The history of intensive care in Colombia

The history of intensive care in Colombia is strongly linked to the decline in MI mortality in our country.

Before the onset of intensive care, MI mortality was around 30–35%, when care was limited to relieving pain, avoiding or treating some complications such as peripheral or pulmonary thromboembolism, treating heart failure and prescribing prolonged bed rest for the patient, which sometimes extended up one month.

The first Intensive Care Unit in Bogotá was established at the San Juan de Dios Hospital, affiliated to the National University of Colombia, between the years 1969 and 1970, with the support of the Pan-American Health Organization and the World Health Organization (PAHO/WHO). The external advisors to those agencies were Drs. Alberto Ramírez and Hernando Matiz, both trained in internal medicine and cardiology in Boston and Buffalo.

A remarkable anecdote is that the first patient to inaugurate the Unit was the representative of PAHO/WHO himself, who had helped in funding and equipping the ICU and on the eve of the inauguration experienced a myocardial infarction.

The Unit opened upon having trained intensive care nurses in defibrillation, cardioversion, and a course on cardiac arrhythmias; unfortunately, absolutely no training was given to physicians and residents which resulted in serious problems that were solved within a couple of weeks through accelerated courses given to these doctors.

The unit had 10 beds, was located on the second floor of the hospital, on the same level as the ORs and the recovery rooms. All of this was planned with the collaboration of Dr. Jaime Casasbuenas who was then the Head of Anesthesia of the San Juan de Dios Hospital.

The unit's operation reduced the myocardial infarction mortality to 15% per year and the results of the first 100 MI cases treated at the hospital were published in the PAHO/WHO journal.¹

At about the same time, the Intensive Care Unit of the Military Hospital and of Shaio Clinic – where cardiac surgery had been initiated – began to operate. Simultaneously, the Intensive Care Unit of Medellín-Colombia, at Dr. Antonio Ramírez's Heart Surgery Department of opened its doors.

Then, Drs. Matiz and Ramírez together with a few nurses from the San Juan de Dios Hospital and other external advisors to PAHO/WHO, travelled for eight weeks visiting Quito-Ecuador, Lima-Peru and Santiago de Chile where training staff to open intensive care units in those cities. Those ICUs are still functional.

Since I was partially and temporarily associated with the Caja Nacional de Previsión (Colombian Pension Fund), we, together with professor Jorge Bernal Tirado, planned the development and inauguration of the ICU of that institution that was named after him.

Some time later and at the request from Dr. Humberto Basto (Head of the Emergency Department of the San Pedro Claver Clinic of Bogotá), a protocol for the establishment and management of the ICU at that Clinic was designed and I was called to temporarily assist to establish the first critical care unit in the ER. The unit was very well equipped and, as far as I recall, it was the first institution to have a critical care unit inside the emergency department, thanks to the perseverance of Dr. Basto. This achievement had not been possible at the San Juan de Dios Hospital.

Furthermore, at the request of Professor José Félix Patiño, I submitted a development plan to establish the ICU at the Samaritana Hospital in Bogotá, a project that was implemented some time later.

Around 1972, mostly due to political difficulties well known to all, some physicians from the San Juan de Dios Hospital began to migrate and at the request of Drs. Guillermo Rueda Montaña (Director of San José Hospital of Bogotá), Juan Consuegra (Head of Cardiology) and Miguel Madero (Head of Cardiothoracic Surgery), we jointly organized the intensive care unit and the Catheterization Unit at that hospital, where we used to practice coronary arteriography using 16 mm film.

As the exodus of some of the professors of the National University of Colombia continued, we founded in Bogotá the El Bosque Clinic, between 1976 and 1977. There we organized the intensive care unit with 5 beds, equipped with central monitoring capabilities, closed T.V. circuit monitors, and one bed at the recovery unit where the patient was taken care of immediately after surgery. This probably gave rise in Colombia to the concept of step-down care, an idea widely developed by Dr. Ricardo Beltrán at Clínica Nueva in Bogotá; this unit has 6 or 8 beds and all the necessary elements to operate as a step-down ICU, reducing costs and with less supervisory staff required.

