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OP Kapoor

Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

Years back when the concept of ICCU was introduced, the Cardiologists were extremely delighted and in fact the mortality rate of myocardial infarction started falling. Now, it has reached a plateau. But we have been watching the events in the ICCU (Intensive Coronary Care Unit) since then. In fact, I wrote a number of articles suggesting that only those young doctors who have obtained DM in Cardiology should be in charge of these units with 8 hourly duty, round the clock. But time has shown that this concept was possibly wrong and we should now change over. The reason is as follows:

A cardiac patient is liable to develop a neurological deficit and other CNS complications either due to infarct or following thrombolysis treatment which the young doctors have started giving very enthusiastically. The result is that we are seeing more and more patients who either develop iatrogenic cerebral haemorrhage or upper GI bleed. In fact the upper GI bleed due to "stress ulcers" is one of the commonest complications in an ICCU and if no proper treatment is given, the patient can land up with acute renal failure.

Hepatic failure can follow "shock" and other events in the ICCU. Now with the concept of multi-organ failure, if any such serious complication develops. Often a neurologist, a gastroenterologist, a nephrologist, a pulmonologist, a hepatologist or a surgeon (neuro-surgeon, or laparoscopist or gastro-intestinal surgeon) should be called in to see the patient and save life.

It is very obvious that the doctor who has done DM in Cardiology has forgotten examination of the nervous system and cannot effectively manage neurological or gastro-enterological emergencies, haematemesis or evaluate blood loss and in turn delays inadvertently to and start immediate treatment to prevent complications.

Thus, the concept of Intensivist (specialist) in ICU should be welcomed by all. Yes, there are very few Intensivists all over the world. So at least the five star hospitals in big cities charging lacs of rupees from the patients should have an Intensivist round the clock with 8 hourly duty. The doctor on night duty should be the most active, qualified and experienced person because unfortunately most of the serious events take place during night time.

If the above situation is accepted, then there is no role in future for an ICCU at all. The hospital should cater for a large ICU (Intensive Care Unit) where even a Cardiologist is called in only to advise in complicated cases just like a nephrologist, pulmonologist or a neurologist who would be called in, if those complications set in.

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