An interview with Ignacio Martin-Loeches, PhD FJFICMI, conducted by April Cashin-Garbutt, MA (Cantab)
What is Intensive Care Medicine and how did the specialty arise?
Intensive care medicine is a young specialty that deals with the medical treatment of the sickest patients in the hospital. Intensive care medicine doctors are called intensivists and are expert physicians with special skills in the management of organ failure.
This is a very special specialty in the modern era of medicine as the complexity of the care and procedures would not have been developed without subsequent intensive care Units (ICU).
Intensive Care Medicine was born in in Copenhagen in 1952 after a polio outbreak in Denmark that affected a lot of people.
Polio is a disease that is characterized by a weakness of the breathing and many of the patients had problems breathing and they needed to be put on mechanical ventilators that were taken from the operation theaters.
Please can you describe the role of an intensivist?
An intensivist’s role is often hard to describe; however, people can normally relate if you explain that you work in the ICU. Intensive care medicine is a specialty that not many people know and often they don't know that there is a specialty by itself.
In hospital, the model of doing things on your own is old-fashioned. Now we work in a multidisciplinary way, so there is joint care of the patient.
The ICU is a good example of many of the specialties are coming to intensive care medicine. They are coming to the ICU because they have patients that are very sick and they need organ support.
Intensive care medicine is a very multi-disciplinary specialty that takes parts of internal medicine, surgery, anesthesia etc. with the expertise in the most severe spectrum of the disease.
What does your role as a Consultant in Intensive Care Medicine involve?
My role as an intensive care consultant in ICU, is mainly to look after very sick patients and to coordinate the intensive care unit.
Normally, we need to make the adequate clinical pathway for the patient. So, when we have a patient that is coming from somewhere else, we are going to have different problems, different organ failures for example and depending on the organ failure, we prioritize the care of the patient.
To give you an example, imagine that you have a patient arriving from the emergency department after a major trauma and the patient is bleeding and with respiratory failure. First we need to optimize his respiratory problem and give blood products and rushing to the operational theatre being in close contact with a surgeon.
We are sometimes like a goal keeper, for the critical illness. We need to make the order of the actions, and this is going to be our main area of work. Also, we are working with different medical and surgical teams and they’re going to focus more on their particular specialties. We however need to provide an integral care of the critically ill patient.
How has Intensive Care Medicine changed over the last twenty years?
Intensive care medicine has changed mainly with the advancement of technology, even in the past few years. For instance, we are using different devices to support the organs and our main area is to provide organ support until they recover from the failure with different machines and different procedures. The machines are always buying time, for organ support, we are buyers of time to get the patient better.
We are using different machines for different organ support such as continuous renal replacement therapy (CRRT), that is an special type of dialysis over a 24-hour period. The second main change, and perhaps one you may find surprising, is that I think we are more human.
In the past, intensive care medicine was seen to be like an island in the hospital. We have patients with a tube in their mouth, deeply sedated with no family allowed to come in. And we worked within 4 walls, working in isolation. But now, we are more open, and we are modelling what we call an extended ICU care.
We try to identify the patient earlier, and we like to follow the patient more. So it's not just working within these 4 walls, what we are trying to do is break down the walls because we think that there is no need to keep ourselves captured in this particular place. This will help us interact with more colleagues that are coming to the ICU.
We are also going to the emergency department, for example, and we are open to move forward and to visit each other's departments. When the patient is discharged, we also now like to follow their progress, because this is an important issue.
We are more interested in the follow up of the patients, as they are going to benefit from us because we could understand better various specific ICU problems such as critically ill weakness, delirium, post-traumatic stress disorders etc., things that are related to ICU care.
That is important for us because we are dealing with very severe and some sad cases, and to see when a patient is leaving the ICU, that this patient is becoming more independent from when they were very weak, and they are trying to continue a normal life. That is the best gift for us.
Relating to the families, and connecting on a human level. Humanization in intensive care medicine means that we are opening the ICU's to the families. And we consider that to be the best treatment for a family, is to have a relative beside them.
We have to think about these patients that are having pain, they are scared, and in a place with machines etc. They are having a bad time, and so it best for them to have their loved ones beside them. And we are opening that.
Not long ago, and it is still happening in some units, there was a glass wall and the family was not allowed to touch their relative because of fears of cross infection etc. We are now allowing the families to come, and to touch and talk to them, with adequate healthcare protection for infection control.
We also keep the patients more awake, because in the past, the ICU was a place where there was no voice, just beeps, and nothing else. Now that we are having new units with families around the patient, we see many patients much more awake, and I think that this is another important issue.
In the past, all the patients were deeply sedated, and they were often asleep. Now we have many patients that are awake. They still have a mechanical ventilator and huge technology beside them, but we have even patients walking in the ICU, that this is something that 20 years ago, that would have never happened.
Walking in the ICU requires a very advanced machine, for instance, an extracorporeal membrane oxygenation (ECMO). The ECMO machine has been used for a long time, it's like an artificial lung, that purifies the blood externally. We have patients now in the ICU that they are not mechanically ventilated, that they don't have a tube in their mouth, or they have a tube in their mouth but they are not given the whole support.
What changes have you seen in the types of patient admitted to ICU?
