Compendium May 1999 20TH ANNIVERSARY Small Animal/Exotics

Highlights and Horizons in

Emergency&
CriticalCare Medicine Ken Drobatz, DVM, Diplomate ACVIM, ACVECC
Associate Professor, Critical Care
University of Pennsylvania
Philadelphia, Pennsylvania

E
mergency and critical care medicine is
one of the most dynamic and rapidly
developing specialties in veterinary
medicine today. Although it is a relatively new field compared with other veteri-
nary specialties, initial interest in this area dates back to the 1950s.

The Early Years

The first presentation on veterinary critical care was given in 1954 by Dr.
Fred Sattler during the annual American Animal Hospital Association meeting
in Miami, Florida. The topic was cardiopulmonary resuscitation (CPR), and
there were 15 participants in attendance. I have been told that the presentation
was rather dramatic, with a demonstration of CPR on a dog. To place this into
perspective, the current recommendations for human CPR were not even in
place at that time. In fact, Dr. Peter Safar’s landmark paper, “Ventilatory efficacy Ken Drobatz
of mouth-to-mouth artificial respiration,” would not be published in the Journal
of the American Medical Association until 1958, the same year in which mouth-
to-mouth respiratory resuscitation was first endorsed by the American Medical anyone who would listen.
Association. Chest compressions for artificial circulation first saved a human life The first extensive patient-side mea-
in 1959, and the first presentation on human CPR as we know it today did not surements of vital signs in veterinary
occur until 1960—6 years after Dr. Sattler’s demonstration! medicine were done in 1957, and the
Some consider Dr. Sattler the father of modern veterinary critical care. He re- first all-day surgery was performed in
portedly had a great interest in electronics, which provided a solid background 1962.1 In this surgery, one veterinari-
for him to develop and use technology in veterinary critical care. He evidently an and three staff members were
flew his own airplane loaded with “gadgets, catheters, monitors, and ventilators” working on the animal at all times.
all over the United States and Canada and “preached” veterinary critical care to Monitoring was intense and continu-

ENDIU Early 1970s 1983 1984 1988

MP 1980 1983
Specific resources
are allocated for defined
The American Society
of Veterinary
The VCCS

1985 19 The first International

Veterinary Emergency
M’

and American

20th

CO

emergency/critical care Anesthesiologists merges Association of and Critical Care

