Intensive care: borne out of an epidemic

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Today almost all large hospitals have an Intensive Care Unit (ICU). Purpose of this facility is to provide care for the severely ill patients, who often require heroic measures to salvage their failing organs. Today Intensive care is complex, demanding, and relies a lot on a variety of gadgets such as mechanical ventilators, invasive monitors, dialysis machines, blood gas analysers, infusion devices etc. Patients often spend days in an ICU, surrounded by an array of gadgets, a web of tubes and lines, and many a brains and hands that provide them with care.

Till 1950s, doctors and nurses would care for those who were more sick, in the same hospital wards as those who had a less severe illness. Nurses did prioritise them, shifting them to beds that were closer to nursing stations. Harvey Cushing – an American neurosurgeon, recognised a need for better care, especially after a surgery. Thus, in 1930s it became a norm for operation theatres to have a recovery room where patients were stabilized immediately after a surgery. Such a dedicated care for patients with a medical illness was still about two decades away.

Polio epidemic and the first Intensive care Unit

In 1952, Copenhagen – capital of Denmark was witness to a Polio epidemic. Many sick children, who could not breathe well, had filled up hospitals. There was only one archaic iron-lung ventilator in whole town. This cumbersome device, which is now obsolete, was a huge iron cylinder, that became patient’s bed for days. The machine applied vacuum to pull and push the chest, so that air could enter and leave the lungs. Even if this machine was available in abundance, about 80-90% of all affected children would have died.

Dr Bjorn Ibsen, an anaesthetist by profession, tried to do things differently. He and his colleagues, decided to make a hole in the patient’s neck (tracheostomy), to pass one end of a rubber tube in the trachea. They attached a rubber-bag to the outer end, so as to use it as a pump to push air inside the lungs. About 250 medical students took turns to become rubber-bag-pushers. With this technique, physicians could save about 60% of 316 affected children. This success prompted Bjorn Ibsen to established first intensive care unit (ICU) in December of 1953, in Copenhagen.

Early intensive care units

In 1960s and 1970s, a few hospitals in US and UK established their first ICUs. Such units had about two to four beds, and one nurse for every patient. At this time, there were very few gadgets in place. One of these was a Cardiotachoscope, a heart rate monitor. By late 1960s, these machines could also show waveforms, and evolved into cardio scopes. Other gadgets were a defibrillator, and a primitive positive pressure ventilator. Most early ICUs started as cardiac or coronary-care units. In-fact, first such facility in India (KEM hospital Mumbai, 1968) was a cardiac ICU.

Later technical developments were blood-gasses and biochemical blood-tests in the 1960s, infusion-pumps, and a microprocessor-controlled ventilator in 1971. As ventilators evolved over the next decade, so did our understanding about how to make them work better. In 1970, pioneer intensive-care (or critical care, which is its American nomenclature) physicians (including Max Harry Weil, and Peter Safar) met to establish society of critical-care medicine (SCCM).

Intensive care is a young speciality

It took another two-decades for Intensive care (or critical care) to officially became a separate speciality. In 1982, intesivists in Europe created their own professional body – ESICM. A few years later in 1988, SCCM created American College of Critical Care medicine, and started a separate fellowship training. ESICM followed suit next year with a European diploma in 1989. In 1993, intesivists in India formed their own society. Stand-alone courses in the speciality, both in India and in the west are only about a decade old. Moreover, in last decade, we have further improved instrumentation, technology, and our understanding about how best to save lives.

There are only a few postage stamps, that depict intensive care Units. It was only after COVID-19 pandemic, that visibility of this speciality grew in postage stamps. Quite like polio epidemics that took place between 1930-1950, large number of patients required mechanical ventilation in 2020-21. Entire world was a witness to overwhelming numbers, and shortages in intensive care beds. However unlike polio, COVID disproportionately affected adults. Borne out of polio epidemic in 1953, COVID in 2020 has led to a growth in ICU beds in almost all countries of the world.

Intensive care is a teamwork

Beyond gadgets and lines, intensive care is a teamwork. ICU team includes specialised nurses, technicians, physiotherapists, helpers, and doctors. We need many hands to care for the ailing ICU patient. These hands feed, lift, and turn patients, help remove secretions and body fluids in addition to pushing knobs, injections, and bags. All these hands need an attentive brain, to process and react to a multitude of signals ICU gadgets provide. Some COVID-19 Postage stamps from across the world show ICU teams.

Growth in ICU beds and teams

In Pre-COVID times, ICU beds were about 2-5% of total beds in a hospital. This proportion was even lower in resource limited settings, as setting up of an ICU is both Labor and cost-intensive. COVID-19 pandemic led to a greater awareness and visibility for ICU care.

In 2013, we estimated that ICU-beds in a hospital will slowly grow from current 2-8% to 10-20% in the coming years. COVID-pandemic accelerated this growth, and in developed countries, the proportion is already close to 15%. More ICU-beds need more trained human resources. Shortage and attrition of ICU-trained Human Resources, remains a global phenomenon.

Zeal, innovation and effort

In a short span of 70 years, growth of intensive care is an ode to our zeal, technology based innovations, and our efforts to ensure care for the very sick. Intensive care story is all about the lives we save, and learnings from all others that we could not. Failures are frequent, but it is sheer joy, when a very sick patient just walks out of clutches of death.

Human emotions are ancient, however technology is recent. We are all set to witness more developments in our understanding of diseases and their remedies. Golden age for intensive care is still ahead of us !!!