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Nature vs. Intensive Care Unit

Keith Scott-Mumby MD, PhD
comments on an article in "New Scientist"

by Dr. Keith Scott-Mumby MD, PhD

I was fortunate to be resident in a medical unit when it was designated a facility for intensive care; the first of its kind in the city. The latest high tech equipment arrived; we did things that doctors had hitherto been unable to do; we saved lives dramatically; we were the new white knights on horseback galloping to the rescue (well, charging with the crash trolley!) It was exhilarating; a great feeling for a 24-year old.

That was nearly 42 years ago (see, I wasn’t always an ornery alternative doc!)

Most people, I think, would pray to find themselves in ICU pretty promptly, if they had serious life-threatening trauma or disease.

But the boundless confidence in the ability of intensive care medicine to save you is not well founded.

The speciality is only 50 years old and there has been very little progress over the decades. The expectation of getting better results at the boundaries between life and death and saving more lives has not been fulfilled, statistically, though I’m sure there are many heart-warming stories to tell.

The truth is a lot of people die DESPITE being given the very “best” of intensive care medicine. All the tubes, drugs, electronics and gizmos have done very little to alter the chances of someone entering ICU who is gravely ill. In fact, for a time, the technical stuff worsened your chances.

We’ve passed the point of realizing that less is more. ICU doctors (the good ones) have come to realize that pumping oxygen into under-performing lungs; dosing the patient with sedatives to take away stress; pouring in lots of antibiotics and bringing in kidney dialysis could all be counter-productive.

Bluntly, more patients survive if the doctors do less. That’s pretty humbling. But why should that be?

Some doctors have started to ask unthinkable questions. Like: maybe Nature’s way works OK without all this high-tech intervention? We have evolved to cope with injury, stress, disease and trauma. We have fabulous life-saving mechanisms to deal with this. Maybe we should work with Nature, instead of assuming she’s out of it?

Nature knows her job and does it well!

Look at military history. There’s plenty of trauma there and not an ICU in sight for millennia!

The Battle of Trafalgar (1805) shed a lot more blood than just Admiral Horatio Nelson’s. By the end of the day there were more than 450 British fatalities; 3200 on the French and Spanish side. Thousands more were wounded, having lost limbs and all but bled out.

Aboard the British flagship HMS Victory alone, there were 102 wounded and the ship’s surgeon performed 10 amputations. Yet out of these 102, only six subsequently died of their injuries. That’s remarkable and I don’t think it can just be written off by saying “Man, those guys were plenty tough”, though clearly they were men of iron in today’s terms.

Ten years later, at the Battle of Waterloo, which finally vanquished Napoleon’s imperialistic aims, only three of the 52 wounded soldiers recorded for one regiment (13th Light Dragoons) later died of their wounds. And I mean wounds: I’m talking legs and arms shot off etc. One of the officers was famously talking with The Duke Of Wellington, who calmly asked “Where’s your leg?” The officer looked down and saw it had been shot off completely by a cannon ball. He hadn’t even noticed in the noise, violence and adrenalin frenzy!

Same statistics in the American civil war: twice as many soldiers died from diseases caused by lousy sanitation and living conditions as died of battle wounds. In the main battles surgeons sometimes worked round the clock, chopping off limbs and parts. Operations often took no more than 10 minutes and, with little water available, hands and instruments went unwashed between procedures. Despite all this, around three-quarters of amputees survived!

So, what does this look backwards tell us about intensive care? Well, we should be able to do better, I suppose. Yet our modern techniques are not even close to these survival rates. ICU doctors are doing something very wrong.

Now here’s Mervyn Singer, director of the Bloomsbury Institute Centre for Intensive Care Medicine at University College London: "Virtually all the advances in intensive care in the past 10 years have involved doing less to the patient."

Doing less, not more!

And Singer goes further, arguing provocatively that modern critical care interferes with the body's natural protective mechanisms—that patients often survive in spite of medical interventions rather than because of them.

Singer believes in an evolutionary perspective and points out that the human body is adapted to deal with the types of threats to which our ancestors were exposed and those include critical illness. Our immune system can fight off infections, our blood clots so that we don't bleed to death with every cut, tissues regenerate and bone fractures heal, if imperfectly, over time. "We have evolved to deal with temperature extremes, starvation, trauma and infection," says Singer.

And, ironically, he adds: "We haven't evolved to cope with being sedated, put on a ventilator and pumped full of drugs."

He’s not the only doctors thinking along evolutionary lines but, as you can imagine, this isn’t a common view in orthodox medicine.

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