When a group of us cardiologists moved over to the office building of Clínica Marly in Bogotá, there was a need to set up an intensive care unit in the same venue where we were then going to have our private practice. A strong driver of this unit was Dr. Rafael Sarmiento and nurse Myriam González, both trained by us at the San Juan de Dios Hospital.

Hence, a team of aficionados in various disciplines such as general intensive care, surgical intensive care and neurological intensive care (developed at that time at the Military Hospital under the leadership of Dr. Jaime Potes), gave rise to the idea of organizing the Colombian Society of Intensive Care. The merit of this society is that it was indeed the first medical society established in the country including nurses among its members, attesting to the multidisciplinary nature that must prevail in our practice and the collegial and team work that should exist with the nursing staff.

Our first president was Dr. Jaime Potes and the vice president was Eduardo García Vargas. I do remember that Carlos Gaviria attended the first assembly; he had been a strong advocate of intensive care at the San Ignacio Hospital in Bogotá, at the extinct Instituto Neurológico, and who took over my place as Head of the ICU of the Simón Bolívar Hospital in Bogotá – a unit designed with 8 beds in the second floor of that hospital, next to the recovery and surgery rooms.

Neurologist Luis Eduardo Amador was also present and should be acknowledged for designing the first magnificent logo of the Society. Other participants at this first assembly and founders of the society were Professor Hernando del Portillo, Dr. Rafael Sarmiento, Dr. José Carlos Miranda (Shaio Clinic), Dr. Jaime Escobar (who for a short time was the Head of the ICU at San Juan de Dios), in addition to Dr. Jaime Casasbuenas (Head or the ICU of the San Juan de Dios). Later on, Dr. Alonso Gómez became the head of the ICU at San Juan de Dios Hospital in Bogotá.

It should be mentioned that together with this group of people, very young doctors who were passionate about intensive care also joined in, including Carlos Manrique Neira, Francois Joachin, Fredy Gil, Jorge Bejarano, Jaime Paz Neil, Alfonso Pinzón, Evalo Real, and Dr. Del Castillo, one of the first general surgeons who became a full time ICU doctor at the San Juan de Dios, then at the San José Hospital, and eventually the only one that has been able to establish a fully private ICU in Montería city.

In 1981, after some time of inactivity of the Society as a result of some legal difficulties, Eduardo García Vargas was appointed; thanks to Dr. García's contacts including Christopher Bryan Brown and others, he introduced our society to the international community and we became a member of the World Federation of Societies of Critical Care.

Eduardo García, José Carlos Miranda, Mario Bernal, and Jorge León, we all attended the first World Intensive Care Congress in London, with the valuable support of Dr. Jorge Reynolds, who had been another founding member of the Intensive Care Society.

Jorge Reynolds was and still is very close to intensive care since he designed in Colombia the first pacemaker and hence was able to meet the economic needs of our hospital.

In 1985 I became the president of the Society for to terms until 1988; I had in mind the creation of the intensive care graduate program or internship, together with one of the schools of medicine.

The internationalization efforts of the Society continued. Delegates were sent to attend world congresses and for the first time we became associated with the Colombian College of Surgeons to organize the First Intensive Care Congress in our country, with the help of Dr. Tito Tulio Roa, then President of the Colombian College of Surgeons. With this same society we later organized another very successful congress with almost 3000 participants. We also produced a brief newsletter from 1985 to 1988 and published the first book of congress abstracts – Memoirs – with Drs. Eduardo García and Hernando Matiz as editors, including abstracts of the national and international conferences. Around this time we became members of the Pan American and Iberian Federation of Critical Medicine and Intensive Therapy (F.E.P.I.M.C.T.).

Later Dr. Alonso Gómez became president and he, with his outstanding vision created the Chapters leading to the decentralization of the Society into the Central, Medellín, Coffee-Growing Region, Western and Eastern – Santanderes – Chapters, where various integration meetings were held and a Third Colombian Congress of Intensive Care, beyond the scope of the Colombian College of Surgeons.

