History of Critical Care Medicine:

The Past, the Present and the Future 1

G. Ristagno, M.H. Weil

Introduction

The term “Critical Care Medicine” was first introduced in the late 1950s at the
University of Southern California (USC) from the concept that immediately life-
endangered patients, the critically ill and injured, may have substantially better
chances of survival if provided with professionally advanced minute-to-minute
objective measurements. Such measurements were largely based on “real time” elec-
tronic monitoring of vital signs, hemodynamic and respiratory parameters, and com-
plementary measurements on blood and body fluids. Care was increasingly delegat-
ed to a new generation of dedicated physicians, professional nurses, therapists, and
clinical pharmacists in special care units. Since then, progress in the management of
the acutely life-threatened patient has been accelerated by rapid advances in both
monitoring and measurement technologies and the interventions that were triggered
by them. Intubation and mechanical ventilation, hemodialysis, volume repletation
guided by measurement of intravascular pressures and cardiac output, resuscitation
by the routine use of chest compression, defibrillation and pacemaker insertion came
into general use. These individual techniques had progressively evolved over the pre-
ceding decades by anesthesiologists in the operating room and postanesthesia recov-
ery units and by cardiologists in the catheterization laboratory. Conventional meth-
ods of observation based on physical examination and largely manual measurement
of vital signs at the bedside were therefore increasingly superceded by electronic
techniques of quantitative monitoring and measurements. These methods of monitor-
ing and measurements became not only acceptable practices but were remarkably
rapidly implemented by hospitals and initially at defined in-hospital sites which
were designated intensive care units (ICUs) or in some European countries, intensive

M.H. Weil ()

Weil Institute of Critical Care Medicine, Rancho Mirage, CA, USA

Antonino Gullo et al. (eds), Intensive and Critical Care Medicine. 3

© Springer-Verlag Italia 2009
 4 G. Ristagno, M.H.Weil

therapy units (ITUs). In major centers, specialized units were later established in part
1 contingent on the volume of patients eligible for specialized cardiac, respiratory, sur-
gical, neurological, and later pediatric and neonatal care [1]. A variety of subsidiary
or “step-down” units with less elaborate monitoring for intermediate care expanded
the availability of monitored care to patients at lesser risk [2]. “Critical Care
Medicine” as it became known in the USA, “Intensive Care,” “Intensive Therapy”
and “Reanimation” in some other countries remarkably rapidly became a new in-hos-
pital practice discipline – within literally a decade. Within 25 years the discipline
became a recognized subspecialty in which continuing on-site medical diagnosis and
management of immediately life-threatening diseases and/or injuries was provided
with high priority by advanced specialists recruited from internal medicine, general
surgery, anesthesiology, and pediatrics. These specialists were intended to be physi-
cally on site, in part comparable to the well-established uninterrupted loyalty of anes-
thesiologists to a defined patient during surgical procedures [3]. At present, almost
every medical and surgical practitioner now increasingly relies on critical care
experts for the care of acutely life-threatened patients outside of the operating room
in general or in specialized intensive care units.

When Did Critical Care Medicine Begin?

The beginning of critical care is debated, in part contingent on definitions of site or

locale, the expertise and qualifications of providers, and the evolution of automated
monitors and modern life support technologies. In the 1850s during the Crimean War,
it was the site which defined the pioneering contribution of what became Critical
Care by Florence Nightingale, who is generally viewed as the parent of professional
nursing. Nightingale segregated the most severely battle injured soldiers and bedded
them in close proximity to the nursing station so that they might receive more “inten-
sive nursing care” [4]. Some 70 years later, in 1923, the concept of postoperative
recovery was modeled by Dr. Walter Dandy who organized a neurosurgical postoper-
ative care unit at Johns Hopkins Hospital in Baltimore, enlisting specialized nursing
staff. Professional nurses therefore became the first bedside specialists rendering
critical care under the direction of neurological surgeons. This initial intensive care
also became a model for postoperative recovery units, which provided intensive post-
operative management for military causalities during the Second World War [5].
Comparable postanesthesia recovery units evolved for postoperative management of
patients in civilian practices in the 1950s, allowing for better outcomes after more
invasive surgical procedures including cardiac and radical cancer operations. Again,
it was the bedside expertise of specialist nurses, supported by anesthesiologists, who
were later equipped with bedside monitors that triggered timely life support interven-
tions and thereby improved management in the immediate postoperative interval.
Accordingly, there was a transition from site to expertise, both among medical
specialists and especially anesthesiologists, and professional nursing. With respect to
life support technologies, reference is often made to the poliomyelitis epidemics of