During the 50th presidential address, William Curreri, the president of the American Association for the Surgery of Trauma, wrote the following on the emerging specialty of critical care [1]:

The future of those of you with strong critical care interest could not be brighter. Technological advances will be achieved at increasingly more rapid rates. There are a few dark clouds threatening such unbridled enthusiasm.

He went on to describe these dark clouds as the challenges of cost containment and widespread fizzling resources. More importantly the potential for holding back resources for patients presumed to do poorly in the first place. It was already clear that efforts had to be undertaken to maintain the flow of resources to the right patients.

Ellen Rudy and Ake Grenvik, a nurse and physician, respectively, wrote the following more than 30 years ago in their article, “Future of Critical Care” [2]:

In response to the rapid increase in the population category aged 85 years and above, we can anticipate a need for separate geriatric and geropsychiatric ICUs during the current decade. Many of these units could provide intermediate care, with special needs considered for this oldest of the old category. We foresee increased research in technology to compensate for physiologic organ dysfunction. Computerized automatic data acquisition systems are being developed to take over components of complicated patient management such as automatically adjusting medical ventilation and artificial heart function to varying patient needs. Development of robotics to perform heavy and difficult tasks such as lifting the morbidly obese and providing intrahospital transportation of critically ill patients. No doubt, the future will bring additional ethical problems as our capacity to compensate for failed body parts increases along with our ability to prolong life.

Sounds familiar? But where are the ICU robots? One of the leaders of intensive care [3] a few years ago predicted that:

There will be less visible equipment and connecting tubes and cables as patient monitoring will all be achieved by one or two simple non-invasive wireless systems and most blood parameters will be measured by percutaneous sensors or breath analysis thus eliminating the need for phlebotomy. Mechanical ventilators will be less abundant and when present much smaller than current respirators. Indeed, fewer patients will undergo endotracheal intubation and mechanical ventilation because extracorporeal membrane oxygenation (ECMO) and extracorporeal CO2 removal (ECCO2R) devices will have developed to such an extent that they can largely prevent the need for mechanical ventilation. These extracorporeal devices will be much smaller and more portable than current machines. Patients will be mobilized almost immediately, with in-bed exercises and out-of-bed movement as soon as is possible, assisted by specially programmed robots for patients. Patients will be better informed and have a more active role in decision-making about all aspects of their care.

The future for them must be more technology, more robots, more artificial intelligence, more biomarkers, more precision medicine. Meissen and colleagues [4] wrote:

It is not a futuristic concept to build a multiprofessional patient-centered critical care team that provides the right care to the right patient at the right time through the entire continuum of acute illness and injury” and “all leading to seamless data availability. Would we really believe that AI algorithms can better recognize early signs of organ dysfunction, speech and vocal biomarkers indicative of dyspnea, asthma exacerbation, cognitive impairment, and high risk for clinical deterioration” and that “the team’s wearable technology will optimize staffing patterns by tracking and mitigating excessive workloads while monitoring for mental and physical fatigue and distraction that could worsen patient care and/or exacerbate clinician burnout?

For sure, optimizing the environment has the potential for substantial positive impacts on patient outcomes and staff health and performance, thereby improving efficiency. An “ideal” intensive care unit (ICU) design should reduce the incidence of preventable problems, such as delirium, reduced sleep quantity and quality, loss of circadian rhythms, and other complications associated with alienation, sedation and prolonged immobility. But when we do look at it critically, aren’t we still mostly practicing medicine as we did a century ago? The principles of clinical practice―clinical history, examination, diagnosis and differential diagnosis, assessment, and plan of management―cannot be easily replaced albeit assisted by artificial intelligence.

Imagine you open your search engine in 2200 and you find an essay of a respected medical historian (assuming they still exist). This is what we could read.

We can hope for a futuristic future. We now have the solid nanotechnology and nanobots and the neocortex is connected to the cloud. What were we thinking? Lack of precision, rudimentary monitoring (electroencephalogram and ultrasound), and ineffective medication and interventions. If there is any theme of the last 75 years, it must be discarding treatments we used for decades and did nothing, same with some approaches, but also the disappearance of a physical and neurological examination. And the specialized modifiable critical care pods did not even exist. We had similar beds in similar ICUs with similar equipment. ICU rooms are now ultraconnected, and interactive modules and screens show patient results and monitor parameters in real time and connect to all members of the team using wearables and spatial computing in virtual worlds simulating options for care. We can monitor what we can, and artificial intelligence integrates it into a simple screen.

Now we have catheters going into the vasculature of organs measuring all changed chemistry that comes into the bloodstream. Pharmacogenetics changed our precision, and we now can exactly know what works for patients, and clinical pragmatic trials made way for explanatory clinical trials. We found solutions to treat all microbes and resistance (the big killer in the 2050s), and we can rapidly change gears when microbes change their biology. Gone are the days of hospital-acquired infections because patients are vaccinated on their way in. We have made dramatic strides in functional magnetic resonance imaging and can now see what the brain is thinking and planning. Neurosurgery has never been as precise, and expert intensivists all over the world could peak in other ICUs when a pressing problem emerged and provide their advice and wisdom. We finally found a way to discard neurologic examination in all its glory because we knew what was happening—it was right in front of us.

We solved the personal problems with artificial intelligence, and rounds were fully assisted by accurate prediction models. Our workload also greatly diminished when lifestyles changed, and food intake was healthy for all of us and eliminated all the diseases that haunted us in the twenty-first century. The planet cooled down, and environmental disasters were far and between.

Or will we read about a dystopian medical world we all tis not totally implausible?

Multiple pandemics followed. Governments were repeatedly unwilling to fund in research and development, and there was a political environment less conducive to public health efforts [5]. Pandemics destroyed specialized care units because treatment of the most affected by the new killer microbe took precedence and everyone had to pitch in. Workforce failed due to rapid burnout of the health care workers who care for the patients. There was no back up, and artificial intelligence–driven robots could not help us. AI hallucinations would negatively impact patient care and outcome. Specialized ICU beds became too expensive, and the ICU of the future became a marque ICU where every specialty would admit their patients without a critical oversight.

Another scenario. Could we read that care would be all encompassing for everyone and that there would not be any limits of any kind with hospital bioethics dying a painful death? What would happen with our moral binaries? Advanced directives would lose any meaning, and families would determine care and even determine death. Extracorporeal membrane oxygenation use would surge, and care would never get tailored or transitioned. Has the early dystopian literature and cinema (Fig. 1) seen the future? Will death become an option? Worse, will we let technology determine clinical management?

Suspended bodies in Coma (1978). Used with permission of Alamy

Clinicians managing neurocritically ill patients know there is an empirical reality. The future will bring this more into focus. Our understanding of the injured brain remains to be discovered. We hope for our own future and fear it with our thoughts. Predicting the future is meaningless. Identifying future concerns is not.