Kirton, Orlando C.

MacLeod, Jana B.A.

Maerz, Linda L.

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Thomas Jefferson University Jefferson Digital Commons Abington Jefferson Health Papers Abington Jefferson Health 1-1-2016 Surgical Intensivist and Global Critical Care: Is There a Role? Jana B.A. MacLeod Orlando C. Kirton Thomas Jefferson University Hospital Linda L. Maerz Follow this and additional works at: https://jdc.jefferson.edu/abingtonfp  Part of the Surgery Commons Let us know how access to this document benefits you Recommended Citation MacLeod, Jana B.A.; Kirton, Orlando C.; and Maerz, Linda L., "Surgical Intensivist and Global Critical Care: Is There a Role?" (2016). Abington Jefferson Health Papers. Paper 78. https://jdc.jefferson.edu/abingtonfp/78 This Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of Thomas Jefferson University's Center for Teaching and Learning (CTL). 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Surgical intensivist and global critical care:is there a role?Jana B A MacLeod,1 Orlando C Kirton,2 Linda L Maerz31Kenyatta University, Nairobi,Kenya2Department of Surgery,Abington-Jefferson Health,Abington, Pennsylvania, USA3Department of Surgery, YaleSchool of Medicine, NewHaven, Connecticut, USACorrespondence toDr Linda L Maerz;linda.maerz@yale.edue000058Received 2 November 2016Accepted 27 November 2016To cite: MacLeod JBA,Kirton OC, Maerz LL.Trauma Surg Acute CareOpen Published Online First:[please include Day MonthYear] doi:10.1136/tsaco-2016-000058THE FRAMEWORK: THE INTERNATIONALARENAFor decades, infectious diseases such as HIV andtuberculosis have been on the forefront of theglobal public health agenda and should rightfullyremain high on the list for the foreseeable future.1Similarly, childhood infectious diseases account fora huge burden of disease and receive enormoussupport and funding, largely because of the poten-tial for successful intervention.2 For example, cam-paigns to eradicate polio and guinea worm capturethe attention of governments and society becauseof the potential for eradicating a disease with adefined impact on the health of a population.Consequently, assistance directed toward systems ofcare in medicine, such as critical care have oftenbeen neglected in programmatic initiatives.However, it has recently been recognized thatsuccess, even in disease-specific programmes, isoften unobtainable by the independent introduc-tion of a single intervention, such as a vaccine ornew medication. For example, in existing HIVintervention programmes, a concurrent expansionof health systems capacity was undertaken alongwith the introduction of HIV-specific treatments.Without this concurrent support of the localhealthcare systems, the delivery of adequatemedical care to contain the HIV epidemic andimprove survival would have been impossible. HIVpublic health programmes now routinely includeinfrastructure development within the hospitalsystems with which they work. Fortunately, globalfunds have made possible completion of facilityand personnel upgrades, and as a result, systems asa whole have benefited.3Accordingly, public health has shifted program-ming strategies to include healthcare infrastructureimprovements, including hospital facilities and per-sonnel, as well as disease-focused assistance. In therecent past, maternal mortality programmesfocused on traditional birth attendants, educationof front-line workers, and health promotion inter-ventions, but with little success.4 Many of the com-monest causes of maternal mortality are onlyaverted by implementation of hospital-based ‘cura-tive category’ interventions, such as a standardizedcaesarian section operative procedure.4 5Scientifically, the current reductions in maternalmortality have been attributed to intrapartum careor, in particular, the support and development ofhospital-based quality caesarian section operations.This example and others like it have led the way inshaping public health agendas to finally recognizethat strengthening a hospital infrastructure is notonly plausible, but can be highly successful inachieving improved population-level patientoutcomes. This has renewed an interest in develop-ing hospital-based care as one of the componentsof overall improvement in the health of popula-tions. Therefore, critical care should be included infuture hospital-based improvement plans. The timehas come to address concerns about introducing orsupporting critical care services in resource-limitedhealthcare settings.THE AGENDA: CRITICAL CAREThe need for critical care is reflected in global mor-tality rates, which can serve as a proxy for theburden of critical care in a region, as those who dieare likely to require high-level care. Globally, thevast majority of deaths, primarily from treatable eti-ologies, occur in low-income and middle-incomecountries.6 Of the 8–10 million children under theage of 5 years who die annually, >90% die in the42 poorest countries of the world.7 8 It is estimatedthat 90% of trauma-related mortality also occurs inlow-income and middle-income countries.9 10Finally, 50% of all maternal deaths that ensueduring pregnancy and childbirth occur in develop-ing countries.4 11 Critical care services in the devel-oping world are urgently needed to address theweight of these serious conditions and their asso-ciated mortality. In Africa in particular, the needfor critical care is urgent.12Globally, over 50% of patients in any givenintensive care unit (ICU) have a surgical problemor are post-trauma. In the USA, estimates demon-strate that there are ∼6000 ICUs across the countrythat care for over five million admissions annually,which amounts to ∼55 000 patients daily beingtreated in an ICU in the USA, with a significantnumber being surgical or trauma-related admis-sions.13–15 The earliest publications from ICUs indeveloping countries have demonstrated a similarepidemiology. For example, in 1968 in Nigeria, areview of the first 100 cases of critical illnessdemonstrated that the majority of the admissionswere either postoperative or postobstetric complica-tions with an overall unit mortality rate of 30%.16Recent publications, such as a 2006 review of ICUsin low-resource healthcare settings in Tanzania andthe Republic of Congo, demonstrate that 5 of thetop 10 admission diagnoses are directly attributedto either trauma or postsurgical patients, withanother 20% directly related to obstetric causes.12Therefore, critical illness in the developing worlddisproportionately affects the young, productiveportion