Changing Landscape of Critical Care

What's fascinating to me is that ICU care has changed dramatically even in a short span of time. When I did my critical care month as a medical student a little over five years ago, I saw vastly different approaches. For example, back then, we sedated nearly all our intubated patients with midazolam and fentanyl infusions. Now less than 1% of our patients have that combination; we've gone to hydromorphone and dexmedetomidine drips. Back then, we had dexmedetomidine but it was exorbitant and we didn't fully appreciate the delirogenic effects of benzodiazepines and the accumulation that would occur over time. Similarly, I saw a lot less continuous renal replacement therapy then than I do now. Not all the changes are good; our bugs are more resistant, and so our antibiotics have evolved as well. Many practices we take for granted such as sedation vacations, nutrition management, and glucose goals were fairly novel when I started as a medical student; back then, we'd discuss these "exciting" papers and now we frown upon anyone who doesn't know about them.

To me, this emphasizes the importance of specially trained critical care physicians. In the past (and in other hospitals), the ICU is managed by doctors who aren't ICU trained. But the landscape changes so incredibly quickly, and unless those physicians keep up with the latest literature, they could be practicing obsolete medicine. In the same vein, ICU doctors need to keep up with the latest research and opinions on controversial topics and new advances in order to stay at the edge of medicine. I am sure that many of the things I learn now as a fellow will be old news in a few years. Part of our learning is understanding how to learn, how to keep up with the literature, and how to evaluate and interpret data to make the right decisions for our patients.