Medico

0039-6109/06/$ - see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2006.09.004 surgical.theclinics.com
Surg Clin N Am 86 (2006) 1305–1321
Critical Care Medicine: Landmarks
and Legends
Matthew R. Rosengart, MD, MPH
Department of Surgery, University of Pittsburgh Medical Center Presbyterian,
Pittsburgh, PA15213, USA
Critical care medicine was born from theselective pressures, or evolution if you will, of human disease, and in combination with the perseverance and foresight of a select few pioneers, has become the independent field of medicine as we regard it today. Its true origin, not surprisingly, is difficult to establish. Florence Nightingale described the benefits of creating an individual facility for the care of postoperative patients; however, itwas the establishment of a three-bed unit for postoperative neurosurgical patients by Dr. W.E. Dandy at the Johns Hopkins Hospital that heralded the development of intensive care in the United States.
Ironically, though not uncommonly, subsequent advancements in caring for the critically ill occurred during the wars of the twentieth century. Insight into the pathophysiology of organ failuregleaned from treating the severely injured provided a large impetus to the development of intensive care. Identifying shock and instituting appropriate intravascular fluid resuscitation (eg, saline, colloid) was well-established at the conclusion of World War I, and the techniques of blood transfusion became operant during World War II [1]. Surgical improvisation led to technical advances and theimmediate survival of previously lethal injuries, yet necessitated prolonged supportive therapy for ultimate recovery. Shock wards were established to resuscitate and care for soldiers injured in battle or undergoing surgery, and postoperative patients were admitted to recovery rooms to facilitate nursing care. The subsequent reduction in morbidity and mortality resulted in the spread of recoveryrooms to nearly every hospital by 1960 [1,2].
A discussion of the development of intensive care would be incomplete without mentioning the polio epidemic of the late 1940s, from which landmark advances in the management of respiratory paralysis occurred. It is
This work supported by NIH grant K12HD049109-01. E-mail address: rosengartmr@upmc.edu

1306 ROSENGART
also during this era that manyreport that the world’s first intensive care unit, as defined as “a ward where physicians and nurses observe and treat ‘desperately ill’ patients 24 hours a day,”was developed by Dr. Bjorn Ibsen in Copenhagen in 1953 [3]. The first patient admitted to that unit at 6 PM on December 21st, 1953 was a 43-year-old-man who had unsuccessfully attempted to hang himself.
“He was agitated, confused andcyanotic with laboured respiration. Temperature 38.6°C and pulse 136. An x-ray showed bilateral infiltrates and oedema of the lungs. It was felt that fatal cardiopulmonary failure was imminent. Oxygen via facemask and when oxygen saturation decreased..., with positive pressure ventilation from a bag and mask, was started. Furthermore, the patient was given one unit of blood (500 mL), isotonic glucose(1000 mL), and an antibiotic (Aureomycin) [3].”He ultimately succumbed to multiple organ dysfunction. By the late
1950s, ICUs had been established in a quarter of large community hospitals, and by the late 1960s, this proportion had expanded to a majority. In 1986 the American Board of Medical Specialties approved a certification of special competence in critical care for the four primary boards:anesthesiology, internal medicine, pediatrics, and surgery. In the years that ensued, critical care significantly reduced the allocation of resources (length of stay, cost), and by 1997 more than 5000 ICUs were operational across the United States [2].
Contemporary critical care differs considerably from that which marked its “birth.”Much of the technology we currently employ is assumed: invasive...