The Development of Intensive Care in the Military Environment.

If the history of critical care is to be addressed, the starting point must be the fundamental and defining qualities of intensive care units. These are the concentration of the sickest patients in a defined area of the hospital, staffed by the personnel most able to care for them (by virtue of specialist training), and the application of the most advanced monitoring or therapeutic techniques available at the time. In the military environment, the ability to provide critical care to ill or injured servicemen has developed in tandem with the civilian experience, but the pressures of the austere environment of the battlefield have, at times, held back military medical services from providing the highest level of care that servicemen might deserve and, indeed, expect in civilian life. On the other hand, the challenges of frequently managing casualties of such a high level of injury acuity have at times spurred the military doctor to achieve levels of success that have made the most experienced civilian trauma specialists sit up and take notice. The history of medicine is a story of conquest and frustration. The defeat, if only temporary, of infectious disease as a major cause of premature death allowed for an increase in mortality rates due to heart disease and cancer, the somewhat successful management of which has revealed the challenge of senility in a longer-lived population. This pattern is mirrored in military trauma care; gangrene and other infections were the often inevitable consequence on severe injury among the battle wounded who did not die immediately; antisepsis and debridement including amputation countered this threat somewhat. The challenge then became managing those even sicker patients presenting in that brief period before death called "shock." Once this was understood and the management of shock improved, surviving patients presented the military doctor with renal failure, coagulopathy, and acute lung syndromes as the the award for his efforts. This article will discuss how critical care on the battlefield has developed to confront these challenges.