In 2006, a routine clinical trial became a dramatic demonstration of the value of intensive care medicine, when six volunteers had a catastrophic reaction to a new drug and began to deteriorate rapidly. Perhaps the only stroke of luck was that they were in a private trials unit within the grounds of Northwick Park Hospital, which meant they could be immediately transferred to the care of the hospital's intensive care team, led by Dr Ganesh Suntharalingam.
That the patients all survived is testament to the dedication and skill of Ganesh and his colleagues, who treated their extreme immune response to the drug, provided round-the-clock monitoring, organ support and then oversaw their initial recovery. However, it also underlines the collaborative, multi-professional nature of intensive care medicine.
As Ganesh reflected when the incident became the subject of a BBC documentary, 'Saving the lives of those volunteers once they were transferred to NHS care required a huge, co-ordinated effort from the intensive care unit team, senior colleagues from other specialities, and many other clinical and operational staff across Northwick Park Hospital, with support from neighbouring critical care units and assistance from other agencies including the London Ambulance Service and the Metropolitan Police.'
Although this was an extreme example, he believes the importance of wide-ranging consultation and co-operation when treating critically ill patients and managing their ongoing care is central to intensive care practice. 'In emergency situations, you have to be able to make quick assessments and decisions but I think one of the most important qualities for an intensive care doctor is to be able to work collaboratively with a range of professions,' he explains.
'The specialty encompasses all aspects of acute care of a patient, which means we often need to obtain specialist opinions and work really closely with our nursing, dietetic, pharmacy, speech and language and other colleagues. While this is true of all healthcare fields to some extent, the urgency and complexity of our patients means we all need to deliver that care together, by their bedside.'
Intensive care is at the acute end of medicine, but the quality of treatment affects the eventual outcome for more than 270,000 people who are admitted to critical care units in the UK each year. 'We've gone from simply trying to get a pulse back, to getting people through their acute illness and bringing forward the recovery and rehab part of their care,' Ganesh says. 'A lot of the things we do right from a patient's first day in intensive care can impact on their long-term recovery, so it's very much about ongoing care as well, in conjunction with the multi-professional team, which requires patience and attention to detail.'
Increasingly, a spell in intensive care is not the result of a sudden deterioration or medical emergency but an important step in patients' planned treatment pathway. 'I think that over time, there has been the realisation that delivering high-intensity post-operative care to a greater proportion of people can actually simplify and speed up their recovery process,' Ganesh observes.
'Maybe 20 years ago, you would have had to be in the sickest category of post-operative patients to be transferred to intensive care but now more or less every patient will go to intensive care after heart surgery. And this is being extended to a greater range of surgery, whether that's through enhanced care of some sort, or time in ICU.'
I think one of the most important qualities for an intensive care doctor is to be able to work collaboratively with a range of professions.
Overall, Ganesh believes there is now greater recognition and appreciation of the role of critical care within the hospital. Surgery and other interventions have pushed medical boundaries, and increasing life expectancy means that patients present with more complex conditions.
Major incidents such as Northwick Park, terror attacks and flu pandemics have also led to the realisation that critical care must have the capacity and resources to respond to extreme situations. For example, the H1N1 flu pandemic in 2009 triggered discussion about the provision of critical care with extra-corporeal membranal oxygenation (ECMO) which supports the circulatory and lung function of critically ill patients.
'These facilities were only available in small numbers until that point which meant that patients had to be shipped abroad in some cases for treatment during the pandemic,' Ganesh recalls. 'It brought about an awareness that a national network of ECMO centres was necessary and shows how niche areas of the service can develop as demand has hit home or we begin using them in new ways.'
'In the last twenty years, there has been a recognition that critical care has historically been underprovided compared with other parts of the developed world,' he continues, 'and actually there has been a trend towards consolidating critical care into larger units and increasing capacity overall.' However, he also notes this expansion of capacity is not universal.
'Some units and hospitals have been able to keep ahead of the curve, so there are increasing numbers of large, well-equipped facilities which will generally have fewer overcrowding issues. Equally, I think a hospital that doesn't expand its intensive care capacity will hear the door knocking with greater urgency as demand increases.'
At the same time, Ganesh believes there is growing public awareness of intensive care as a distinct specialty. 'Historically, the general public didn't necessarily know what intensive care was, what we did or the distinction between that and the emergency department. If someone was critically ill from a heart attack or after trauma, the focus was on the specialties treating those fields. Even though that patient may have passed through intensive care and received a lot of complex critical care, it was seen as part of their hospital journey.'
Education and understanding
However, there is still need for continued public education about the range and complexity of intensive care because so much of the focus is on acute resuscitation and end-of-life care. This can lead to the misconception that the purpose of intensive care is to keep patients alive at all costs. 'In fact,' insists Ganesh, 'what we are there to do is to enable a patient to get better from a treatable, reversable acute illness and to treat that condition, while keeping them alive. But if a condition isn't treatable, then unfortunately the patient won't survive the experience. That is something that people need to understand better - and obviously it's our job to explain that to them.'
He stresses that the process of making decisions about life-sustaining treatment is often rewarding and very much part of the job. 'You are making these ethical judgments continually as a routine part of care. A typical example is when the patient needs emergency surgery and isn't in a condition to give consent. If it's clearly in their best medical interests to have a procedure and we make the assumption that they would wish us to go ahead, we would explain that to their family.
'If they then give us reason to think that might not be the case, we need to stop and discuss that in more detail,' he continues. 'Where we think the treatment may not be in the patient's best interest, we need to make a decision on their behalf - and the families' role is to explain what they think the patient would want.
