Thank you very much. It's a real pleasure to be here. Thank you to Amy for that introduction. Thank you to SCCM for the opportunity to speak to you, and thank you to all of you for coming out on the last morning of Congress. I do want to just start out by cooking through, saying my talk's about from polio to the present, how epidemics have shaped critical care. I do have a couple of disclosures. One is that I do have funding from a number of research organizations, including the U.S. Department of Defense, although none of it's relevant to the talk today. And as mentioned, I do have a book coming out on this topic. I also want to pause to just acknowledge Dr. Aki Grenvick, who is obviously a giant in the field. Born in 1929, died very recently in 2021. I did not have the pleasure of knowing him, but I put up here a quote from Dr. Martin, SCCM president. Aki was instrumental in establishing how critical care medicine is taught, how intensive care professionals work together, and how patients are treated today in intensive care units around the world. And I know that Dr. Grenvick was a mentor to Dr. Derek Angus at the University of Pittsburgh. I met Dr. Angus here exactly 20 years ago as a medical student, and then he became my mentor. So I feel really honored to be up here presenting this particular lecture. Now, when Dr. Grenvick was young, this is probably what he experienced in terms of care in hospitals. And this is a quote from Dr. Eugene Braunwald, who is a cardiologist. As an intern in 1952, we admitted patients with AMI wherever a bed was available on the medical service, but always as far from the nurse's station as possible so that they would not be disturbed by the commotion, especially the frequent telephone ringing. It was not uncommon for me when arriving on the medical floor at 6 a.m. to draw blood to be sent for testing to discover that one of my AMI patients had died quietly during the night. Older physicians accepted this as just the way it was. So it gives you a flavor of care in the early 1950s, and just to kind of emphasize what was and was not available, there was no invasive mechanical ventilation, oxygen was given through masks or tents, almost all operating rooms still used hand ventilation, there were no blood gases, a few antibiotics, no ICUs, and a lot of a disease that you and I really have never seen, poliomyelitis. Now I know it's been in the news recently, but just as a quick primer, polio is an enterovirus, meaning it's an oral fecal route of transmission. A lot like COVID-19, a lot of patients who get it are asymptomatic, they never know they've had it. For the ones who do get symptoms, it's the kind of nonspecific symptoms there on the left. And for the very unfortunate few, usually less than about 5% of polio patients, the virus would attack the spinal nerves and cause paralysis of some sort, often a limb, multiple limbs, and if you were very unlucky, it would hit the respiratory muscles and you would have respiratory paralysis. And this was a common image of the era, of course, of a little girl with a brace on her leg needing crutches because of paralysis. If you were incredibly unlucky, you got what was called bulbar polio because it actually hit the bulbar nerves and caused difficulty with swallowing, difficulty with secretions, and then a tiny, tiny percentage got the combined spinal bulbar polio where you would get paralysis of limbs, difficulty breathing, and also the bulbar symptoms. So until 1928, there was nothing to do for polio. At that point, the iron lung came in, invented by Phil Drinker and Louis Agassiz-Shaw, and it became synonymous with care of polio patients. Now I know I'm talking to a bunch of people who take care of patients in the ICU, but nobody probably has seen an iron lung in a very long time. Just to describe, it is negative pressure ventilation, creates a seal around the neck, and then air is sucked out of the tube, causing the lungs to open with air rushing in in a negative pressure manner. So exactly the opposite of what we do today. It was incredibly effective for respiratory paralysis, not so effective for bulbar polio because, of course, you can imagine, you've got secretions in the back of the throat, you suck everything into the lungs as soon as you put them in an iron lung. But these were incredibly successful, and polio, particularly in the US, they were able to use the iron lung to care for a lot of these patients. So by the 1950s, you have respiratory centers where they're caring for patients in iron lungs. You have up there on the top the kind of changes in shock treatment and understanding of resuscitation from battlefields. You have things like Walter Dandy's neurosurgical unit, where the idea of having expertise all located in one place. You have down there on the bottom the introduction of things like dialysis, so other organ support. And you do have some very primitive ventilators that are being used in operating rooms. But what you don't have is anything that brings all of these things together. It was still incredibly siloed in terms of these different modalities and ways of thinking about care. So now we shift to Denmark. And in Copenhagen, there was one infectious disease hospital