For this "After ICU" edition of ICU Management, Managing Editor Sherry Scharff sat down with Jean-Daniel Chiche to discuss a range of engaging topics including the allure of intensive care medicine as a specialty, the need to push away from the "hero" culture and the importance of being human.
What Brought You to the Field of Intensive Care?
When I first entered the ICU as a medical student, I was immediately struck by the emotional intensity. It is one of the few specialisations in medicine where you can go from complete quiet to a crisis situation within minutes and you will be called upon to use not only your hands, but also your brain— and your heart all at the same time. I often say that this is internal medicine of life-threatening disease, and this is the concept that I love about intensive care... Who doesn't want to be a specialist of life-threatening diseases? It basically challenges you to become knowledgeable about every discipline in medicine and then to be pragmatic enough to intervene quickly. There are so many unique and amazing attributes to working in the field of intensive care; it is not only that you play an instrumental role in life and death daily, but also that you do so as a team. There is powerful feeling of continuum from the head nurse to the nurse to the doctor to the scientist... A clear bedside to bench and back push towards a common goal of saving patients. I can't imagine doing anything else with my life.
What has Propelled You to Take on a Leadership Role?
In my 24-bed, mostly medical unit, we work as a cohesive team to care for the more than 1,600 patients admitted per year. But I realised early on that even if you work 24 hours a day in your unit, every day of your life, there is a limit to how much of an impact you can have on your patient's lives or the lives of the other members of your team. You may treat all 1,600 patients to the best of your ability, but you will not affect the system and the only way to truly improve outcomes is by changing the system. In this way, we really need to move away from the culture of the hero to the culture of the system. An excellent example of an industry where this culture is in place is air travel. When you decide to travel, you choose the location you need to get to, and the time you need to be there. You choose the airline based on the best combination of these elements (and cost). However, you would never consider basing your decision on which pilot is flying which flight, because you trust that the pilot from the 4 pm flight will be as good as the one from the 6 pm flight and they all have the proper credentials and training.
In intensive care, the ambulance goes right or left, and you are lucky or you are unlucky based on where you go and when you arrive. This is wrong. In intensive care, quality of care should be uniform from hospital to hospital and the level of care should not differ whether you arrive on Saturday at two in the morning or Monday at 11 am. If the disease is the same, than the response, treatment and outcome should be consistent, independent of all of these factors. If you feel strongly about the need for systematic change and the evolution of the field into a more structurally uniform state, you really need to take on a leadership role.
What Practical Advice can be Given to Those People Who Want to Incite Constructive Change in Their Units?
As a leader, you need to reflect on the organisation of your department. It might not be that there is one perfect organisation that works everywhere; but in every department you to need consider the same factors:
• Pattern of ICU admission;
• Performance levels, and
• Observed mortality rates (are they lower than the predicted mortality in specific groups and across all patients?)
Finally, you need to make a candid assessment of the department, highlighting any areas where you can improve quality of care. It is striking to see for example, that volume matters. Patients who are ventilated in a high volume unit have much better outcomes than those who are suffering the same disease, with the same level of severity and are ventilated in smaller unit, with only 150-200 ventilated patients a year. I think that these observations will have some organisational consequences that may result in regionalisation of care in certain countries. Perhaps it will mean closing some small ICUs and instead putting the resources into bigger, more organised ICUs where you can also incorporate in-house teaching programmes and implement a staffing structure where there is at least one senior intensivist available at the bedside around the clock, daily.
This desire to change the predominant culture of intensive care has also been the drive for me to become more involved with ESICM. The scientific society is a wonderful instrument to provide better science, better education and training as well as to improve patient and public outreach for intensive care medicine.
What do You Think are the Predominant Challenges in Critical Care for the Next Decade?
