Hannah Wunsch is a critical-care physician at Sunnybrook Health Sciences Center and a professor at the University of Toronto. She is the author of The Autumn Ghost: How the Battle Against a Polio Epidemic Revolutionized Modern Medical Care.
Intensive care units (ICUs) are the last repository of hope in hospitals. Working with the most cutting-edge medical technology, teams of individuals skilled in critical-care medicine save lives in an ICU by combining high-tech support with nursing and medical expertise. ICUs provide a place to care for those who need high-risk surgery, those who have suffered traumatic injuries, and those with overwhelming infections. But ICUs are not, and never should be, the front line of medical care.
Critical care – a medical specialty focused on patients who have organ failure – is a relatively new area of medicine. The first modern critical care (or intensive care) unit was only created in 1953 in Copenhagen. Born out of the need to care for patients experiencing respiratory failure during a polio epidemic the year before (and spurred on by advances in surgical and resuscitation practices), the first ICU was established by Danish anesthetist Bjorn Ibsen. He recognized that certain people could be rescued from near death, but only with concentrated skills and equipment all in one place. Over the next 30 years, ICUs proliferated across hospitals in high- and middle-income countries. However, to give a full idea of the relative youth of the field, the first ICU in Thailand was only set up in 1975, and China had no ICUs until 1982.
The reality of what privilege provides when it comes to home-driven medical care during the Ebola epidemic in 2014. Many health care workers from across the globe (including two of my critical-care colleagues at Sunnybrook Hospital in Toronto) volunteered in West Africa to provide medical care, help create treatment infrastructure and study ways to reduce mortality for Ebola patients. Despite precautions, some of these volunteers contracted Ebola. Between August, 2014, and May, 2015, 27 people (mostly health workers) were infected, and then received treatment in high-income countries, with full access to critical care. While the death rate from Ebola in West Africa has historically been between 70 per cent and 80 per cent and was reduced to 40 per cent in a specialized treatment centre, the mortality rate for those cared for in hospitals in developed countries was much lower, at 18.5 per cent – a stark example of the success of modern medical care, for those with access.
Given these clear benefits of modern ICUs, I often get asked: If we didn’t have enough beds in these units during the height of the COVID-19 pandemic, shouldn’t we build more in anticipation of the next wave of COVID, or a different onslaught?
To a certain extent, we should increase our number of ICU beds and the resources we put toward them. However, being perpetually ready for the next large global pandemic is a bit like suggesting that we should have an army of the size mobilized during the Second World War ready for when the next global conflict breaks out. Keeping such a high number of troops trained, and huge amounts of equipment maintained, would be astronomically expensive. Some good at war analogies for medicine, but this one is apt: It takes an army of people – physicians, nurses, pharmacists, physical therapists and respiratory therapists (to name just a few) – as well as a lot of complex equipment, such as as ventilators, dialysis machines and monitoring devices that all have to be purchased, maintained and replaced when out of date – to keep people alive in an ICU. These elements – particularly the personnel – can’t all be left on standby for months, or years. Even expanding ICUs by just a little is a huge undertaking, as the extra space, equipment and trained staff are expensive. And basic training in the army (which unlike traditional lasts 10 weeks), takes years of training to become a critical-care provider.
That doesn’t mean we can’t plan for the next pandemic. We can stockpile some of the supplies we need, and strategize ways to scale up the delivery of care more quickly than we did during COVID. Administering basic training about critical care to a wider array of health care professionals should also ensure we are more prepared the next time.
The availability of ICU beds also does not necessarily change the overall health of the population. While health care spending (and the number of ICU beds per capita) has a strong relationship to many markers of overall health in a population, this is not always the case. Despite having more ICU beds per capita than most other countries, the United States also has one of the worst maternal mortality rates of developed countries, a lower life expectancy, and one of the worst death rates from COVID. However, this doesn’t mean there isn’t value in ICUs. As humans, we value each individual life, and as health care professionals, we care about each life we can save.
The majority of care I provide in the ICU is for patients who have suffered a medical emergency, or who need critical care because of disease progression, despite the expertise of other health professionals. The number of ICU beds and providers we have is a balancing act between supply and demand from events that occur regardless of our best efforts. This balance breaks down when all the upstream components of medicine that provide preventive and other, less intensive care, start to fail, and that is what is happening now.
Recently, a patient was admitted to an ICU who had tried to end his own life. The reasons? He was in terrible pain from cancer and felt unable to access adequate relief. A woman who was bleeding from uterine fibroids needed an MRI before scheduling a procedure for embolization. The wait time for the scan? Six months. While waiting, she began to bleed so badly that she was rushed to the hospital and underwent emergency surgery.
Individuals who, whether through personal hardships or choices, have developed a severe illness that was preventable, have and will always receive critical care. But what creates a sense of despair in an ICU team is to deploy critical care to those whom the system has clearly failed – those who are suffering from the effects of cancer that was detected late; an emergency due to delayed surgery; a lack of timely access to pain medication. What we are starting to see is critical care as the catcher, routinely fielding pitches, rather than the backstop, there is to block the occasional wild curve ball. why? Because the entire health care system is fraying to the point of collapse.
Do we need to invest in critical care? Yes. It is one of the great luxuries of wealthier societies to be able to offer the latest innovations in life-support. Our goal should be to protect and maintain what we have, and plan for some modest expansion to meet the needs of an aging population. In particular, we need to train more critical-care nurses and better support the ones we have. But the only way critical care can function properly in the future as part of our health care system is if we protect it as a scarce resource.
The current pandemic threatening to overwhelm our ICUs is not COVID-19, but one of preventable illnesses. The dominoes of public-health infrastructure, vaccine uptake, access to family doctors and specialty services, such as surgery, have started to topple. We must invest in all the necessary upstream health care, not only to provide the best front-line care, but to allow critical care to do what it does best: save one precious life at a time.