Looking for a Few Just Men

In the biblical tale of Abraham interceding with the Lord on behalf of Sodom, because the men of Sodom were considered so wicked by the Lord, He was proposing to completely destroy the city. Abraham started to negotiate the number of just men that would need to be found to halt the planned demolition. The Lord agreed that 50 would be sufficient, and Abraham proceeded to get the number down to 45, then 40, then 30, then 20, and finally 10. Two angels were dispatched to the city and stayed at the house of a just man—Lot. Apparently, no other good men were to be found, and the angels advised him to flee Sodom the next day and not look back. Lot went with his wife and daughters, and the Lord destroyed Sodom, and the neighboring sinful Gomorrah, with a rain of fire and brimstone. Lot’s wife was unfortunate enough to look back and was turned into a pillar of salt, but the others escaped. An interesting point in this lesson is the liberty with which Abraham had to bargain with the Lord, and when the outcome produced only a small fraction of the agreed amount, the proposed solution was set into motion! A judgment had been placed on the value of just human beings, and a ratio established (although this day we do not have the denominator) as to the comparative value of wicked men. Sooner or later, all of us in the practice of critical care have to make judgments regarding the value of human life; frequently, because of limited resources; occasionally, because the outcome looks bleak; and sometimes, because the risk/benefit ratio is considered low in terms of what we have offer. The major problems facing critical care today are related to resource allocation and misallocation resulting in inadequate manpower, a perceived shortage of beds, sepsis, and a long-term quality and length of life that has a startlingly poor return for the amount of energy expended. How much critical care do we need? This question never has been satisfactorily answered. In terms of intensive care unit (ICU) beds available per capita, the United States is overwhelmingly the world leader. On any day, US hospitals have about 55 000 patients in 6000 ICUs. Typically, between 8% and 12% of a medical center’s beds are devoted to some form of critical care, which consumes about half of an institution’s direct patient care budget. This is a tremendous amount of money and represents more than 1% of the gross domestic product or more than $200 billion annually. (Total healthcare costs for 2004 were almost 14%, or approximately $1.7 trillion.) The frightening aspect of this predicament is that no one is responsible for the U.S. healthcare, and 45 million people currently are without health insurance. Most countries with similar standards of healthcare operate with much lower percentages of critical care beds; in general, non-US hospitals devote less than 3% of beds to critical care patients. Critical care staff are often in charge of, or work closely with, highdependency or step-down units that care for patients who require extra care, but who are not critically ill. Longer term postanesthesia care units (PACUs) may also augment acute surgical recovery. In the United States, many patients who are placed in an ICU to receive a little extra care and observation could receive the care they need in a unit with a lower but appropriate level of management and then be transferred to the general floor. Does the United States have too many ICU beds, or do other countries have too few? The smaller number of beds in some countries allows for a 1-to-1 patient-tonurse ratio to be the norm, or at least the goal. At times when the incidence of critical illness rises, it is possible that the low capacity will be insufficient in meeting the needs of the hospital patients, the ICU will become overloaded, and the PACU and stepdown units must provide a higher level of care than EDITORIAL