Emergency And Critical Care

Compendium May 1999

20TH ANNIVERSARY

Small Animal/Exotics

Highlights and Horizons in

Emergency& CriticalCare Medicine

Ken Drobatz, DVM, Diplomate ACVIM, ACVECC Associate Professor, Critical Care University of Pennsylvania Philadelphia, Pennsylvania

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mergency and critical care medicine is one of the most dynamic and rapidly developing specialties in veterinary medicine today. Although it is a relatively new field compared with other veterinary specialties, initial interest in this area dates back to the 1950s.

The Early Years The first presentation on veterinary critical care was given in 1954 by Dr. Fred Sattler during the annual American Animal Hospital Association meeting in Miami, Florida. The topic was cardiopulmonary resuscitation (CPR), and there were 15 participants in attendance. I have been told that the presentation was rather dramatic, with a demonstration of CPR on a dog. To place this into perspective, the current recommendations for human CPR were not even in place at that time. In fact, Dr. Peter Safar’s landmark paper, “Ventilatory efficacy of mouth-to-mouth artificial respiration,” would not be published in the Journal of the American Medical Association until 1958, the same year in which mouthto-mouth respiratory resuscitation was first endorsed by the American Medical Association. Chest compressions for artificial circulation first saved a human life in 1959, and the first presentation on human CPR as we know it today did not occur until 1960—6 years after Dr. Sattler’s demonstration! Some consider Dr. Sattler the father of modern veterinary critical care. He reportedly had a great interest in electronics, which provided a solid background for him to develop and use technology in veterinary critical care. He evidently flew his own airplane loaded with “gadgets, catheters, monitors, and ventilators” all over the United States and Canada and “preached” veterinary critical care to

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ANNIVERSARY

Early 1970s Specific resources are allocated for defined emergency/critical care services in teaching hospitals.

1983 The American Society of Veterinary Anesthesiologists merges with the Veterinary Critical Care Society (VCCS).

Ken Drobatz

anyone who would listen. The first extensive patient-side measurements of vital signs in veterinary medicine were done in 1957, and the first all-day surgery was performed in 1962.1 In this surgery, one veterinarian and three staff members were working on the animal at all times. Monitoring was intense and continu-

1984 The VCCS and American Association of Veterinary Emergency Clinicians merge to form the Veterinary Emergency and Critical Care Society (VECCS).

19 1985

1980 1983

1979

1982

1988 The first International Veterinary Emergency and Critical Care Symposium is held in San Antonio, Texas.

1984

19

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20TH ANNIVERSARY

ous and included electrocardiography, temperature, arterial and venous pressures, pH, carbon dioxide partial pressure, and respiratory rate and volume; all of these measurements were recorded on a strip chart. Another significant event in the evolution of critical care was the allocation of specific resources toward defined emergency/critical care services in teaching hospitals and its emergence as a clinical rotation for students and veterinarians.2 Colorado State University, the University of Pennsylvania, the Animal Medical Center (New York City), and Angell Memorial Animal Hospital (Boston) were the first facilities to have dedicated intensive care units in the early 1970s.

Organization Although veterinary critical care was initially promoted by a small group of individuals (Fred Sattler, William Whittick, Ira Zaslow, Robert Knowles), its acceptance into mainstream veterinary medicine did not really begin until individuals interested in the field began organizing. One of the first recognized groups to develop was the Veterinary Critical Care Society (VCCS), which established its bylaws in 1978. The American Society of Veterinary Anesthesiologists, established in 1970, merged with the VCCS in 1983. The most pivotal year in the continued development of veterinary critical care medicine was 1984, the year the Veterinary Emergency and Critical Care Society (VECCS) was formed through the merger of the VCCS and American Association of Veterinary Emergency Clinicians. The VECCS contained approximately

Compendium May 1999

200 members at that point; 2 years later, there were 500 members. In 1988, the first International Veterinary Emergency and Critical Care Symposium was held by the VECCS in San Antonio, Texas. This symposium has become a biannual event, with nearly 2000 people participating in 1998. In 1990, the American College of Veterinary Emergency and Critical Care (ACVECC) was given probational status by the American Board of Veterinary Specialties; there were 19 charter diplomates. Full status as a specialty college was granted by the American Veterinary Medical Association in 1996. More than 60 veterinarians are currently board-certified in veterinary emergency and critical care. The VECCS has sponsored the development of the Student Veterinary Emergency and Critical Care Society (SVECCS) as well as the Academy of Veterinary Emergency and Critical Care Technicians (AVECCT), which held its first qualifying examinations in late 1998. In addition, the VECCS and ACVECC work together to publish the Journal of Veterinary Emergency and Critical Care, which is dedicated to furthering the science of veterinary emergency and critical care. It is the organization of those interested in the specialty that has brought critical care to the forefront of veterinary medicine and that, in my opinion, has been the single most important development in the field. The development of VECCS and its extensive membership (now more than 1700) has provided a framework for involvement in the specialty on all levels—from students to technicians to veterinarians. Unlike hu-

