SCCMPod-571: Sustaining Critical Care Amid Rising Demands

Dr. Bulloch: Hello and welcome to the 2026 Congress edition of the Society of Critical Care Medicine podcast. I'm your host, Marilyn Bulloch. Today, I am speaking with SCCM Past President Dr. Jose Pascual, MD, PhD, FRCS(C), FACS, NCC, and FCCM, about the 2026 Congress session, Critical Care Under Pressure, Sustaining the Workforce and Infrastructure Amid Rising Demands. Dr. Pascual is a professor of surgery and neurosurgery specializing in trauma and critical care who has a special interest in shock and head injury. He is the section chief for the surgical critical care for the University of Pennsylvania Health System and his research interests are shared in translational and basic science investigation where he evaluates through intravital microscopy, the real-time microcirculation of the PIA in live rodent brains after traumatic brain injury. He seeks to learn how a variety of insults including head injury, shock, and sepsis affects the brain and systemic microcirculation and how different management and strategies influence these changes.

This basic science is translated into several clinical projects, both retrospective and prospective, evaluating the effects of different neuroprotective agents and strategies in multi-injured and TBI patients across the PEN, SICUs, the TSICU, and the neuroICUs. He serves in multiple national and international research groups seeking to improve outcomes in polytrauma, traumatic brain injured patients, as well as studying the effects of different resuscitation fluids and management strategies in different forms of shock. His research interests also include the dissemination of critical illness management education utilizing high fidelity simulation.

In the past five years, this has become heavily weighted out of the simulation center and into the regular clinical hospital beds, spearheading the now monthly flash or unscheduled bedside in-situ simulations that are led and hosted by different groups across the health system and across cardiac, heart and vascular, medical, neurotrauma, and surgical critical care units. Results of this education have presented at national meetings and several published in peer-reviewed journals. So welcome.

You sound so busy. I am honored we even just got a little bit of your time today. So I appreciate you being here.

In addition, he is a father and a husband and a big family man. So welcome, Dr. Pascal. Before we start, do you have any disclosures to report?

Dr. Pascual: I do not have either academic or financial disclosures. And Marilyn, thank you for the introduction. You said it very, very nicely, probably overly nicely.

Dr. Bulloch: Well, let's start. So your talk at Congress is on critical care under pressure and sustaining the workforce and infrastructure amid rising demands. What does that mean?

Dr. Pascual: So critical care under pressure, that was a session we're going to have with the different CCSC collaboratives. So the collaborative critical care, which is our ATS, American Thoracic Society and the CHESS Society and the American Association of Critical Care Nurses, as well as us, which is a compendium of different critically ill patient space societies in the United States. Now, they're not the only ones.

The Neurocritical Care Society is a notable one that's also in the space, but traditionally has not been part of this group. And of course, there's non-American societies, like the European Society of Intensive Care Medicine and many others. But this group has tried to put together different aspects of the difficulties in staffing and subsidizing and distributing the care of critically ill patients in this nation.

And I think we have some discussion, even debating of how we can solve those problems in the future, how we can learn from each other, adult critical care with pediatric critical care, neurocritical care with surgical critical care, etc. But collaborate and not just build silos where we each try to solve the same problem that the other groups solve. The attrition of beds, particularly in pediatric critical care, that is absolutely an existential crisis, I believe.

If you listen to leaders like Laurence Source, this is not going away, it's becoming worse. And many people don't know about it. So I'm an adult critical care practitioner.

And in that sense, you know, this was foreign to me until our pediatric colleagues explained that to us and to the point where now a lot of the pediatric care, just general pediatric care is going to the outpatient world. And there's fewer and fewer resources, less remuneration for practitioners at the bedside. And you know, the mom and dad in this country wants to know that they don't know.

And perhaps we need to, to do a better job of also explaining that degree of difficulty. But I think that session will bring together leaders from all those four societies that will discuss that and then we'll have hopefully time for question and answers where other issues that maybe hadn't surfaced or bubbled up will be brought up.

Dr. Bulloch: And for our listeners who might not be at Congress, that session will be available on Congress Digital. And I encourage you to go watch it. And I know that it's going to be very informative.

I'm going to put you on the spot here a little bit because you are at a big academic medical center. And I practice at a large community teaching hospital, but I'm from a rural area. My mom has a critical access hospital.

