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In Memoriam

Remembering the Explorers: Vladimir Kvetan, MD, FCCM

Buchman, Timothy G. PhD, MD, MCCM

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doi: 10.1097/CCE.0000000000000003
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Vladimir (“Vlad”) Kvetan, MD, FCCM, Chief of the Division of Critical Care Medicine at Montefiore Hospital and Professor in the Departments of Medicine and Anesthesiology at the Albert Einstein College of Medicine - Yeshiva University, died October 4, 2018 at age 67. He was the epitome of the intensivist-explorer. Known internationally for his leadership of Disaster Medicine and for his conception and execution of the “ICU Without Walls”, Vlad was a revolutionary innovator.

Vlad was also an extraordinary teacher. His first paper, written while a critical care fellow at Sloan Kettering and published in Critical Care Medicine (CCM) in February 1982, was squarely aimed at the clinician struggling to manage acute pulmonary failure in asymmetric lung disease (1). That struggling clinician would be me—as a junior resident assigned to the surgical ICU. Vlad reminded readers of the importance of positioning the good lung down, championed the use of the pulmonary artery catheter to guide the application of positive end-expiratory pressure, and noted the utility of double lumen endotracheal tubes and independent lung ventilation in extreme cases. He closed the paper with a gentle warning about vasodilators such as nitroprusside overcoming reflex hypoxic pulmonary vasoconstriction, increasing admixture of unoxygenated blood, thereby causing profound hypoxemia. Vlad helped me save more than one life with those insights.

Vlad continued to mentor me over the years. Soon after I was appointed founding Director of the Emory Critical Care Center, I asked him to share the “secret sauce” that made his program successful. His reply was succinct, “Our CCM is an institutional program endowed by the board of trustees and controlled by the CEO as the only real safety net for the patients. With 10-min consult/RRT times, we handle all medical director designee functions plus all ACLS, CVPs, futility DNRs, etc. We do it all. That makes it cost effective.” He wryly added, “It also helps that the New York State Department of Health boss is a former trainee and an intensivist.”

He closed his note with his signature value proposition, “The overriding principle is that as a formal interdepartmental subspecialty with control over all adult ICUs, our faculty is 100% CCM and prohibited from doing anything but CCM.” Vlad inaugurated one of the very first CCM organizations in the USA. I knew that it could not be duplicated. He advised me to focus on whatever local resources were in abundance, and build with them.

A few years later, Vlad invited me to present Grand Rounds at Montefiore and focus on value-based care as we had integrated advanced practice providers (APP) with technology. The evening prior to the lecture, he shared the interim results of a survey characterizing critical care organizations in the United States and asked whether it would be publishable in CCM (2). He then asked whether there was a place for a standing committee within the Society of Critical Care Medicine for the academic leadership of the discipline to advise and advance the concept of critical care organizations—departments, centers, committees-- as integral components of health care systems (3,4). I encouraged both.

We corresponded regularly, testing ideas and seeking each other’s unvarnished opinions. Vlad and I exchanged emails in early February 2018, making plans for our annual “one-on-one, away-from-the-limelight” chat at the Clinical Congress. Among the agenda items for meeting was a clear focus on his transition to retirement, “I am working on optimizing our CCM service (including opening a new unit, submitting additional A/CCM track FTEs, doing a CCM article on PICS) so I can hand over my operations in 1+ year to a new chief in good shape and then focus on my wife and son, to whom I owe so much.”

Grim news followed later that month. Vlad wrote that he would miss our meeting, “Tim, I am now a prisoner of love in one of our units. Pancreatic cancer with complete duodenal obstruction 10 days ago, improving short term. So it goes.” Vlad fought back with chemotherapy, radiotherapy, and immunotherapy. Despite all, the cancer spread quickly. He did indeed focus on his family, and yet he still found the energy to speak and to write. His last note to me concluded, “A true privilege to have a friend like you. Be well.”

Vlad’s last paper will appear in the April 2019 issue of CCM (5), a review examining workforce, workload, and burnout among critical care providers. Such problems were unknown and could not have been foreseen when Vlad published his first paper 37 years earlier. Such was the essence of Dr. Vladimir Kvetan: he saw what others had yet to glimpse, he understood what was yet uncharted, and he offered answers before we knew how to frame the questions.

REFERENCES

1. Kvetan V, Carlon GC, Howland WS. Acute pulmonary failure in asymmetric lung disease: approach to management. Crit Care Med. 1982;10:114–118
2. Pastores SM, Halpern NA, Oropello JM, Kostelecky N, Kvetan V. Critical Care Organizations in Academic Medical Centers in North America: A Descriptive Report. Crit Care Med. 2015;43:2239–2244
3. Leung S, Gregg SR, Coopersmith CM, Layon AJ, Oropello J, Brown DR, Pastores SM, Kvetan V. Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine: Critical Care Organizations: Business of Critical Care and Value/Performance Building. Crit Care Med. 2018;46:1–11
4. Moore JE, Oropello JM, Stoltzfus D, Masur H, Coopersmith CM, Nates J, Doig C, Christman J, Hite RD, Angus DC, Pastores SM, Kvetan V. Academic Leaders in Critical Care Medicine (ALCCM) Task Force of the Society of the Critical Care Medicine: Critical Care Organizations: Building and Integrating Academic Programs. Crit Care Med. 2018;46:e334–e341
5. Pastores SM, Kvetan V. for the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine: Workforce, Workload and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Crit Care Med. 2019 in press
Copyright (c) 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.