called the Blydam Hospital. It is pronounced Blydam, despite the spelling. And this was the infectious disease hospital for all of Copenhagen and the surrounding areas. And now they'd seen a fair amount of polio. And the head of this hospital, Henry Kai Alexander Lassen, went by HCA Lassen, was an expert in polio. So he'd never seen a major, major epidemic. But he'd certainly taken care of a lot of patients with polio over the years. But because they'd never had a major epidemic, they only had one iron lung in the city. And that was fine until the summer of 1952, when this started to happen. They started admitting 50 cases a day of polio, and 10 to 12 of them had respiratory failure. So you can imagine, with one iron lung, he describes the fact of the ethical dilemma of who to put in that one iron lung, and basically who to leave to die, because that's what would happen. And in fact, in the city archives in Copenhagen, they have the book of deaths from that particular hospital in 1952. And by mid to late July and into August, every single death recorded is from polio. By mid-August, their death rate was 87% for patients with bulbar polio. They'd lost 27 people. And now in Scandinavian countries, polio peaked in the autumnal months, September and October. In the US, it was called the summer plague. It peaked in July and August. But it was shifted. And so they knew, by mid-August, they were only seeing the beginning of this epidemic. So the question was what to do. They couldn't get more iron lungs, even if they could have. They knew for bulbar polio, it would not be particularly successful. And working for Lassen was this man, Dr. Mogens Bjornboe, and apologies to any Danish speakers in the audience. That is absolutely an American pronunciation of that name. And he was a very senior trainee, and quite experienced, although still technically in training. And he had experience of caring for a tetanus patient, a baby with tetanus, a few months earlier, where he had decided to call in someone he'd heard about, an anesthesiologist by the name of Bjorn Ibsen, to try to help him to break the spasm of the muscles from the tetanus. And they had given some anesthesia, they'd done a tracheostomy, they'd given a little bit of paralysis with curare, they hadn't really put it all together in a way. They kept the baby alive for a few extra days, but the baby died. But Bjornboe recognized that Ibsen seemed to have sort of knowledge and skills of drugs and techniques that were different from what they normally did with polio patients. And although he couldn't really articulate why he thought Ibsen could help, he did. And he badgered his boss to allow him to bring Ibsen in to meet them and see if he could offer something to help. Now Lassen resisted for a while. Anesthesiology was a very new specialty. There were only about five or six anesthesiologists in the whole city. They were kind of itinerant, they didn't have permanent posts anywhere. And Lassen was this big chief of a major hospital, and it felt wrong to him to ask for help from someone like this. But he ultimately relented. And on August 25th of 1952, they held a meeting in Lassen's office that Ibsen attended. And this is not a picture of the actual meeting, there isn't one that I know of. But they all sat around, and Lassen said to Ibsen, what's your experience with polio patients? And Ibsen's response was, I've never taken care of one. So to Lassen's credit, he absolutely could have kicked him out at that point. But instead he said, well, I'm going to show you around. And so he took him to examine the patients in the hospital in all stages of polio. And some were obviously in the stages of dying from polio. And these were the symptoms that Ibsen noted when he was rounding. Hypertension, tachycardia, twitching, confusion, clammy skin. Lassen explained this to him, and he said, this is polio. It's overwhelming the brain, it overwhelms the kidneys. This is end-stage polio, and there's nothing we can do to stop this. Ibsen looked at those same symptoms, and he said, I think that's carbon dioxide retention, and I think I can do something about it. Now why did Lassen have this view of what was going on? Well, there's just kind of received wisdom, right? So over time, people get these ideas of what's going on. But there was also what I call the bicarbonate mix-up. So they had one measurement they could make, and that was of total bicarbonate in the blood, which encompassed both carbon dioxide and the bicarbonate. And they kind of recognized that if the bicarbonate was low, this was generally a metabolic acidosis. And so they just extrapolated and assumed that if the total bicarbonate was high, that this was a metabolic alkalosis. They never measured the pH of the blood, they couldn't. And so they just extrapolated, and basically they didn't think about the respiratory side of things at all, but of course Ibsen did. Not only because he was an anesthesiologist and sort of because of that spent time thinking about these things, he actually, and this is the first weird coincidence, had true expertise in carbon dioxide and carbon dioxide retention. He had been playing around that very year with this machine, the Brinkman carbovisor, and