Taking care of the critically ill
Severe infections, asthma attacks, complicated deliveries, road traffic accidents and so many other conditions can lead to death within few hours in previously healthy persons. Critical Care Medicine consists in supporting the failing organs until the condition of the patient stabilizes, through medical treatment or emergency surgery. Treatment and level of organ support needs minute to minute adjustments because both insufficient and excessive support may be harmful for the patient.
Critical Care Units not only need high tech equipments such as ventilators and monitors: first and foremost, they require skilled and dedicated medical and paramedical staff which is available around the clock. Studies have shown that mortality in ICUs could be reduced by up to 40% with appropriate staffing. The ICU physician on duty is like a pilot in a plane. He has to face situations where things can go for the worst within few minutes, like take off (initiation of organ support), landing (withdrawal of artificial ventilation) or unexpected events (sudden cardiac arrest). He has to be constantly on alert, even when everything seems under control; he needs a co-pilot in case of problems he cannot face alone. Both of them cannot leave or sleep at the same time, handing over the plane to the cabin crew! The idea is similar for an ICU: the intensivist cannot remote control his ICU from home; he has to be at the bedside of the patient. Nurses need specialized training to cope with any unexpected situation: you would not expect a cabin crew to be unfamiliar with safety procedures. Trained doctors and nurses available round the clock in the ICU are the main ingredient and prerequisite of a good ICU, before anything else.
The comparison with an airplane can be extended to safety issue in the ICU: regular preventive maintenance of equipments is as critical an issue as it is in a plane. When you are in the air, there is no time to check whether there is something to fix! Our critically ill patient are highly dependent on the equipment supporting their vital functions (ventilators, dialysis machine,…). Any technical hazard during their ICU course may be fatal. A strong biomedical engineering department and carefully negotiated maintenance contracts are necessary because our patients so much rely on the devices that are critical to save their lives. First, do not harm, as one of the oldest rules in medicine says. Strong hygiene policies are required as well to avoid hospital-acquired infections related to the use of invasive medical devices such as intravascular catheters.
ICUs are highly dependent on hospital performances and services. Easy access to diagnostic facilities such as endoscopy, radiology and pathology is needed to quickly get find the cause of the critical state of the patient. The sole supply of organ dysfunction is indeed not sufficient to improve the prognosis of the critically ill: the disease behind it needs to be addressed at the earliest trough medical treatment (antibiotic, blood transfusion…) or surgery. This supposes efficient logistics and good coordination of the care in the hospital.
Critical Care Medicine is not yet recognized as a specialty in Pakistan. Very few physicians dedicate themselves fully to this activity. The career perspectives are poor. There is no Pakistani training program in Critical Care Medicine. However, critically ill patients deserve the best trained and skilled physicians.
Critical Care Medicine uses costly and invasive medical equipments and devices which are taking a lot from hospital resources. Commissioning ICUs should not impair other health priorities. In a resource limited health system, managers of health facilities have to assess whether they can afford critical care areas, to which kind of patient they want these facilities to be benefiting to and how to monitor the performance and the quality of the care delivered in those units. Admission criteria should be seriously documented so that the most deserving patient with a good probability to survive their acute illness can be accommodated without delay. Tertiary care teaching institutions should go ahead in order to build a community of skilled doctors familiar with the concepts of critical care medicine who can disseminate their knowledge to the young doctors. Critical Care Medicine should be a discipline taught during medical studies. In the non-teaching institutions, management of the critically ill patients in the emergency department and before / after surgery should be improved. Short courses enabling young doctors to efficiently manage the critically ill during the first 24 hours of their hospital stay should be organized. These skills need to be shared widely, especially at the level of district hospitals. Scientific conferences like the Critical Care Medicine seminar organized during the PIMS Symposium 2008 are supporting the promotion of this specialty in the medical community.
Critical Care Medicine in Pakistan is challenging. Comparing to western countries, patients are younger and often suffer from more reversible diseases. If given a chance to go trough, they are coming back to socially and economically active life. A couple of high profile institutions need to take the lead and a national strategy has to be designated for the provision of care to the critically ill. Emerging countries like Indonesia and Malaysia have developed very good diploma courses and a powerful community of intensivists. Why not Pakistan?
