Gary Masterson, President Elect of the Intensive Care Society
Are we for the sickest or the slightly less sick? When I started my consultant career almost 20 years ago, I worked in my own silo which had high walls constructed to keep us and the outside world apart. The barbed wire at the top of the walls was pretty effective in keeping those meddling single organ doctors (SODs) out.
In those days we didn’t need them because we could do everything ourselves. Sometimes patients got better and we turfed them out with the belief that they all left hospital a couple of days later and returned to their normal lives with eternal gratitude to us for saving them. However, it was always disappointing that so few made the effort to return and say thank you, but it didn’t matter because we knew we were doing a great job.
Becoming the go-to people
The world changed with the publication of Comprehensive Critical Care in 2000. We spread our wings and took our skills to the general wards with outreach teams. We delivered education to the masses through ALERT courses and similar. We all enjoyed the increase in popularity and appreciation from the rest of our hospital colleagues.
The SODs and their minions realised quickly that we were really quite useful people to call upon for help. We became victims of our own success. We fought this trend but probably not strongly enough as they became less and less able to look after even vaguely unwell patients. We were at least partially responsible for their de-skilling.
“I didn’t train to be a palliative care doctor but that is what I spend most of my time doing”
How the world has changed and what a price we have paid for becoming such important cogs in our hospital machines. When I walk the corridors of my hospital in the early hours, I know I am almost certainly the only consultant on site. I have grown weary of being expected to take clinical responsibility for every slightly unwell patient in the hospital.
I didn’t train to be a palliative care doctor but that is what I spend most of my time doing. In fact, no patient in my hospital is allowed the luxury of death unless it is authorised by the duty intensivist. Does that sound familiar?
Like it or not, we are where we are. There are on-going conversations about the future of the intensivist role and the structure of intensive care services in general.
“Should we stay as we are, looking after the sickest patients in our units while providing some support to the wards?”
Should we stay as we are, looking after the sickest patients in our units while providing some support to the wards? After all, it would be hard to go back and remove the support we already offer outside of our units. Or should we expand our roles and also look after slightly less sick (level 1+) patients scattered throughout our hospitals.
The reality is that we are not only good at looking after very sick patients, but are also pretty good at identifying deterioration and at preventing slightly ill patients becoming very ill. The latter choice pretends that we currently have the workforce available to take this on which, of course, we don’t.
I know what you’re thinking but here’s the problem – if I were a patient on the general ward and a bit unwell, I would certainly welcome an intensivist having input into, or even directing, my care. Wouldn’t you? When I speak to colleagues about this I hear mixed responses but the balance certainly isn’t 50/50. We need to dictate our own future. One day I might even tell you what I think!
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