The Generalist of the Pediatric Subspecialists: The Pediatric Intensivist

When I wrote a chapter article about “A History of Pediatric Critical Care Medicine”, I had just finished my fellowship training in pediatric critical care medicine in 2003. It still strikes as odd that I was able to write a historic article, given that I was so fresh out of training. I had never experienced the early evolution of pediatric critical care medicine and was only in high school/college in the 1980s and 1990s when it became an established subspecialty. But, nevertheless, I researched events and milestones of the subspecialty and came up with a relatively coherent narration of incidents that shaped the pediatric critical care medicine subspecialty.

The one thing that I realized from the history of the subspecialty is that much of the initiation of its creation was the evolution of other subspecialties. As medicine had become more and more complex with the detailed understanding and treatments of various diseases and the technologies needed to support children during critical stages of their illnesses, a dedicated physician was required to take care of these children. Previously, I had heard that the early iteration of the pediatric intensivist (a physician who specializes in pediatric critical care medicine) was a general pediatrician who had the time and interest to care for these children or pediatric subspecialists would care for their own patients in these dedicated intensive care units. They were termed, “open units”, because any pediatrician or pediatric subspecialist could admit a child to these intensive care units and care for the children themselves.

Over time, the medical knowledge became too vast and the dedicated time needed to care for these children became too demanding to have pediatricians or other pediatric subspecialists manage these critically ill children. Furthermore, if a child with kidney disease was being managed by a pediatric nephrologist or a child with heart disease was being managed by a pediatric cardiologist, who was managing the other organ systems? The emphasis was not only on just the specific disease, but also the whole child. A child with kidney failure could get fluid overloaded and develop pulmonary edema with respiratory distress and, then, require intubation and mechanical ventilation. A child with heart failure could suffer injury to the kidneys and suffer respiratory failure as well. There was more involved than just the organ system that the subspecialist was caring for.

This added complexity led to pediatric intensive care units being considered “closed units”. Once a child was admitted to the intensive care unit, all primary physicians would relinquish management to the pediatric intensivist and work with them to help care for these critically ill children. The realization was that there were too many systems that needed attention, as well as additional expertise in nutrition, pharmacology, sedation, understanding life support technologies, and other areas that required orchestration and management.

I like the word, “orchestration”, when it comes to pediatric critical care medicine because there is a lot of care coordination that goes into managing critically ill children. As I mentioned in my previous article about, “A Night in The Pediatric Cardiothoracic Intensive Care Unit”, it takes a village to care for these children. There are many professionals from many different disciplines that take part in healing these children. But, the efforts need to be coordinated by someone. That someone is the pediatric intensivist.

The pediatric intensivist is the “conductor of the orchestra” of multiple subspecialties and ancillary services. Knowing what a critically ill child looks like and how to improve their condition is in the lane of the pediatric intensivist. Don’t get me wrong…a pediatric intensivist is not the smartest physician in the room. However, they have the skill of getting the information that they need from all of their resources to care for some incredibly complex and critically ill children. They know enough about the other subspecialties to know what they don’t know and when to ask for help. Coordinating, navigating, and negotiating complex care issues and communicating amongst various subspecialists or ancillary services is a pediatric intensivist’s superpower. Understanding a pediatric intensivist’s role in the care of critically ill children has led me to frame the pediatric intensivist as the generalist of the pediatric subspecialists.