this giant contraption did one thing, it measured end tidal CO2. And so, you know, kind of amazing to think about with our little cassettes that we plug in that this is what it took. So he had been playing around with this with a thoracic surgeon in the operating room, and they had been observing what happened when you bagged someone down and the carbon dioxide went down, and what did the patient look like, and then what happened when you stopped breathing for them and the carbon dioxide went up, and even to the point where he was the world expert. He had just published a paper, Continuous Carbon Dioxide Measurement in the Respiratory Air During Anesthesia in Thoracic Operations. So he had a great understanding that really almost nobody who was a clinician at the bedside did of the role of carbon dioxide in the body. So Ibsen was confident it was carbon dioxide retention that was killing people, or I should say that was giving them these symptoms, and then of course hypoxia and the whole, you know, everything combined was killing them. And so he recommended tracheostomy for these patients, and Lassen said, no, we've tried that. But what they had tried was tracheostomy without any actual ventilation, and so Ibsen said, no, no, no, positive pressure ventilation, that's what I'm going to do for your patients. Now this was radical. It had not been used outside the operating room, except, this is the other weird coincidence, it had been, and Ibsen knew this, because there had been a really obscure paper in what was called the Annals of Western Medicine and Surgery. It was a journal that existed for just a few years, published in the United States, and Ibsen happened to be the consultant to the medical library in Copenhagen, and so he sat there two hours a day flipping through journals, and he'd come across this paper, and he'd actually written away for a reprint of it, and had it with him. And it was from a group in Los Angeles, Albert Bauer and V. Ray Bennett and their colleagues, reporting on a polio epidemic in Los Angeles in 1948 and 1949, where they had a lot of patients with bulbar polio, and even with the iron lung, they were seeing 90% mortality. And so they tried adding positive pressure ventilation to this, and they decreased the mortality from 90% to 20%, and this paper reported on this. Now they used what was called the Bennett Positive Pressure Respirator Attachment, you can see an image here, that sort of hooked onto a tracheostomy, but of course, the difference here was they were doing both negative and positive pressure ventilation, and they didn't sort of disambiguate the two of those things, and so what they were reporting on was the combination of the two, but Ibsen recognized you didn't actually need the iron lung, you just needed the positive pressure ventilation. And so he proposed using what was called the Waters To and Fro Circuit, very simple device with just soda lime for scavenging the carbon dioxide, a bag on one end, and oxygen attached to a tracheostomy. So Lassen was skeptical, but he had nothing else to try, so he said, okay, I'll let you try this on one of my patients, I'll choose that patient. The very next day, August 26th, admitted to his hospital was Vivi Ebert, she was 12 years old, she's a little bit younger in this picture, and she lived in this house in Copenhagen with her mother and her grandparents, and she came down with classic spinal bulbar polio, and by the time she was admitted to the hospital, it was very clear they knew the natural progression of this disease, that she was going to die. The next morning they rounded on her, she was struggling to breathe, and Lassen pointed to her and said, she's the one. So they wheeled her into a side room, everybody crowded in, an ENT surgeon was called to do a tracheostomy, and then Ibsen made a mistake, and he said, I'm worried she's going to die, and if I give her general anesthesia, I'm going to cause a cardiac arrest, therefore please do this under local anesthesia only. So the surgeon did this, but of course it's a lot harder technically to do, and he got into some bleeding, and so now the care was handed over to Ibsen, and so she was not only an extremist because she couldn't breathe, but she'd gone into bronchospasm from the blood in her lungs. And we have the record, minute by minute, of this case, and so he could not ventilate her, and so even though he was worried he'd cause a cardiac arrest, he eventually relented and said, now in a situation where we cannot perform ventilation because of her spasms and agitation, therefore we administer Pentothal 100 milligrams. Everybody had left the room, they'd gone to lunch, they assumed that Vivi Ebert was going to die, and when they came back, he had written, the patient is immediately warm and dry, she actually woke up, she was interactive, and it's hard to imagine what this must have been like for the people in that hospital, seeing patient after patient die of polio in this miraculous recovery. And so it was an N of 1 experiment, and it worked. And Lassen recognized that this was what he needed to do for his patients, and immediately said, okay, we're going to do this for every single patient who's coming in with any kind of