And I like to tell people, my friends who are at the big centers like Penn State, you have nice things like we don't even have nice things. So in your opinion, what do you feel is hitting a lot of those community hospitals in terms of this topic? Because I feel like they may be even experiencing it at a bigger level than the big centers.

Dr. Pascual: Very well said. And I think I would say the majority of patients in this country, critically ill patients are seen in places very much like you described that you're at, or did you see your mom was at?

Dr. Bulloch: My mom's at a very, she has like a 20 bed hospital. I'm not even sure if they have an ICU. I think it's a stabilizing emergency room.

No, that's where she lives. But if she were to get sick, that's where she would end up.

Dr. Pascual: And there's a trend now that the bigger and bigger hospital systems are purchasing for profit. Other systems that may appear as a source of profit and not purchasing others that are not. Leaving those others alone at times in pediatric in general, but also in regular care.

And then there's the critical access hospitals, which are even less supported by resources. So it's a Canadian in origin and in Canada, right? Hospital systems do not see profit.

In fact, they're at a loss so much so that it erodes actual facilities and resources. But I'm not used to the idea that you can sell critical care or any care, medical care. This is very much the truth in the United States and in many parts of the world, but not at all.

There are some places that are still very heavily regulated by the government. And so I think we need to look with a strong critique that perhaps that's not the solution to go. And if it's partially the solution to go to seek profit when distributing healthcare resources, then it should be done in an equitable way and keeping in mind the whole pie, not just those sections that are particularly tasty or more palatable for the buyer.

I don't know, but the concept of regionalization of care is also a real one, right? We know that if you have an MI or a stroke and you don't present yourself to a stroke center, for example, your outcomes are going to be worse. So the idea that all hospitals in every corner of the United States should have a stroke service is probably not a good thing.

In total, may be harmful. So there's also that side of the equation where if you want to give the best care for the precise patient in the precise condition, having a distribution of all resources everywhere may not be. So how do we balance all of that together?

Dr. Bulloch: Well, you made me think about something that I see on practice all the time. We frequently will have patients with us that just exceeded our level of care that we can provide in terms of specialization or equipment. You know, we don't have all of the equipment that our big academic medical center down the road has, but to transfer them is like an act of God.

I mean, I think in 17 years, I have seen two patients successfully transfer to that higher level of care because they are overwhelmed too. So what do we do? Like, how do we make that better for the patients and provide that equitable access short of saying next time don't come here, go to their ER?

Dr. Pascual: Yeah. I'm at Penn and we have a blanket policy where we're not allowed to refuse any.

Dr. Bulloch: Really? That's impressive.

Dr. Pascual: In fact, you know, sometimes we're overwhelmed when I was on service and the admitting surgeon for trauma or for nervous surgery or for critical care. We are sometimes full and yet we have this victim. And when I cover the neuro ICU, for example, what we've been told is if you decline a patient, you will immediately have to answer to the chair of neurosurgery and they name them by name.

And so you can imagine in the surgery world, we're all scared to be brought in front of a chair. So we never say no, even when we are overwhelmed and it sometimes happens. And so I am ready to accept that my very notorious and wonderful hospital system that I work for is not doing this out of magnanimity.

They're probably doing it in part, at least for the bottom line. And so maybe we can find ways on helping the finances of those hospitals that are constantly receiving patients from the hospitals that have less resources. You know, I also work in the VA, which has a lot of resources, but sometimes don't put those resources to use or can't utilize them.

So just giving the resources, would that even be possible? It doesn't matter. It may not be the solution.

So how do we distribute the care? As you said, it ties into the initial question, right? Is it that every hospital should be supplemented somehow by government transfer funds, everything?

Probably not. Do some hospitals have to close? Maybe.

We at Penn, for example, we just purchased part of the Mercy system. And the reason I'm hearing, and I'm a little guy in the totem pole, so maybe it is true, maybe it is not. The reason I heard that our billion dollar hospital system purchased that system was to not leave those communities without a hospital.

So the alternative would have been that those hospitals closed in less resource-rich communities and those patients would be less stranded. And here we walked in and purchased them so that wouldn't stop, but now we're going to take the name of our institution. If that was true, if that is 100% true, then I would be very proud.

Maybe it wasn't. It was partially the reason. Maybe in part there's profit there, but it also...

So how to find solutions on not just having the resources concentrated for the patients that can afford it and having it missing for those that can't, I think is a question that I think we all need to work on and perhaps governments do.

