...more than worthy successor. As farewell to the editorship of AJCC (now in its 16th year of publication!), I have been asked to write an overview from my personal perspective of critical care.

My perspective is half a century long, so I have plagiarized my editorial title after a book by one of my senior and beloved role models: Dr Alec Cooke's My First 75 Years of Medicine. (1) To celebrate Dr Cooke's 90th birthday, his children gave him his first computer, with which he wrote his memoirs. He was renowned for statements that contained the humor of Yogi Berra and the wisdom of Socrates. One of Cooke's Laws that has guided my practice as a physician is this: "Doctors do not treat diseases; they treat patients."

A half-century overview would be too long and tedious to insert into AJCC, so I am choosing to cover a few closely related topics that by chance may be of universal interest; issues that I have tried to promote, with varying degrees of success, in these pages and in my life. These musings are frequently anecdotal and personal.

Critical Care: The Early Years

My first experience of critical care was in 1956, when I volunteered as a locum (temporary) medical student intern in the respiratory unit of the Churchill Hospital in Oxford, England. Multidisciplinary critical care had been in existence only for about 3 to 4 years, and had been started by Bjorn Ibsen, (2,3) who was in charge of a hospital in Copenhagen given over to the management of a particularly virulent strain of poliomyelitis that gave rise to a pandemic in the early 1950s. (This pandemic was cut short in the United States by the introduction of the Salk vaccine.) The unit was started by the chief of neurology and run by Dr Spalding (a neurologist) and Dr Crampton Smith (later Nuffield Professor of Anaesthetics). They encouraged research into respiratory care, and later produced the first comprehensive, science-based "how-to" book: Clinical Practice and Physiology of Artificial Respiration. (4)

The change from the use of iron lungs, which were expensive and cumbersome, to prolonged positive pressure ventilation through a cuffed endotracheal or tracheostomy tube was an essential factor in the development of critical care. Positive pressure ventilation allowed easy access to the patient for nursing and medical procedures. Most of the patients were relatively long term and presented with poliomyelitis or tetanus. Assiduous attention was paid to hand washing, nutrition, pulmonary toilet, skin integrity, and psychological stress.

Patient Comfort

By its very nature, an intensive care unit (ICU) is not a comfortable place. There is generally too much noise, bright light, bustling activity, and physical disturbance in the environment. Pain and fear are ever-present for patients, and such challenges require constant attention. Resources often seem less than needs.

When critical care became established, which probably happened nearly a decade earlier in Europe than in the United States, one of the immediate concerns was for the physical and mental comfort of the patients. Tetanus was the first condition for which sedation was used as part of the treatment. The best standard of care quickly became paralysis (initially with curare and later with pancuronium) and mechanical ventilation. The use of nitrous oxide seemed an obvious choice to the anesthesiologists, who comprised the majority of intensivists in the early days. The gas was easily obtained, respirable, analgesic, and would readily sedate the...

NOTE: All illustrations and photos have been removed from this article.



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