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2019
Annual Update
in Intensive Care
and Emergency
Medicine 2019
Edited by Jean-Louis Vincent
123
Annual Update in Intensive Care
and Emergency Medicine 2019
The series Annual Update in Intensive Care and Emergency Medicine is the con
tinuation of the series entitled Yearbook of Intensive Care and Emergency Medicine
in Europe and Intensive Care Medicine: Annual Update in the United States.
Jean-Louis Vincent
Editor
Annual Update in
Intensive Care and
Emergency Medicine 2019
Editor
Prof. Jean-Louis Vincent
Dept. of Intensive Care
Erasme Hospital
Université libre de Bruxelles
Brussels, Belgium
jlvincent@intensive.org
ISSN 2191-5709 ISSN 2191-5717 (electronic)

Annual Update in Intensive Care and Emergency Medicine
ISBN 978-3-030-06066-4 ISBN 978-3-030-06067-1 (eBook)
https://doi.org/10.1007/978-3-030-06067-1
Library of Congress Control Number: 2019931833
© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
Cover design: WMXDesign GmbH, Heidelberg
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
Part I Precision Medicine

1 Precision Medicine in the Intensive Care Unit: Identifying
Opportunities and Overcoming Barriers�� 3
T. L. Palmieri and N. K. Tran
2 Precision Delivery in Critical Care: Balancing Prediction and
Personalization �� 15
V. X. Liu and H. C. Prescott
Part II Acute Respiratory Failure and ARDS
3 Acute Respiratory Failure in the Oncologic Patient: New Era,
New Issues�� 31
B. L. Ferreyro and L. Munshi
4 Universal Low Tidal Volume: Early Initiation of Low
Tidal Volume Ventilation in Patients with and without ARDS�� 47
J.-T. Chen and M. N. Gong
5 Recruitment Maneuvers and Higher PEEP, the So-Called
Open Lung Concept, in Patients with ARDS�� 59
P. van der Zee and D. Gommers
6 ARDS in Obese Patients: Specificities and Management�� 71
A. De Jong, D. Verzilli, and S. Jaber
Part III Extracorporeal Respiratory Support
7 ECMO After EOLIA: The Evolving Role of Extracorporeal
Support in ARDS�� 87
M. Salna, D. Abrams, and D. Brodie
8 Physiological and Technical Considerations
of Extracorporeal CO2 Removal�� 101
C. Karagiannidis, F. Hesselmann, and E. Fan
v
vi Contents
Part IV Cardiac Arrest

9 Cardiac Arrest in the Intensive Care Unit�� 113
J. Tirkkonen, I. Efendijev, and M. B. Skrifvars
10 Targeted Temperature Management After Cardiac Arrest:
Where Are We Now?�� 125
A. Ray, S. Paulich, and J. P. Nolan
Part V Cardiac Function
11 Left Diastolic Function in Critically Ill Mechanically
Ventilated Patients �� 139
P. Formenti, M. Brioni, and D. Chiumello
12 The Effects of Disease and Treatments on Ventriculo-Arterial
Coupling: Implications for Long-term Care �� 155
F. Guarracino, P. Bertini, and M. R. Pinsky
Part VI Shock
13 Mechanical Circulatory Support Devices for Cardiogenic Shock:
State of the Art �� 167
L. A. Hajjar and J.-L. Teboul
14 Sodium Thiosulfate: A New Player for Circulatory Shock
and Ischemia/Reperfusion Injury?�� 183
M. Bauer, P. Radermacher, and M. Wepler
15 Lactate in Critically Ill Patients: At the Crossroads
Between Perfusion and Metabolism �� 199
M. Greco, A. Messina, and M. Cecconi
Part VII Hemodynamic and Respiratory Monitoring
16 Continuous Non-invasive Monitoring of Cardiac Output
and Lung Volume Based on CO2 Kinetics�� 215
F. Suarez-Sipmann, G. Tusman, and M. Wallin
17 Should We Abandon Measuring SvO2 or ScvO2 in Patients
with Sepsis?�� 231
J.-L. Teboul, X. Monnet, and D. De Backer
18 Perioperative Hemodynamic Monitoring: MERCI
to Predict Economic Impact�� 239
F. Michard and G. Manecke
19 The Pulmonary Artery Catheter in the Management
of the High-Risk Surgical Patient �� 247
M. Heringlake, S. Brandt, and C. Schmidt
Contents vii
Part VIII Fluid Issues

20 Resuscitation Fluid Choices to Preserve the Endothelial
Glycocalyx�� 259
E. M. Milford and M. C. Reade
21 Should Albumin be the Colloid of Choice for Fluid
Resuscitation in Hypovolemic Patients?�� 277
J. Montomoli, A. Donati, and C. Ince
22 What the Intensive Care Physician Should Know About
the Transurethral Resection Syndrome �� 293
R. G. Hahn
23 Relationship Between Central Venous Pressure and Acute
Kidney Injury in Critically Ill Patients�� 303
P. M. Honoré, C. Pierrakos, and H. D. Spapen
24 Fluid Management in Acute Kidney Injury�� 313
M. Ostermann, A. More, and S. Jog
Part IX Altered Renal Function
25 Diagnostic Implications of Creatinine and Urea Metabolism
in Critical Illness�� 327
R. W. Haines and J. R. Prowle
26 New Insights into the Renal Microcirculation in Sepsis-Induced
Acute Kidney Injury�� 339
A. Harrois, N. Libert, and J. Duranteau
27 Atypical Sepsis-Associated Acute Kidney Injury�� 347
J. A. Kellum, K. F. Kernan, and J. A. Carcillo
28 Latest Developments in Perioperative Acute Kidney Injury �� 355
M. Meersch and A. Zarbock
29 Renal Replacement Therapy During Septic Renal Dysfunction �� 365
S. Romagnoli, Z. Ricci, and C. Ronco
30 Acid-Base Disorders and Regional Citrate Anticoagulation with
Continuous Renal Replacement Therapy�� 383
C. Ichai, H. Quintard, and L. Velly
31 Acute Kidney Injury and Delirium: Kidney–Brain Crosstalk�� 397
R. Y. Y. Wan and M. Ostermann
viii Contents
Part X The Neurological Patient

32 Brain Ultrasound in the Non-neurocritical Care Setting �� 407
C. Robba, L. Ball, and P. Pelosi
33 Brain Fog: Are Clearer Skies on the Horizon?
A Review of Perioperative Neurocognitive Disorders�� 423
S. Saxena, A. Joosten, and M. Maze
34 Uncovering Consciousness in Unresponsive ICU Patients:
Technical, Medical and Ethical Considerations�� 431
B. Rohaut, A. Eliseyev, and J. Claassen
Part XI Infection and Antibiotics
35 From Influenza-Induced Acute Lung Injury
to Multiorgan Failure�� 449
B. M. Tang, T. Cootes, and A. S. McLean
36 Multidrug Resistant Gram-Negative Bacteria
in Community-Acquired Pneumonia �� 459
C. Cillóniz, C. Dominedò, and A. Torres
37 Light and Shade of Antibiotics Recently Approved and
in Advanced Development for Critically Ill Patients�� 477
M. Bassetti, E. Righi, and A. Carnelutti
38 Target Controlled Infusion in the ICU: An Opportunity
to Optimize Antibiotic Therapy�� 497
P. Colin, K. Ferdinande, and J. J. De Waele
39 Antimicrobial Stewardship in Sepsis �� 507
E. Plata-Menchaca, E. Esteban, and R. Ferrer
Part XII Sepsis
40 Heterogeneity in Sepsis: New Biological Evidence
with Clinical Applications �� 523
A. Leligdowicz and M. A. Matthay
41 The Role of Mitochondrial Dysfunction in Sepsis: What Is New?�� 537
Y. Wang, M. Chakraborty, and A. McLean
42 Potential Harm Related to Fluid Resuscitation in Sepsis�� 547
F. van Haren, L. Byrne, and E. Litton
43 Extracorporeal Cytokine Removal in Septic Shock�� 559
F. Hawchar, N. Öveges, and Z. Molnár
Contents ix
Part XIII Iron Metabolism

44 Iron Metabolism: An Emerging Therapeutic Target
in Critical Illness�� 573
E. Litton and J. Lim
45 Transferrin as a Possible Treatment for Anemia
of Inflammation in the Critically Ill �� 585
M. Boshuizen, G. Li Bassi, and N. P. Juffermans
Part XIV Extremes of Age
46 Functional Impairments in Pediatric Critical Illness Survivors�� 599
C. S. Ong and Z. A. Puthucheary
47 Care of the Critically Ill Older Adult �� 611
C. A. Gao and L. E. Ferrante
Part XV Patient Comfort
48 Inhaled Sedation and Reflection Systems�� 627
A. Meiser and H. V. Groesdonk
49 Intensity Matched Algorithm for Comfort in Intensive
Care Patients: I-MAC ICU�� 641
Y. Shehabi, A. Pakavakis, and W. Al-Bassam
50 Sleep and Circadian Rhythm in Critical Illness�� 651
I. Telias and M. E. Wilcox
Part XVI Medical Education
51 Social Media in Critical Care: Entering an Exciting New Era�� 667
J. N. Wilkinson, A. V. K. Wong, and M. L. N. G. Malbrain
Index�� 675
Abbreviations
AKI Acute kidney injury

