70 years of intensive care: caring for patients when they need it most

Dr Sundeep Kaul
By Dr Sundeep Kaul     20/11/2018

When the NHS came into being 70 years ago, ICUs (intensive care units) didn’t exist. We didn’t have the technology or the drugs to help patients who were so ill they needed these high levels of medical support.  Advances in pharmaceuticals, such as antibiotics and new technology – including machines that can assist with breathing – have been game changers when it comes to caring for people who are very ill and would not be able to live without innovative medical intervention.

Technology and ICU

Although breathing devices, such as the ‘iron lung’, did exist for patients with conditions like polio, they were bulky. The size of the devices resulted in lack of portability, lack of access to the patient, problems with correct fitting, a requirement for significant operator experience, patient discomfort, time-consuming application, and the risk of upper airway obstruction.

The concept of helping patients to breathe through positive pressure ventilation was really developed in Copenhagen in 1953, when there was a polio epidemic. Using positive pressure ventilators, doctors could now force oxygen into the lungs making them inflate. Patients still exhaled because of the elasticity of the lungs, diaphragm and chest wall.

During the 1960s and 1970s, ICUs were established in the UK. Dr Margaret Branthwaite from Royal Brompton Hospital was a key figure in this, working closely with Professor Ron Bradley, who ran the ICU at St Thomas’ Hospital.

Fast-forward to 2018, and you have people who are highly-trained in very specific areas within intensive care: cardio-thoracic, renal, liver, neuro, as well as general. There has been a fantastic evolution of this whole branch of medicine.

It is scientifically quite beautiful; we can assess and track minute details of the patient’s condition, enabling us to intervene more effectively when they require more support.

As well as ventilatory support, you can look at other strategies to minimise organ damage – for example, how we prevent and manage infections: across the board, there’s so much more that can be done these days than in previous decades.

Take ECMO (extracorporeal membrane oxygenation). This is a piece of machinery, which works by removing blood from the person's body, oxygenating the red blood cells and removing carbon dioxide.

ECMO is invasive and not a treatment – it’s a stabiliser. It allows you to stabilise patients to get better on their own or with treatment. It’s a bridge to something else which may be recovery on their own or a transplant, or a mechanical heart device or last stages of life.

Incredibly, ECMO is over 50 years old. Is the ECMO we use today different to the ECMO machines of 50 years ago? Yes and no. In some respects, the principle behind ECMO is exactly the same. The technical improvements in the equipment have been honed over the years. We’ve also got better at selecting the patients for whom it is most likely to be beneficial. The decision-making is evolving all the time.

Antibiotics

When the NHS came into being, there were no antibiotics in general use. Penicillin may have been discovered in 1928 by Alexander Fleming – who went on to become regional pathologist at Harefield Hospital in 1939 – but antibiotics weren’t in mass use until after the Second World War.

There is no doubt they have saved millions of lives since then. However, nowadays we have newer, antibiotic-resistant bugs. Everybody worries about antibiotic-resistance. And of course, it is a concern. But saying ‘we need to stop using antibiotics’ to prevent antibiotic resistance is a bit short-sighted.

It’s like saying, we need to stop driving to stop pollution – in fact, we need to stop driving polluting vehicles.

Likewise, we need to stop using antibiotics that are no longer helpful, or are less helpful. They should be taken out of use – it’s about us, as clinicians, making sure we are using them responsibly and appropriately.

The good news is, now after a lull, we have newer antibiotics coming through.

We need to reduce the regulatory process to get these through and improve access to these lifesaving drugs so that doctors can use them for patient benefit. The good thing is, we’re tailoring our research to meet the clinical needs and, at last, the antibiotics are coming through to tackle these bugs.

In terms of antibiotic use for very sick patients, I feel passionately we should use our best antibiotics early. Each time there is an infection, there is more organ damage, more loss of muscle – in addition to the physiological battering there is psychological hit (often immeasurable). They’re less able to cope after each infective episode. Go in early, go in hard.