The society became disorganized, less Board of Directors Meetings and Assemblies were held; a “shattering situation” which I think was necessary occurred. Such situation was the establishment of the Colombian Association of Critical Medicine (ACMC), led by the Caribbean Chapter, originating in Montería. It was founded by Drs. Guillermo Quintero and Ricardo Beltrán; the latter was the only certified career-graduate intensivist with a degree from the Universidad Nacional Autónoma de México. The rest of us were amateur “intensivist” out of the genuine need to develop the profession that we practiced side by side with our primary specialization (usually internists, cardiologists, neurologists, general surgeons, and of course a very important group of anesthesiologists that became increasingly stronger).

Upon a reform of the by-laws, other Pan American associations and other healthcare disciplines became members; these usually served the ICUs.

This last Society was incorporated in 1994, with the consequent demise of the old Colombian Society of Intensive Care. The new Society was then chaired by Dr. Juan Manuel González and then by Dr. Edgar Celis, from the Fundación Santa Fe de Bogotá.

We worked together with Dr. Edgar Celis (President of the Society) to establish the graduate intensive care program, with the participation of the Colombian School of Medicine of El Bosque University. The graduate program was a diversified 4 year training for general practitioners or a 2 year program for specialists in some specific areas such as internists, anesthesiologists, cardiologists, and general surgeons which then became emergency physicians.

I served as peer academician appointed by the Colombian Institute for the Development of Higher Education (ICFES) and the Ministry of Education, to evaluate and approve the program and I suggested that the program director should also be a specialized emergency physician. It must be said that the maker of this emergency medicine program was Dr. Doctor Luis Eduardo Vargas, the Director of the emergency Department at Shaio Clinic.

This project entailed the eventual certification of a number of intensivists with a minimum number of year working in intensive care and ICU education, as well any additional university requirements.

The Sabana University (Chía-Colombia) completed the intensivist validation process for approximately 50 physicians awarding them the academic degree as intensive medicine specialists. The curriculum designed then included basic internships through internal medicine, sepsis, burned patients, trauma, ObGy and pediatric intensive care. Evidently this will not be a one-hospital program but several institutions would participate for the students to rotate in Bogotá and other cities. Finally, the required conditions failed to be met and the El Bosque University withdrew its endorsement, which was then replaced by the Sabana University.

This graduate program is also intended to bring together the efforts of a Critical Care Society and one University to jointly develop the postgraduate program, since only universities are called to issue specialization diplomas.

Recently the practice of intensive care has moved to medical teams where six or eight intensive care specialists accept under contract to run the intensive care units at certain clinics or hospitals, with or without providing medical equipment and give comprehensive intensive care at these institutions.

Colombian Academy of Critical Care

In 2009 – for reasons yet unknown – a group of the old founding members of the intensive care practice were left outside of the society; so, together with Dr. Alonso Gómez we founded the Colombian Academy of Critical Care, a decision frowned upon by the current critical care society.

This society has organized two national and international congresses and in October 12 through 15, 2014, the First International Congress of Sepsis was held, on the International Sepsis Day.

The “Bogotá Sepsis Consensus” was also organized, with the participation of 25 worldwide experts, under the leadership of the current board of directors that I am honored to chair as the first founding president.

The current Academy is a member of the World Society of Critical Care whose then president, Dr. Jean Louis Vincent was a Guest of the First Congress on Sepsis in Bogotá (September 2014). Approximately 1000 doctors and 150 critical care nurses attended the meeting.

This is how the Colombian Academy of Critical Care is currently operating. Unfortunately, the two associations are working completely alienated and it has not been possible to bring them together, particularly for research purposes. We hope however that this situation will change in the near future.

Please forgive me if I failed to mention other people that contributed to the establishment and continuation of intensive care in Colombia. There are probably other clinics or hospitals that started their own ICUs and have not been mentioned in this editorial.

Financing

The authors did not receive sponsorship to carry out this article.

Conflicts of interest

The author has no conflicts of interest to declare.