ARDS Acute respiratory distress syndrome
CAP Community-acquired pneumonia
COPD Chronic obstructive pulmonary disease
CPR Cardiopulmonary resuscitation
CRRT Continuous renal replacement therapy
CT Computed tomography
CVP Central venous pressure
ECMO Extracorporeal membrane oxygenation
EEG Electroencephalogram
GFR Glomerular filtration rate
ICU Intensive care unit
IL Interleukin
LPS Lipopolysaccharide
MAP Mean arterial pressure
NO Nitric oxide
NOS Nitric oxide synthase
PAC Pulmonary artery catheter
PAOP Pulmonary artery occlusion pressure
PEEP Positive end-expiratory pressure
PPV Pulse pressure variation
RBC Red blood cell
RCT Randomized controlled trial
ROS Reactive oxygen species
RRT Renal replacement therapy
RV Right ventricular
ScvO2 Central venous oxygen saturation
SvO2 Mixed venous oxygen saturation
TBI Traumatic brain injury
TNF Tumor necrosis factor
VAP Ventilator-associated pneumonia
VILI Ventilator-induced lung injury
xi
Part I
Precision Medicine
Precision Medicine in the Intensive Care
Unit: Identifying Opportunities 1
and Overcoming Barriers
1.1 Introduction
Is precision medicine really precise? Precision in medicine can only be achieved

with precision diagnostics. Unfortunately, barriers, such as access to clean elec-
tronic medical data, accurate and precise laboratory tests, and a propensity to over
simplify complex pathophysiology, hinder this transformation to achieve the ‘four
Ps’ of precision medicine: Personalized, Preventive, Predictive, and Participatory.
The rapid evolution of intensive care medicine has resulted in advancements for
integration of technology with disease pathophysiology. The result: improved thera-
peutics and reduced patient mortality and morbidity. However, current medical
practice is predicated on the Cnidarian School of Medicine, a three-tiered approach
consisting of: (1) patient evaluation and disease diagnosis; (2) comparison and
matching to a similar patient population via databases or data sets; and (3) initiation
and monitoring of treatment [1]. As such, treatment is reactive and compartmental-
ized; intensivists initiate therapy for a specific organ system after disease identifica-
tion. The ultimate success of treatment, however, relies on the interaction between
the individual, the disease and the treatment. For example, infection is diagnosed by
obtaining a sample of the infectious source, identifying an inciting organism, and
choosing an antibiotic based on culture results in a petri dish. The efficacy of that
treatment is dependent on the patient, the organism, the therapy, and the interaction
among the three. Current paradigms tend to underestimate the variability and com-
plexity of the system.
T. L. Palmieri (*)
Firefighters Burn Institute, Burn Center at the University of California, Davis, CA, USA
Burns Department, Shriners Hospitals for Children Northern California, Sacramento, CA, USA
e-mail: tlpalmieri@ucdavis.edu
N. K. Tran
Department of Pathology and Laboratory Medicine, UC Davis School of Medicine,
Davis, CA, USA
© Springer Nature Switzerland AG 2019 3

J.-L. Vincent (ed.), Annual Update in Intensive Care and Emergency
Medicine 2019, Annual Update in Intensive Care and Emergency Medicine,
https://doi.org/10.1007/978-3-030-06067-1_1
4 T. L. Palmieri and N. K. Tran
The four pillars of precision medicine allow healthcare to be proactive and pre-
dictive, enabling clinicians to address the patient-disease-therapy triad by develop-
ing targeted patient and disease-specific therapies [2]. Initial precision medicine
endeavors focused on oncology, an arena in which genetic biomarkers transformed
therapeutic interventions [3]. Molecular oncology has created a better understand-
ing of malignancies and identified exploitable targets, such as human epidermal
growth factor receptor 2 (HER2), for therapy. However, application in intensive
care, which represents a significant health burden, has been far slower. This is due
to multiple factors, including the complex nature of critical illness in an intensive
care unit (ICU), poor characterization of patient populations (generalized defini-
tions), lack of informatics that integrate physiologic data with laboratory and genetic
data, timeliness of usable data analysis, and appropriate clinical trial platforms that
can capture discreet patient populations [4]. However, the ICU, housing patients
with the greatest severity of illness, also has the greatest opportunity for benefit for
improving both patient survival and quality of life while also containing cost. The
purpose of this chapter is to present a framework for application of precision medi-
cine in the ICU and introduce potential current challenges and future areas of con-
flict that may arise.
1.2 Definitions
Clarity in definitions is essential to any discussion of medical treatment para-

digms. Perhaps the greatest example is the definition of the ‘critically ill’ patient
by the United States (US) Food and Drug Administration (FDA)—it does not
exist! How can a disease be studied or targeted if it is not well defined? Further
exacerbating the challenges faced by intensivists in defining the ‘critically ill’
population is the variation of the definition between institutions. In 2015, US
hospitals were faced with a dilemma involving the intended use of point-of-care
blood glucose monitoring systems. At the time, no blood glucose monitoring
device was approved by the FDA for use in critically ill patients, and point-of-care
glucose monitoring in these patients was considered off label use. Due to the lack
of a definition of critical illness, hospitals were stymied in trying to conform to the
regulations and risked citation by regulatory agencies including the Centers for
Medicare and Medicaid Services (CMS).
Another definition challenge has been the transformation of the term individual-
ized medicine, to personalized medicine, to now, precision medicine. Although per-
sonalized medicine has many overlapping features with precision medicine,
personalized medicine and precision medicine are distinct concepts. The concept of
personalized medicine, introduced in the early 2000s, was partially developed in
response to the completion of the human genome project. As such, personalized
medicine emphasizes specific analyses for unique treatments for each individual
patient [5]. Essentially, the personalized medicine model is an N-of-1: individuals
receive customized treatment designed specifically for them. Precision medicine, on
the other hand, is characterized by tailoring medical treatment to patient
1 Precision Medicine in the Intensive Care Unit: Identifying Opportunities… 5
characteristics, i.e., classifying individuals into subpopulations with different sus-

ceptibilities, disease biology and/or prognosis, or response to treatment. Hence, the
model is 1-of-N [6]. Accurate identification of subgroups, likely by genomic,
metabolomic, proteomic, and immunologic data, will be essential for the success of
the precision medicine model.
Due to the complexity of critical care and the multifaceted nature of the ICU
environment, it is important to distinguish populations based on prognosis versus
prediction. Prognostic patient selection involves the selection of patients with a
greater chance of a disease-related event, such as mortality, whereas predictive
selection involves selection of patients more likely to respond to an intervention
based on biological mechanisms associated with a disease [7]. Prognostic precision
medicine examples predominate in sepsis [8]. Predictive precision medicine is
advancing rapidly with the advent of pharmacogenomics, allowing for the more
targeted use of antibiotics in sepsis [9]. Both forms will be needed in the ICU set-
ting. The most logical approach is to first define patient subpopulations followed by
the use of targeted therapies designed for that population.
1.3 Diagnosis
One of the more exciting aspects of precision medicine in the ICU is its potential to
identify subgroups with similar disease states or outcomes based on biomarkers. A
range of critical illnesses are defined by syndromes or clinical signs which may or
may not be caused by a single underlying disease, including acute respiratory syn-
drome (ARDS), sepsis, acute kidney injury (AKI) and delirium [10]. Sepsis trials,
in particular, have suffered from this syndromic issue. Unfortunately, although bio-
markers have been proposed to define a host of clinical conditions ranging from
sepsis [11] to AKI [12], all have lacked the specificity necessary to define study
populations.
Additional challenges with diagnosis include significant variation within labora-
tory testing methodology. Modern medicine has often taken for granted what is
being tested. For example, a serum lactate cut-off of 2 or 4 mmol/L has often been
used as part of sepsis protocols. However, the lack of standardization of lactate as a
test is an underappreciated limitation. Ridenour et al. reported that many lactate
tests differ significantly as values approach 4 mmol/L [13].
Even cardiac troponin (cTn), a very common biomarker of myocardial injury, is
not standardized. Differences between cTnI and cTnT are well known, but, the ref-
erence materials (National Institute of Standards and Technology Standard
Reference Material 2921) for manufacturers are native cTn-ICT ternary complexes
[14]. However, biologically, cTn could exist as dimers, trimers, and monomers—
each with a different epitope targeted by various assays. Thus, cTnI between differ-
ent manufacturers are different as illustrated by their 99th percentile cut offs. In
summary, to achieve precision medicine, we must also achieve precision laboratory
testing. Table 1.1 shows the intrinsic differences between different common critical
care tests based on the assay used to perform the test.
6
Table 1.1 Variation between common critical care tests