bulbar polio symptoms. Just one problem, tracheostomy, positive predatory ventilation, no ventilators, right? There are a few scattered in operating rooms across the world, none in Denmark, some in Sweden, so they turned to the students of Copenhagen. The university students in the medical school were called first the second year students, and then expanded to first year students and older students, and you can see, stood, sat by the bedside, six to eight hours a day, 24 hours a day, hand ventilating these patients through this epidemic. They ultimately used more than 1,200 students, medical and dental students, recruited over the course of a number of months, and this is actually a picture of Vivi Ebert being ventilated with her mother reading to her. These students became very close to these patients, they read to them, they got to know them, there's incredible stories of the care they provided, and also some scary moments, as you might imagine, taking students, many of whom had never been at a patient's bedside yet, they were first and second year medical students, and after five minutes education on how to ventilate a patient, being told, go forth and ventilate, but they did it, and a lot of them found it very scary, a lot of them were kind of scarred by the experience, but a lot of them also found it incredibly exhilarating. Okay, so then there was the question that was left over, of would it be, if they could check the pH of the blood, you know, lemon juice, was it going to be really acidic, or was it going to be bicarbonate of soda, was it going to be really alkalotic, as Lassen and his team thought, and there was one man who was at these meetings, Dr. Paul Astrup, who was the head of the laboratory, and he said it was like a light going off when Ibsen started describing carbon dioxide retention, and he said later, he said, we just didn't think about carbon dioxide, I mean, they really didn't think about respiratory physiology at all taking care of these patients, and so he set out to figure out what the pH actually was, and so he didn't have a pH monitor in his lab that he could use, but he knew who did. There was a company called Radiometer AS, and they had a pH monitor they developed for the Carlsberg Brewery, because apparently knowing the pH of your beer was way more essential in the early 1950s than knowing the pH of blood, but they made the machine such that it could actually run just a very small amount of fluid, including blood, and of course, as soon as he checked it, the pH was incredibly low, Ibsen was, of course, correct, and Astrup realized that these numbers were incredibly important for safe care of these patients and to guide ventilation, and so he started figuring out how to run blood gases on patients to get all of these measurements, and he said by January 1st, 1953, we'd done 705 determinations of pH in arterial and venous blood, and so this is the birth of all of acid-based physiology in the bedside in critical care medicine, and in fact, for many people, it was not a blood gas, it was an Astrup, and people would actually call out, I need an Astrup when they wanted a blood gas run. Okay, by December 1952, the epidemic has peaked and come down, and they reported on the mortality for their patients. They'd gone from 87% mortality midway through down to 36% mortality, and by the very end of the epidemic, the mortality was down to 11%. It was pretty, almost identical to the data from Bauer and Bennett in Los Angeles, and I think, you know, just to pause on this slide, there's nothing in my lifetime that's ever going to look like this. It must have just been extraordinary to be part of this. Lassen lost no time in publishing this, and he did not make the mistake of Bauer and Bennett. He published in the Lancet, where everybody would see it, but also note, there's one author on this paper. It is H.C.A. Lassen. He was pretty clearly determined to take credit for the events there, and it started a bitter feud over the next sort of 30, 40 years between Ibsen and Lassen, and because of the lack of Lassen's support for Ibsen, he was up, Ibsen was up for the job of the first chief of anesthesia at the university hospital, and he didn't get it, and instead, he moved to the municipal hospital, which was essentially the public hospital in Copenhagen, and right here in these windows on the second floor, he started a post-operative care unit, which by the end of 1953, he had turned into a full-on ICU admitting both medical and surgical patients. Now why do I say that this is sort of the first ICU? Well, I've highlighted in red here the things that come from the polio epidemic, but these are the components of his ICU. Care for a range of patients, a dedicated area, 24-7 staffing, frequency of vitals and monitoring, blood gas analysis, invasive mechanical ventilation, other organ support, and specialized nursing, right? You would recognize this as the components of every major ICU in the world, and so that's why I argue that this is really the first true ICU, because he could offer all of these things in one place. There are also, I think, they literally called them mechanical students, this whole array of ventilators with amazing names, it's like something