Ashish Khanna, MD, FCCP, recently visited India to promote best critical care practices. On his return to the United States, he wrote a brief vignette about his experience for Critical Connections, specifically addressing his efforts at three major Indian medical centers. Dr. Khanna is a staff intensivist with the Surgical ICU at the Cleveland Clinic and assistant professor of anesthesiology at the Cleveland Clinic Lerner College of Medicine of the Case Western Reserve University, Cleveland, Ohio, USA. He is also the current chair of the Society of Critical Care Medicine’s In-Training Section. He is also on staff at the Department of Outcomes Research within the Anesthesiology Institute at the Cleveland Clinic. Dr. Khanna can be reached at firstname.lastname@example.org.
A trip to India always comes with mixed emotions, especially when your co-passenger is a two-year-old toddler. Indeed, the anxiety component of sentiments was heavy on my mind as we boarded our 14-hour nonstop flight headed to New Delhi, the national capital. A week into our family vacation in the beautiful city of Chandigarh, 150 miles north of New Delhi, jet lag and toddler adjustment problems over, we were finally smiling. This “honeymoon period” gave me an opportunity to focus on a mission that had been near and dear to me for many years, that being an outreach to some large-volume medical centers in the region, with a focus on current critical care practices and the aim to educate and propose changes in keeping with the mission of the Society of Critical Care Medicine (SCCM) to promote good critical care practices the world over.
My first stop was the Government Medical College and Hospital (GMCH) in Chandigarh. A high-volume medical center, this was my alma mater; I had gone through medical school and a residency in anesthesiology and intensive care medicine at this institution. The intensive care unit (ICU) here contains 10 beds, mixed medical-surgical, with an additional four beds that are treated as a high-dependency/step-down unit. I spent a morning rounding and interacting with the care teams, along with teaching bedside ultrasound and echocardiography to the residents. The chairman of the department, Professor Satinder Gombar, talked to me extensively about ideas and new initiatives that would help improve standards of critical care in the unit.
Next, I headed to the Postgraduate Institute of Medical Education & Research (known famously as the PGIMER in this region). PGIMER is an apex institution that serves as a tertiary-care center of excellence to most of the northern half of India. Here, I visited the post-cardiac surgery ICU, a large unit (30-plus beds), in which adult and pediatric cardiac and thoracic surgery patients are cared for. Professor G.D. Puri is the chair of the department, with a special interest in cardiac anesthesia and critical care. He explained the ICU and operating room work flow specific to the unit. I returned on a subsequent day for an interactive educational session and presented my recent work on postoperative hypoxemia to the residents and faculty.
The common major problem plaguing both of these large government-run, highly subsidized institutions is the population burden. In a country of more than a billion, this problem of numbers puts enormous stresses on the limited resources and manpower available in critical care units here.
By contrast, my last stop, the Fortis Heart Institute and Multi Specialty Hospital, is a private hospital, the largest of its kind in the region. Since patients here are mostly direct payers in the system, it is devoid of the population pressures that PGIMER and GMCH face. I walked through the medical ICU at Fortis and discussed work flow and patient care issues with the leadership, Drs. Mandal and Arun Sharma. This institution is approved by the Joint Commission and the National Accreditation Board for Hospitals & Healthcare Providers, and maintains standards of care that we are used to in North America. The patient population comes from the highest socio-economic strata though, and issues such as end-of-life care and discussion of poor outcomes have not been easy for the treating intensivists. Part of the reason is the sense of entitlement that the patient families feel and part of it is the Indian legal system in which doctor-driven end-of-life care practices have to go through considerable legal tangles to get through.
This is a brief snippet of a fulfilling critical care mission to India. It is highly satisfying to be able to give back to these institutions, all of which played a part in my career growth while I trained in India. These healthcare organizations have grown immensely in the field of critical care and are doing some wonderful clinical work in this area. They need organization, structure and a protocolled approach. SCCM has supported my vision, and the hope is that the Society will reach out again with a team of experts who will help these and other institutions with ideas, structure and inspiration. Needless to say, my involvement with critical care education and improvement of best practices in this part of the world is ongoing and relentless.