angus 75

Will Angus, ST6 Anaesthesia and Intensive Care Medicine, runner up in the Pecha Kucha session at State of the Art 2017, gave the following presentation where he looked back from 100 years hence.

Reflecting on the past century working within the speciality of Intensive Care, from the vantage point of the year 2117, and with only fifty years left before I reach retirement age, I wanted to share some pearls from the future via the medium of t-t-e-mail (time travel electronic mail).

Back in 2017, the dark days when I was a registrar, Intensive Care was booming, yet demand outstripped supply.  We were faced with numerous problems: not enough intensivists, not enough beds, wards full to bursting, nowhere to admit patients from A&E, nowhere to discharge patients from ICU, and many hospitals financially crippled and facing cuts to funding.  I remember the then Health Secretary and his subsequent fall from grace after putting the Health Service up for sale, in what became the great eBay scandal of 2020.

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To give you some perspective: flying cars, a cure for cancer, world hunger solved by genetic engineering, congenital diseases eradicated, prosthetic organs, world peace, holidays to Mars, and yes, the NHS still uses fax machines.

I work in the Northern hospital, a 30,000 bedded acute care trust built on what I believe used to be the Peak District National Park. It serves the entire Northern half of the UK, with our sister hospital the Southern hospital serving the rest. My Intensive Care Unit has over 2,000 beds, I ride a scooter on my ward rounds and we travel round the hospital in tubes.

To rescue the specialty from crisis things had to change. Resources were under strain, our workforce underpowered and overstretched, with increasing demands as more therapies became possible.

The first step seemed to be trying to decide who would survive and who wouldn’t, and then only admitting the likely survivors. We tried big data, physiological prediction models, biomarkers, and more.  None were any good.  We only found one thing that universally predicted a bad outcome – the family describing the patient as a “fighter”. “Fighters” seemed particularly vulnerable to multi-organ failure and prolonged, unsuccessful ICU treatment and there was an argument for not admitting them on the grounds of futility.

To meet the demands of a growing specialty we needed to expand our workforce.

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New training pathways were created and we opened the doors to intensivists from all specialities. A notable failure of this model was the world’s first (and only) orthopaedic intensivist.

Centralisation meant that many units became super subspecialised.  However, as hospitals grew and merged, all units had to cater for all sub-specialities, so we all became generalists again. We gave the haematologists their own ICUs to finally allow them to do whatever they want. They are closed units and don’t report outcomes but anecdotally nobody dies and patients are rapidly cured and live forever.

Sepsis was a major problem back in the day, but we really don’t see it that often anymore and certainly nobody dies from it. The post antibiotic era was not such a big deal after all – it turns out all patients need is some vitamin C1, we get it into patients as quickly as we can. One notable pre-hospital case report describes rectal Jaffa cakes to treat septic shock. This has become the biro cricothyroidotomy of our time.

The mode and method of mechanical ventilation continues to be a source of debate. We have tried all sorts over the years: oscillation, jet ventilation, APRV, liquid ventilation, upside down back to front inside out inverse prone ventilation. We have nebulised pretty much every single substance that it is possible to nebulise.

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None of these therapies have demonstrated any outcome difference. So, to be honest, we just let the nurses choose the settings which, as it did in 2017, works quite nicely.

Looking back in history the obsession with fluid overloading patients and calling it resuscitation is hard to understand. Giving a litre of fluid to achieve 20mls of urine output – when did this ever make sense? We have moved on; intravenous fluids are now a controlled drug and fluid bolus is a swear word.  Let that be the end of it.

Obviously, it’s the future so we have tried a lot of cool stuff. Suspended animation, cryopreservation, extra-corporeal cerebral perfusion, stem cell total body regrowth and even brain transplantation. However, in a heterogeneous ICU population, we were unable to demonstrate a mortality benefit from any of these therapies.  It’s clear to us now that the basic things are the most important. There are no magic bullets. Timely vitamin C and source control. Not over ventilating. Not giving too much oxygen. Not over sedating. Not overloading with fluid. Getting patients out of bed and moving as soon as possible. This is hardly a revelation from the future.

The important thing remains delivering timely interventions that will deliver a quality of life acceptable to the patient and their family. As the number of things we can do increases, we really do need to think hard about what we should do. Don’t let us become a menu of aggressive treatments that have no hope of success. We need to focus on the outcome of intensive care, not just the process.

 

References

  1. Marik PE, Khangoora V, Rivera R et al. Hydrocortisone, Vitamin C and Thiamine for the treatment of severe sepsis and septic shock: A retrospective before-after study. Chest 2017 Jun; 151(6): 1229-1238.

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