|| CRITICAL CARE
"It will be easy for us to help them, if we find a separate area in the hospital for sicker patients,” Florence Nightingale wrote during the Crimean war in 1854 about the advantages of demarcating a separate area in the hospital for patients recovering from serious illnesses.
The Intensive Care Unit (ICU) refers to a specialised area in the hospital where very sick patients are provided with intensive care and medications. The term ‘intensive care’ is now less often used and has been replaced by ‘critical care’, derived from ‘Critical Care Medicine (CCM)’, the branch of medicine dealing with the critically ill.
Intensive Care started during World War II when ‘shock wards’ were established but it was in 1947-48 that major developments were witnessed when during the polo epidemic, there was a breakthrough in treating patients dying from respiratory paralysis. Manual breathing was introduced through a tube placed in the trachea (intubation) of polio patients by a Danish anaesthetist, Dr. Bjørn Aage Ibsen, who started the world’s first ICU at Copenhagen. In 1958, Dr. W.E. Dandy started a three-bed unit for post-operative neurosurgical patients at Johns Hopkins Hospital in Baltimore, USA that became the first ICU in USA and also the first ICU to be covered round the clock by a resident physician (anaesthesia resident).
The development of breathing machines (mechanical ventilators) then led to an expansion of ICUs in the early 1960s. By the late 1980s, CCM was established as a branch of medicine and started functioning as a separate department, not attached to internal medicine, pulmonary medicine or anaesthesiology. Since then, a separate curriculum has been introduced in medical schools for Critical Care Medicine in North America, Europe and even in India.
In Nepal, the first ICU was established at the Bir Hospital in 1973 and it was 20 years before the country got its second ICU in 1990 at TU Teaching Hospital. Since then, an increasing demand for ICUs has made it an ‘attractive business’ and almost all hospitals in the country have ‘ICU beds’, though the quality and efficiency of these so-called ICUs has never really been measured. The functioning of most ICUs in Nepal is still as good as, or perhaps even inferior to, that of the one established by Dr. Dandy in 1958 and several operate without an on-site doctor.
The functioning of most ICUs in Nepal is as good as that of the one established by Dr W E Dandy at John Hopkins in 1958.
Most ICUs in Nepal are ‘open ICUs’ where all departments can admit patients and treat them in their own way. This system has several disadvantages including polypharmacy, more doctors than needed and the absence of responsibility of a specific doctor. Since the early 1990s, these open ICUs were converted to ‘closed ICUs’ in various parts of the world after various researches proved that patient care and survival rates were better in ‘the latter.’ In a closed ICU, while any doctor can refer the patient to the ICU and advise on management, it is the lead doctor that makes the decisions.
These closed ICUs are usually led by specialists in anaesthesiology or internal medicine, with an additional academic certification in CCM, and are also referred to as ‘intensivists’ or ‘critical are physicians’. Even though the intensivist leads the Critical Care Unit, patient care is multidisciplinary, giving the patient the option of seeking an opinion from all departments as needed. Unfortunately, there are no intensivists in Nepal. Since 1994, however, the ICU in BPKIHS, Dharan, (managed by the department of anaesthesiology) has been functioning as a closed unit, and marks the beginning of new era in CCM here.
The primary function of any ICU is to identify and treat an immediate life threatening issue that includes airway, breathing and circulation (ABC). ‘Airway’ signifies the use of natural or artificial devices to keep the airway open so that oxygen can be sent to the lungs. This might involve putting a tube in the patient’s trachea or creating an opening in the neck (Tracheostomy). Breathing includes monitoring, augmenting or providing active support to the patient whose breathing may have become inadequate because of a disease. This can be done either manually through self-inflating devices (AMBU bag) or by using machines (Mechanical Ventilator). Circulation refers to the pumping action of the heart needed for maintaining blood flow and hence, the delivery of oxygen to all vital organs. This involves monitoring the patient’s heart rate, ECG and use of drugs to normalize the blood pressure and heart rate so that adequate tissue perfusion is maintained.
Critical Care also involves management of a subset of patient with ‘sepsis’, which can arise from numerous diseases. A standard ICU bed should be equipped to deal with all of these and also should have the facility for an immediate ultrasound, endoscopic services, and other organ support facilities like dialysis. ICUs without these facilities, but with monitoring services, are called High Dependency Units (HDU) or Step-Down Units (SDU). These HDUs or SDUs serves the intermediate category of patients who are neither sick enough to remain in an ICU nor normal enough to stay in a general ward.
Critical Care Unit is a multidisciplinary area where other healthcare professionals also play important roles. For instance, adequate nursing care is a must for the effectiveness of an ICU, which requires a patient-nurse ratio of 1:1 for those on ventilator support and 2:1 for those who are not. Needless to say, respiratory therapists, pharmacists, dieticians and physiotherapists also play a vital role in the recovery of critically ill patients.
CCM actually became highly advanced only over the past decade, particularly after the SARS pandemic in 2003. An increase in the number of patients with respiratory failures led to an increase in the demand for ICU beds and thus, greater resources were directed towards CCMs. Unfortunately, Nepal has been unable to realise the full need and upgrade accordingly; thus, being tragically behind time in this respect.
The Nepalese Society of Critical Care Medicine (NSCCM) was founded two years ago with the aim of improving the status of CCMs in Nepal and April 16 is considered as NSCCM day. NSCCM faces massive challenges, which include effective and stern monitoring and supervision of ICUs in the country. The recognition of Critical Care Medicine as a separate branch of medicine and starting speciality courses in it, ramping up the number of closed ICUs and drastically improving the infrastructure and effectiveness of existing ICUs is the need of the hour in Nepal. If we fail to act now, we may forever carry the burden of lives lost due to inadequate care.
The author is a lecturer in Anaesthesiology at the Institute of Medicine and is currently working as clinical fellow in Critical Care Medicine at University Health Network and Mount Sinai Hospital, University of Toronto, Canada