say, 'This isn't right,'" explains Glass. The collaborative team concept has "been the hallmark of effective ICUs for 25 or 30 years," he adds.

"I would say that if Mosenthal founded the multidisciplinary ICU, Dave Glass . . . brought this ICU to national prominence," says his colleague Andy Gettinger. To be sure, Glass has long been involved in national efforts to improve critical-care medicine. He participated in efforts to get critical-care medicine certified as a specialty. He was also one of two people who developed the original exam for certification in critical care for anesthesiologists. And, in the 1980s, he served on a national committee that considered combining training programs for anesthesiology and surgery.

Gettinger, too, has left a mark on history. When DHMC was preparing for the 1991 move from Hanover to the new Lebanon facility, Gettinger, then medical director of the ICU, seized the opportunity to improve the design of the ICU. He wanted to make it more efficient for staff and more comfortable for patients.

These two photos—dating back to the early 1980s—are of the ICU in the old MHMH. The bottom image shows an early Emerson ventilator.

So now all patient rooms in the ICU have windows. Instrument panels in each room are built away from the walls so caregivers can approach patients from behind rather than having to reach over them. Each room has a dual-function glass door, which can both swing open and slide horizontally. The nursing

Photo by Jon Gilbert Fox

David Glass (second from the right) was named director of Dartmouth's ICU in 1977. His successors include (from the left) Howard Corwin, Stephen Surgenor, and Andrew Gettinger.

stations are built on two-foot-high platforms, providing nurses with a downward view toward—and thus greater visibility of—patient rooms. And supplies are located right outside each nursing unit.

Patients in an ICU today are a lot sicker than ICU patients of the 1950s. Many patients are now cared for in step-down units that have advanced monitoring equipment but are elsewhere in the hospital. "We're trying to very carefully manage what are increasingly limited resources and, at the same time, maintain a really high quality of care and keep our staff satisfied," says Stephen Surgenor, M.D., the current medical director of the ICU.

Keeping staff satisfied was something Mosenthal paid attention to as well, back in the '50s. He was careful to staff the unit with people who had certain characteristics. "Qualities required are vigorous aggressiveness, love of hard work, optimism, and accuracy in detail," Mosenthal wrote in his 1957 journal articles. He was also concerned about staff morale and thought it a bad idea to put patients in the unit who had no chance of survival. "We did not want it to be a pre-cemetery roosting place," he said in the 1988 interview. And Mosenthal knew it was important for staff to be aware of their successes. "In order to prevent discouragement and to promote job satisfaction, successful end results should be communicated to the Special Care Unit staff," he wrote. Staff elsewhere in the hospital "often send a 'graduate' down to pay a visit to his 'alma mater.'"

Surgenor says the same qualities are essential today. "I would add to that that

it is not a banker's-hours job. This is a job that requires continuous care to provide patients what they need, when they need it." And just as the 1950s staff enjoyed seeing their "graduates," so do today's staff. "There's nothing better than having some of our patients who have . . . done well come back and visit us," says Surgenor.

But the ICU's ability to save lives in ways that were impossible 50 years ago has raised tough ethical questions. "The keys right now in my view are we can do a lot in terms of life-sustaining therapy—artificial kidneys, artificial ventilators, nutrition, cardiac support— you can go on and on about all the technology that's available," says Glass. "The big issue is . . . and will continue to be . . . just because we can do it, should we do it? And how do you decide who should get this very high-cost, very invasive intervention and identify those where comfort should be a more predominant feature? When I started in intensive care," he adds, "there were no such things as living wills."

Today's ICU has "a very important relationship with the palliative-care program," Surgenor says. The best thing in some situations, he explains—"if it's what the patient wanted"—is to focus on comfort, on what's important to that patient, on "a quality end-of-life experience." The key goal, he says, is "compassionate and good pain control at the end of life. It feels good to know that we can do that right . . . and help families manage what is an untenable, un- fixable problem."

Ethical questions aside, what might the ICU of the future look like? "Well, I always thought Buck Rogers [had] the answer to that," says Naitove, recalling the 20th-century science-fiction hero. "Buck would always be killed or broken or whatever. Dr. Huer would put him on a machine that would make a diagnosis of all the things that were wrong with him. Then he'd move him to another machine and push all the buttons that would make him correct. . . . [Buck] would come out the other end, all fixed up."

Several centuries from now, Naitove says, maybe there will be "a special unit for reconstitution": in goes the critically ill patient, on go an assortment of genetic repairs, out comes the patient, "all fixed up."