out of Harry Potter, and just want to highlight the Engstrom, which is up there, was one of the preferred, that was described as the Rolls-Royce of ventilators, and of course these are the precursors to our modern ventilators that we're using every day. So ICUs proliferate, 1958 is when we start to see ICUs founded in the United States, Peter Saffer on the East Coast in Baltimore, Max Harryweill on the West Coast in California, and then actually north of the border in Toronto, Barry Fairley, all in 1958, introduce again sort of units that we would recognize in terms of what they were able to offer for patients. And at this point, ICUs proliferate around the world. And I say that, but I also wanna pause and recognize that there are still parts of the world where ICUs have not proliferated, and that there are very much less developed places where they cannot afford that type of care. But in the highly developed countries in the world, by the sort of late 60s and 70s, ICUs are sort of part and parcel of most major hospitals. So what do we get from battling polio? A lot. Positive pressure ventilation, blood gases, respiratory physiology, rehabilitation, which I didn't even talk about, and ICUs, as well as some other things that are maybe a little less relevant to intensive care, but still very important, disability rights, long-term sequelae of viral illnesses, vaccine development. And if we look at the vaccine story for polio, it's pretty remarkable. This is the cases of polio in the United States, and you can see this precipitous drop after the introduction of the vaccine in 1955, to the point where essentially there's no cases and no deaths after about 1960. And this is actually, to a lesser degree, the story of most infectious diseases, right? Because we had so many vaccines that came in, in protection, diphtheria and measles, and kind of the list goes on, such that I would argue from about 1960 onward until about 2020, it's really a story of non-infectious diseases, because we were so good at dealing with these virulent infections. And so these are interesting data that Craig Lilly published back in 2011 as a benchmarking exercise of US ICUs. It's a neat paper that just kind of gives you a great snapshot of who are the patients in ICUs, what's the care being provided? And I went through, and this is pulled from that paper, and it's the top, I think it's 46% of patients broken down by their diagnoses. And I've pulled out everything that could be considered infectious, and you can see I'm being very generous, that top one, respiratory medical really could be anything. But even all added together, this is 10.5% of patients. So 10.5% out of 46%, right, so it's about 20, 25%. But it's still not the majority of patients that we're being cared for in ICUs in the US. And so really, a lot of our talk has been about sepsis, our care and thinking has been about sepsis, but in fact, we're taking care of a lot of patients who do not have infectious diseases. If we think about major infectious diseases that we've dealt with, this is my little schematic, and we can certainly quibble over what should or should not be on here, but there's some early epidemics of influenza, I'd argue before kind of ICUs really come in and have their own. There's HIV, which is sort of a different type of epidemic, and it's not kind of the acute fulminant presentation immediately that these other diseases have. And then we have all these blips leading to COVID-19. And I just also want to mention that SCCM was founded 1971, just to give you a sense of the timing. So it's almost 20 years after Ibsen's first ICU, so there is a long run-in before we sort of really get to the point where critical care medicine is coming into its own. I view SARS as what I think of as a wake-up call for all of us that happened. And not a lot came out of SARS in terms of changes in our care, but this is something, Toronto was one of the epicenters for the SARS epidemic, and one thing that they did realize, and this work was led by Rob Fowler, who was a colleague of mine in Toronto, was that they didn't even know how many ICU beds there were in Toronto or Ontario or Canada when SARS hit. And it was a huge scramble, and that's why I call it the wake-up call, because it was a realization that we just didn't even have basic information to help us cope with epidemics. And so he set out to remedy that for Canada and published this paper, and of course, COVID-19 became the giant wake-up call in many other places that didn't have SARS in terms of figuring these things out. H1N1, I always think of as sort of the ECMO blip, where people started to think more about ECMO again. That said, I think it kind of crept into our consciousness, but if you actually look at cases in the U.S. of ECMO utilization, so 2008 is pre-H1N1 and 2009 is H1N1. You can see it's already going up, and the absolute numbers of ECMO are still incredibly low. So although it certainly, I think, spurred some innovation and increased thinking about ECMO, it didn't change practice very much sort of day-to-day for anybody. I do want to mention, though, that some of these early epidemics and kind of blips there did spur organizations such as ISARAC International