Critical Care Medicine  

History

In 1974, the Departments of Medicine and Anesthesia at Stanford University determined that the development of a formal critical care medicine program within the adult intensive care units at Stanford was a direction to pursue for both the education of their respective housestaff and students and to improve the provision of patient care in this setting. Under the leadership of Phil Larson (Anesthesia Chair) and Dan Federman (Medicine Chair), these two departments gained the support of the Medical School and Stanford Hospital to initiate a search for a Medical Director of the Intensive (ICU) and Intermediate Intensive Care (IICU) Units with the goal to establish a leadership position for administrative direction of the units and a teaching service for critical care medicine. In 1975, the hospital established a Respiratory Intensive Care Unit (RICU) as a 5 bed unit for the care of patients with primarily pulmonary insufficiency and designated that the care would be provided by a team of physicians consisting of attendings from the Anesthesia Department with housestaff from both Anesthesia and Medicine. This unit opened on the E2A ward in September, 1975. In February, 1975 the search for a medical director of the ICU, RICU and IICU identified Myer Rosenthal as their choice and he arrived on October 1, 1975 to assume that position. At its inception the ICU/RICU service consisted of 3 attendings from the Department of Anesthesia – Myer Rosenthal, Tad Nishimura and William Dolan, a pulmonary/CCM fellow – Judith Pickersgill, one medical and one anesthesia resident. At this time primary care was provided by this team in the RICU and consultative care as requested by primary physicians in the ICU on E2B. The 32 bed E2B ICU was a converted ward of Stanford Hospital with closed rooms housing 1, 2or 4 patients, while the RICU on E2A was an open 5 bed ward.

Over the next 5 years many changes took place including the establishment of a formal critical care fellowship, the addition of a second medicine resident, a decision by the Department of Medicine to have the ICU service provide primary care for all medicine patients on the ICU and RICU, a decision by Thomas Fogarty and his community cardiovascular surgery service to have their post-operative patients cared for by the ICU service, and the addition of 4 critical care attendings with CCM training, representing both anesthesia and medicine. In 1977, a new 25 bed ICU opened as the North ICU (NICU) and the RICU was closed. The NICU was primarily for cardiac surgery patients, however, other surgical and medical patients would be placed in the NICU dependent on nurse staffing. The E2B-ICU remained for medical and non-surgical patients. For a brief period of time in the late 1970’s and early 1980’s the E2B unit was divided into 2 separate ICU’s with 8 beds designated for medical patients and 14 for surgical. After several years it was concluded that the economic impact of separate nursing and administrative support for the two units did not justify its continuation. The opening of the new wing of Stanford Hospital in 1987 included a new 24 bed intensive care unit – the East ICU – and replaced the existing E2B for medical and non-cardiac surgery patients as a single multidisciplinary medical-surgical ICU as it exists today in 2004. In 2000, 10 additional beds on the adjacent D2 unit were added for ICU patients.

Over these years the ICU service has continued to expand assuming the responsibility for additional patients from surgical subspecialties including orthopedic, ENT, plastic, urologic, OBGYN and consultative support for Neurosurgery. As the patient numbers increased and a hospital policy instituted that required in-house physician coverage for every patient in the ICU, the need for additional housestaff was recognized by the hospital and was increase form 3 to 6 allowing for 2 residents always in hospital for the ICU. The housestaff were mainly from Anesthesia (2) and Medicine (3) with additional support from Emergency Medicine and for a brief period in the late 1980’s from General Surgery. The Critical Care Fellowship also expanded over this time beginning with 1 in 1975, 2 in 1982, 4 in 1984, 5 in 1993, and 7 in 1998. The CCM program also expanded in 1993 to the Palo Alto Veterans Administration Medical Center (PAVAMC) with the establishment of a formal ICU service at that facility under the leadership of Eran Geller .

In 1997, Myer Rosenthal stepped down as Medical Director of the Stanford ICU’s, after 22 years in that position, and was replaced by Norman Rizk from the Department of Medicine. It was also determined at that time that the ICU service should be equally divided between anesthesia and medicine with 3 attendings from each specialty.

The success of the CCM program at Stanford is to the greatest extent attributable to the unswerving cooperation of Stanford Nursing Service with special mention of Laurie Gunderson who served as Head Nurse of the E2B ICU beginning at the time of inception of the critical care service and program, Head Nurse of the NICU, Assistant Director of Nursing for Critical Care, and Director of Nursing. Her support and that of her staff were essential to the development of the CCM program and the progress that was made in both patient care and housestaff education. The leadership of Phil Larson from Anesthesia and Dan Federman and Ken Melmon from Medicine were also invaluable assets to the CCM program. Their confidence in the CCM service providing a hands-off yet readily available resource for guidance and support was critical as was their recognition of the necessity to develop the program without particular department allegiance or identification, eliminating the political difficulties that often arise when groups or departments desire to impose their own identities and control over such a complex environment.

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