To use a cricket analogy, if your team were playing a one day international, do I leave my best batsmen to go in last? Who does that? You get the best out of them first. Use your best antibiotics first. This idea of salvage therapy feels like ‘too little too late’.

Delirium

Large proportions of patients admitted to an intensive care unit develop delirium, or suffer problems with cognitive impairment or fearful visions. In cardiac ICU this can be 50 per cent of the patients.

It is common in the elderly, but it may happen to anyone. Patients might imagine everyone is trying to kill them, or see snakes coming out of people’s heads. It can be terrifying and we, and other ICUs around the country, do everything we can to reassure, care for, and treat patients affected by it.

In the early days of ICU, there was a poor prognosis. Now we are much better at identifying it, treating reversible causes such as infection, pain, metabolic abnormalities or medication related adverse events, and supporting patients through this frightening experience thereby improving patient outcomes. The way we treat delirium has changed 180 degrees.

Sedatives were often the mainstay of treatment, but, of course, it reduces your respiratory drive and can increase your level of confusion; the patient might have a quiet night on sedation but they are set back in their recovery overall. Now we have more data about which drugs and treatment strategies work and do not work.

You need a high attention to detail and to really listen and observe the patient in immense detail. For a start, delirium can indicate infection. For example, one of my patients had had part of her lung removed because of cancer. After the operation, when she was on intensive care, she swung at the nurse. I realised she was suffering from an infection, which we treated. After being treated appropriately and a decent couple of nights sleep she left the unit – after profusely apologising to the nurse! The poor patient was mortified when it was relayed to her that she had tried to punch the nurse looking after her. But it wasn’t her, it was the delirium. We are always keen to hear from patients when they’ve been discharged from our ICUs – really listening to and understanding their experiences helps us to provide better care.

We’ve also discovered that rather than making patients stay in bed, getting them up and mobilising them early really help the delirium pass more quickly too.

What is vital when treating patients with cognition issues is to treat them as individuals, as people.

Even in patients with dementia, the ability to trust is the last thing to leave them. People undergoing the turmoil of delirium sense the person they can and can’t trust. We clinicians should never underestimate the power of a look or a gaze, the use of a kindly caring sensitive tone when dealing with people with delirium in ICU.

Palliative care

The vast majority of our patients, I am pleased to say, get better or go on to another stage in their treatment.

However, working in ICU with people who are very ill, can mean that palliative care is a regular part of my job – arguably, looking after those who are about to die is the most important thing I do.

The palliative care administered in ICU allows families and patients time. We actively manage the patient’s symptoms, treat complications, and support their community of family and friends, who can come and visit and spend time with one another.

At some stage, we’ve all got to die. And we have to get the whole environment absolutely right for each family and those relationships.

This is one of the most crucial times in all of our interactions as humans. People want to let each other know they love and care. This is such a vital thing.

Someone with a terminally-ill relative may phone me up and say, ‘I’m ill myself. I can’t travel to be with him, but I know he wouldn’t want to suffer.’ I can tell this person, I will look on him as my own father, and make sure he is well cared for.

Then there is the other scenario, the person who is flying from Australia, who desperately wants to see their loved one before the end.

We pull out all the stops in every situation. It’s about getting it right, every time.

When it comes to conveying difficult and upsetting news, I don’t have a system or a method.

I meet people on their terms. I’ve taught communication to other doctors and staff – phrases to say and eye contact. But I don’t use them in a robotic fashion. I look at the people I’m talking to. I check with them verbally and non-verbally.

I try and feel with them.  We are humans before we are professionals so connecting at a human level has to be the most important type of engagement. Some people want details, others don’t. Hopefully I get it right, but I’m still evolving – every situation is different. The only important anchor is how we make people feel through our words and actions.

For patients and families, I ask myself, ‘Did I get it right for them?’ Yes, it’s about science, about pharmacology, but it’s also about more than that. The effect of this experience on their perceptions and on their lives can be quite profound.

Processes are generally in place in the NHS, but we can’t always be prescriptive, one size certainly does not fit all and we should avoid being process driven when we’re dealing with people and their loved ones on the edge of life. We must make sure we never lose our humanity.