Sepsis today remains extremely frequent and although mortality has slightly gone down thanks to work that was initiated following the surviving sepsis campaign, for instance, we see know that sepsis still carries a high burden and remains a challenge in critically ill patients. It is also important to start realising that the patients we treat successfully and discharge from our ICUs don't all go back to a normal life within a couple of weeks or months and long-term outcomes from intensive care medicine are going to become extremely important. This emphasis on long-term outcomes will certainly influence the way we treat ICU patients today. We already see a trend with regards to the use of less sedation, early mobilisation of these patients and now that we are studying occurrence of neuro-psychotic dysfunctions, cognitive defects, anxiety and depression, there will not only be an impact on how we treat our patients, but also on how we design our ICUs.
How Would You Describe Your Profession?
Intensive care is a lot like Formula One. It's quick. It's dangerous. There is a lot of high tech equipment and high emotion—and it is expensive. The main difference I see however is that Formula One is known to everyone and to our detriment intensive care is not. This leaves us with a huge vacuum of information—one that we must fill. We must connect citizens with intensive care medicine; before they or their families are in a life-threatening situation. It is the only way to confirm they understand the importance of the work that is done there and thereby ensure that we receive the resources that are needed to continue to improve short and long-term outcomes.
Is the Life Campaign Part of this Initiative to Connect the Public?
Last year we launched the LIFE Campaign at the European Society of Intensive Care Medicine with exactly this mission. This is not a short-term project, and we plan to carry on in the coming years, building on our successes and broadening our efforts. The 2011 edition of LIFE begins with increasing awareness on "What is intensive care? Why is it needed? And how can we make it better?"
Can You Explain the Motivation Behind the Displaying of Letters at the 2010 Congress?
Part of connecting the public with intensive care came through an invitation to patients and their families to submit letters describing their experiences during and following their ICU stay. For most of these patients we are transient in their lives; if they survive, they usually return to their primary physician or specialist (i.e. cardiologist; oncologist; etc.) and we don't have an opportunity to reconnect with them, to speak with them and or check their progress after they leave the doors of the ICU. What the letters did is to provide these patients and families with an opportunity to speak up and share their feelings about the time spent within the confines of the ICU and afterwards. For intensive care professionals, these letters opened their eyes to the realities, both good and bad, of patients and families experiences and moreover, emphasised the fact that many of these patients go on to lead enriched lives.
You may recall the concert pianist Fred Hersch who performed in Barcelona last year: He spent two and a half months in ICU in a coma, ventilated, tracheostomised, undergoing haemodialysis and paralysed. He could not move his arms; much less envision playing the piano. Now, if you hear him play you cannot dispute that he has recovered. When he discusses it, he attributes intensive care with giving him a second chance at life. In fact, he has also gone on to produce a stirring and poignant musical based on his experiences during his time his time in the ICU. I think that for all healthcare professionals that work as a team in the ICU, the greatest reward is to see these patients come back, dressed and well and have them say "thank you for what you have done".
Do You Feel that Life and Similar Campaigns are Making a Real Impact on Strengthening the Connection Between the Public and Intensive Care Staff?
We had a very interesting experience last year, which for me really emphasised the impact. At the congress in Barcelona, I asked some intensivists and nurses to read the letters from their patients aloud, in their own languages, for our video crew. When they began to read, most were unable to look at the camera, and became overwhelmed with emotion. At that moment, there was a clear realisation of the importance of what they do and they become more human beings than doctors.
I think sometimes we need this reminder, as nurses and doctors that we are in fact, first and foremost, human beings.
I often say to my students in class, that in our country, in France, if you want to become a flight attendant for Air France, for example, and serve diet cola in the air, you must first undergo a series of interviews where they will assess your motivation to do the job and ultimately, judge whether you are worthy and able to do it. This is not the case for medical students. On the contrary, if you have good grades and a good ranking, you become a doctor. So I think that one of the side effects of the LIFE Campaign is to remind the doctors and nurses that work in intensive care that the essential element of what we do is LIFE—not only supporting survival, but improving quality.