OWNERS’ OUTLOOK ■ Population Explosion! Pet owners’ demands for quality emergency care for their animals have skyrocketed since 1979. In the past 20 years, the number of veterinary emergency clinics has grown from perhaps a dozen in a few major cities to more than 400 nationwide.a ■ A Star is Born. The public’s growing interest in veterinary emergency medicine is evident just by turning on the television. Critical care practitioners are becoming TV’s newest celebrities as their profession is highlighted in such popular cable series as “Emergency Vets” and “Wildlife Emergency” on the Animal Planet network and in documentaries, such as “Animal ER,” which aired on the TBS Superstation in November 1998 and was the highest rated documentary of that week on basic cable. ■ Insuring a Healthy Future. The importance of emergency care to pet owners is also exemplified in the success of such companies as Veterinary Pet Insurance. Realizing the importance of being able to provide emergency (and routine) health care for their pets—but unable to foot the often pricey bills involved—owners are turning to Veterinary Pet Insurance for help. Founded in 1982, the company currently markets pet health insurance plans in 46 states plus the District of Columbia, and more than 750,000 policies have been sold to date. a

Information obtained from the online transcript of the March 29, 1999 edition of the ABC news show “20/20.”

1992 1995 987 1998 1994 1991 986 19891993 1997 1990 The American College of Veterinary Emergency and Critical Care (ACVECC) is given probational status by the American Veterinary Medical Association (AVMA).

1990

1991 The Journal of the Veterinary Emergency and Critical Care Society is published (initially published in the 1970s as the Journal of Critical Care on a sporadic basis).

1994 The Student Veterinary Emergency and Critical Care Society is formed (SVECCS).

1996 The ACVECC is granted full status as a specialty college by the AVMA.

1996 The Academy of Veterinary Emergency and Critical Care Technicians (AVECCT) is officially recognized as a technician specialty by the North American Veterinary Technician Association.

1999

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20TH ANNIVERSARY

man medicine, in which the growth of critical care is now mainly driven by technology, I think what has truly pushed veterinary emergency and critical care forward was (and is) the realization that the philosophy of critical care is important. Critically ill animals are very dynamic physiologically, and practitioners realized that they had to keep pace with changing conditions. It took dedicated people with special interest and knowledge in this area to make the specialty take off. Today, veterinary critical care is probably starting to drive technology rather than vice versa. As critical care specialists realize what they need to be more effective, they are making demands of industry to create the required technology.

Technology The practice of veterinary emergency medicine has developed substantially since its inception. Several years ago, Dr. Knowles described the sequential progression of developments as beginning with gentle neglect and continuing with temperature monitoring, crude attempts at regulating body temperature, improved physical examination, flow sheets, the expiratory whistle, urine output monitoring, central venous pressure monitoring, aggressive fluid resuscitation, aggressive antibiotic administration, corticosteroids, database collections, hemograms, electrolytes, blood gas, the Oxford titrator, extensive database determinations, blood pressure monitoring, and serial monitoring. The list of available monitoring equipment is extensive and will grow as computerization and technological development continue. Instruments are now commonly used to measure oxygen saturation of hemoglobin (pulse

Compendium May 1999

oximetry), point-of-care blood gas and electrolytes, blood pressure (invasively and noninvasively), and end-tidal carbon dioxide as well as to perform hemodialysis, peritoneal dialysis, and more. The technology available for use in critical care medicine is impressive. It is only useful, however, if there are veterinary technicians capable of using and maintaining the machines and veterinarians who can interpret the massive amount of data in the context of what is happening with the patient.

Looking Toward the New Millennium The future of veterinary emergency and critical care looks very bright. As this specialty matures, training at all levels will continue to create more public and professional recognition and credibility. I see veterinary emergency and critical care being incorporated into the core curriculum of veterinary education as it becomes increasingly recognized as an area requiring special expertise. Finally, increasing public awareness and expectations will demand that our profession provides state-of-the-art critical care. The strengths of the ACVECC, VECCS, ACVECC residency training programs, AVECCT certification process, and SVECCS ensure that the field will be up to the challenge as veterinary medicine heads into the 21st century. References 1. Sattler FP, Knowles RP, Whittick WG (eds): Veterinary Critical Care. Philadelphia, Lea & Febiger, 1981. 2. Stamp GL: Advances in emergency and critical care. Compend Contin Educ Pract Vet 19(6):670–671, 1997.