Key advances in critical care in the out-of-hospital setting: the evolving role of laypersons and technology

As we first developed intensive care units (ICUs) for our hospitals in the 1960s, we also developed our first mobile ICUs [1,2]. For some of us, our critical care practice has focused more and more on the out-of-hospital setting, and emergency medical services systems have now become our ICUs [1-3]. During the past decade, the out-of-hospital mobile ICU transcended the advanced life support practiced on-scene by paramedics, nurses, doctors, and other prehospital care providers [4,5]. As explained in the following discussion, many of the life-saving efforts and advances for critical care situations have now begun to focus increasingly on how the average person can save lives, and perhaps even spare precious ICU resources.Many prehospital care providers have espoused the concept that 'a gram of good prehospital care can save a kilogram of in-hospital ICU care'. In the case of automated external defibrillators (AEDs), it seems that the 1,500 grams constituting the typical weight of an AED may indeed save much more than that. In fact, the technological evolution of AEDs has now also changed our traditional notions of a 'critical care practitioner'. Today's AEDs are so easy to use that even schoolchildren can operate them easily with little or no previous instruction [6]. Today, AEDs have become a standard part of basic cardiopulmonary resuscitation (CPR) training for the average person, and public access to defibrillation has become an encouraged practice, at least within certain guidelines [7-9].The most striking testimony to the success of AEDs was the recent study conducted at the Chicago airports where AEDs were deployed throughout the airport terminals for use by the public at large [9]. It had been previously established that AEDs could be used successfully by specially targeted, specially trained 'laypersons' such as flight attendants and casino security guards [7,8]. However, this particular study was conducted specifically to determine whether the average, rand