Severe Acute Respiratory and Emerging Infection Consortium to develop, and I think these organizations have been incredibly important in terms of helping us to move forward and think about international collaboration and moving forward research and such. And so that did kind of come out of these early epidemics. Now MERS came along in 2012, and I just put this slide up because I think sort of the problem or the good of MERS is that it really happened in a very isolated location, so although we were all aware of it, there was not a lot of fallout. It kind of came and went. Now another disease, though, that sort of similarly was not really located in, I think, any of our ICUs, but had a big impact, I think, was Ebola. And so although it was centered in West Africa, I think there are a couple of really important lessons for our community that did come out of this. And this is from a paper that was published, again, by Rob Fowler, who was actually on the ground in West Africa in this outbreak, and he made a really important observation. He said, the potential effect of supportive care is great for a condition with high baseline mortality and one usually occurring in resource-constrained settings. With more personnel, basic monitoring, and supportive treatment, many of the sickest patients with Ebola virus disease do not need to die. Ebola virus disease represents an illness ready for a paradigm shift in care delivery and outcomes, and the profession of critical care medicine can and should be instrumental in helping this happen. And it was the important recognition, right, that basic care is what we need first and foremost, and that it's easy to get away from that, but that if we can just provide even, not even critical care, basic care, we can make a difference in some of these diseases. Now on the opposite extreme, in the same epidemic of Ebola and the same group, they made another really interesting observation, which is that they cataloged the patients who received care, not in West Africa, but in highly developed countries with full-on critical care services. And this is a fascinating table, which is like something out of the 1950s, because you don't usually see this anymore. It is line by line each individual patient who had the disease, right? It's kind of a case series, but we don't see that that often. But if you look at that far right column, the outcome, survived, survived, right? It is not what you expect if this were West Africa. In fact, the mortality when summed up is 18% versus 40% to 90% for those who were cared for in West Africa. And if you take those extremes, like the 18% versus 90%, those are Lassen's numbers from the polio epidemic for the intervention of mechanical ventilation. It's exactly the same. And so it is actually a modern day example of the impact that critical care and what we do every day can have on these new and emerging diseases. And it's not very often that we get to see this in these types of studies. So what about COVID-19? Clinical advances that we've had from COVID-19 that have been spurred by this, well, recognition that steroids works, monoclonal antibodies, antivirals, non-invasive ventilation, increasing use, proning, more ECMO, all really important. I have a little bit of the kind of meh feeling when I look at that, right? I don't want to diminish all of the work and the importance of those advances. But when you compare it to that 90% down to 20% mortality, nothing comes close here. These are all incremental improvements in the care we're giving. And the reason I also say that is I think actually kind of like what came out of Ebola and Rob's point about the importance of just basic care was that what we really learned was that we just needed to deliver good, solid, critical care, do what we do and do it well. And that it was when we deviated from what we know how to do well that we actually got into more trouble. And so weirdly, COVID-19 I think has almost the innovation has been to recognize that we already know how to take care of critically ill patients well and that that was kind of the big revelation. Now where I think we have seen massive changes is in the research side of things and that COVID-19 really has spurred a whole new, a whole shift in the way we're sort of doing studies, thinking about doing studies in critical care. And in particular, platform trials have really taken off. And this is just a rabid review of them that came out. And just the sheer number, each of these represents a trial, is astonishing given how quickly there were a number, a kind of a few platform trials that had happened before COVID hit. And then just this explosion in them. So when I think about what COVID-19 has actually done in terms of its impact on our field, this is kind of the way I think about it in terms of the size of the impact. We have had clinical impact in terms of the things that we've discovered and learned. And I've also highlighted though in red here a couple of the negatives, rogue practices and long COVID that have come out of it. Culturally, as a group in critical care, I think having had these universal experiences has really made critical care much more of a global profession where we are much more tuned into each