Biomarker
Purpose (standard) Manufacturer Platform Format Methodology Challenges
Cardiac Troponin I Abbott Architect Mainframe Chemiluminescent Biologically released troponin can be
injury (SRM 2921) immunoassay monomeric, dimeric, and/or trimeric with
Beckman Coulter DxI Mainframe Chemiluminescent differing epitopes detected by each
immunoassay immunoassay. Different troponin I assays
Siemens Centaur Mainframe Chemiluminescent cannot be compared, nor can I against T assays
immunoassay [15, 16]
Troponin T Roche Elecsys Mainframe Electro-
(SRM 2921) Diagnostics chemiluminescent
immunoassay
Coagulation PT/INR Abbott i-STAT POCT Electrochemical Multiple standards exist for PT/INR tests.
(multiple, Instrumentation ACL TOPS Mainframe Spectrophotometric Some assays use rabbit thromboplastin,
recombinant or Laboratories others use recombinant human
rabbit Roche CoaguChek POCT Electrochemical thromboplastin. Recent reformulations
thromboplastin) Diagnostics XS resulted in significant differences between
POCT and lab [17]
Glycemic Glucose Abbott i-STAT POCT Enzymatic (GO) Previous studies show statistically significant
control (SRM 965b, IDMS) Beckman Coulter DxC Mainframe Enzymatic (GO) differences across POCT and laboratory
AU Mainframe Enzymatic (HK) platforms using paired specimens despite
Nova Biomedical StatSensor POCT Enzymatic (GO) efforts to standardize [18]
Radiometer ABL90 POCT Enzymatic (GO)
Roche c702 Mainframe Enzymatic (HK)
Diagnostics
Siemens epoc POCT Enzymatic (GO)
1
Liver ALP, ALT, AST, Abbott Piccolo POCT Enzyme activity Since 1971, it has been established that it is not
function GGT Beckman Coulter DxC Mainframe Enzyme activity feasible to determine the true accuracy of
(None) Roche c701 Mainframe Enzyme activity enzyme activity assays [19]
Diagnostics
Perfusion Lactate Abbott i-STAT POCT Electrochemical Lactate is not standardized, with several
(None) Beckman Coulter DxC Mainframe Electrochemical studies showing significant discordance as
Nova Biomedical StatStrip POCT Electrochemical values approach 4 mmol/L and beyond [20]
Radiometer ABL90 POCT Electrochemical
Roche c702 Mainframe Electrochemical
Diagnostics
Siemens epoc POCT Electrochemical
Renal Creatinine Abbott i-STAT POCT Electrochemical Although creatinine was standardized to SRM
function (SRM 967, IDMS) Beckman Coulter DxC Mainframe Electrochemical 967 by IDMS, variations in methods and the
Cartridge significant biological variability of the
DxC Jaffe Mainframe Jaffe Reaction biomarker causes substantial discordance
Nova Biomedical StatSensor POCT Enzymatic between platforms [21]
Radiometer ABL90 POCT Enzymatic
Roche c702 Mainframe Enzymatic
Diagnostics
Siemens epoc POCT Enzymatic
ALP alkaline phosphatase, ALT alanine transferase, AST aspartate aminotranasferase, GGT gamma glutamyl transferase, IDMS isotope dilution mass spectrom-
etry, INR international normalized ratio, POCT point-of-care testing, PT prothrombin time, SRM standardized reference method, GO glucose oxidase, HK
hexokinase
Precision Medicine in the Intensive Care Unit: Identifying Opportunities…
7
1.4 Treatment
Several studies have used biomarker data to identify predictive cohorts that would
respond to a therapeutic intervention. For example, several groups have analyzed
biomarkers in ARDS to predict responsiveness to positive end-expiratory pressure
(PEEP) and fluid management [22, 23]. However, the more precise identification of
subtypes may make prospective trial conduct problematic, as the number of patients
eligible for a study will diminish. Trials will require a greater number of participat-
ing centers, more advanced screening methods, longer conduct times, and different
trial methodologies to achieve statistical significance.
1.5 Potential Conflicts/Weaknesses
Why has the adoption of precision medicine in the ICU been slower than in oncol-
ogy? Perhaps the most intuitive argument is the lack of a clear well-defined target
(disease process and subpopulation). Oncologists can target a cancer molecular sig-
nature in a specific organ or system. Patients in an ICU are admitted for diverse
problems ranging from sepsis to cardiac failure, traumatic or burn injury to postop-
erative cardiac care. As such, ICU patients often have multiple potential targets. For
example, a patient admitted with a closed head injury has frequently sustained other
injuries (such as hemorrhagic trauma or burns) and/or has multiple organ system
dysfunction, which could lead to conflicts in treatment. Should a patient with a
closed head injury and major burn be treated with massive fluid resuscitation to
address the burn injury or with fluid restriction to minimize intracranial edema?
Precise treatment of one disease may have no effect or may even adversely impact
morbidity and mortality from another medical issue. Precision medicine may assist
in formulating an answer to such questions, but the answers will be late in coming,
as the precise treatment of the index injuries or diseases must occur prior to deter-
mining the best treatment for combined problems. Although clinicians have made
tremendous progress in the identification of pathophysiology of illness, the under-
standing of the complex interplay among multiple medical issues remains elusive in
many medical conditions commonly encountered in the ICU.
In addition, one therapy may alter the efficacy of another. Perhaps the best exam-
ple of this occurred at the end of the twentieth century. Two landmark studies, the
TRICC (Transfusion Requirements in Critical Care), which reported that stable ICU
patients could be maintained at a hemoglobin of 7 g/dL as opposed to the traditional
10 g/dL [24], and Van den Berghe’s intensive insulin therapy study [25], which sug-
gested that tight glycemic control improved outcomes in critically ill patients, were
published. As a result, many critically ill patients were treated with both a restrictive
transfusion policy and tight glycemic control. However, clinical practice combining
the two strategies had a different outcome. Tight glycemic control did not yield the
benefits that were reported in the randomized trial. The subsequent NICE SUGAR
study suggested harm using tight glycemic control [26]. Why? First, there was a dis-
tinct difference in the types of patients enrolled. The Van den Berghe study enrolled
a very specific subpopulation, whereas the NICE-SUGAR trial had much broader
enrollment criteria. Second, and equally important, the methodology for glycemic
control (i.e., point-of-care glucose testing) used by most clinicians for glucose moni-
toring in NICE-SUGAR differed from that used in the Van den Berghe trial (serum
glucose). Unbeknownst to the NICE-SUGAR investigators at that time, point-of-
care glucose monitoring overestimated serum glucose levels by as much as 20% in
anemic patients, likely creating unrecognized hypoglycemia in the cohort [27]. The
application of the TRICC trial restrictive transfusion policy, in which ICU patients
have sustained anemia, may have influenced the outcomes for patients also treated
with tight glycemic control. Independently both strategies worked. Together they did
not. Is tight glycemic control beneficial? The answer will require an in-depth under-
standing of the metabolomics of various forms of critical illness and subsequent
application of targeted strategies to address the clinical variations. The application of
precision medicine to the ICU will need to carefully consider the potential conflicts
inherent in treating multiple different medical issues simultaneously.
The intersection of the TRICC trial and the glycemic trial also illustrate another
important concept: precision medicine in the ICU will require standardization of
sample collection, storage, testing and reporting; assurance of quality and reproduc-
ibility of test results; timely reporting of clinically applicable results; and clear
delineation of test results in a format that clinicians can understand and apply.
Recent reports from the precision method Surgical Critical Care Initiative (SC2i)
have attributed data quality as the largest hurdle to the development of a comprehen-
sive precision medicine program [28]. Even today, clinicians are bombarded with
test results that need to be integrated to treat patients. Yet key elements remain
unstandardized. Lactate is but one example. Lactate is currently measured using
different platforms. However, no reference method or traceable material exists for
lactate, resulting in non-standardized testing [13]. This is compounded by the influ-
ence of pre-analytic factors, such as testing delays and interfering substances, which
can falsely elevate lactate levels. As a result, lactate measurements may vary by as
much as 1.5 mmol/L for values >2 mmol/L [29]. The use of lactate in clinical trials
should carefully evaluate the platforms used as well as the timing of sample analysis
to assure comparable results between centers and platforms. Knowledge of how
samples are analyzed and what they mean will be essential if precision medicine is
to be ‘precise’. Standard operating procedures, use of certified clinical laboratories,
specimen storage protocols and quality assurance for every step of the laboratory
analytic process will need to be employed not just for clinical samples, but for
metabolomics, genomics, biomarkers, and other testing methodologies.
1.6 Pharmacokinetics
One of the core principles of precision medicine is delivery of the right treatment at
the right dose at the right time. Understanding pharmacokinetics, pharmacogenom-
ics, and pharmacokinetic variability among critically ill patients will help guide
appropriate medication administration in the critical care setting. Changes in
pharmacokinetics are both drug-specific and time sensitive and are often influenced
by other treatment modalities. For example, hypothermia reduces phase I cytochrome
P450 metabolism, thus increasing concentration of drugs (such as fentanyl, mid-
azolam) that are metabolized using this system [30]. In contrast, the metabolic rate
of severe burn patients is more than doubled, resulting in augmented renal clearance
of many agents [31]. Effective dosing of antimicrobial agents as well as narcotics
requires drug doses far exceeding the ‘normal’ standards. Drug interactions may also
influence pharmacokinetics of a given agent. Concomitant administration of medica-
tions may increase, decrease or offset the effect of any given agent. This can be par-
ticularly problematic in the ICU, as patients receive multiple different agents.
Critically ill burn patients, for example, receive, on average, more than 40 agents,
many of which interact with each other [32]. Pharmacogenomics, which evaluates
the influence of patient genomic makeup on pharmacokinetics and pharmacodynam-
ics, will likely play a major role in future ICU precision medicine practice.
1.7 Data Collection and Analysis
Regardless of the type of patient being studied, the data acquired in precision medi-
cine efforts will include not just patient physiologic and ‘routine’ laboratory analyses
(such as electrolytes, blood counts) but also genomic, proteomic, metabolomic and
transcriptome data; biomarkers; and data from other sources. Current electronic
health records are fraught with inconsistent and inaccurate data due to both machine
and human limitations. Data recording, integration, and interpretation will require
quality assurance prior, during, and after data integration into a centralized data
repository. New data management and analytic techniques (including machine learn-
ing) will be required to integrate the data sources and develop valid, clinically mean-
ingful, and actionable data with which to treat patients. One of the keys to successful
implementation of precision medicine in ICU patients is consistency in data acquisi-
tion, storage and reporting. This will require a level of collaboration far beyond what
has occurred in medicine to date. In addition, how data are analyzed will need to be
standardized. Study results can also vary depending upon how informatics is used.
Precision medicine will require fundamental changes in the conduct of clinical
trials. Specific requirements will include development of trial methodologies that
streamline collaboration to generate sufficient data for studies of smaller, better
defined patient cohorts; additional time allotted to complete patient enrollment, and
different trial platforms employing computer-based learning to maximize output
from any given trial. One promising methodology, the registry-based randomized
controlled trial (RRCT) uses data collected for other reasons, such as registry data,
to identify appropriate targets for trial enrollment [33]. The RRCT can be used to
identify patients who already meet pre-specified enrollment criteria (with their asso-
ciated built-in screening, data capture and outcomes measurements), thus identify-
ing new subjects for consent. This type of methodology is designed to optimize
patient enrollment and increase collaborations among centers. In essence, the RRCT
can use prognostic precision medicine to assign patients to different predictive
therapeutic options. Another potential new trial design is the platform trial, which
uses response-adaptive randomization to test multiple treatments in a pre-specified
patient group. The system uses Bayesian analysis to identify effective treatments for
specific patient subgroups [34]. Ineffective treatments are eventually discarded, as
are patient groups that do not benefit from a given treatment. Essentially, the plat-
form trial system is an example of computer learning applied to clinical trials.
1.8 The Future
The key to successful implementation of precision medicine in the ICU is collabora-

tion. Different disease processes are in different stages of precision medicine devel-
opment, particularly with respect to subgroup identification and delineation. For
example, oncology has identified subgroups based on genomic markers; sepsis uses
broad-based physiologic definitions; trauma and burn patients are categorized on
the basis of injury characteristics. Each has unique cohort identification require-
ments and will require a different strategy to develop meaningful subgroup analysis.
Informed groups consisting of clinicians, biostatisticians, basic scientists, epidemi-
ologists and pharmacologists need to gather for the major disease processes to
delineate the current state of the disease process, identify the key steps needed to
identify subpopulations for prognostic marker testing, and map out the initial course
to define prognostic markers. Concurrently, biomarker development at both the
bench and clinical level should continue to validate subgroup selection and study
conduct for the given subgroup, as biomarker development requires time for devel-
opment, testing and implementation.
Just as disease states need to be defined, so do data capture and processing.
Consistent and coherent data analysis will rely heavily on the development of a uni-
versal critical care ontology that can accommodate specialty-specific topics so that
data gathered are all based on the same foundation [35]. Currently different hospitals
use different electronic health records, each with a unique structure. Harnessing the
power of the electronic health record to gather physiologic data requires either all
programs to use the same data capture system (unlikely) or the development of algo-
rithm-based programs that can extract common data elements from multiple differ-
ent data sources and collate data into a consistent, analyzable database. These data
will then need to be combined with biomarker data, including genomic, metabolomic
and proteomic data. Database development teams consisting of informaticists, bio-
statisticians, scientists and clinicians will need to unite to complete this challenging
process, which will be essential to the development of precision medicine.
1.9 Conclusion
The vision for precision medicine in the ICU has been articulated. The goal is visi-
ble on the horizon. However, the road leading to the vision is unpaved, the ground
is rocky, the path crooked and the construction team has not yet been assembled.
Success will depend on collaboration, strategic resource utilization, funding avail-

