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In most modern children’s hospitals, the practice of paediatric critical care medicine occurs in a high technology, resource intensive environment “beyond the double doors”. Few venture into this foreboding environment without good reason. However, recognition that critical illness is a dynamic process behoves us to step “outside” and attempt to decrease the need for our services “inside”. Therefore, it gives me great pleasure to state that my colleagues (1) have gotten the message. As Pierre and Augier state in a previous issue of the Journal, critical illness defines evolving pathophysiologic derangements which if uninterrupted may ultimately lead to death and disability (1). It is well recognized that regardless of the inciting insult, severe organ dysfunction will eventually lead to cardiorespiratory compromise and failure. Because frank cardiorespiratory failure is associated with dismal outcomes, to ensure the best outcomes, we need to be vigilant to detect and reverse the subtle signs of altered physiology which if left unchecked leads to a downhill spiral. The holistic approach involving health maintenance to complex tertiary care is cost effective and simply stated, prevention is better (and less expensive) than cure. The rigid hierarchies sometimes created by subspecialty disciplines is counterintuitive to this philosophy. It therefore needs to be discouraged especially in a country in which many deaths are due to conditions that can be treated or prevented with minimal resources. It is heartening to see critical care specialists championing public health initiatives such as immunizations, accident prevention and safety measures, and health maintenance rather than having tunnel vision focused on high technological cures only. There is no doubt that relevant public health programmes should be the foundation of healthcare in all societies. This approach to delivery of care in children is outlined in Figure 1. Public health initiatives and health maintenance should be the bedrock of the healthcare system and may stave off the need for upstream care. For those who suffer illnesses, the response should be graded depending on their physiological status. For instance, resuscitation and

Paediatric critical care stepping beyond the double doors