Critical care by its very nature is a multidisciplinary disease. Virtually every critically ill patient requires input from a multiplicity of practitioners. Physicians in the ICU provide direct care, and orchestrate and coordinate care for all other practitioners who participate. Given this complexity, it is interesting to note that critical care has been a recent development. The first true multidisciplinary ICU was opened in 1958 at the Baltimore City Hospital, now named Johns Hopkins Bayview. It was also the first ICU that had 24-hour physician coverage.
Critical care was rapidly becoming its own discipline, yet it lacked efficient organization. In 1970, 28 physicians met in Los Angeles and formed the Society of Critical Care Medicine. The society's leaders and first three presidents were Peter Safar, an anesthesiologist; William Shoemaker, a surgeon; and Max Harry Weil, an internist. Throughout the 1970s, 1980s, and 1990s, these three disciplines represented the backbone of critical care in the United States.
As critical care began to develop, emergency medicine also began to develop as a real discipline. In 1961, Dr James Mills started a full-time emergency medicine practice in Alexandria, Virginia. The American College of Emergency Physicians was founded shortly after that, in 1968. Residency training began at the University of Cincinnati, followed by the Medical College of Pennsylvania, and then the Los Angeles County Hospital. Finally, in 1979, the American Board of Emergency Medicine was approved. Other institutions then developed emergency medicine residencies. Today, there are over 150 accredited programs. Fellowship training followed in subspecialties such as toxicology, pediatrics, and now critical care.
The link between emergency medicine and critical care seems natural—both require understanding of complex physiology. Practitioners in both specialties must understand a multitude of diseases, synthesize solutions for complex problems, and do this quickly. When I founded the Department of Emergency Medicine at SUNY Downstate and Kings County Hospital in 1991, we created a 4-year residency program that was heavy in critical care. However, I soon realized that emergency physicians who wanted to practice real critical care would need additional training. Thus, when I became the Physician-in-Chief at the R Adams Cowley Shock Trauma Center, I established a critical care fellowship designed for emergency physicians. The University of Pittsburgh had been training emergency physicians for some time in its multidisciplinary critical care fellowship. There are now over 100 fellowship-trained emergency physician intensivists. Over two-thirds of them are trained at either Shock Trauma or the University of Pittsburgh. Many graduates practice in major academic centers and now provide leadership roles in these institutions.
Emergency physician intensivists have become commonplace in ICUs. This will continue. Emergency physicians who wish to be leaders will need to be clinically excellent, academically productive, and superior educators. The current textbook goes a long way toward establishing emergency physicians as credible intensivists. Although not every chapter is written by an emergency physician, many are. The authors are emergency physicians who most of us expect to become the leaders in critical care. The book is unique, as it blends the perspective of a true intensivist with that of emergency medicine. The book is the first of its kind, and I predict it will become known as the standard reference for those emergency physicians, as well as others, who wish to understand the overlap between emergency medicine and critical care.
Despite the lack of board certification and many other local political impediments, some emergency physicians have embraced critical care clinically, academically, and now in this textbook. The role of emergency physicians in critical care remains controversial, but the controversy is not as sharp as it was at the beginning. Those of us who have been there from the beginning look forward to the day that there will be no controversy left at all.
Thomas M. Scalea, MD, FACS, MCCM
Physician-in-Chief, R Adams Cowley Shock Trauma Center
System Chief for Critical Care Services
University of Maryland Medical System
The Honorable Francis X. Kelly
Distinguished Professor in Trauma
Director, Program in Trauma
University of Maryland School of Medicine