ability, flexibility and patience. New technologies and trial designs will need to be
created. Collaborations will need to be extended. The traditional medical paradigm
will need to change. The ICU team has the dedication and capability necessary to
complete the journey. We just need to take the first step.
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Precision Delivery in Critical Care:
Balancing Prediction 2
and Personalization
V. X. Liu and H. C. Prescott
2.1 Introduction
Recent developments in healthcare data availability, advanced analytic algorithms,

and high-performance computing have produced incredible enthusiasm about a new
age of data-driven healthcare [1–8]. When it comes to clinical care specifically,
‘precision delivery’ is an emerging term to describe the “routine use of patients’
electronic health record (EHR) data to predict risk and personalize care to substan-
tially improve value” (Table 2.1) [7, 9, 10]. While clinical risk prediction tools have
a long history in critical care, novel machine learning applications can offer
improved predictive performance by maximally leveraging large-scale, complex
EHR and other data [5]. Perhaps, even more importantly, these approaches may help
overcome the problem of heterogeneity, which is routinely noted to be a hallmark of
critical illness as well as a major barrier to improved treatment [11–13]. In this
chapter, we discuss the overarching concept of ‘precision delivery’, the important
balance between clinical risk prediction and personalization, and the future chal-
lenges and applications of data-driven critical care delivery.
V. X. Liu (*)
Kaiser Permanente Division of Research, Oakland, CA, USA
e-mail: Vincent.x.liu@kp.org
H. C. Prescott
Department of Medicine and Institute for Social Research, University of Michigan and VA
Center for Clinical Management Research, VA Ann Arbor Healthcare System,
Ann Arbor, MI, USA
© Springer Nature Switzerland AG 2019 15

J.-L. Vincent (ed.), Annual Update in Intensive Care and Emergency
Medicine 2019, Annual Update in Intensive Care and Emergency Medicine,
https://doi.org/10.1007/978-3-030-06067-1_2
16 V. X. Liu and H. C. Prescott
Table 2.1 Key domains and concepts underlying the potential of precision delivery in critical
care
Key domains Concepts
Electronic health Granular EHR data are becoming increasingly ubiquitous in healthcare
record (EHR) data and these data can now be used routinely to inform data-driven
approaches to clinical care delivery
Risk prediction Machine learning algorithms can facilitate the use of complex,
multi-faceted EHR data to improve the performance and capability of
risk prediction models across many adverse outcomes of interest
Personalization Machine learning can also be used to identify underlying subgroups
within a heterogeneous cohort of at-risk patients allowing for treatments
to be maximally targeted towards responsive subgroups
Improved value When embedded within well-defined clinical pathways and delivered at
the right moment, targeted care can improve outcomes while also
reducing unnecessary resource utilization across large populations of
patients
2.2 Changing Landscape: The Fourth Industrial

A
Revolution
In God we trust; all others must bring data. (frequently attributed to W. Edwards Deming)
Klaus Schwab, the founder of the World Economic Forum, notes that we are in
the midst of a rapid societal upheaval driven by technological advances that are
evolving at an exponential, rather than linear, scale [14, 15]. Prior industrial revolu-
tions were marked by incredible achievements yielding the steam engine, the light
bulb, the telephone, the internal combustion engine, the personal computer, and the
internet. Today, the Fourth Industrial Revolution is heralded by advances in data
availability, mobile computing, machine learning and artificial intelligence, robotics
and autonomous vehicles, energy innovation, and nano- and bio-technology. Given
the pace and complexity of change driven by these technological advances, it
remains unclear how this revolution will impact societies and individuals. However,
we are already bearing witness to rapid disruptions of existing industries and norms
driven by expanded uses of data to risk stratify individuals and tailor actions to suit
their needs.
Familiar examples of these disruptions outside of healthcare include the Amazon
recommender system which uses item-based collaborative filtering algorithms
when a customer is preparing to purchase a specific item to identify other ‘related’
items that are likely to be of interest [16]. This and other innovations have already
altered the landscape of consumer purchases. Similar systems are also in place at
Netflix, whose suite of algorithms seek to deliver the ‘Netflix experience’ by com-
bining prediction and recommender systems that leverage personal interests, prior
viewed content, and temporal trends in activity [17]. This approach has allowed
Netflix to target content development to highly-specific subgroups and vastly
increase the viewable or ‘effective’ size of their library even within narrow genres.
Similar algorithmic approaches are used in applications like advertisement targeting
software to surface the most relevant marketing content based on prediction algo-
rithms using background browsing data.
2 Precision Delivery in Critical Care: Balancing Prediction and Personalization 17
2.3 Precision Delivery in Healthcare
In healthcare today, precision delivery describes a similar process for leveraging data-
driven predictive approaches to improve the value of clinical care [9]. Rapid expan-
sions in the availability of health data driven primarily through the increasing ubiquity
of EHRs and other key emerging data sources (e.g., sensors, -omics), along with
advances in machine learning algorithms have improved the performance and capabil-
ity of contemporary risk stratification models. Machine learning algorithms can rapidly
sift through voluminous and complex data to find clinically-relevant risk strata by
applying computationally-intensive statistical modeling at scale [18, 19]. These risk
models can then be used to improve the personalization of patient care by identifying
patient subgroups in whom specific interventions can have the maximum impact, or
those in whom specific interventions are unlikely to offer any benefit. Precision deliv-
ery is based on using this prediction-personalization approach, deployed at precisely
the right moment in clinical treatment, to drive improved clinical outcomes [10]. At the
same time, given the rapid rise in healthcare expenditures in the United States and in
many other nations, the hope is that the precision delivery model can control or even
reduce healthcare costs through improved patient targeting.
2.4 Critical Care: A Risk-Based Specialty
It is important to note that risk prognostication is not a new concept in medicine and
has long been used to identify patient groups who might benefit from specific, tar-
geted interventions [20]. Indeed, one could argue that the field of critical care arose
as a byproduct of risk prognostication: a system in which patients with key observ-
able criteria portending a high risk of imminent death (e.g., vital signs, traumatic
injury, organ failure) were identified and triaged to a setting of increased monitoring
and clinician staffing [21].
Given this history, it comes as no surprise then that the field of critical care has
also been a leader in the development of clinical risk stratification models [22–24].
Highly robust mortality models developed decades ago, prior to the routine use of
personal computers, continue to be widely used today. For example, the Acute
Physiology and Chronic Health Evaluation II (APACHE II) scoring system, pub-
lished in 1985 and based on 12 routine physiologic measurements [25], remains a
common risk stratification system used even for contemporary, high-profile ran-
domized controlled trials. Similarly, the Sepsis-related/Sequential Organ Failure
Assessment (SOFA) score from 1996 [26, 27], continues to play a key role in sever-
ity of illness assessment as well as in the definition of sepsis [28].
2.5 ovel Capabilities with Improved Data

