in medicine and surgery, stimulated by the war experiences and by the increasing import of the MHMH as a referral center, resulted in a significant increase in clinical, administrative, and financial problems in the care of acutely ill patients," Mosenthal's 1992 letter continues. "The problems demanded solution. I won't review all of these, but they included the expense of necessary special nurse (privateduty) care, paucity of qualified private-duty nurses, patient complaints concerning the constant hubbub surrounding acute care, lack of expertise in acute-care techniques, potent new medications and machinery, lack of special interest in this difficult subspecialty by some nurses and physicians, etc. Of course the main concern was the increasing inability to provide the expert special care that these acutely ill patients required."

So Mosenthal again brought up the idea of an organized special care unit (SCU), as it was first known—this time in a meeting of the newly formed hospital patient-care committee, made up of medical staff, nurses, and administrators. The committee not only welcomed the idea but also helped Mosenthal develop a plan.

"We worked out a program of special training for nurses; special forms; a standard operating procedure for anybody who was going to get into this unit; rules and regulations about who could admit, who couldn't admit, who could discharge; other restrictions about not admitting moribund people; and minding the psyche of the nurses who were taking care of these people—not to have everybody in there die on them," Mosenthal explained in the 1988 interview.

"The administration okayed" the establishment of the special care unit, said Mosenthal. "The absolute delight of working in a hospital like this was that when the doctors or clinical staff came up with something significant or important or obviously needed . . . they'd say, 'Well, certainly, that sounds fine. If that's what you want we'll see if we can't get it for you.' And they always did."

Photo by Jon Gilbert Fox

John Sibley, who worked as a resident in the 1955 ICU, shows off the sketches he created to illustrate the problems that the ICU solved—see the facing page for two examples.

So in 1955, one ward was renovated into an 18-bed SCU—for both medical and surgical patients who were critically ill. In addition to its own nursing staff, the unit had its own supply of medications and equipment; piped-in oxygen and suction; wall-mounted blood pressure manometers; wall brackets for IV bottles; and sterile instrument sets to perform emergency tracheotomies (to relieve airway obstructions), vein cut-downs (to administer fluids or draw blood), thoracenteses (to remove fluid from the chest cavity), catheterizations, irrigations, or lumbar punctures. Equipment on the unit included laryngoscopes, intratracheal tubes (now called endotracheal tubes), an electrocardiograph, a resuscitator, and even a set of bed scales.

In 1957, Mosenthal published two journal articles—in Modern Hospital and the Journal of the Maine Medical Association—describing the special care unit. That year he also took an exhibit to the American College of Surgeons' Clinical Congress in Atlantic City, N.J. "I thought if it's good, people will benefit by seeing what we'd done [and] improve on it, adapt it to their own needs," he said.

The exhibit included several sketches drawn by surgical resident Sibley, who was working in the special care unit at the time, as well as a three-dimensional model depicting two hospital-floor layouts at 3:00 a.m.: one with lights blazing and nurse figures running around everywhere, and another with an illuminated special care unit surrounded by darkened

rooms where the other patients were sleeping undisturbed. "The interest was amazing," said Mosenthal, who spent most of the conference sitting beside the exhibit and answering questions while Sibley attended the lectures. "They wanted to know everything about how it worked, nursing problems, how many nurses would you need in a place like this, what was the occupancy. It just came along at the right time. . . . It was right after that the whole thing kind of ballooned up—everybody had an ICU."

Mosenthal gave presentations around the country, and by the late 1950s, according to the Society of Critical Care Medicine, about 25 percent of community hospitals with more than 300 beds had an ICU. A decade later, most hospitals in the United States had at least one.

But the ICUs of the 1950s were not the high-tech units they are today. "It wasn't intensive care the way we think of it now, with oodles of people circulating constantly and monitors going jingjang," says Naitove. He spent part of his residency working in the Hitchcock SCU, and his wife was a patient in the unit in 1961, after she was in a serious automobile accident. "It was really a place where people were aware they had somebody seriously ill and followed them as closely as they could," says Naitove.

It's become clear that there are different definitions of what constituted an ICU in the early part of the 20th century. However, Mosenthal's ICU may have been the first to concentrate nursing care and medical equipment in one place for critically ill surgical and medical patients.

Anesthesiologist Andrew Gettinger, M.D., agrees. He was medical director of the ICU from 1987 to 1996 and says the 1955 unit was "not an intensive-care technology space" but was "about the nursing."

To achieve round-the-clock staffing, Mosenthal's unit had one head nurse, six staff nurses, five senior nursing students,