Understanding critical care

Critical care medicine is a relatively new but increasingly important medical specialty. Physicians with training in critical care medicine are referred to as intensivists.The specialty requires additional fellowship training for physicians having completed their primary residency training in internal medicine, pediatrics surgery or emergency medicine. Most medical research has demonstrated that ICU care provided by intensivists produces better outcomes and more cost-effective care. This has led to make a primary recommendation that all ICU patients be managed or co-managed by a dedicated intensivist who is exclusively responsible for patients in one ICU. However there is a critical shortage of intensivists and most hospitals lack this critical physician team member.

Other members of the critical care team may also pursue additional training in critical care medicine as intensivists. Nutrition in the intensive care unit presents unique challenges and critical care nutrition is rapidly becoming a subspecialty for dieticians who can pursue additional training and achieve certification in enteral and parenteral nutrition. Pharmacists may pursue additional training in a postgraduate residency and become certified as critical care pharmacists.

Patient management in intensive care differs significantly between countries. In countries such as Australia and New Zealand, where intensive care medicine is a well-established speciality, many larger ICUs are described as “closed���������. In a closed unit the intensive care specialist takes on the senior role where the patient’s primary physician now acts as a consultant. The advantage of this system is a more coordinated management of the patient based on a team who work exclusively in ICU. Other countries have open ICUs, where the primary physician chooses to admit and, in general, makes the management decisions. There is increasingly strong evidence that ���closed” intensive care units staffed by intensivists provide better outcomes for patients.

The ICU���s roots can be traced back to the monitoring Unit of critical patients through nurse Florence Nightingale. The Crimean War began in 1853 when Britain, France, and the Ottoman Empire (Turkey) declared war on Russia. Because of the lack of critical care and the high rate of infection, there was a high mortality rate of hospitalised soldiers, reaching as high as 40% of the deaths recorded during the war. Nightingale and 38 other volunteers had to leave for the Fields of Scurati, and took their “critical care protocol” with them . Upon arriving, and practicing, the mortality rate fell to 2%.

A school of nursing dedicated to her was formed in 1859 in England. The school was recognised for its professional value and technical calibre, receiving prizes throughout the British government. The school of nursing was established in Saint Thomas Hospital, as a one-year course, and was given to doctors. It used theoretical and practical lessons, as opposed to purely academic lessons. Nightingale’s work, and the school, paved the way for intensive care medicine.

Bjorn Aage Ibsen (1915–2007) graduated in 1940 from medical school at the University of Copenhagen and trained in anesthesiology from 1949 to 1950 at the Massachusetts General Hospital, Boston. He became involved in the 1952 poliomyelitis outbreak in Denmark, where 2722 patients developed the illness in a 6-month period, with 316 suffering respiratory or airway paralysis. Treatment had involved the use of the few negative pressure respirators available, but these devices, while helpful, were limited and did not protect against aspiration of secretions. Ibsen changed management directly, instituting protracted positive pressure ventilation by means of intubation into the trachea, and enlisting 200 medical students to manually pump oxygen and air into the patients lungs. At this time Carl-Gunnar Engstr��m had developed one of the first positive pressure volume controlled ventilators, which eventually replaced the medical students. In this fashion, mortality declined from 90% to around 25%. Patients were managed in 3 special 35 bed areas, which aided charting and other management. In 1953, Ibsen set up what became the world’s first Medical/Surgical ICU in a converted student nurse classroom in his hospital in Copenhagen, and provided one of the first accounts of the management of tetanus with muscle relaxants and controlled ventilation. The present ICU what we see today is evolved over time by dedicated hard work by many intensive care physicians.

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    Cochin safeskills academy has great pleasure in inviting you to “RESPIRATORY SYMPOSIUM” which will be held soon at Dubai.The programme will be a full day event.This academic programme will cover some of the core topics in critical care with focus on the most recent updates. Topics will be handled by renowned faculty in critical care , pulmonary medicine and infectious diseases. Physicians, Surgeons, Anaesthesiologist and other doctors who manage ICU patients will find this programme extremely useful. (more…)


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