N
and Computation
Critical care already has a robust history of risk prognostication, but recent innova-
tions in data and computation provide several new opportunities (Table 2.2). First,
the breadth of data available for incorporation into prediction algorithms has
Table 2.2 Potential capabilities available through improved platforms for data collection, analy-
sis, and computation
Domain Improvements
Electronic health Increasing routine collection of health data within the EHR fosters a
record (EHR) data vastly increased breadth of data available for incorporation into clinical
risk prediction models. In general, models developed with expanded
data have shown improved predictive performance
Variable subset With a vastly increased set of variables, or ‘feature space’, the risk of
selection or identifying random associations increases. Machine learning algorithms
dimensionality can be used to statistically identify the most relevant variables to a
reduction specific problem of interest
Non-parametric Traditional risk prediction algorithms largely depended on linear
modeling modeling, which places potential limitations on interactions between
complex data elements. Improved computation platforms allow for more
flexible modeling approaches to maximally leverage EHR data.
However, they may also decrease the interpretability of prediction
models
Real-time predictive As greater numbers of risk prediction models are incorporated within
modeling EHR systems, the incremental costs of additional calculations are small
(when compared with the costs of manual calculation). This allows for
multiple models to be calculated for each patient, as well as multiple
time points for model updating (e.g., every minute, hour, or day).
User-friendly Alarm fatigue and distractions already plague clinicians working in
systems high-acuity settings. By tuning model parameters at the development
and deployment stages, models can be embedded within clinical
workflows to enhance, rather than distract, clinical care
expanded tremendously, owing to the transition from pen and paper recording of
data into automated EHR-based data collection. Thus, while simpler hand-calculated
models continue to be calculated and used even in modern EHR systems (e.g., the
Model for End-Stage Liver Disease [MELD] score), most newer prediction models
now incorporate a considerably larger set of variables or ‘features’. In general, these
models show improved predictive capability, at least when measured by standard
quantitative performance metrics like test error rates, area under the receiver operat-
ing characteristic (AUC) curves, or positive predictive values [1, 2, 5].
However, the expansion of variables available for model inclusion, or the ‘feature
space’, brings with it new challenges related to finding robust data signals within the
noise. This is an area in which machine learning excels, because algorithms can be
used to empirically identify the most relevant subset of variables in a model (i.e.,
dimensionality reduction) as well as to apply non-parametric modeling approaches to
complex data that account for non-linear relationships between variables [18, 19]. For
example, gradient boosted trees, which iteratively combine many individual weaker
decision trees based on random subsets of data to improve classification, have shown
robust performance across many different types of clinical risk prediction challenges.
This use of machine learning algorithms does not come without cost.
Computationally-intensive platforms are often needed to implement advanced model-
ing strategies, particularly in large databases. However, the cost of these platforms has
decreased tremendously while their availability has also increased rapidly, largely
2 Precision Delivery in Critical Care: Balancing Prediction and Personalization 19
offsetting these concerns in all but the most complex scenarios. There is also an impor-
tant trade-off between the ease of model development or scoring and the ability to
interpret and apply the risk predictions themselves [19]. While some methods, like
decision tree-based models, offer moderate degrees of intelligibility (i.e., the ability to
understand which variables are driving predictions), others, like the deep learning neu-
ral networks recently used by Google [29], are considerably more challenging to inter-
pret. Traditional linear models, including logistic regression, have generally shown
weaker predictive performance in recent comparisons but offer the advantage of allow-
ing for high degrees of intelligibility and potentially easier technical implementation.
In some cases, extensions of linear models, like penalized logistic regression models—
designed to identify the subset of variables which maximally contribute to prediction—
have shown similar performance to other non-parametric approaches [18].
In addition to the advantages afforded by an expanded universe of potential vari-
ables and more flexible modeling approaches, the widespread uptake of EHRs and
mobile computing has facilitated the deployment of real-time risk scoring and dis-
play without requiring significant additional manual effort. Thus, the incremental
operating costs associated with using an EHR-based system to simultaneously cal-
culate and display 100 risk models compared with only a single model may be rela-
tively modest. This would certainly not be the case for individuals who might have
to manually calculate and record 100 risk scores for each patient every hour.
This flexibility offers further opportunities to deploy risk models that are more
user-centric and aligned with the so-called “5 rights of clinical decision support” [30]:
providing the right information, to the right people, in the right format, through the
right channels, and at the right time. Given that all clinicians, and in particular those
operating in high-acuity environments like the intensive care unit (ICU), are already
vulnerable to alarm fatigue and distractions, few would be excited about using an
EHR system that simultaneously displayed 100 risk scores for each patient [31].
Instead, a more sustainable approach would be to allow risk prediction scoring to
occur silently in the background, with specific alerts only surfacing when a key alert
threshold has been crossed or users actively seek out the information. A car dashboard
offers a familiar example outside of healthcare of a data display that has remained
remarkably focused over many decades, despite the tremendous increase in the num-
ber of onboard computers constantly surveilling specific automotive functions.
2.6 Current Risk Prediction Applications in Critical Care
As described above, critical care already has numerous models designed to predict
hospital mortality [22, 23]. Recent machine learning-based models incorporate a
variety of newer elements including variable transformations, time-series data, and
unstructured data from clinical documentation (Table 2.3). While these have con-
tributed to some improvement in predictive performance, in many cases, the incre-
mental gains have been modest and of uncertain benefit for clinical practice [32–34].
The capabilities available through natural language processing (NLP), a field that
leverages computational approaches for understanding text-based, unstructured
Table 2.3 Balancing prediction and personalization in precision delivery by leveraging super-
vised and unsupervised machine learning approaches
Prediction Personalization
Goal Precisely quantify the risk of Identify subgroups of patients from a
experiencing an adverse outcome, while diverse at-risk group who would
minimizing the false-positive rate respond to specific targeted
associated with a given risk alert treatments
threshold
Machine Supervised learning approaches fit a set Unsupervised learning approaches
learning of model variables to a pre-defined surface latent subgroups based on
approach outcome of interest identifying underlying patterns and
associations
Examples ICU mortality Subgroups responsive to statin
Early warning scores therapy in acute respiratory distress
Sepsis ‘sniffers’ syndrome; steroids in pediatric
septic shock
documents like clinical notes or pathology reports, are now in wide use outside
healthcare. However, the advantages of NLP in predictive models for patients who
already have ‘high-density’ structured data available during hospitalization (i.e.,
frequent physiologic, laboratory, and treatment data) remain unclear [35].
Another active area of risk prediction relevant to critical care includes risk mod-
els designed to identify ward patients with a high likelihood of imminent deteriora-
tion [36, 37]. Again, many simpler scores (e.g., the Modified Early Warning Score
[MEWS]; National Early Warning Score [NEWS]) have already seen widespread
use within routine clinical workflows. Broadly speaking, more advanced scores
(e.g., Advance Alert Monitor [AAM]; electronic Cardiac Arrest Risk Triage
[eCART]; Rothman Index) demonstrate modest to moderate levels of improvement
compared to existing models [38–42]. Where they are likely to excel is in their abil-
ity to reduce the number of false positives that trigger the need for clinical workup
when compared to simpler models. Given the clinical burden imposed by the need
to workup false positive alerts to find a single ‘true positive’ case, favorable reduc-
tions in the ‘workup-to-detection ratio’ or the ‘number needed to screen’ could have
considerable downstream benefits on clinician sustainability and uptake.
Other areas of active focus include risk prediction models designed to accelerate
the identification, triage or treatment of sepsis patients [43–50]. Although several
reports suggest that use of risk prediction models has contributed to large reductions
in sepsis-related mortality, it is unclear whether the described benefits actually
accrue from the quantitative risk stratification (i.e., the relative improvement in the
discrimination and performance of the model itself versus other screening criteria)
or from the increased attention to sepsis and the clinical workflow alignment that
becomes essential when an alerting system is turned on (i.e., the creation of a team-
based standardized process for screening, identification, treatment, escalation and
hand-off). Even prior to the advent of real-time predictive models, similar reduc-
tions in sepsis adverse outcomes were previously reported as part of system-wide
quality improvement efforts.
Another random document with
no related content on Scribd:
Yet in spite of my obstinacy I was still everywhere demanded. When
the American Negro delegate was invited to attend meetings and my
mulatto colleague went, the people asked: "But where is the chorny
(the black)?" The mulatto delegate said: "Say, fellow, you're all right
for propaganda. It's a pity you'll never make a disciplined party
member."
"Bigger shots than you have said the same thing," I replied. Zinoviev
had referred to me as a non-partisan. "My destiny is to travel a
different road."
We were sitting in on the discussions as to whether there should be
an illegal or legal Communist party in America, and on the Negro in
American life. I was there not only as a writer, but I was given the
privileges of a special delegate. One thing sticks in my memory
about that American delegation in Moscow. It had the full support of
the Finnish Federation and the Russian Federation of America. The
representatives of these organizations voted en bloc, rallying to the
support of an illegal party. The argument of the Yankee
representatives of the legal group was unanswerable, but they were
outvoted every time by the foreign federations. The Finnish and the
Russian federations were not only the most highly organized units of
the American party, but, so I was informed, they contributed more
than any other to the party chest. They controlled because they had
the proper organization and the cash.
I said to the mulatto delegate: "That's what Negroes need in
American politics—a highly organized all-Negro group. When you
have that—a Negro group voting together like these Finns and
Russians—you will be getting somewhere. We may feel inflated as
individual Negroes sitting in on the councils of the whites, but it
means very little if our people are not organized. Otherwise the
whites will want to tell us what is right for our people even against
our better thinking. The Republicans and the Democrats do the
same thing. They give a few plum places to leading Negroes as
representatives of the race and our people applaud vicariously. But
we remain politically unorganized. What we need is our own group,
organized and officered entirely by Negroes, something similar to the
Finnish Federation. Then when you have your own group, your own
voting strength, you can make demands on the whites; they will have
more respect for your united strength than for your potential strength.
Every other racial group in America is organized as a group, except
Negroes. I am not an organizer or an agitator, but I can see what is
lacking in the Negro group."
I listened to James Cannon's fighting speeches for a legal

