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Q-and-A: Dr. Clifford Deutschman on the challenges of critical care medicine

Clifford S. Deutschman, MD, MS, FCCM, is professor of anesthesiology and critical care and director of the Sepsis Research Program at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia. He is serving as the 2012 president of the Society of Critical Care Medicine.

What are the top challenges facing critical care providers? What are some of the solutions? And what opportunities do you see for improvements in critical care?

First, we need to remember that the SCCM is an international organization. The challenges facing those of us who practice in countries with highly-developed health care systems are quite different than those faced by our colleagues in other parts of the world. In the U.S., Canada, Europe, Japan, Australasia, etc., we have issues, but there are tangible solutions. People practicing in large parts of South America or Africa or most of the Caribbean are faced with problems that we can hardly imagine, for example, how to safely sterilize and recycle equipment that we routine discard after a single use. In India, which has some excellent medical facilities, simply getting a patient to a health care facility can be a nightmare. So the challenges facing some of our members and colleagues are difficult for most of us to comprehend. The current SCCM treasurer (soon to be president-elect), Chris Farmer, is leading a joint SCCM–ESICM Task Force examining the problems of providing critical care services in under-developed medical environments, and we are very much anticipating their conclusions and recommendations.

That said, I see two key challenges confronting critical care practice in the developed world. And I think that there are some very interesting potential solutions in the offing that will provide the sorts of opportunities that you are asking about. The first is manpower. There simply are not enough practitioners to care for all of the critically ill. Studies like COMPACCS and ProMIS looking at physician manpower only hint at the magnitude of the problem. And it’s going to get worse. We don’t have the necessary numbers of critical care nurses, for example. And it is clear that more and more, critically ill patients in smaller hospitals are being cared for by hospitalists. These providers are dedicated, but the current educational paradigm doesn’t prepare them to care for patients who truly require critical care services. Now, there are potential solutions in the development of qualified alternative providers such as acute care nurse practitioners or critical care physicians assistants. Programs that are being developed by (former SCCM President) Tim Buchman and (current SCCM Secretary) Craig Coopersmith in Atlanta and (SCCM Council member) Ruth Kleinpell in Chicago are promising. And our recent conversations with the leaders of the Society of Hospital Medicine indicate an acute awareness of the extent to which hospitalists are being asked to assume responsibility for the care of critically ill patients and of the need to address enhance education to provide the background required. My predecessor, Pam Lipsett, recently co-authored a paper describing a pathway to critical care certification for hospitalists. This paper has created a great deal of controversy, but it represents one of a very few detailed and thoughtful approaches to a huge problem. We need to see just where these important new developments lead. But there is another approach that begs for consideration. And that involves reconsideration of just what constitutes a critically ill patient. Clearly, some patients in ICUs are “sicker” than others. So the questions we need to ask ourselves are “who really needs care managed by a trained critical care practitioner?” and “how do we do a better job of matching the needs of a given patient with skill level required to care for him/her?” Jeremy Kahn and Derek Angus at Pittsburgh have been writing about regionalization of critical care services for some time now. It may be that substantially fewer patients require the services of an intensivist (and that designation shouldn’t be limited to physicians, but that’s a discussion for another day) than we have imagined, and quality in triage may be very helpful in resolving manpower issues. I’ve had preliminary discussions with Jeremy about how we can examine these agenda in the near future.

The second key issue also involves providing optimal care, but it isn’t about manpower. Rather, it reflects limitations in implementing available, proven approaches to managing certain disorders. We know that early initiation of broad spectrum antibiotics and fluid resuscitation to criteria (early goal directed therapy) reduce mortality in sepsis. Similarly, limiting the tidal volume when mechanically ventilating patients with ARDS improves outcome. Yet neither of these approaches is universally used — in fact, it’s not even close. We need to do a much better job of taking advantage of the strategies that we know work. Along these lines, the Surviving Sepsis Campaign, which is a joint endeavor of the SCCM and the ESICM, is preparing a new initiative to improve provider awareness and increase the penetration of these potentially lifesaving strategies so that their use becomes universal.

How has technology advanced the field of critical care medicine in recent years? And what do you see ahead in 2013?

People who know me have long recognized that I’m something of a skeptic. Convincing me that something “new” is of value often requires a pretty significant body of evidence. By the same token, getting me to abandon something that I have found useful can be a struggle as well. The use of technology in caring for critically ill patients provides examples of each.

Consider, for example, the use of the pulmonary artery catheter in the critically ill. A series of papers in recent years has led to a dramatic decrease in the use of this tool to manage fluid resuscitation. And yet these papers don’t really take advantage of all the data a PA catheter provides. Most studies focus on changes in pressures, either in the pulmonary artery or the right atrium. Yet SCCM member Michael Pinsky, who is a senior member of the outstanding critical care medicine department at Pittsburgh, demonstrated years ago that pressure measurements in critically ill patients are capricious. Using a PA catheter to examine the response of stroke volume to fluid administration provides much more valuable information. It’s essential for the critical care provider to take advantage of all the available information and to understand what data are most truly meaningful. As one of my former teachers used to say, “The magic is in the magician not in the wand.”

Alternatively, enhanced technology has led to a tremendous emphasis on measuring “biomarkers,” indices that provide an early clue to the presence of dysfunction or perhaps prognosticate trajectory, that is, improvement or deterioration. But I’ve often remarked that “biomarkers” actually represent biology that we don’t yet understand and therefore can be extremely misleading. For example, we’ve been examining cytokine levels in septic patients for decades now. Have they helped us? We have assumed that pro-inflammatory cytokine activity becomes pathologically increased in septic patients. Therefore, therapy has been directed at reducing levels or blocking inflammation. But recent studies by, among others, SCCM member Richard Hotchkiss clearly demonstrate that a lack of appropriate inflammation worsens outcome in septic patients by enhancing the development of secondary infections. And our own work in animal models clearly demonstrates that the pathways within cells that normally are activated by cytokines fail to respond in sepsis. One can argue that the increase in pro-inflammatory cytokines is actually adaptive, a protective response to insufficient inflammation. So, now that we understand the biology a little better, we can see that we misinterpreted the biomarker.

Now, I’m not under-valuing the incredible role played by technological advances in our ability to provide support for critically ill patients. When I was an intern at the University of Florida in Gainesville, the SICU had several old MA-1 ventilators that John Downs had modified, using parts that probably came out of his garage, to provide PEEP and IMV. It’s hard to imagine caring for our patients without the advances in mechanical ventilation brought about by new technology. But the efficacy of some of new modes of ventilation, intellectually attractive as they may be, remains unproven. The paper on intensive insulin therapy by Greet Van Den Berghe in 2001 spawned a entire industry creating advanced glucometers and algorithms for managing glucose levels. But the repeat studies, culminating with the NICE-SUGAR study in 2009, didn’t support the original findings. And we are left with technology that has no real use.

On the other hand, SCCM Council member Jean-Louis Vincent recently opined that the stethoscope isn’t all that useful any more. I agree with that.

This question-and-answer session was produced as part of SmartBrief’s 2012 Best Of reports, which capture the year’s most important stories in each industry. Sign up now for Critical Care SmartBrief to get tomorrow’s report on the top must-read stories for critical care physicians.

Image courtesy of the Society of Critical Care Medicine.