Every year about 5 million patients are admitted to the intensive care units (ICUs) in India. Pediatric intensive care in India started in the early 1990s. It simultaneously initiated at four centers in the north, south, and west by individual efforts. The pioneering institutions were the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh; Sir Ganga Ram Hospital, Delhi; Hinduja Hospital, Mumbai; and Child Trust Hospital, Chennai. Pioneers who were trained abroad returned to India to set up pediatric ICUs (PICUs). Soon the specialty became popular with pediatricians; and in 1996, there were already 21 centers offering pediatric intensive care and the number grew steadily. In 2004, the number of ICUs in the country had surpassed 100. During the early period, intensivists worked with limited gadgets and encouraged indigenous manufactured equipment.
The tremendous growth in pediatric intensive care (PIC) was due to the continuous emphasis on training programs. The Indian Academy of Pediatrics (IAP) was quick in realizing the importance of critical care training. IAP introduced Pediatric Advanced Life Support (PALS) courses in the early 1990s with the help of Dr N Janaki Raman. In 1995, a formal IAP-PALS course was launched. By the year 2000, almost 200 courses were conducted and more than 7,000 pediatricians had been trained. The IAP—Intensive Care Chapter was established in 1998 to provide satisfactory critical care to the needy children across the country. And in the year 2000, the Indian Society of Critical Care Medicine—Pediatric Section was founded. The first National Conference of PIC was held at Nagpur in the year 1999. It was followed next year at Chandigarh. Since then the conference is conducted every year with faculties from India and abroad. From national to international conference was not a long journey. In 2007, the International Advanced Course in PIC was organized, and in 2009, the First Asian Congress of PIC was conducted at Chandigarh. The later was attended by delegates from 21 countries and regional leaders from Asia, and the faculty included giants of PIC.
In the past decade, pediatric critical care has rapidly grown, but still remains a developing branch as far as our country is concerned. Throughout modern science, and increasingly within the fields of medicine, new hybrid disciplines have emerged from division and recombination of mature specialties. Pediatric critical care is one such permutation and combination in evolving medicine. Subspecialty chapters were identified to promote research, 2to impart specialized training in pediatric subspecialties, and to organize scientific meetings on pediatric subspecialties. Pediatric critical care medicine is a relatively new but a rapidly growing pediatric specialty in resource-limited countries.
Since then we have come a long way with more than 1,500 members, 17 state branches, 3 city branches, around 300 fellows, and an index journal. The intensive care chapter of the IAP started a formal fellowship program in 2002, and it is now being run through 22 accredited centers in India. A well-organized, multi-layered, training program has evolved—we are one of the few countries with a well-organized training program in pediatric critical care.
Because of its lack of ionizing radiation, as well as its availability and its ability to be performed without sedation, ultrasound is an ideal imaging modality for children, and numerous pediatric-specific point-of-care ultrasound (POCUS), echocardiography (ECHO) applications are clinically relevant and is being introduced in the fellowship training curriculum. An adequate dose of subspecializing training cannot be defined as it is not known whether “bolus” doses of focused subspecialty care of 3–6 months or steady infusion of caring for similar patients over 1–2 years results in a better retention of knowledge and skills.
The role of pediatric critical care nursing is complex. First, the nurse has to continually examine physiologic monitors and treatment devices, along with the child's body. Second, in the event of any irregularity, the nurse has to instantly judge the significance of the event and initiate an appropriate response. Third, the nurse has a primary responsibility for ensuring patient safety. Fourth, the nurse is also responsible for maintaining a bedside environment that fosters the psychosocial adaptation of the child and family. Fifth, the nurse also functions as an “integrator” of patient information. The strength of a PICU's service is directly tied to the quality and rigor of care that the nursing team can provide, in collaboration with the entire pediatric critical care team.
Many of the PICUs in metropolitan cities have state-of-the-art facilities, including extracorporeal membrane oxygenation (ECMO). In large cities, the transportation of a critically ill child has moved on from a hand–ventilated child in a basic ambulance to the state-of-the-art transport which includes a trained team, transport ventilators, oximetry, and end-tidal CO2 (ETCO2). Children previously thought to be too unstable for transport can now be safely transported from one center to a higher one. Needless to say, large proportions of children in rural and remote parts of India are still deprived of timely critical care services and succumb to the illness. Simulation is now a well-accepted and practiced method of training.
India is a fast-growing emerging market, with a great potential for research, especially in pediatrics given the young population and disease burden. As the Pediatric Critical Care Medicine specialty continues to grow, more research is likely to occur at both government-run teaching institutions and corporate hospitals. Multidisciplinary, interdisciplinary, and transdisciplinary are the ways forward in pediatric critical care. Sharing knowledge and research bring multiple perspectives and help avoid some of the blind spots of a single discipline. Patient care shared by a local regular pediatrician and the superspecialist known as “shared care” is an appropriate model for our country.
The biggest question is whether specialization is a boon or a bane? Do we need people who know more and more about less and less until they know everything about nothing? Subsub-specialists should develop new knowledge in their areas of critical care, identify best practices and at the same time—keep in touch with basics and other systems. The contributions of 3national societies and quality of standards of Pediatric Critical Care Medicine Fellowship programs will define the future of pediatric critical care training in India.
In short, since the beginning of the new century, the Pediatric Critical Care Medicine training in India has grown by leaps and bounds and is still growing. About 30–40 years from now, will there still be an ICU? There will be a department of intensive care for sure, but a dedicated unit for that maybe obsolete. Experts suggest that rather than having a separate ICU, if a patient needs intensive care, the regular hospital bed itself can be transformed into a critical care bed by bringing in equipment like the respirators and other sophisticated monitors.
SUGGESTED READING
- Bhalala US, Sadawarte J, Sadawarte S, et al. Development and Implementation of Pediatric Critical Care Focused Simulation Workshop and Program in India. J Paediatr Critical Care. 2014;1(4):240–4.
- Bhalal U, Khilnani P. Pediatric Critical Care Medicine Training in India: Past, present and future. Front Pediatr. 2018;6:34.
- Carnevale FA, Dagenais M. Nursing care in the paediatric intensive care unit. In: Wheeler D, Wong H, Shanley T (Eds). Paediatric Critical Care Medicine. London: Springer; 2014.
- Good R, Orsborn J, Stidham T. Point-of-care ultrasound education for pediatric residents in the pediatric intensive care unit. MedEdPORTAL. 2018;14:10683.
- IAP-Intensive Care Chapter. Available from: http://www.piccindia.com.
- World Federation of Pediatric Intensive and Critical Care Societies. Available from: http://www.wfpiccs.org/history-of-picu-in-india.
- Yeolekar ME, Mehta S. ICU Care in India - status and challenges. April 2008;56:221–2.