Communist party in America. Cannon's manner was different from
Bill Haywood's or Foster's. He had all the magnetism, the
shrewdness, the punch, the bag of tricks of the typical American
politician, but here he used them in a radical way. I wondered about
him. If he had entered Democratic or Republican politics, there was
no barrier I could see that could stop him from punching his way
straight through to the front ranks.
I think Trotsky was the first of the big Russians to be convinced that
there should be a legal Communist party in America, then Rakovsky
and finally Zinoviev, a little reluctantly. Bukharin was for the illegal
group. He said: "Remember what Jack London has told us about the
terror and secret organization in America in his Iron Heel." That was
so rare that I had to smile. While Cannon was informing the
Russians about actual conditions in America, Bukharin was
visualizing the America of Jack London's Iron Heel. Bukharin always
did make me think of that line about some men having greatness
thrust upon them. I believe that Lenin said of Bukharin, as Frank
Harris said of H.G. Wells, that he could not think. Yet Bukharin was
the author of the A B C of Communism, which once had a big vogue
among the radicals.
At last even I was asked my opinion of an illegal Communist party in
America. I tried to get excused, saying that as I was not an official
delegate or a politician, but merely a poet, I didn't think my opinion
was worth while. But as my colleague the mulatto was for the illegal
party, I suppose they needed a foil. So then I said that although I had
no experience of the actual conditions of social life in Czarist Russia,
I believed there was no comparison between them and American
conditions today. There were certain democratic privileges such as a
limited freedom of the press and a limited right of free speech that
our governing classes had had to concede because they were the
necessary ingredients of their own system of society. And American
radicals could generally carry on open propaganda under those
democratic privileges. Our Upton Sinclairs, Eugene Debs's, Max
Eastmans and Mother Jones's might be prosecuted and imprisoned
for a specific offense against the law, but they were not banished for
their radical ideas to an American Siberia. And I said I thought that
the only place where illegal and secret radical propaganda was
necessary was among the Negroes of the South.
What I said about the Negroes of the South was more important than
I imagined, and precipitated the Negro question. The Negro question
came under the division of the Eastern Bureau, of which Sen
Katayama was an active official. Because of his American
experience and his education among Negroes, Sen Katayama was
important as a kind of arbiter between black and white on the Negro
question. It was an unforgettable experience to watch Katayama in
conference. He was like a little brown bulldog with his jaws clamped
on an object that he wouldn't let go. He apparently forgot all about
nice human relationships in conference. Sen Katayama had no
regard for the feelings of the white American comrades, when the
Negro question came up, and boldly told them so. He said that
though they called themselves Communists, many of them were
unconsciously prejudiced against Negroes because of their
background. He told them that really to understand Negroes they
needed to be educated about and among Negroes as he had been.
Think not that it was just a revolutionary picnic and love feast in
Moscow in the fifth year of Lenin! One of the American delegates
was a southerner or of southern extraction. An important Bolshevik
facetiously suggested to him that to untangle the Negro problem,
black and white should intermarry. "Good God!" said the American,
"if Jesus Christ came down from Heaven and said that in the South,
he would be lynched." The Bolshevik said: "Jesus Christ wouldn't
dare, but Lenin would."
Also I remember Walton Newbold who was the first Communist
candidate elected to the British House of Commons. Saklatvala, the
Indian Parsee, had announced himself a Communist only after he
had been elected as an independent, but Walton Newbold was the
first candidate of the British Communist Party. Just after his election
to Parliament Newbold came to Moscow, while the Fourth Congress
of International Communism was in session. For any reader who
might not understand why a Communist member of the British
Parliament should go to Moscow, I may explain that by the parallel of
a cardinal going to Rome after receiving his hat. It was a big day for
the little insignificant delegation of British Communists when
Newbold arrived in Moscow. Of that triumphant arrival, one incident
sticks more in my memory. I was informed that a member of the
Chinese Young Communists, who was attending the Congress, met
Newbold in the lobby of the Lux Hotel. He went up to Comrade
Newbold to congratulate him and began: "Comrade Newbold—"
"Hello, Chink," Newbold cut in.
"But Comrade Newbold, I am not a Chink."
"Who told you that you weren't?" said Comrade Newbold as he
turned away.
In a little while the incident had flashed like an arrow through
Communist circles in Moscow. The young Chinese was a member of
an old Chinese clan and had been educated in America. At that time
Bolshevik eyes were fixed on China. Chinese soldiers made up
some of the crack units of the Red army when Great Britain was
supporting the White war against the Reds and tightening the
blockade against Russia. I remember Radek's saying to me: "We are
pinning our hopes on China more than any other country. If we can
make China Red, we will conquer the world."
I don't know if that incident of the young Chinese and the first
Communist member of the British Parliament ever reached the ears
of the big Bolsheviks. I do know, however—I got it from a good
source—that the big Bolsheviks gave Newbold a hell of a skating
over the Communist ice of Moscow. Newbold returned to the
Parliament of British gentlemen and finally drifted over to the
capitalist side.
I was asked to write a series of articles on the Negro group for
Izvestia, the Moscow organ of the Soviets. Thus I came to meet
Steklov, the editor-in-chief. Steklov was a huge man with a leonine
head, more picturesque than intelligent. He told me that he was
interested in Negroes being won over to the cause of Communism
because they were a young and fresh people and ought to make
splendid soldiers. I didn't relish that remark out of the mouth of a
Communist. So many other whites had said the same thing—that
Negroes make good cannon fodder when they were properly led—
led by whites to the black slaughter. That filled me with resentment.
The head of the French General Staff had proclaimed to the world
the same thing, that France with its African empire had an army of a
hundred millions. When Trotsky, the chief of all the Bolshevik fighting
forces talked to me about Negroes he spoke wisely. Trotsky was
human and universal in his outlook. He thought of Negroes as
people like any other people who were unfortunately behind in the
march of civilization.
Karl Radek was one of the Big Five of the Politbureau, which
decided Bolshevik policy in those days. He invited me to dinner at
his apartment in the Kremlin along with the Negro delegate of the
American C.P. Radek wanted to know if I had a practical policy for
the organization of American Negroes. I said that I had no policy
other than the suggestion of a Negro Bund, that I was not an
organizer or an agitator and could not undertake or guarantee any
practical work of organization.
The Negro delegate said that I was a poet and a romantic. I said I
was not as romantic as he and his illegal party with their secret
names and their convention in the wilds of Michigan. Radek laughed,
and as I looked at his face set in a thick circle of hair I thought how
much he resembled a red spider. Radek said that the Communists
should adopt a friendly attitude to all writers who were in sympathy
with the soviets. For example, Upton Sinclair, he thought, would be a
valuable asset to the revolution if the Communists knew how to
handle and use him. The mulatto said that Upton Sinclair was a
bourgeois Socialist.
"Oh, no, no," said Radek, "I insist that is not the attitude to take.
Upton Sinclair is a powerful writer with an enormous influence, and
the American Communists should make use of his influence, even
though Sinclair is not a Communist. Now with our Gorky—" At this
point an infant wailed and Radek said, "My baby comes first." He left
the room, to return a few minutes later with the maid, who brought in
the baby. Radek and Mrs. Radek kissed and fondled the child. The
maid then brought the child to the mulatto, who touched its hand and
patted its hair. From the mulatto she brought the child to me, but it
shrank away, hid its face, and began to cry. Radek was interested
and told the maid to take the child to the mulatto again. The mulatto
took the child in his arms and it stopped crying, but when the maid
tried me again, the child hid its face and cried. The maid retired with
the child, and Radek said: "Now I understand the heart of the
difference between white and black in America. It is fear. The
Americans are like children, afraid of black complexion, and that is
why they lynch and burn the Negro." I told Radek that his deduction
was wrong; that in the South, where Negroes were lynched and
burned, the black complexion was not a strange thing to the whites,
and that the majority of the children of the better classes of the South
were nursed from their birth by black women, and that those children
were extremely fond of their black foster mothers. Radek said that
that was a strange thing.
XVII
Literary Interest
THE Congress ended and with a happy relief I turned from political
meetings to social and literary affairs. The majority of the delegates
had left, but I remained in Moscow writing. I was magnificently paid
for poems and articles and became a front-page feature. Sometimes
what I received in rubles for an article amounted when I figured it out
to fifty American dollars. I had plenty of money to spend for food and
cigarettes and even to frequent the cabarets. And besides, I was
saving my fare to return to America.
I had no idea that I was being paid as a literary celebrity until one
afternoon when I went to a newspaper office to receive my check.
There I met an interesting Russian journalist. He was a titled person,
a Count Something. After the revolution he had discarded his title,
but since the Nep he had resumed it and signed himself Count. He
remarked to me facetiously that perhaps his title of the old economic
policy might help him to a better place under the New Economic
Policy.
When I drew my check he looked at it and said: "Why, if they paid
me one-tenth of what they pay you I would be rich. I could go to the
casino and gamble and the cabarets to dance and wine."
"Why," I said, "I thought you got as much as I got."
"No," he said, "I couldn't, for you are a guest writer, a big writer—
bolshoi! bolshoi! bolshoi!" The interpreter who accompanied me was
annoyed and he said something to the Count, who immediately
clamped up. That, bolshoi! bolshoi! bolshoi! (big! big! big!) was sweet
music in my ears and an inspiration. But it also stirred up a hell of
discontent within me. Why should I be "big" translated into Russian?
It was because I was a special guest of the Soviets, a good subject
for propaganda effect, but inflated beyond my actual literary
achievement. That was not enough for me. I felt that if I were to be
bolshoi as a literary artist in a foreign language, I should first make a
signal achievement in my native adopted language, English.
I met some of the notable Russian writers: Chukovsky, Boris Pilnyak,
Eugene Zamiatin, Mayakovsky. I was invited to read at literary
gatherings. My audiences were always enthusiastic and applauding,
and also sometimes critical. "Tovarish," I was often told, "your poems
are not proletarian." I replied, "My poetry expresses my feelings." I
shocked the pure proletarian intellectuals and I was proud that I was
a privileged person in Russia, and in a position to shock them. One
night I was invited to the Arbat to hear the proletarian poets read and
discuss their compositions. Without understanding the language I
was able to appreciate certain poems from their swing and
movement and the voice of the reciter. And I had a good interpreter
who rendered some into English for me. After each poem was
delivered there was a general discussion of it. I was particularly
pleased with the poem of a slim young man in a coarse peasant
smock buttoned up to his chin, and with a worried, unhappy
expression in his sensitive features. I knew at once that he was a
peasant become proletarian like myself. He gave a charming poem.
Even before translation I knew from its communicative color tone
and the soft threne running through it like a silver chord that it
expressed an individual longing for the life of the country, perhaps
the ways that nevermore would be.
As soon as the poet had done I clapped my hands heartily. His poem
and personality had unusually excited me, because I rarely applaud.
I liked that poet with the intellectual anxiety of his face showing
clearly that he was a little bewildered by that world-moving social
shake-up. That expression was real, more real to me than the
automatic enthusiasm of his fellow poets which seemed to me less
sincere. They all jumped on him. "Alexis, you are not a proletarian
poet!" And they criticized his subject matter. So I asked my
interpreter to let me say a word. I said I thought it was natural for a
man who had lived in the country to express his longing for it,
whether he was a bourgeois or a proletarian.
Mayakovsky was then the premier proletarian poet. Chukovsky, the
popular author of Crocodile and other children's books, did not have
the highest opinion of Mayakovsky. He told me that before the
revolution Mayakovsky had been a futurist and that he used to wear
fantastic clothes and had proclaimed his poems at the court of the
Czar. Now Mayakovsky was a thundering proletarian poet. He
recited one of his poems for me. It sounded like the prolonged bellow
of a bull. He very kindly presented me with a signed copy of his
latest book. Also he presented me to his wife, and said that she
desired to dance a jazz with me. She was a handsome woman of an
Arctic whiteness and appeared as if she had just stepped proudly out
of a Dostoyevsky novel. We went to a gypsy cabaret and danced a
little, but I am afraid that I did not measure up to the standard of
Aframerican choreography. Mayakovsky told me that his great
ambition was to visit America. I said I thought he would be a big
success there in Russian costume, declaiming his poems in his
trumpet voice.
The contemporary Russian poetry of the period which I liked best
was that of the peasant poet Yessenin. His intimate friend, Zonov,
translated some of his poems, and I was enchanted by their lyric
simplicity and profundity. Zonov was always hoping that Yessenin
and I would meet, but we never did. Just about the time when I
disembarked at Petrograd, Yessenin and Isadora Duncan were
landing in New York. And Yessenin did not return to Russia until after
I had left in June of 1923.
Zonov held a place either executive or artistic at the Meyerhold
Theater, which I visited frequently, for there was a congenial gang
there. He often invited me to a private little feast in his den, where he
served sweet Caucasian wine and caviar and sometimes
champagne. Always with him was a little actress whom he fancied,
but who did not seem to love him too much. Zonov looked like a tired
professor, and he was always bewailing the absence of Yessenin.
He exhibited a snapshot of Yessenin that he carried in his pocket
book, and I was startled by its resemblance to the strange dancer I
had known in New York. Zonov said unlovely things of Isadora
Duncan, because she had married Yessenin and taken him from his
friends. He said that Yessenin had proclaimed to them all that he did
not love Isadora. But he had married her to get out of Russia, to see
Europe and America. I said I did not consider love as always
necessary, and that sometimes it might be expedient for a woman to
save a man from his male friends. Zonov translated what I said to
the actress and she screamed with laughter.
Meyerhold's was the revolutionary constructivist theater, which did
the most daring things in dramatic production. There were no
curtains. The audience saw clear through to backstage and watched
the actors waiting to take their parts and come up to and retire from
the front of the stage. The plan was novel. Meyerhold himself was a
fanatic crusader in his ardor to make a great revolutionary theater
express the revolutionary social system. All the symbols of the
machine system were assembled on the stage: dynamos, cranes,
scaffolding and turbines, until it resembled a regular workshop.
Meyerhold said to me: "We need now great revolutionary plays and
playwrights to make my theater the unique dramatic expression of
the revolution." I had to talk to Meyerhold through an interpreter, but
he impressed me as being more romantic than practical with his idea
of making the stage the unique expression of the factory. I felt that
after all the worker's life is not limited to the factory and should never
be.
I was interested in the Moscow workers' attitude to the Meyerhold
Theater. Whole blocks of seats were given to the factories and the
barracks, but the theater, which was not very large, was never full.
Yet the plays which Meyerhold put on were technically highly
interesting. Vastly exciting to me was the presentation of The
Inspector General, by Gogol. And unforgettable was one realistic
scene of another play, in which the Czar was sitting on his chamber
pot, with the imperial crown painted big upon it. But the workers and
soldiers really preferred the ballet of the Bolshoi theater, the Moscow
art theaters, the expressionist theater and the ordinary vulgar
theaters. Whenever the workers received free tickets for the above-
named theaters they never missed; workers and soldiers always
filled them. But the audience of the Meyerhold Theater was of the
intelligentsia—students and professional people. While the workers
and soldiers showed a distinct preference for the straight familiar
entertainment, it was the intelligentsia that was avid of revolutionary
drama. The situation made me think of a Frenchman's saying that
most of the work of the experimental artists was not intended to
enlighten the working class, but to "épater la bourgeoisie."
I was invited to dinner by Lunarcharsky, the Commissar of Education
and of Arts. He was one of the most flamboyant orators of the Soviet
Union and also a talented playwright. I told him a little of the little I
knew about education in general in America and Negro education in
particular, and I seized the opportunity to mention the Russian
theater and the theater of Meyerhold. I remarked that it was
interesting that the workers and soldiers seemed to prefer the old
ballet to the new experimental theater. Lunarcharsky said that in the
early days of the revolution some had desired to suppress the ballet,
but he had held out against it. He considered the ballet a great form
of art and what he did was to give the workers and peasants and
soldiers the chance to enjoy it, which they hadn't had under the old
régime. He had conserved and subsidized the best of the classical
theaters for the entertainment of the people. But also he had granted
subsidies to the experimental theaters to give them their chance to
experiment in creating their best. Lunarcharsky was a wise mediator.
It is related that when the Moscow masses, excited to high
resentment against the Russian Orthodox Church, attempted to
destroy the wonderful Cathedral of Vasilly Blazhenny, they were
stopped by the intervention of Lunarcharsky. There was not a day of
my stay in Moscow that my eyes failed to be glad in contemplation of
Ivan the Terrible's super-byzantine burnt offering to humanity. And
Lunarcharsky in Moscow appeared like a guardian angel to me
because he had made it possible for my eyes to see that glory.
XVIII
Social Interest
MY constant companion and interpreter was Venko, a big, strong,
gloriously boisterous and comparatively young Russian. He had lived
for years in an English Midland town and had left an English wife and
children there to come to Russia after the revolution. The only
sentimental thing in his mind was his family in England. Sometimes
he was perplexed thinking about them. He said he was sure they
wouldn't like living in Russia and he had no desire to return to
England. He was not sentimental about his substitute Russian wife.
He said she had married him only to get good food and a good
apartment to live in. He was of peasant origin and she seemed to be
from the poor professional class. Their living room constantly
reminded me of that of the poor officer in The Brothers Karamozov. It
was like a seamstress's place, with a sewing machine installed and
scraps of cloth lying carelessly about, from which one's clothes
picked up bits of thread, and it had a peculiar odor like that of clothes
being washed with brown soap. But she was a good wife.
Sometimes I stayed at Venko's house, after we had finished at a
meeting and resorted to a café to drink vodka. And however late we
got there, his wife would get up to serve food.
Venko was an interpreter in the O.G.P.U. He was not connected with
the intelligence work. He didn't like office work. He preferred to
agitate crowds. He was a marvelously gesticulating, noisy and frothy
agitator, but there was not much substance in his phrases. And if you
don't give Russians some meat to chew on when you talk to them,
they soon tire of you, however brilliant your fireworks may be. If you
have something to say they will listen for long hours upon hours, as
patient as sheep, even if you are speaking in a strange language.
And afterward they will ruminate on it with satisfaction through more
long hours of interpreting. Venko was a good enough interpreter. My
stay in Moscow was a vacation for him, of which we made a picnic.
He was unorthodox about life, whether it was old or new, even as I,
and he made the most unguarded and biting criticisms of things and
personalities in his profane and boisterous Russian way.
The Moscow Soviet made me an honorary member at one of its
meetings. A few days later Venko accompanied me to the office of
the Soviet, where I was to receive the little red book that would make
me even a more privileged personage than I was. The card was
made out by a comrade clerk and my photograph was affixed. Then
Venko and I were ushered into the presence of Commissar
Kamenev, the president of the Moscow Soviet, for him to affix his
signature.
Kamenev was extremely dignified and perfectly attired in black, with
white collar and black tie, the best-dressed Bolshevik official
(according to the smart European standard) that I had met. He
welcomed me with a courteous smile, signed my card, shook my
hand, and said he was proud to deliver it to me in the name of the
Moscow Soviet. Venko translated. The simplicity of Kamenev's
official dignity moved me very much, for in his fine-fitting
conventional clothes, I might have mistaken him for a responsible
banker, or a Protestant clergyman, or a high-ranking continental
diplomat, anything but what Venko startled me by suggesting.
For as we got outside Venko exploded: "Good God, Comrade! I have
seen the Czar!"
"What do you mean, the Czar?" I said.
"Kamenev in the place of the Czar. The same clothes, the same
manner of wearing his beard! Good God, Comrade, a Jew in the
place of the Czar!" Kamenev's features were indeed remarkably like
the Czar's.
"Why, don't you like Jews?" I asked in astonishment. It was the first
anti-Jewish sentiment I had heard from a Russian Communist.
"No, Comrade, I won't lie to you; I don't like Jews."
"Are you a pogromist?" I asked.
"Good God, Comrade, no. I fought the White-guard pogromists in the
Ukraine and was wounded. The White guards started pogroms
against the Jews. I fought them and fought the pogroms too, for
pogroms are a crime against our Communist party. But I don't like
the Jews, Comrade. All the Nep men are Jews."
"All?" I exclaimed.
"Well, if not all, nearly all. And all the money changers of the Black
Bourse are Jews."
I record this conversation because it was one of the impressive and
unforgettable things I heard from a Communist in Russia. I was
particularly impressed because, as a member of a minority group in
America that was the victim of blind and bitter prejudice, I was
interested to know if the prejudice against the Jews had been
automatically swept away with the Czarist régime.
I was interested, because I did not hold to the sentimental idea that
the deep-rooted prejudices of a people could be eradicated
overnight. What the Bolsheviks had accomplished was to put a stop
to the vicious political exploitation of group and race prejudice. I don't
think the saintliest human being could ask more. Individual prejudice
is one of the most natural sentiments. It is easy enough for an
individual prejudice to become a family prejudice, for family ties are
real. And it is also easy for such prejudice to spread to a group, for
groups exist and the majority of human beings are fundamentally
tribal.
I was not at all shocked by Venko's revelation. I was merely
enlightened. If he were an intellectual Communist, he could not have
spoken to me as he did. I preferred to go around with him, because I
could learn more.
One evening Zonov invited me to a party which he did not want
Venko to know about, for it was a bourgeois party. The guests were
celebrating a holiday of the old régime which had been abolished by
the Bolsheviks.
The party of that little remnant of the Russian bourgeoisie was
something not to be missed. It was even more Russian, noisy, and
elastic than the proletarian parties, for these people did not have to
bother about correct Communist conduct. Maybe there was a
flickering note of futility, of despair, which made them more reckless,
because, unlike the Communists, they had no future. The limited
luxury of the Nep for the moment was theirs to enjoy. And they were
giving themselves to the moment unforgettably, as you might give
yourself to a page of Chekhov.
Russian life seems to blow through space like a big breeze, and this
remnant of a bourgeois society was no less a part of that big breeze.
How they ate and danced and chattered in loud harmony! Two huge
fruit cakes reared themselves like wedding cakes on a sideboard,
and there were platters of caviar, sturgeon, salads, cheeses, every
delicious food to tickle the palate, and gallons of Caucasian wine and
vodka to wash it down.
I was introduced all round as a guest of Russia. They all knew that I
was a guest of the Soviets, and if they wanted to make it a guest of
Russia instead, I had no objection to the added distinction. One very
beautiful and proud-looking young woman got the back of her hand
up to my lips with one of those exquisite gestures that only people
who are born to them can make, I guess.
I made the best bow that was natural to me for that honor. But the
young woman was not satisfied with my bow. She stamped her foot
petulantly, though not unkindly, and rubbed my nose with the
perfumed back of her hand. I was convinced that something more
was expected of me, so I reached up my hand and took hers.
She led me to a seat and said rapidly in a voice that sounded like
fine tinkling glass: "Why did you refuse to kiss my hand? Do you
think it is degrading for a Communist to kiss a lady's hand?" She
spoke lovely English.
"No, Tovarish—"
"Please don't call me by that disgusting name," she interrupted. "I
am a barishna."
"Well, Barishna, then, if that is your preference, I did not kiss your
hand simply because I don't know how to do it well. Nobody I know
kisses hands in America."
The Barishna conceded an indulgent smile. "Tell me," she said, "do
you like our Russia—Moscow and Petrograd?" I said that I did.
"As much as London and Paris and Berlin?" she asked.
I said, "More than London and Berlin. But I do not know Paris."
"I believe you," she said. "I know London and Paris and Berlin, but I
love Petrograd more. Now there is no Petrograd." "But you have
Moscow. Moscow is more beautiful," I said. "Oh, but Petrograd was
magnificent before the revolution." I could never imagine Petrograd
being more beautiful than Moscow, but so many Russians said it
was.
Said the barishna, "I tell you, I don't like the foreign Communists. You
come here to gaze at us as if we were strange animals in a zoo, to
mock at and insult us in our distress. That is hateful."
"Barishna," I said, "I don't understand. What do you mean? The
foreign Communists come here bringing greetings from the workers
abroad to the workers of Russia. They do not come here to mock
and insult, but to praise and learn about the revolution."
"Oh, they do mock at us," she insisted. "My young brother works in
one of the important departments and he heard a foreign Communist
boasting that he had slept all night with a lady of title for ten cents.
Now isn't that a mean and despicable thing to say? If a real man
could buy a lady of quality for ten cents, shouldn't he be ashamed to
mention it?"
"I guess so, Barishna," I said. "I don't care anything about the
difference between titled and untitled loving."
"But you do think it was an unspeakable thing for a civilized man to
say, don't you?" She stressed the word civilized as if I were a savage
in her sight and she was eager to hear the opinion of a savage upon
a civilized person.
"But, Barishna," I said, "the men of your class used to do worse
things than that to the women of the class of the man who said he
possessed a titled lady for ten cents. They did it to weak and
ignorant girls and often didn't even pay the price of ten cents."
"Oh no," said the barishna, "no gentleman does that."
"But they do, Barishna. Many of your gentlemen still exercise even
the medieval droits de seigneur in a different way. That's what
Tolstoy's Resurrection is all about."
"So you read our Tolstoy? You like our Russian literature? Oh, I am
glad that you do. They have destroyed everything, but they cannot
destroy our Russian literature."
I was very embarrassed. Most of the bourgeois people I had met had
refrained from saying anything against the Communists, even though
they did not praise them. Suddenly the barishna said, "I want to
leave Russia; I have friends in England. Would you marry me so that
I could leave the country with you—just a formal arrangement?" I
hesitated and said that I didn't know that I could.
"But many of the foreigners have married Russian girls and got them
through to Berlin," she said.
"Communists too?" I asked.
"Yes, Communists too."
"Barishna," I said, "I am sorry. I couldn't shoulder even the formal
responsibility. And besides, I am not a Communist. I don't even know
yet how I am going to get out of Russia myself."
In my rare contacts with members of the expropriated classes I felt
the weirdest sensations, as if pages out of Tolstoy, Turgenieff,
Dostoyevsky, Artzybashev and Chekhov were suddenly patterned
and peopled with actual life.
Many of the people I knew from the International Club in London