Dr. Bulloch: Let's talk about distribution of resources, including human power, right? Because I feel like that's a big one. Everybody just went through Match Day as we're recording this.

Medicine did. I mentor a lot of medical students and pharmacy students. They both professions had their Match Day and people were very excited to find out where they're going.

Are we seeing any change in the number of trainees and students that are wanting to pursue critical care as a specialty across any of the disciplines or has that been fairly consistent?

Dr. Pascual: Yeah, that's actually a problem. So as you know, in the United States, you cannot enter critical care directly from medical school. You need to do a parent specialty, most commonly internal medicine, pulmonary medicine, but also anesthesia and surgery, and more recently, emergency medicine, neurology and nursing.

And one of the mother specialties that are really seeing a change or radical change is anesthesia. In fact, we have across the country, fewer and fewer anesthesia graduates, anesthesia residents that graduate and then go into critical care. Why?

Because there's not enough anesthesiologists in the country. The salaries have jumped tremendously and there's little incentive to do an additional fellowship. And not so much the case in surgery and trauma, where trauma has become trauma, which always comes with a twin of surgical critical care, has always been a surgical specialty.

It's all different. It's one that is non-operative. Really, there are no other general surgery specialties that are not really operative other than the procedures.

But that seems to have a resurgence and continues to be very well populated by fellows and residents with now certain bodies like the American Association for the Surgery of Trauma declaring that you can have an acute care fellowship. It's not a trauma fellowship. It's an acute care fellowship that comes joined to surgical critical care.

Less known to me, medical critical care through pulmonology and internal medicine remains very successful with lots of candidates and lots of leaders emerging from those mother specialties and then critical care specialties. And it's really exciting to see emergency medicine, a space that has a lot of intensive type care or acute care that is now rising in those ranks, same as neurocritical care that has been there a bit longer. But that continues to have applicants.

You know, I do neurocritical care a little bit and see how they move from all neurology residents applying to neurocritical care for an extra two years to it being anesthesia and emergency medicine applying for two more years of neurocritical care. So that's a really nice mix. I'm the only non-neurologist emergency medicine or anesthesiologist in our neurocritical care group.

And, you know, for many years, there was logistics difficulties to have me be part of that because I'm in the trauma division. And so I stopped being and attending for about two years or three years. And then I heard from the neurology neurocritical care leader that their fellows had said it was a loss not to have that surgery or general surgery background for their trainings.

And so they brought me back. And for the last five years, I've been very lucky to do neurocritical care. So the idea that critical care self-pollinates each other and we don't all have to be one type of general intensivist.

We can be specialized intensivists, but that we should have knowledge and learn from these other subspecialties. It's really good and becoming more and more mature in this country.

Dr. Bulloch: You brought up a great point that I was going to touch on soon. You said you quit being and attending for two years. And I see this across all the disciplines, whether it's nursing, pharmacy, medicine, RT, everyone.

To go into critical care, I feel like almost you have to be a leader in a lot of ways. You have certain skillsets and a mentality that we just are all drawn to. And sometimes we might be a victim of our own, I won't say our own success, but we're hardworking and we're committed.

A lot of times as you get more seasoned, you end up finding yourself in more administrative positions and things that take you out of the clinical space. Do you think that that's something that is good for medicine overall and healthcare? Or do you feel like there's a way we need to make sure that we keep some of those seasoned practitioners at the bedside more, especially when we're looking at some of these demands that we need to meet?

Dr. Pascual: Yeah, I think it's an interesting question. It applies to more than physicians, right? I hear from my nurses that the best nurses out there go into an administrative position and then they don't work at the bedside.

And in fact, they lose some of the trust of the other nurses because they're no longer at the bedside. And to be an effective leader, one could say that you need to be in the trenches to do it. So I think what you're saying is an interesting problem, but does it have a solution?

I'm not sure. In my case, I didn't quit being in attending altogether, just in neurocritical care attending. I'm still in surgical critical care and trauma, emergency surgery attending.

But I think you're right in where you hope that the promotion to leadership roles, if not administrative, those two are slightly different, are the cause of your excellence in that field. But is your excellence in that field absolutely relevant to your experience? So it's not an acquired excellence where you have it forever because it erodes after time if you're not at the bedside with the family, with the patients, with the technology, et cetera.

So how do we do that? Maybe a future model might be to come back. Universities have moved the model of chairs of departments as not being the traditional way, which was you became a chair and then you were a chair for 20 years and then you would retire.

