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Critical Care: Career Options & Opportunities Dr. Lava N Joshi MD ( Cardiology ) Consultant Cardiologist Om Hospital and Research Center INTRODUCTION The term “Intensive Care” refers to the great amount of care that a critically ill patient requires in comparison to a regular and less sick patient. The term Intensive Care unit refers to separate ward in the hospital, which caters such sicker group of patients. • The concept of Intensive care was put forward by Florence Nightingale after the Crimean war when she started treating sicker patients in a separate area. Following the Polio epidemic in 1952, Dr. Bjorn Aage Ibsen, a Danish Anesthetist , started the world’s first ICU in Copenhagen in 1953, when he started treating respiratory paralysis polio patients by intubating and ventilating them. Then after, ICU started flourishing all over the world with the advancement of modern technologies and electronic revolution. At that time ICU used to function as a multidisciplinary unit with involvement of various subspecialties. Since early 1990s, after the establishment of Critical Care Medicine, the branch of medicine that deals with study of these critically ill patients, ICUs started functioning as separate department. NEPALESE SCENARIO In Nepal, the first ICU started in 1973, at Bir Hospital, as a five bed medical ICU. This ICU was established in 1970 when king Mahendra developed heart problem. This was the only ICU in the country for almost 20 years. Marasini B R, Health and Hospital development in Nepal, past and present ,JNMA 2003. Another ICU became functional after the development of TUTH at IOM in 1990 and was a six bed mixed medical and surgical ICU. Then after , with the increasing demands of ICU beds, critical care slowly progressed and has reached its current status. Now almost all hospitals in the country have few ICU beds, accounting to a total of around 500 ICU beds in the country. A survey of ICU beds in 51 hospitals within Kathmandu Valley with 50+ bed capacity, showed 21.6 % in Govt hospital 15.7 5 in Community hospital 62.7% in Private Hospitals Shrestha RR,Vaidya PR,Bajracharya GR, A survey of adult intensive care units in Kathmandu Valley Postgrad med J NAMS, 2011 There were 48 intensive care units , with total of 331 ICU beds, which comprises of 4.7 % of all hospital beds. Facility for mechanical ventilation was available only in 161 ( 2.3 %) of total hospital beds Considering population of around 20 million in 2011, there are only 15.2 ICU beds per 100,000 population and only 7.2 ICU beds with ventilator per 100,000 population. FACILITIES IN ICU Most ICU have non-invasive facilities with ECG, NIBP and pulse oximetry. 50 % have intra-arterial BP monitoring. CV catheterization is done in almost all ICU even outside the valley. Blood gas analyzers are available in 10 ICUs, portable X-ray in 28 ICUs, bedside USG and Echo in only few ICU Mechanical ventilators are available in almost all ICUs in Nepal. Renal replacement therapy is available in only few ICU. ICU AUDIT Magh 1st 2070 - Jestha 2072 The new ICU was inaugurated on 1st of Magh 2070. Om ICU is known for diversity of disease. Since then the total admissions during this period is 1351. Among them a total of 214 ( 15.8%) mortalities occurred “Age Distribution” 398 400 350 300 250 200 150 100 50 0 119 111 155 180 213 67 0 0 0 0 31 -4 41 -5 51 -6 61 -7 >7 0 0 21 -3 20 -N ov 10 -J an 16 “Systemic Disease Categorization 367 271 176 155 rn 9 Bu ni ng o Po i so th e 20 cr in ro En do ph s Ne Ob co na e/ On Gy GI T 32 89 86 51 Or 95 CN S Re sp CV S 400 350 300 250 200 150 100 50 0 “Duration of stay” Duration of ICU Stay 9.13 2.81 1--3 18.07 4--6 7--10 70.18 >10 15 10 Magh F al g u n Ch a i tra Bais akh Je s t h a Asad Shra w an Bh a d ra A soj Karti k Mang sir Pous h Magh F al g u n Ch a i tra Bais akh Je s t h a “Ventilator Used” 25 20 20 17 19 17 15 8 6 18 9 10 13 10 14 Ventilator used Improved Deceased 14 12 11 9 5 0 Global challenges Critical care is costly With increase in life expectancy and improved overall care of patients, the need for ICU bed is increasing Crit Care Med 2010;38:65-71 The key challenge for the future will be to provide adequately trained intensivists as there is a predicted shortfall. Crit Care Med 2008;36:1350-1353 Training programs in Nepal DM program in Critical Care Medicine started at Institute of Medicine, Tribhuvan University from October 2013. Formal collaboration with Royal College of Physicians and Surgeons of Canada (RCPSC) 1 candidate in first batch 2 in second batch JSAN 2014;1(2) DM Pulmonary Critical Care and Sleep medicine, started in Bir Hospital NAMS in 2012 Introduced in BPKIHS Dharan in 2014 JSAN 2014;1(2) Levels of ICU Level III: Tertiary referral unit Should be capable of providing comprehensive critical care including complex multi-system life support for an indefinite period Involvement in education and research All patients to be referred to attending ICU specialist for management Requirements of Level III ICU: At least 8 staffed and equiped beds Sufficient clinical workload and case-mix to maintain clinical expertise Should manage more than 400 mechanically ventilated patients per annum Run by medical director – full time commitment to the operation of ICU and trained in Intensive Care Medicine Minimum of 1:1 nursing for ventilated and other similarly critically ill patients and 1:2 nursing for lower acuity patients (clinically determined) Defined protocols, admission, discharge and referral policies Suitable infection control and isolation procedures and facilities 24 hours access to pharmacy, pathology, operating theatres and imaging services Level II: Capable of providing general intensive care including complex multisystem life support Capable of providing mechanical ventilation, renal replacement therapy and invasive cardiovascular monitoring for an indefinite period of time Should have arrangement for patient referral to tertiary hospital when appropriate specialty support (neurosurgery, cardiothoracic surgery) is not available At least 6 staffed and equipped beds More than 200 mechanically ventilated patients per annum Run by medical director – full time commitment to the operation of ICU and trained in Intensive Care Medicine Nursing requirement similar to Level III Level I: Capable of providing immediate resuscitation and short term cardiorespiratory support for critically ill patients Major role in monitoring and preventing complications in “at risk” medical and surgical patients Capable of providing mechanical ventilation and simple cardiovascular monitoring for at least several hours. Should have established referral relationship with Level II and III units CHALLENGES Lack of governing bodies to monitor the services, quality and facilities required to run an ICU. Lack of certified Intensivists to manage and run the ICUs Lack of certified training courses for the allied health staff. High cost of treatment, which has to be borne by the patient or their family. Unavailability of medications, drugs, and equipment . Apart from litigation and legal claims, health care in Nepal also experiences vandalism, physical threats and even blackmailing. THANK YOU ALL FOR YOUR KIND ATTENTION.