were in Russia, some as visiting delegates, while others were
permanently settled. Arthur McManus was one of the English-
speaking delegates whose company I found congenial, and we were
often together, although I found it difficult to keep up with his
gargantuan boozing, which perhaps finally knocked him out dead.
Both of us were guests of the Soviet fleet at Kronstadt and were
photographed together. McManus and I had our points of difference,
and sometimes when we were vodka-heated, our tongues flew
sharply at each other.
McManus was one of the men who had gunned the hardest after
Sylvia Pankhurst. He still felt venomous about her. "Intellectually
dishonest," was his pet phrase for describing her. I said I thought
Sylvia Pankhurst was as honest as any imperial Briton could be. And
I really preferred Pankhurst to persons like Lansbury, and perhaps
even to McManus himself. McManus shot up like a rabbit (he was a
tiny man) and demanded in his remarkably beautiful Glasgow brogue
if I meant to "insinuate" (that was the word he used) that he was an
imperialist. I said that I had not said "imperialist," but "imperial," and
that all Britons were imperial by birth and circumstances because of
the nature of the political set-up of Britain. McManus asked if I did
not believe that there were really radical Britons. I said that no man
can be more radical than his system can stand. McManus said I was
a bloody bigoted black nationalist, and his b's had such a wonderful
ring (he stammered a little) that it made me laugh and laugh until
both of us fell into a prolonged fit of black-and-white laughter. It was
a good satisfying feeling to see McManus laugh aloud, for there was
a perpetually crucified expression on his countenance that all the
Scotch whisky and Russian vodka in the world could not dispel.
McManus did not appear to like my O.G.P.U. friend and companion,
Venko. It was well known among us that Venko was an interpreter
and translator for the O.G.P.U., but had nothing to do with the
department of investigations and arrests. Anyone with a little
knowledge of police organization knows that a police clerk has
nothing to do with the actual duties of policing. If Venko had been a
secret agent of the O.G.P.U. we would never have known that he
worked in that department. And I think I can nose out a secret agent
whether he is red or white. I spent a year of my early youth in a
police department in a position where I was in constant contact with
all the branches of the department. For my part I liked to have Venko
along whenever I was invited to a carousel among Communists. For
Venko could beat anybody carousing and I thought that if any issue
were raised about the affair afterward, Venko would be an excellent
asset to have. Whenever I went on a drinking bout with comrades I
always saw that they got drunker than myself.
It was necessary to do a little thinking while drinking and laughing.
For sometimes funny things happened. Some of the foreign
comrades seemed to enjoy playing at political intrigue, apparently
without fully realizing that political intrigue, to the Russians, was a
serious and dangerous thing. For instance, one of the youthful Indian
delegates occupied a room next to mine, and we often went down to
our meals and also over to the Comintern offices together. One
morning when I called for him his room was locked and there was a
seal on the door. The O.G.P.U. had arrested him during the night.
Months later I met him in Berlin under the most unusual
circumstances, which I shall relate in another place. There was also
the young Whitechapel Jew whom I used to know slightly at the
International Club in London. He had come to Russia as a youth
delegate. But he wasn't functioning as anything when I saw him. He
told me fretfully that he had been denounced. One evening he and I
were on our way to a motion picture when a group of armed police
dramatically pounced upon him. They said something in Russian and
he must have answered satisfactorily, for they did not take him. But
he was scared, and said, "I am always scared." Shortly after that
incident he was gone too, and I never saw him again. When I
reached Berlin the following spring I met William Gallacher (now
Communist Member of Parliament) and asked him what had become
of the boy. "He was a spy," Gallacher said, "and he was fixed."
I said angrily, "But what have you in the little British Communist Party
for anybody to spy on?"
"More than you think," said Gallacher, with a mysterious nod of his
friendly head.
One night in Moscow I was invited to a celebration given by a minor
Communist official. The address had been written down for me and I
had to take somebody along to find it, as I did not know my way
around Moscow. So I asked Venko; but first we had to attend a
meeting of women workers at which he interpreted for me and we
did not get to the entertainment until very late. The large apartment
was full of comrades when we got there. I think the man who was
throwing the treat was a Finn and there were many Baltic types
there, blonde and heavy of movement and impassive of spirit. There
was plenty of hard drinking, but it was a dull atmosphere, nothing of
the stimulating renascent effervescence of the barishna's evening.
Venko stepped upon the scene with a burst of boisterous
enthusiasm, and drinking a big glass of vodka, he took the center of
the room and started speechifying, saying there was a time for good
comrades to fight, a time to work, and that now was the time to be
festive.
Venko was applauded, and from somewhere McManus came
swaying like a tipsy little imp, and pointing at Venko cried in a
chanting voice: "O.G.P.U.! O.G.P.U.! O.G.P.U.!" Venko laughed, and
all of us. For he and the others thought that McManus was merely
putting over a joke about his working for the O.G.P.U. But then
McManus shouted in English, "Spy! Spy! I am not going to stay here,
I am going home. Spy!"
"What do you mean, Comrade?" Venko asked in amazement. "Did I
ever spy on you? Do you want to say that I am here spying on my
comrades?" Venko said something in Russian and everybody looked
serious. But McManus repeated "O.G.P.U. spy! O.G.P.U. spy!" A
murderous look took possession of Venko's face. "Comrade," he
cried in a terrible voice, "if you don't stop, I'll kill you; you hear?
You're not drunk and irresponsible. If you don't stop, I'll hit you, as
little as you are." But McManus shouted again: "O.G.P.U. spy!
O.G.P.U.—"
Venko knocked McManus down with one blow and kicked him
straight across the room, where he lay curled up like a half-dead
snake. "You dirty little Englishman!" cried Venko. "Go back home and
make your own revolution and don't stay in Russia to insult a real
Communist." McManus picked himself up and began shouting: "I am
not a Communist, I am an Anarchist! Anarchist! Anarchist!" A
comrade clapped his hand over McManus' mouth, and lifting him up
like a kid, carried him out of the room.
I couldn't understand the meaning of McManus' outburst, except
perhaps that he, like some of the other visiting comrades, was
afflicted with spy mania. The company settled down again to drinking
and toasting and the singing of revolutionary songs.
The carousel ended with me again uplifted in glory. Venko had shed
every vestige of the murderous brutality of a moment before and was
acting like a commanding master of ceremonies. With strong
exuberant gestures he toasted me to the company. Always a poet in
action, he became a poet in words: "Comrade McKay, you must stay
in Russia. We want you. All Russia loves you, not we Communists
only, but even the damned bourgeoisie. Tell us, Comrade McKay,
why is it you have bewitched us? Tell us, Comrade McKay, what is
it? Is it the black magic we have heard about? Comrade McKay, we
are bewitched, men, women and children. We all love you, we all
want you. Oh, do stay with us forever! Comrade McKay, you must
leave Moscow and see Russia. We want you everywhere....
Comrade McKay, my heart is bold"—here Venko brutally beat his
breast with his enormous fist—"and my back is broad and strong"—
Venko bent himself over. "Get up on my back and I will carry you all
over Russia: from Moscow to Kazan, from Kazan to Samara and all