Dr. Bulloch: Now it cycles. It cycles.

Dr. Pascual: So even the best of candidates have five years and they have to leave after to leave room for the next excellence person. And then this person now after five years may go back to going from an administrative position to back to a clinical position. And that may be better to recycle what you were saying, which is to make better leaders because they're not there forever without clinical or bedside content and vice versa.

Make the bedside providers more conscious of the administrative responsibilities, cost and so forth that sometimes we don't see at the bedside and recycle the whole system. That might be one of the solutions.

Dr. Bulloch: Let me ask you this because you mentioned equipment and resources and we talked a lot about human power. What difficulties do you think are probably the most encountered in terms of non-human resources like equipment and medicines and things like that, that either have simple solutions or that maybe we need to refocus our efforts because 10 years from now if we don't deal with it now it's going to be a problem?

Dr. Pascual: I don't know where that specific resource. What you say seems to point me towards education resources. And in critical care there's a lot of technology and a lot of group discussion and communication and collaboration within the care of patients in that code or otherwise.

And to me the resource that has become more and more ubiquitous is simulation. And there was a time where 50% of critical care programs did not have that. And it was something that was sought after and even in FCCS courses simulation was not required.

And now it's very common. So I think if a resource that would be useful to try to preserve in the critical care space, particularly for academic or educational institutions, would be some form of simulation to be able to, at no cost to any patient, recreate acute illness with meeting of procedures of acute decision making and the ability to fail at it without harming a patient and at the same time be brief and discuss it. And then have multiple learners or groups, for example, that do in situ simulations.

Now we video record it and we used to video record it for later evaluation and critique. Now we simultaneously display. So we minimize the people in the room so it doesn't become that the simulation trainees are standing in front of 15 of their peers or their superiors and have to perform and get performance anxiety.

We close the door, there's just a regular number of people and then there's a whole conference room with a telemedicine camera that is looking into the room that gives the real-time video and they can learn hopefully the same thing without changing the experience. So different ways of using technology and particularly around simulation that could potentially be a resource that should try to stay there, not to disappear even in lower resource settings.

Dr. Bulloch: That's got to be a great opportunity because while we've all been, you know, trained by fire at some point, I think we prefer not to have to go through that and, you know, this new group of learners, they want that immediate feedback. So I think that that's very useful. Well we are almost out of time and I know you've got a million places to go.

You're a very busy man. Before we go, if you had to give our listeners one best piece of advice about this topic, one thing that they could take and practically apply at their institutions, what would it be?

Dr. Pascual: I think what I've learned this one year where I've been traveling a lot is that we can learn forever. You know, one of the things I've learned is that we think of American medicine and critical care as teaching the rest of the world. And the rest of the world does see us as educators because we have the greatest science, the greatest technology at times.

But there's so much we can learn from other places and not just the other first world nations from places that have used all kinds of second ways or more efficient ways or more economical ways to do the same deliberate care and sometimes more natural and better care. And we don't have a sense that we can learn from others. And at the personal level, as you advance through time and you get your experience, you feel like you don't have to necessarily learn from the fellow, but maybe from the resident, maybe from the med student.

And I think if you do that, it's a barrier. It's a barrier for yourself, but it's also a barrier for your patients to get the best care. So if you try to stay humble and always welcome the education, I think that's one thing that in a rapidly changing world would be useful for all of us.

Dr. Bulloch: I would like to echo that sentiment. You know, I think no matter how long I have been an educator, one of the things that I'll tell all of my trainees at any level is I can always still learn. If you ever get to that point of that arrogance that you think, I feel like you almost become a bad clinician at that point.

So I agree. Well, thank you so much for being here. And listeners, thank you for being part of our episode today.

This concludes another episode of the Society of Critical Care Medicine podcast. If you're listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. If you're listening and you haven't already gone to Congress Digital, I encourage you to do that.

For the Society of Critical Care Medicine podcast, I'm Marilyn Bulloch. Thanks for listening.

Announcer: Marilyn N. Bulloch PharmD, BCPS, FCCM is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama Birmingham School of Medicine.  Join or renew your membership with SCCM, the only multi-professional society dedicated exclusively to the advancement of critical care. Contact a customer service representative at 847-827-6888 or visit sccm.org/membership for more information. The SCCM podcast is the copyrighted material of the Society of Critical Care Medicine and all rights are reserved.

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