other internationally and aware of that. The downside, of course, on the cultural side is I think we are much more aware of the issues of PTSD and burnout and issues of work-life balance that were there already. I don't think these are new things, but that COVID-19 has really pushed to the forefront. Structurally, I think we've learned a lot thinking about provider-patient ratios, number of ICU beds availability of ventilators and dialysis, rationing protocols. And then again in red, the horrific detrimental experience of having such limited visiting policies and really kind of new research into that area to better understand how do we best care for our families as well as our patients. And then as you can see, I think really where COVID-19 has pushed things is in terms of this explosion in research. Now, some will argue that the research infrastructure wasn't great when COVID-19 hit, but I would say that really we've kind of taken off in terms of platform trials, global network, speed of research. But I do want to highlight again some negatives, neglect of other areas, and then inequitable time. And what I mean by that is it's really highlighted the challenges for those, for instance, who had child care responsibilities or were pulled in different directions because of personal or professional needs and that there has been inequity in terms of who is publishing and also who is getting prime time and being asked to speak about topics as experts. I want to mention rogue practices because I think this is something that really came to the forefront in COVID-19. That's always been there, but of course, when everybody was searching for the next headline, really started to become an issue. And in terms of the rogue practices, what I mean by that is sort of trying random drugs that haven't been tested and just kind of going off on your own and giving people cocktails of things. And I think the ways to combat that are one is to kind of think about practice group policies. And what I mean by that is we all work solo in the ICU in a way, but we also, none of us work solo in an ICU. Every ICU is made up of a team of practitioners. And I think it's important to come together as a group in whatever ICU you're part of to really be weighing the risks and benefits together. So maybe you're all going to go rogue, but at least you'll be going rogue together and supportive of that. But I think that that sort of peer pressure does help to tamp down some of those instincts to just try things, right? And also is supportive in the sense of helping each other to feel comfortable with the idea of don't just do something, stand there, because that ultimately is often the best thing we can do for our patients. Depending on where you work, hospitals can also help with this. So if there are drugs that are sort of particularly controversial in some hospitals, they can actually mandate that these drugs cannot be prescribed or can be prescribed, depending, to be able to partner with the hospital administration to do this. And then of course there's data to refute practice. And ultimately that as a community I think is what we did and really impressive that these trials came out so quickly. Things like hydroxychloroquine, ivermectin, others. Now the downside of this, of course, this is an enormous amount of time and energy and money that goes into refuting these things. And so ideally we don't have to go through this process, but I think it's always gonna be there until the best thing we can do is to do the rigorous studies to be able to make good informed decisions about whether or not these treatments should be used. There's also a lot of misinformation in COVID-19. And I think that this was sort of a shock to all of us. Critical care is always, for better or worse, operated kind of in the shadows of the press. We have not been front and center. And in fact, it's been a frustration, right? That nobody knows what the, nobody knew what the ICU was. Nobody knew what a ventilator was. And suddenly we were headline news. And so this is from the Washington Post. Ventilators were embraced as pandemic lifesavers. Now some COVID patients wrongly fear the machines will kill them, right? And this was just the lack of understanding of causation versus association. There's no easy answer to this. I actually did write a bit about this because it was pretty frustrating to watch these headlines. And I wrote, it's not the job of the scientific community to police the press. And skipping down, it may be more important than before to ask a non-scientific reader to look at an abstract or read a manuscript before it goes to press. And editors who have more expertise than most researchers in clear communication of data must help scientific writers ensure transparent presentation of results, setting aside any focus on generating headlines or publicity. And I think this is where we kind of got into trouble, or not when I say we, I mean sort of editors and others at journals where there's always the urge to try to generate the headline for your journal. And that I think that it is really the responsibility of all of us as a community to move away from that, to be really careful about our messaging and recognize that