Care Unit in 1926. In the 1952 Danish polio outbreak, the Danish anesthesiologist Bjorn Ibsen, who trained in anesthesiology at the Massachusetts General Hospital, formed a respiratory Critical Care Unit and enlisted medical students to manually pump oxygen-enriched air into intubated patients.

Ibsen also developed the first set of Critical Care management principles. These principles evolved to guide current physicians in methodically assessing critically ill patients on a system-by-system basis, with interventions determined by monitoring each organ system.

Anesthesiologists have always been intimately involved with Critical Care Medicine, and indeed frequently care for critically ill patients in the operative setting. While the majority of intensivists now practicing in the United States come from a Pulmonary-Internal Medicine background, historically Critical Care Medicines in the United States has strong roots in anesthesiology.

In 1986, the American Society of Critical Care Medicine was formed as an organization for Anesthesiology-Intensivists (Reference 1). Additionally, in 1986 the American Board of Anesthesiology was the first specialty board to issue certification of special qualifications in Critical Care Medicine by virtue of an examination (Reference 2).

Subsequently, the American Boards of Surgery, Internal Medicine and Pediatrics followed suit.

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Pennsylvania and the ‘Father of CPR’

Pennsylvania is at the forefront of Critical Care Medicine. Anesthesiologist Peter Safar, M.D. (1924-2003), is considered the first “Intensivist” (Reference 3).

As Chief of Anesthesiology at Baltimore City Hospital, Dr. Safar opened the first integrated fully staffed Critical Care Unit in the United States in 1958. Three years later, Dr. Safar became the Chair of Anesthesiology at the University of Pittsburgh and started the first Critical Care Fellowship in 1962.

He spent the remainder of his career advancing Critical Care Medicine and resuscitation, transitioning to full-time research in 1979 and creating the International Center for Resuscitation Research, now known as the Safar Center.

Known as the “Father of CPR,” Dr. Safar was nominated for the Nobel Prize in medicine three times. More recently, the evolution of Critical Care at the University of Pittsburgh has resulted in the first independent Department of Critical Care Medicine in the United States.

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Remote Critical Care

A recent innovation in Critical Care Medicine is remote critical care. Several hospitals in Pennsylvania are taking advantage of this emerging technology, among them are the University of Pennsylvania (Reference 4) and Lehigh Valley Hospital and Health Network (LVHHN) (Reference 5) in Allentown.

This is a novel model of critical care staffing in which traditional bedside intensivist care is supplemented by remote distance care. In this model intensivists are linked via telemedicine and computer monitors to the patient’s critical care monitors, extending manpower and providing a vigilant, timely early warning system in the care of critically ill patients.

Critical Care Units are characterized by advanced monitoring and equipment as well as specialty trained nurses and physicians. Smaller hospitals may have only a single Critical Care Unit for all patients. Larger hospitals may have a number of further specialized Critical Care Units, such as neonatal and pediatric critical care units for infants and children as well as a variety of medical, surgical, cardiac, trauma, neurologic and transplant units for adults.

Patients in Critical Care Units may be cared for by a variety of physicians, ranging from their own primary physician to specialists with advanced training in Critical Care Medicine.

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What is an Intensivist?

Specialists with advanced training in Critical Care Medicine are known as Intensivists. Regrettably, there is a current shortfall in the number of fully trained intensivists.

As the population ages, the need for intensivists continues to grow. A growing body of evidence suggests that critically ill patients have improved outcomes, with as much as a 30 percent decrease in mortality for an annual savings of nearly 55,000 lives and $4.28 billion if they are cared for by such dedicated intensivists (Reference 6).

Intensivists come from a variety of medical specialties, including internal medicine, pulmonary, surgery (and surgical specialties), obstetrics and gynecology, neurology, emergency medicine and anesthesiology. They enter specialty fellowship training after completion of training in their primary specialty.

While in most parts of the world, anesthesiology-intensivists provide the majority of Critical Care Medicine, pulmonary-internal medicine intensivists provide the majority Critical Care in the United States.

Anesthesiologists are uniquely well suited to provide Critical Care Medicine. In the perioperative setting, anesthesiologists utilize invasive and noninvasive measurement of vital signs as well provide airway management, ventilatory support of breathing, cardiac support, sedation and pain control.

Anesthesiology-intensivists are ready, willing and able to provide the broad array of specialist care required to diagnose and treat patients with life-threatening illness. 

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By David M. Gratch, D.O., and
C. Christopher Wesley, M.D.

In the last 20 years, major changes have taken place in the training and certification of critical care physicians. Separate certifications have developed from the fields of anesthesiology, internal medicine, pulmonary medicine and surgery.

Currently, the certification process is broadening to include physicians from the fields of emergency medicine, pediatrics and neurology. Perhaps the greatest change in the last decade has been the addition of non-physician members to the critical care team (respiratory therapists, pharmacists, and nutritionists) trained in the use of evidence-based protocols developed by critical care physicians to improve patient outcomes. 

The following is a list of links and references to some of these evidence-based advances.

Journal References and Sample Protocols:

1. Weaning from Mechanical Ventilation
MacIntyre NR, Cook DJ, Ely EW Jr, et al: Evidence-based guidelines for weaning and
discontinuing ventilatory support: A collective task force facilitated by the American College of Chest Physicians
; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001; 120 (Suppl 6):375S–395S.

2. Ventilator Management in ARDS
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. New Engl J Med. 2000;342:1301–1308.

3. Transfusion
Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care.   Lena M. Napolitano, MD; Stanley Kurek, DO; Fred A. Luchette, MD; et al. for the American College of Critical Care Medicine of the Society of Critical Care Medicine and the Eastern Association for the Surgery of Trauma Practice Management Workgroup.     Critical Care Med 2009 Vol. 37, No. 12.

4. Glycemic Control
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-1297

Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359-1367

Surviving Sepsis Campaign Website on Glycemic Control

2009 SSC Statement on Glucose Control

5. Prevention of Catheter Related Blood Stream InfectionsReference
Guidelines for the prevention of intravascular catheter – related infections
MMWR 2002;1(RR-10):1-29.

6. Sepsis
Dellinger RP, Levy MM, Carlet JM, et. al: Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008 Crit Care Med 2008; 36:296-327.

Surviving Sepsis Website

7. Sedation in the ICU
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Med 2002 Jan;30(1):117-14.

Anesthesiologists

Physicians Protecting Patients