reflected a minute," Mosenthal recalled, "and he said, 'Well, I think we can handle that.' We used it for years."

Along with better equipment came improved techniques. The method for inserting catheters into the superior vena cava—one of the vessels that returns blood to the heart—was standardized in the 1970s. By the late 1980s, central venous lines—tubes put into a blood vessel in the neck and snaked down into the heart or vena cava—had become commonplace. Tubes were also used for feeding people who couldn't eat. And transfusion therapy and dialysis became possible, too. "All those things improved and got better and better," says Naitove.

In 1970, the Swan-Ganz catheter was developed. It had a small balloon at its tip which, when inflated, caused the blood flow to pull the catheter into the heart and then into the pulmonary artery. The catheter was connected to a monitor that provided a constant, direct readout of pulmonary blood flow, pressure, and cardiac output.

By the 1970s, the ICU environment had gotten so specialized that even Mosenthal realized the specialty was getting beyond him. "As it got bigger and bigger, and into the hands of the anesthesiologists and the intensivists, they began to know so much more about this stuff than I or anybody generally did, who hadn't had special training, that you kinda get pushed out," he said in the 1988 interview. He resigned from the ICU committee in 1970 after having chaired it since 1955.

When Glass arrived at DHMC as medical director of the ICU in 1977, he was the first faculty member trained in critical-care medicine. Until then "DHMC's ICU was primarily a specialized nursing unit, as Mosenthal had developed it," Glass explains. "In 1977, we introduced the concept" of staffing the ICU with physicians who had trained in critical-care medicine. This concept was so new, he adds, that it existed in "only a very few medical centers in this country."

Glass had been inspired by one of the pioneers in critical-care medicine, Peter Safar, M.D., who in 1958 had begun a

Top: The photo on which the painting on page 40 is based; Mosenthal is third from the right. Bottom: The 1957 exhibit, on view at MHMH.

medical-surgical ICU at Johns Hopkins's Baltimore City Hospital. In the 1960s, Safar moved on to the University of Pittsburgh, where he started the largest training program for critical-care specialists. Glass did his surgical internship there, met Safar, got hooked on criticalcare medicine, and went on to Harvard's Mass General Hospital for a residency in anesthesiology. There, he trained with a group that had started a respiratory-care unit and a surgical ICU in the mid- 1960s. Then in 1972, he went to the University of Mississippi, where he helped to start a medical-surgical ICU in Jackson; he directed that unit from 1975 to 1977.

Soon after Glass arrived at DHMC, he started one of the first intensive-care fellowship programs in the country. It has since become one of the most sought-after fellowships in critical care.

Being led and staffed by critical-care specialists since 1977 puts DHMC's ICU in the forefront nationally. In fact, in 2000, the Leapfrog Group—a consortium of major businesses that is initiating improvements in the safety, quality, and affordability of health care for Americans—determined that the best ICUs were those staffed by physicians with credentials in critical-care medicine.

DHMC's ICU has been Leapfrog compliant since 1977, decades before the Leapfrog Group existed.

DHMC's ICU was also unusual—perhaps even unique—in that it has always been multidisciplinary. "There were trauma ICUs and there were certainly burn ICUs and so forth," Glass says. At many institutions, "this was a time of a fair amount of money, and unfortunately also was a time when fiefdoms were growing up in various medical disciplines." So there was a tendency at other institutions for different departments to each have their own ICU. But gradually some institutions began to appreciate what DHMC had recognized all along—that multidisciplinary ICUs made the most sense, because "medicine patients when they were critically ill were really no different from surgical patients when they were critically ill," as Glass puts it. Now everyone realizes "that concentrating physician and nurse resources for critically ill people [is] a much more efficient, cost effective, and ultimately better outcome-based environment."

Being led by critical-care specialists since 1977 puts DHMC's ICU in the forefront nationally. In 2000, the Leapfrog Group determined that the best ICUs were those staffed by physicians with credentials in critical-care medicine. DHMC was Leapfrog compliant decades before Leapfrog existed.

Although DHMC has since then created some specialty ICUs— including an intensive-care nursery, cardiothoracic units, and a pediatric intensive-care unit—its main ICU is still multidisciplinary.

It also became clear over the years that critically ill patients do better when they are cared for by collaborative teams of health-care providers, including not only physicians and nurses but also respiratory therapists, clinical pharmacologists, nutritionists, social workers, occupational therapists, and physical therapists. The team develops "a camaraderie and an ability to work together without turf battles and without pecking orders getting in the road—where a nurse can approach a physician and