maybe it doesn't sound as exciting written one way, but it's actually the accurate way of writing what we've found. What about going forward? Well, war is obviously gonna be a major factor, is a major factor, and I think that this is going to lead to a surge of infectious diseases again, HIV, tuberculosis, COVID, you name it. This is even without war, a projection for China of the rates of untreated MDR-TB, that's the blue line there, and you can see going out to 2050, just an ever increasing line. And so I fear that we are going to see more of things like MDR-TB in units that traditionally have not been needing to take care of such patients. I think we're gonna see a lot with climate change. There've been some great sessions here at SCCM already about this, and I was just saying that it's fascinating to watch the progression of the different topics at major meetings in critical care and the evolution of that, and I think we're gonna see more and more talks about climate change and its impact. This is just one example of a simulation for a disease. You pick your kind of equatorial disease and name it, and it's going to increase, and we'll be seeing it in places that we never expected to before. And so in terms of the past, I think that we've had huge advances in care that have been incredibly exciting. I think we've lived through a period of trust in vaccination that isn't there anymore and is going to be a major problem for us going forward and is going to change the face of critical care. And I think we've lived through an era of non-infectious diseases being the predominant focus for much of our care in the ICU. What about the future? I think we'll continue, of course, to see incremental advances in clinical care, but I do think they will primarily be incremental. I'd love to be wrong about that, but I think it's pretty hard to come up with the next positive pressure ventilation, and we are gonna see infectious diseases again, much, much more of them over the next 20 to 50 years. Long-term sequelae of ICU. This has been there in the past, but I think obviously with COVID-19 and with infectious disease reemerging, we're gonna see much more of this, and we're just more aware of it than we were 20, 30 years ago and so I think it will become a real focus for us. And then worsening inequity and access globally. Again, this was there in the past as well, but I think that unfortunately, particularly with climate change and with all the stresses of that, we're gonna see much more inequity in this sort of access, particularly to critical care. Interactions with the public. That just means this issue that is going to be ongoing, I think particularly as we have more epidemics where critical care will be front and center, that we need to learn to be better at interacting with the public and messaging things better. And then accelerating international research. I think this is where it is exciting that because we've all come together globally and we have much more in the way of networks, the pace of research really has taken off and it's gonna be exciting to see what that looks like. I wanna leave you with a couple of thoughts. First, happy 70th anniversary of the first ICU, 1953 to 2023. It's kind of incredible what has been accomplished in just 70 years from those early days of hand ventilation till now. As mentioned, just plugging my book, which will be out in May 2023, and it is written for the general public, so I hope you'll be able to share it with your families and family and friends. I think of it as the origin story for our specialty. So if you like Marvel Comics and their movies, hopefully you'll like this. And then I wanna leave you, though, with this map. This is the map that was actually, you probably didn't notice it, behind Henry Lassen in his office. And it's a map of Copenhagen. And he put it up in August of 1952. You can go see it in the Medical Museum in Copenhagen. And in it is a pin for every single patient who had polio that year. And you can see that there is huge swaths of the city that are just full of pins. And of course, every one of these pins represents a person. And some of them didn't survive the epidemic. Some of them survived with severe disability that was with them for the rest of their lives. Some of them recovered completely, but they were definitely left with scars from the experience, both themselves and their families, of having been through such a terrifying disease. I was privileged to meet a whole bunch of the survivors. These are all people who were in that epidemic, cared for at Blydam Hospital in 1952, who have gone on to lead full lives. And I think it's just so important. This is just a tiny portion of the pins of all the people we have taken care of over the years who have been the ones who have led us all to be here at the Society of Critical Care Medicine, able to provide the cutting-edge care that we provide. And it is really thanks to them and everything they have experienced that we are able to do this. So I'm just gonna leave you with that. Thank you very, very much. Thank you.

polio

positive pressure ventilation

intensive care units

infectious diseases

clinical advancements

research innovations

outbreaks

global