ANZCA Bulletin - June 2009 - Australian and New Zealand College ...

Joint Faculty of Intensive Care MedicineThe future of intensivecare medicineThis is an edited extract of the JFICMGraduation Ceremony Oration “TheFuture of Intensive Care Medicine inAustralia and New Zealand” by Dr CaroleFoot, staff intensive care specialist,Royal North Shore Hospital.What does the future hold for intensivecare medicine? I’m going to focus on whatI see as the three most importantand interlinked areas: technologicaldevelopments that will influence how wepractice, the nature of critically ill patientsand the implications for the intensivecare workforce.TechnologyICU environmentWhat will our ICUs look like in theyears to come? We are already seeing theresults of exciting major design changes.For patients, more comfortable andpressure-easing beds that enable easypositional changes are entering the market.Access to natural light that facilitatesrestoration of circadian rhythms, a trendtowards single rooms that offer greaterprivacy and reduced risks of cross-infection,noise-reducing and mood- enhancingdecors, personal entertainment systemsand more comfortable facilities for relativesare some of the staples of new ICUs.Wireless technology is expanding andI think the spaghetti-like tangle of cablesfrom patients monitoring systems willsoon become a thing of the past. Advancedcomputer networking with more powerfulplatforms and improved user interfaces,offer the promise of more efficientmonitoring and record keeping,decision support and availabilityof reference materials.ResearchI am hopeful that basic scientists willhelp us understand and potentiallymanipulate cellular systems that influencesurvival and assist in prognostication.It will become clearer why some patientsappear remarkably resistant to criticalillness and yet others equally fragile.We are already starting to understandsome of the genetic polymorphismsthat control the inflammatory responseinfluencing the outcome of septic shockand ARDS.New drugs and equipment will comeand go. We must continue to ensurethat they are evaluated in an ethical andscientifically robust manner that can bebest achieved by being part of the process.We must inspire, mentor and supporta generation of ICU basic and clinicalresearchers who will push the envelopeof our knowledge. This will not be easy asscarce resources are stretched, but creativeways of funding this must be pursued.Co-operative relationships that cross theborders of institutions, specialties anddisciplines will foster synergism andefficiency that isolated silos cannot achieve.TeachingAs multimedia technology changes ourdaily lives, the opportunity to blend new,sophisticated learning platforms withtraditional medical educational pedagogyis truly electrifying.Borrowing from aviation, medicalsimulation is here to stay. Its role is beingincreasingly defined as evidence mountsthat it is a reliable and well-receivedmethod of teaching and assessing technicalskills, as well as team crisis management.I feel extremely strongly that we must notunderestimate our common sense whenevaluating how to incorporate simulationinto our ICU training programs. Practice canmake perfect, patients should not be guineapigs and doctors and nurses who worktogether every day should train together. Inthe future the insights and understandingthat this will bring will make us moreeffective as well as cohesive.Screen-based simulation is only inits infancy but is likely to come into itsown over the coming years as computerpower and bandwidth expands. Virtualworlds such as “Second Life” are beingincorporated into university teaching forother disciplines and healthcare is catchingup. Second Life is a 3D on-line environmentwhere users can socialize, connect, explore,learn and create using voice and text chat.There have never been so many methodsavailable for communicating informationto our trainees and with each other.Social networking sites such as Facebook,Podcasts, Blogs and Wikis are the preferredmedium for exchanging information for anincreasing number of people.These new developments are a challengefor older clinicians who did not grow upwith and become comfortable with thesemodalities. I am one of these. I am an adultof the email generation and student of thetextbook and yet I feel strongly that failureto embrace these new technologies risksopening up a communication chasm andmissed opportunities. Although there aremany unanswered questions, includinghow to control the quality of informationexploding in the virtual world, I feelstrongly that we must not be neo-luddites- resistors of new technology!PatientsThe wave of obesity sweeping westerncountries is no small matter! Australia isnow the fattest nation in the world. Weare already seeing the consequences ofthis problem in our ICUs, with the needfor bariatric equipment and increasingadmissions of morbidly obese adults.This trend is predicted to increase overthe coming years.Competing for these beds is a waveof elderly patients. Like many countries,the Australian population is ageing as aresult of unprecedented improvementsin healthcare. The ANZICS database tellsus that the number of intensive care daysprovided to patients over 70 has beenincreasing by around 14% per annum. Thisis not surprising as over the last decadepapers reporting excellent ICU outcomescan be found for older patients with a rangeof admission diagnoses and organ failures.Addressing the difficulties of ICU triage,particularly for chronically ill and elderlypatients, is beyond the scope of this talk.I strongly believe, however, that regardlessof clarifying the best candidates for ourcare, the pressure on hospital and ICUbeds will only increase and resources arealready stretched.Our emergency medicine colleaguesconstantly struggle with access block andambulance ramping on a daily basis and inthe ICU I am starting to see exit block, wherethe hospital is so full that ICU patients nolonger needing our care remain in our unit.As an example of this I recently worked withan endocrinologist in managing a younggirl with her first diagnosis of DKA fromadmission right through to discharge homefrom our ICU. The situation is exacerbatedThe ANZCA Bulletin June 2009 81