of society. Accordingly, improvement incritical care services has the potential to greatlyimpact population-level mortality rates andimprove the impact of mortality on society.MacLeod JBA, et al. Trauma Surg Acute Care Open 2016;1:1–3. doi:10.1136/tsaco-2016-000058 1Open Access Current opinioncopyright. on May 12, 2023 by guest. Protected byhttp://tsaco.bmj.com/Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2016-000058 on 21 December 2016. Downloaded from However, obstacles to implementation and support of criticalcare in the developing world remain. Critical care is viewed as ahighly specialized, highly technical field that requires bothexpensive equipment and personnel training. Ironically, some ofthe expensive equipment in US ICUs is infrequently used andlacks scientific merit with respect to improving patient out-comes.17 For example, after the polio epidemic of the 1950s,the Bird respirator was developed to provide a more portableform of mechanical ventilation. Since that time, many newmodels of ventilators have been developed. However, only theprovision of positive end-expiratory pressure and maintaininglow plateau pressures have scientifically demonstrated a reduc-tion in mortality, and these components of mechanical ventila-tion are neither technology-specific nor ventilator-specific.18Many technologies, such as pulmonary artery catheters, wereonce extensively used, but have subsequently been demonstratedto be of little benefit and are now rarely used.19 Conversely,timely, appropriate sepsis management that provides early insti-tution of fluid resuscitation and antibiotics has been demon-strated to reduce mortality, whereas technology, per se, hasnot.18Therefore, critical care is a clinical service that is feasible toimplement, requires less technology than is commonly realized,and has the potential to substantially impact the young, product-ive portion of a population, minimizing years of life lost. Withinmost resource-limited countries, surgeons are still needed inlarge numbers, and anesthesiologists are even scarcer.20 Forexample, in Africa, the clinical care of most ICU services, if pro-vided by doctors with specialist training, is often limited toanesthesiologists who commonly lack formal critical care train-ing. Interestingly, critical care training for nurses is often moreeasily available than for physicians or surgeons. With the excep-tion of a few countries in the north and south of the continent,there is no formal critical care fellowship-level training for phy-sicians and surgeons. Additionally, the allocation of space andbeds for an intensive level of care is sparse. Even in SouthAfrica, in large cities such as Cape Town, it is estimated thatonly 6.6% of all beds are allocated to critical care.21 In a surveyof anesthetic services in 68 hospitals in Zambia, only 7%reported having an ICU.22 Finally, the majority of units arefound in tertiary care centers and major urban locations, furtherreducing access to the appropriate level of care when needed.Therefore, even those patients who seek hospital care often donot receive the intensity of care they require to survive theirillness. In a community, non-tertiary hospital in a northeasternstate of South Africa, a review of admitted hospital patientsdemonstrated that 25% met criteria warranting ICU admissionhad they been admitted to a hospital with such a unit.21 Patientacuity in the trauma units, operating rooms, and wards of thelow-income countries is often high. Malnutrition, chronicanemia, and the high prevalence of HIV coupled with the manycultural and socioeconomic factors that result in patients pre-senting late, all contribute to acuity severity on admission.Therefore, in low-income and middle-income countries, thechallenge for critical care is significant, with a potentially largerburden on hospitals than is seen in other parts of the world. Asthe United Nations Development Program’s (UNDP) new 2030sustainable development goals are rolled out, there is a majorfocus on improved health. Its goals include an increasedemphasis on universal quality healthcare access for communic-able, non-communicable, and injury-related illness.23 As theglobal agenda in health expands, critical care must be broughtinto the clinical service agenda.24 25THE PERSPECTIVE: THE SURGICAL INTENSIVISTThere is a burden of unmet need in the international criticalcare arena, there is a global recognition by UNDP of this need,and at present, local resources, including facilities and person-nel, are inadequate to address it. Concurrently, some colleaguesin high-resource countries are increasingly interested in reachingout to other institutions globally to share knowledge, experienceand mentoring—now is the time to match the high-resource andlow-resource institutions and individuals to maximize thebenefit to all. Technology, expensive equipment, and advancedmedications are not essential to primary critical care. This isbest reflected in the motto of the international Society ofCritical Care Medicine (SCCM): ‘Right Care…Right Now’.This approach is universal and can be adopted globally wher-ever critically ill patients are found. The basic tenets of surgicalcritical care should be included in essential surgical careinitiatives.FULL CIRCLE: THE PATHWAY TO BUILDING A SOLUTIONMatching high-resource and low-resource institutions and indi-viduals requires communication, mentorship, and collaboration.High-level communication technology does not require physicalpresence, but provides a means for involvement in critical careabroad and can be leveraged to facilitate mentorship, education,and research, all of which require collaboration. The inter-national need for surgical intensivists is great, and the desire toprovide assistance exists. Facilitating the partnership of low-resource and high-resource institutions and individuals willbenefit all involved, including, and especially, the world’s critic-ally ill patients.Competing interests None declared.Provenance and peer review Not commissioned; externally peer reviewed.Open Access This is an Open Access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work isproperly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/REFERENCES1 Murray CJ, Ortblad KF, Guinovart C, Lim SS, Wolock TM, Roberts DA, DansereauEA, Graetz N, Barber RM, Brown JC, et al. 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Surgical Intensivist and Global Critical Care: Is There a Role?

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