Medicine: The Spread of Intensive Care
Over the past 10 years, the number of patients assigned to the ICU has increased, and Hadassah is actively developing the technology and the space to care for the influx.
It is the success of modern medicine that is filling intensive care units in hospitals worldwide. Accidents, terror attacks and burns, cardiac arrest, strokes and cancer, sepsis, pneumonia, poisoning and organ failure are among illnesses and traumas that were once almost always fatal.
But today, intensive care medicine is saving 90 percent of patients with life-threatening illnesses and injuries.
“Medicine keeps moving forward,” says Dr. Yaakov Naparstek, head of the Hadassah–Hebrew University Medical Center at Ein Kerem’s Department of Medicine, which operates one of Hadassah’s nine specialized ICUs. “More complex conditions have added layers of challenge to its practice, and a vast variety of procedures and technologies have been developed to address them.”
Intensive care medicine provides life support and organ support to critically ill patients and is generally the most expensive, most high-tech and most resource-intense area in medical care. Each year, it costs the United States more than $200 billion, around 1.5 percent of its entire gross domestic product. Hadassah spends three to five times as much on its intensive care beds as on its standard inpatient beds in intensive care units equipped with help from Hadassah donors and the United States Agency for International Development.
“The intensive care bed is a life-giving cocoon that bolsters chances of survival,” says Dr. Charles Weissman, head of the Department of Anesthesiology and Critical Care Medicine at Hadassah since 1997. “Intensive care combines advanced technology with teams of highly trained physicians, nurses, nurse practitioners, respiratory therapists, physiotherapists, nutritionists, pharmacists and other health professionals.”
Patients spend anywhere from 3 to more than 40 days in intensive care at Hadassah. They are admitted into its ICUs from all over the medical map. The medical center’s emergency room and trauma unit account for half of admissions, with the operating rooms, inpatient wards and other hospitals comprising the remainder.
“We have 65 intensive care beds and 8 intensive care cribs at Hadassah in 9 ICUs—general, surgical, two medical, cardiothoracic, coronary, neurosurgical, pediatric and neonatal,” says Dr. Weissman. “With occupancy of at least 100 percent, we often overflow into the recovery rooms.”
Over the past decade, the number of patients needing intensive care has steadily increased. Dr. Weissman attributes this to an aging population, more complicated and aggressive treatments and people living longer with diseases such as cancer and AIDS. At the same time, more procedures are performed on an outpatient basis, and those patients that are hospitalized are more likely to need intensive care.
“Modern hospitals are on their way to becoming large intensive care units,” Dr. Weissman says.
This trend informs the sarah Wetsman Davidson Tower under construction at Hadassah–Ein Kerem, its completion scheduled for 2012.
“Here we’ll have 25 percent more beds in the surgical ICU and 50 percent more in the medical,” says Dr. Weissman. “All medical and surgical wards will also have step-down or intermediate units, so patients can be ventilated [mechanically helped to breathe] on every floor.”
This is a remarkable trajectory for a specialty that’s less than 60 years old. The world’s first ICU was opened in 1953 in Copenhagen to ventilate victims of the polio epidemic then raging. Soon afterward, anesthetist Peter Safar began setting up what were then called Urgency & Emergency rooms in the United States. Later renamed intensive care units, it was in these rooms that the ABC (Airway, Breathing and Circulation) protocols were formulated and mechanical ventilation and external cardiac massage pioneered. In the 1960s, with the invention of the cardiac fibrillator, which channels bursts of electric current to the heart to restart or regulate its beating, the first coronary ICU opened.
“More and better techniques for maintaining life in critical patients are continually being created,” says Dr. Weissman. “In ventilation alone, we can move oxygen-enriched air in and out of a patient’s lungs in many ways.”
Ventilation is the most common reason for intensive care, he says. The average 52 patients ventilated each day at Hadassah represent a 68-percent increase in the past decade, with a whole unit at the medical center developed to handle mechanical ventilators and related equipment.
Respiration is only one of the body systems that the ICU supports. “With IVs and pumps inserted into veins, we supply patients with essential fluids, vitamins, nutrients, medication and blood,” says Dr. Weissman. “Flow is continually adjusted in response to our constant monitoring of critical bodily functions—heart rate and rhythm, pulse, airflow to the lungs, blood pressure, kidney function, electrolyte and fluid balances and levels of blood oxygen.”
Nowhere in modern medicine, however, is the physician’s oath to cause patients no harm as fragile as in the ICU. “Because our patients are critically ill, every lifesaving action can have negative consequences,” says Dr. Weissman. “Intravenous lines can trigger infection, for example. Ventilated lungs can collapse, medical stress can cause gastrointestinal bleeding, prolonged immobility can result in blood clots in leg or lung and antibiotic-resistant bacteria are an ever-present threat to weakened patients.”
Over the years, ICUs have accumulated vital knowledge about supporting patients. “As a result, a lot of our care is preventive,” says Dr. Weissman. “Nor do we work blind. For every procedure and treatment, we first monitor the patient, perform the procedure and then monitor its impact.”