S

services in with the Veterinary Veterinary Emergency Symposium is held in

1 9 7

ANNIVERSARY
9 - 1
9 9 9

1979
teaching hospitals.
(VCCS). 1982
Critical Care Society

1984
Clinicians merge to
form the Veterinary
Emergency and Critical
Care Society (VECCS).
San Antonio, Texas.

19
 Small Animal/Exotics
ous and included electrocardiogra-
phy, temperature, arterial and ve-
nous pressures, pH, carbon dioxide
partial pressure, and respiratory rate
and volume; all of these measure-
ments were recorded on a strip chart.
Another significant event in the
evolution of critical care was the allo-
cation of specific resources toward
defined emergency/critical care ser-
vices in teaching hospitals and its
emergence as a clinical rotation for
students and veterinarians.2 Colorado
State University, the University of
Pennsylvania, the Animal Medical
Center (New York City), and Angell
Memorial Animal Hospital (Boston)
were the first facilities to have dedi-
cated intensive care units in the early
1970s.
Organization
Although veterinary critical care
was initially promoted by a small
group of individuals (Fred Sattler,
William Whittick, Ira Zaslow,
Robert Knowles), its acceptance into
mainstream veterinary medicine did
not really begin until individuals in-
terested in the field began organiz-
ing. One of the first recognized
groups to develop was the Veterinary
Critical Care Society (VCCS), which
established its bylaws in 1978. The
American Society of Veterinary Anes-
thesiologists, established in 1970,
merged with the VCCS in 1983.
The most pivotal year in the con-
tinued development of veterinary
critical care medicine was 1984, the
year the Veterinary Emergency and
Critical Care Society (VECCS) was
formed through the merger of the
VCCS and American Association of
Veterinary Emergency Clinicians. The
VECCS contained approximately
987 1992
1990
1990
1995
The American College
of Veterinary
1991
The Journal of the
Veterinary Emergency
1998
Emergency and and Critical Care
1991
Critical Care Society is published
1994
19891993 1997
(ACVECC) is given (initially published in
probational status by the 1970s as the
986 the American
Veterinary Medical
Association (AVMA).
Journal of Critical Care
on a sporadic basis).
20TH ANNIVERSARY
200 members at that point; 2 years
later, there were 500 members. In
1988, the first International Veteri-
nary Emergency and Critical Care
Symposium was held by the VECCS
in San Antonio, Texas. This sympo-
sium has become a biannual event,
with nearly 2000 people participat-
ing in 1998.
In 1990, the American College of
Veterinary Emergency and Critical
Care (ACVECC) was given proba-
tional status by the American Board
of Veterinary Specialties; there were
19 charter diplomates. Full status as
a specialty college was granted by the
American Veterinary Medical Associ-
ation in 1996. More than 60 veteri-
narians are currently board-certified
in veterinary emergency and critical
care. The VECCS has sponsored the
development of the Student Veteri-
nary Emergency and Critical Care
Society (SVECCS) as well as the
Academy of Veterinary Emergency
and Critical Care Technicians
(AVECCT), which held its first
qualifying examinations in late 1998.
In addition, the VECCS and
ACVECC work together to publish
the Journal of Veterinary Emergency
and Critical Care, which is dedicated
to furthering the science of veteri-
nary emergency and critical care.
It is the organization of those in-
terested in the specialty that has
brought critical care to the forefront
of veterinary medicine and that, in
my opinion, has been the single most
important development in the field.
The development of VECCS and its
extensive membership (now more
than 1700) has provided a frame-
work for involvement in the specialty
on all levels—from students to tech-
nicians to veterinarians. Unlike hu-
1994
The Student
Veterinary Emergency
1996
The ACVECC is
granted full status as a
and Critical Care specialty college by
Society is formed the AVMA.
(SVECCS).
Compendium May 1999
OWNERS’ OUTLOOK
■ Population Explosion! Pet owners’
demands for quality emergency
care for their animals have
skyrocketed since 1979. In the past
20 years, the number of veterinary
emergency clinics has grown from
perhaps a dozen in a few major
cities to more than 400 nationwide.a
■ A Star is Born. The public’s growing
interest in veterinary emergency
medicine is evident just by turning
on the television. Critical care
practitioners are becoming TV’s
newest celebrities as their profession
is highlighted in such popular cable
series as “Emergency Vets” and
“Wildlife Emergency” on the
Animal Planet network and in
documentaries, such as “Animal
ER,” which aired on the TBS
Superstation in November 1998 and
was the highest rated documentary
of that week on basic cable.
■ Insuring a Healthy Future. The
importance of emergency care
to pet owners is also exemplified
in the success of such companies as
Veterinary Pet Insurance. Realizing
the importance of being able to
provide emergency (and routine)
health care for their pets—but
unable to foot the often pricey bills
involved—owners are turning to
Veterinary Pet Insurance for help.
Founded in 1982, the company
currently markets pet health
insurance plans in 46 states plus the
District of Columbia, and more
than 750,000 policies have been
sold to date.
a
Information obtained from the online
transcript of the March 29, 1999 edition
of the ABC news show “20/20.”
1996
The Academy of Veterinary
Emergency and Critical Care
Technicians (AVECCT)
is officially recognized as a
technician specialty by the
1999
North American Veterinary
Technician Association.
Small Animal/Exotics 20TH ANNIVERSARY
man medicine, in which the growth of critical care is now
mainly driven by technology, I think what has truly
pushed veterinary emergency and critical care forward was
(and is) the realization that the philosophy of critical care is
important. Critically ill animals are very dynamic physio-
logically, and practitioners realized that they had to keep
pace with changing conditions. It took dedicated people
with special interest and knowledge in this area to make
the specialty take off. Today, veterinary critical care is
probably starting to drive technology rather than vice ver-
sa. As critical care specialists realize what they need to be
more effective, they are making demands of industry to
create the required technology.
Technology
The practice of veterinary emergency medicine has de-
veloped substantially since its inception. Several years ago,
Dr. Knowles described the sequential progression of devel-
opments as beginning with gentle neglect and continuing
with temperature monitoring, crude attempts at regulating
body temperature, improved physical examination, flow
sheets, the expiratory whistle, urine output monitoring,
central venous pressure monitoring, aggressive fluid resus-
citation, aggressive antibiotic administration, cortico-
steroids, database collections, hemograms, electrolytes,
blood gas, the Oxford titrator, extensive database determi-
nations, blood pressure monitoring, and serial monitoring.
The list of available monitoring equipment is extensive
and will grow as computerization and technological devel-
opment continue. Instruments are now commonly used
to measure oxygen saturation of hemoglobin (pulse
Compendium May 1999
oximetry), point-of-care blood gas and electrolytes, blood
pressure (invasively and noninvasively), and end-tidal car-
bon dioxide as well as to perform hemodialysis, peritoneal
dialysis, and more. The technology available for use in
critical care medicine is impressive. It is only useful, how-
ever, if there are veterinary technicians capable of using
and maintaining the machines and veterinarians who can
interpret the massive amount of data in the context of
what is happening with the patient.
Looking Toward the New Millennium
The future of veterinary emergency and critical care
looks very bright. As this specialty matures, training at
all levels will continue to create more public and profes-
sional recognition and credibility. I see veterinary emer-
gency and critical care being incorporated into the core
curriculum of veterinary education as it becomes in-
creasingly recognized as an area requiring special exper-
tise. Finally, increasing public awareness and expecta-
tions will demand that our profession provides
state-of-the-art critical care. The strengths of the
ACVECC, VECCS, ACVECC residency training pro-
grams, AVECCT certification process, and SVECCS en-
sure that the field will be up to the challenge as veteri-
nary medicine heads into the 21st century.
References
1. Sattler FP, Knowles RP, Whittick WG (eds): Veterinary Critical
Care. Philadelphia, Lea & Febiger, 1981.
2. Stamp GL: Advances in emergency and critical care. Compend Con-
tin Educ Pract Vet 19(6):670–671, 1997.