'Families have a really important role and it is absolutely right that they should be involved in those discussions and that we explain our thinking and our decisions to them. However, I think that line can become blurred, such as when there are stories about families making the decision to turn off a patient's ventilator. In reality, that isn't the family's decision. We would make this decision on behalf of an adult patient and involve the family and ask them to explain what they think the patient would want. It is a subtly different but important distinction.'
In recent years, there have been headline-making disputes between doctors and families over the issue of life sustaining treatment, such as the Charlie Gard case, but Ganesh points out that these high-profile disagreements tend to be paediatric cases, which differ in terms of family involvement and consent. 'I don't want to downplay the ethical dimension, but my colleagues would probably agree that it is just something that has always been there,' he says. 'In the vast majority of cases, it is a matter of communication to help families understand what we're trying to do.
'If we have done our best and our clinical opinion is that it would be futile and not in the patient's best interests to continue, in the majority of cases people understand that. Where they don't, it's our job to continue to explain the situation to them so they feel comfortable that we are making a considered decision.
'Sometimes it needs explaining and it needs a bit of time, but it can also be reassuring to have a range of people involved. I think where there are disagreements, it helps is to have a clear consensus of opinion and to have detailed and sympathetic discussions with the families.
'I don't go into work thinking, 'There is going to be a major issue again today'. Of course there are occasionally difficult cases, but the vast majority of times people understand what we are trying to do our best given the patient's condition but that sometimes it doesn't work.'
Complaints and claims
That is not to say that intensive care is immune from complaints when things don't go well, but Ganesh doesn't believe there is an upward trend in his specialty. He also points out that a significant proportion are multi-part complaints where the family also have concerns about the patient's deterioration and the timing of their transfer to intensive care. Raising awareness of how to recognise a deteriorating patient is another example of where intensive care professionals can have a positive impact beyond ICU.
'Initiatives like critical care outreach or the national early warning score (NEWS) have projected the recognition of critical care into the hospital and the wider community,' Ganesh notes. 'Recognising that a patient has sepsis, a heart attack or stroke at the time it happens, wherever the patient may be, is key to them getting the right treatment early. From our point of view, if a patient has a critical illness and is at risk of organ failure, it's vital to be able to recognise and treat the underlying cause, but to also be in a position to provide organ support early and pre-emptively.'
My recommendation to anyone with an interest in critical care would be to unequivocally commit to it and develop it, because it is an extremely rewarding career.
Intensive Care Society
Education is one strand of the work of the Intensive Care Society, of which Ganesh is president and which celebrates its 50th birthday in 2020. 'We were originally set up as a professional association and scientific society at a time when intensive care was becoming a specialty in its own right,' he explains. 'We now have 3,500 members across multiple hospitals and our activities encompass everything from education, practice development and research to guidelines and professional and public representation.'
The ICS is distinctive among medical societies in being multi-professional, with members drawn from doctors, nurses and allied health professions; something Ganesh believes is important because that's how care is delivered to patents. 'Involving all these professions in our decision-making and addressing their concerns and interests is what ensures we're guided by the correct range of insights. It would easy to go down a wrong track if you only talk to a narrow group of people.'
To steer its development and growth over the next five years, the ICS has recently published a four-pronged strategy document and is setting up new organisational structures - learning, research, standards, and public affairs and professional affairs - to replace the small decision-making body on its national council.
In its education work, the ICS works closely with the Faculty of Intensive Care Medicine (within the Royal College of Anaesthetists), which is responsible for the training, assessment, practice and continuing professional development of intensive care specialists. 'The jewel in the crown of this collaboration is the Guidelines for the Provision of Intensive Care Services (GPICS),' Ganesh says. 'It's the standards bible for critical care in the UK.' Downloadable from the ICS website, GPICS sets out detailed standards and recommendations on all aspects of intensive care medicine, including service delivery and staffing, as well as ethical concerns such as end-of-life decision-making and the need to initiate discussions with families about organ donation where a patient meets the criteria.
Intensive care medicine once operated in a narrow space. The default entry was through anaesthetics and critical care was required for a small proportion of patients. These days, intensive care has its own dedicated training path and there's far greater awareness of the importance of intensive care in stabilising a wider range of patients and supporting their recovery.
Ganesh hopes that the specialty's growing profile will encourage more young doctors to choose a career at the sharp end of medicine. 'My recommendation to anyone with an interest in critical care would be to unequivocally commit to it and develop it, because it is an extremely rewarding career in a fascinating and complex field,' he advises.
'I'd encourage them to engage because there is a range of good conferences and meetings out there, members are very active in terms of social media and very accessible and welcoming too. We often get trainees from other specialties asking to spend some clinical time with us for exposure and there are opportunities to clinically practice at an early stage as well, even rotating onto ICUs as an FY1.
'Those of us who practise in intensive care medicine want it to be a specialty without high barriers to entry - we don't see ourselves as an elite behind fortress walls!'
Interview by Susan Field.
Dr Ganesh Suntharalingham
Dr Ganesh Suntharalingam is president of the Intensive Care Society and former medical lead of North West London Critical Care Network. He qualified as a doctor from Cambridge University Medical School in 1991 and initially trained as an anaesthetist. He joined the specialist register in 1999 and is a fellow of the Faculty of Intensive Care Medicine. Between 2006-2014, Ganesh was director of critical care and anaesthetics at North West London Hospitals NHS Trust, based at Northwick Park Hospital.
See more by Dr Ganesh Suntharalingham