Research to prevent medical intervention harming ICU patients is ongoing, from creating new antibiotics to upgrading technology. A recent Hadassah contribution to the growing body of knowledge appeared in the New England Journal of Medicine in January 2008. The article concerns treatment for septic shock, which occurs in a fifth of hospitalized patients and kills up to 60 percent of them.
“Septic shock results from overwhelming infection,” says Dr. Charles Sprung, director of Hadassah’s general intensive care unit, who coordinated the Israeli-European research study whose findings may change septic shock treatment. “While hospitals worldwide routinely use steroids to help reverse septic shock, we have shown this doesn’t help these patients, and may even harm them.”
New knowledge and techniques have led to specialization in intensive care, as in other areas of medicine. In the neonatal ICU, for example, a whole science has developed to keep very premature babies alive.
“We hospitalize about 120 infants weighing less than 3 pounds each year in our 8 intensive care cribs,” says Dr. Ilan Arad, Hadassah’s head of neonatology. “Even babies born after 27-weeks gestation weighing less than 2 pounds now have an 85-percent chance of surviving.”
In the neurosurgical ICU, treatment of stroke victims has moved from conservative to interventional.
“We dissolve blood clots in the brain with medication,” explains Dr. Felix Umansky, head of Hadassah’s neurosurgery department. “We surgically unblock vessels and stop bleeding. Brain lesions and tumors are treated in new subspecialties such as interventional radiology and endovascular neurosurgery. For patients undergoing invasive procedures like these, neurosurgical intensive care plays a critical role in their recovery.”
Interventional procedures are saving the lives of heart patients, too, according to Dr. Chaim Lotan, head of Hadassah’s Heart Institute. Cardiothoracic intensive care helps patients recover from the rigors of surgical correction of malfunctioning heart valves, tumors, congenital heart malformations and end-stage heart failure.
“The cardiothoracic team has also achieved outstanding results with trauma victims injured by blunt or penetrating wounds of the heart and lungs,” says Dr. Weissman. “With the region’s sole level-1 trauma unit at Hadassah, we see large numbers of very badly injured people in our ICUs.”
Almost half of the 5,000 victims of the second intifada were treated at Hadassah, many of them in intensive care. Teenager Michal Yacobson, who boarded the same Jerusalem bus as a suicide bomber in 2004, is one that everyone in the ICU remembers. A fading scar on her neck shows where surgeon Haim Anneer extracted a wristwatch. “We never found out who it belonged to,” Dr. Anneer says, “but we’re very proud of Michal and her recovery. She’s the most severely injured patient I’ve ever treated.”
Another intifada victim was Steve Averbach, 37, an Army hero who served in the Golani Brigade. He spent five critical weeks in Hadassah’s ICU after challenging a suicide bomber masquerading as an ultra-Orthodox Jew on a bus. Averbach, who moved to Israel from New Jersey, drew a gun and panicked the killer into premature attack, saving many lives. Paralyzed from the neck down by a steel ball bearing lodged in his spine, Averbach could breathe independently, speak, move his head and even bend fingers, toes and an elbow by the time he left the ICU. Seven months after the attack, he returned to Hadassah with his parents and a gift: state-of-the-art intensive care beds, donated by his parents’ Long Branch, New Jersey, community.
Today, Averbach, who has not recovered full use of his arms and legs, is a spokesman for Maccabi World Union’s Project Tikvah, which fundraises for victims of terror.
Success in treating trauma patients owes much to a new approach (one also widely practiced by the United States Army Medical Command in Iraq) of doing a little at a time.
“Trauma patients with shattered bones, ruptured organs or heavy bleeding are taken to the OR, where surgeons do damage control,” explains Dr. Weissman. “With the bleeding stopped and the patient packed, he is sent to the ICU, where we stabilize him with fluids and mechanical ventilation. A day or two later, the patient returns to the operating room in better condition and the surgeons complete the job.”
New medical technologies, more aggressive treatment and a fresh understanding of injury and disease all mean that the demand for space in the ICU will continue to increase. “Worldwide, the shortage of ICU beds is already severe,” says Dr. Naparstek.
The building of a new inpatient facility gives Hadassah the opportunity to increase its number of ICU beds and incorporate new knowledge about providing intensive care. With infection control an emphasis, intensive care beds in the new building will be arranged in eight-bed pods, each with its own infrastructure and facilities.
“Each pod will comprise individual patient rooms, something we’ve already introduced in one of our existing ICUs,” says Dr. Weissman. “With one nurse to every two patients, this would seem to complicate nursing life, but our nurses prefer the arrangement, as do patients and families. It quiets the whole unit.”
The newly built ICUs will also have infrastructure for scanners of all kinds. “As scanners become smaller and more portable, we’ll be able to introduce bedside imaging into the ICU,” says Dr. Weissman.
For a glimpse at the medical future, it seems we need look no further than the beeping, flashing, high-tech ICUs taking shape in the inpatient center now rising at Hadassah.