Critical Care Medicine - Current State And Suggestions For The Future

The diagnosis and management of emergency conditions that need complicated life support systems is defined as critical care medicine [1]. Critical care is invariably seen in an intensive care unit (ICU) or in hospitals treating trauma patients [2].

1500 BCE Procedural documentation similar to tracheostomies to remove obstruction of the airways by the Egyptians
500 BCE Development of a type of organ support, so that lungs could draw in air by Hippocrates
1850s Soldiers injured in the Crimean War were segregated according to the gravity of their injuries by Florence Nightingale
1953 First Intensive Care Unit (ICU) set up by Dr Bjorn Ibsen
From 1950s Setting up of complicated ventilators, replacement therapy & monitoring of the cardiovascular system; Tele ICUs [3]

Current State of Critical Care Medicine Around the World:

USA: In July 2013, the Critical Care Assessment and Improvement Act was brought in to take care of America’s critical care needs. Critical Care has a major share in the hospital bills of the US, year after year- $121 million (> 17% of the entire amount) (4). The American population totals to 5 million per year, in different types of ICUs (surgical, pediatric etc.). As the number of elderly persons keeps increasing over time, the shortcomings of the system would also get highlighted (e.g., mismatch in the demand and supply of the quality and quantity of intensivists) [5].

According to research done by the RAND Corporation, intensivists account for 4% of the entire lot of physicians in the US; 28% of the emergency care is provided by them [6].

Various societies spreading awareness about critical care medicine in the US:

• The Critical Care Societies Collaborative (CCSC) comprising of-
1. The American Association of Critical-Care Nurses (AACN)
2. The American College of Chest Physicians (ACCP)
3. The American Thoracic Society (ATS)
4. Society of Critical Care Medicine (SCCM) [7]

• Neurocritical Care Society (NCS) [8]

UK: Critical care in the UK does not go by any official law; opinion is formed according to common laws, bits from Human Rights Act 1998 and Mental Capacity Act 2005. In the UK as of now, the right of providing treatment to the individual whose consciousness and understanding is not up to the required level, lies with the intensivists instead of the patient’s relatives [9].

Intensive Care Society spread the word about the multidisciplinary aspect of emergency medicine in the UK [10]).

In February 2013:
The number of beds for emergency treatment in adults was 3770; for pediatric treatment, the numbers were 429 and for neo-natal treatment, the number of beds was 1365 [11].

Societies spreading awareness about critical care medicine in the UK:

• The Intensive Care Society (ICS) [12]
• The Pediatric Intensive Care Society (PICS) [13]

Australia: Ambulances are provided by the state in critical care treatment in Australia; in the Northern Territory and Western Australia, St John Ambulance makes the emergency care available to the patients.

Various agencies provide air ambulances in Australia. They are:
• Ambulance Service of New South Wales
• Emergency Management Queensland
• RACQ CareFlight, RACQ CQ Rescue, RACQ Capricorn Helicopter Rescue, RACQ NQ Rescue, AGL Action Rescue Helicopter
• MedStar
• Royal Flying Doctor Service

Workforce in these ambulances is separated into two sections, namely, Paramedics and Transport Officers. Critical Care contact number in Australia is 000 [1].

From 2010-2012, emergency cases rose by 11.8% in Western Australia and 11.2% in South Australia. The number of emergency cases in the year 2011-2012 was more than 6.5 million. The age group that required the highest amount of critical care was 0-4 years [15].

Societies spreading awareness about critical care medicine in Australia:
• Australian and New Zealand Intensive Care Society (ANZICS) [16]
• The Australian College of Critical Care Nurses Ltd (ACCCN) [17]

Current State of Critical Care Medicine in India:

Emergency or critical care medicine in India is a recent addition. Farokh E Udwadia was the pioneer of emergency medicine in India. The starting points of critical care medicine practice were Chennai, Mumbai and Pune. The Indian Society of Critical Care Medicine (ISCCM) was constituted in 1993. The Resuscitation Council of India was formed with the help of ISCCM. Share of beds for emergency treatment is 5-8% in public hospitals and 10% in a handful of centers. Every year about 5 million patients are admitted to the ICU in India. Giving additional skill sets to the intensivists with proper training has been the biggest problem.[18][19][20]

Workshops for transplantation of cadaver organs have also been hit badly due to paucity of beds in critical care treatment- paucity being directly proportional to the number of protocols in harvesting organs from patients that are brain dead [19].

Societies spreading awareness about critical care medicine in India: [21][22][23]
• Indian Society of Critical Care Medicine (ISCCM)
• The Critical Care Nurses Society (CCNS)
• Indian Society of Neuroanaesthesiology and Critical Care (ISNACC)

Suggestions for the Future in Improving Critical Care:

• Emergency medicine or intensive care is a specialized field which should keep up contacts with various departments, inside a center that provides medical care.

• The paucity of well-trained and skillful doctors or intensivists in a critical care setting inconveniences the patients and increases the cost of treatment. Hence, involving the doctors in emergency care treatments in the initial periods of their studies would help in developing their interest in the field of critical care.

• Establishment of a standard procedure for treating septic patients- translational research would play a key role in fulfilling this requirement. Monetary help given to the researchers in comparison to ICU patient care is very less (with frequent negative outcomes in the trials related to ICU patients). The pharma companies need to be given some sort of a guarantee of a positive outcome from randomized trials in patients.

• Involvement of tele-ICUs to enable huge amounts of data to be collected and compared from ICU patients. This would enable standard procedures of care to be developed [24].

• For the Indian scenario:
- ICUs have to be upgraded, licensed, regulated & accredited.
- Rise in the percentage of beds in the ICUs to 10-15% [19].

About Author / Additional Info:

3. Dr Marsh S. The Evolution of Critical Care Outreach.
5. Matheson J, Paulsen E. The Critical Care Assessment and Improvement Act of 2013 (H.R. 2651); 1-9.
6. Dr Glatter R. The evolving role of ER doctors and emergency departments in delivery of healthcare.
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15. Australian Institute of Health and Welfare. Australian Hospital statistics 2011-12: Emergency department care. 2012.
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