The patients that we have now compared to 30 years are totally different. In the past, it was common not to bring patients with certain age or certain commodities and we were very straight and strict in the admission criteria. Now, we do have a different population, but this is not reflecting the ICU world, this is reflecting the society, we live longer for example. If we live longer, we are going to have more health issues.
With more chronic conditions and aging, they are now also coming to the ICU. They are making very good outcomes, and good progression. We have learned a lot about the criteria of admission. It is important to understand that with this particular model of extended ICU care, we are acting earlier.
A good example of this is sepsis, we have in the past had many patients come in late to the ICU because they were not adequately treated, or they were not well identified as having sepsis, for instance, which is a general infection with some organ dysfunction. Now, we identify these patients earlier, which mean we are going to provide adequate on the worse, they are not going to need to come to the ICU.
So, not only is the population that is coming different, but the potential population to come. This is not just exclusive of the ICU physician, this is because the hospital and the whole hospital is working together and we are working more towards the same direction, and we allow the patients to get better before they have an alteration.
The outreach model or also known as the extended ICU care, is going to bring all of this together. There is a criticism in the last year about intensive care, that they used to be expensive care medicine. But I think that intensive care is not expensive at all. And I think that, in the way that we work, we are going to have a modern intensive care medicine and we are going to produce a huge reduction of the resources, because we are going to act in a very effective way. We are going to be aggressive when we need to be, and this is going to provide an additional benefit for life.
In what ways has the healthcare system had to adapt to these changes? Such as an aging population?
Adaption of the healthcare system to change is a process that is not straightforward. In the past, the healthcare system has put in a lot of resources on the wards. So, they were opening more and more wards, and the ICU still small. This meant, it was very common to have an ICU in a big hospital, to have barely 10 or 15 beds. But, this is something that has changed over the years.
Now we see the number of beds on the ward is reduced. So, we have less patients that need to be in the hospital. They still need the workup, and to have tests etc., but they can do these tests without the patient being hospitalized. This saves money and reduces complications.
So, we have reduced the number of beds on the wards, we have more acute medicine beds. And this is reflecting in ICU. I am expecting this is going to be the ICU based healthcare change which has started to occur in the last year or so. The ICU's are going to be totally in the opposite way that it was in the past.
So, instead of a big hospital size with a small ICU, now what we are going to have a big ICU within small hospital wards. Why? Because I think that we are going to have highly acute medicine patients in the ICU.
How do you think the advances in Intensive Care Medicine will impact other medical specialties?
In the past, intensive care medicine was not very well defined. Not very well defined many specialties were having their own ICU. This is something that again, has been improved in the last year.
There are several advances that have been pioneers in the development of the specialty of intensive care medicine.
Spain, Australia, the U.K., and Switzerland, are all countries that have put a lot into the development of those specialty, as well as many others.
Intensive care medicine is now, becoming a specialty itself with different models, like single specialty, or super specialization. For example, in in other countries in Europe, or it happens in Canada, the US, there is more of an understanding about the need to have a full-time person with very special training in intensive care medicine, not just to be there some days, these patients need to be looked after by an intensivist all the time.
We have very good research and reports from all over the world than when you have an intensive care doctor working in a hospital, this is going to reflect in the better outcome of the patients.
What do you think the future holds for Intensive Care Medicine?
The future of intensive care is mainly something that needs to be done in connection with other specialties. We need to work very closely with a very global care of the patient. They are not just an ICU patient, or a surgical, or an infectious disease patient. They are hospital patients, and all of us, we need to provide the best care based on our expertise in that field.
What we are going to do is, in the future benefit from all the different point of views. At this moment, the approach is going to help.
In the future, intensive care medicine is going to grow, in order to have a more integral approach of the patient, from before to after the ICU admission. We have decided to break the walls. We are happy to visit different places in the hospital. This is something that is going to impact in the future.
We are also going to develop more artificial intelligence, better technology with different machines, and we are going to integrate more data in order to analyze what is going on with our patients, big data analysis from all departments.
In the ICU we work with many variables, such as cardiovascular variables, as well as respiratory variables etc. Adequate analysis is going to help us improve the outcome of our patients. All of these new ways of thinking are going to change totally the landscape of ICU in the next years.
Where can readers find more information?
About Ignacio Martin-Loeches, PhD FJFICMI
Ignacio Martin-Loeches, PhD, FJFICMI is a full-time Consultant in Intensive Care Medicine and Senior Clinical Lecturer & Research Director of the Multidisciplinary Intensive Care Research Organization (MICRO) at Trinity College, Dublin.
Currently Vice-Chair of Intensive Care Medicine at St James’s University Hospital, Dublin. He has served as executive member for the European Diploma in Intensive Care (EDIC) and as Deputy for the Sepsis and Infection Section at the European Society of Intensive Care Medicine (ESICM).
He is the Chair of the Severe Sepsis and Septic Shock Working Group “4SWG” and executive member of the research-working group of the Surviving Sepsis Campaign (SSC).
He is the currently member of the Clinical Trials of Health Research Board in Ireland and the President of the Spanish Research Society of Ireland [(under the Embassy of Spain in Ireland and The Spanish Foundation for Science and Technology (FECYT)].
He is principal Investigator of European Regional Development Funds (ERDF) grant and the European Network for ICU-related respiratory infections (ENIRRIs) under the European Respiratory Society (ERS).
He has published several manuscripts in high impact factor journal and serves as section Editor at the Intensive Care Medicine (ICM) journal.