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Annual Update in Intensive Care and

Emergency Medicine 2019 Jean-Louis

Annual Update in Intensive Care and Emergency Medicine

Revision notes in intensive care medicine 1st Edition

OSCEs for Intensive Care Medicine Peter Hersey

POCUS in Critical Care, Anesthesia and Emergency

Compelling Ethical Challenges in Critical Care and

Surgical Intensive Care Medicine 3rd Edition John M.

Critical Care Emergency Medicine 2nd Edition William

Handbook of Critical and Intensive Care Medicine 4th

Edited by Jean-Louis Vincent

ISSN 2191-5709 ISSN 2191-5717 (electronic)

Library of Congress Control Number: 2019931833

© Springer Nature Switzerland AG 2019

Cover design: WMXDesign GmbH, Heidelberg

Part I Precision Medicine

Part IV Cardiac Arrest

Part VIII Fluid Issues

Part X The Neurological Patient

Part XIII Iron Metabolism

AKI Acute kidney injury

T. L. Palmieri and N. K. Tran

Is precision medicine really precise? Precision in medicine can only be achieved

© Springer Nature Switzerland AG 2019 3

Clarity in definitions is essential to any discussion of medical treatment para-

characteristics, i.e., classifying individuals into subpopulations with different sus-

Table 1.1 Variation between common critical care tests

1.5 Potential Conflicts/Weaknesses

1.7 Data Collection and Analysis

1.8 The Future

The key to successful implementation of precision medicine in the ICU is collabora-

Success will depend on collaboration, strategic resource utilization, funding avail-

V. X. Liu and H. C. Prescott

Recent developments in healthcare data availability, advanced analytic algorithms,

© Springer Nature Switzerland AG 2019 15

2.2  Changing Landscape: The Fourth Industrial

2.3 Precision Delivery in Healthcare

2.4 Critical Care: A Risk-Based Specialty

2.5  ovel Capabilities with Improved Data

2.6 Current Risk Prediction Applications in Critical Care

I listened to James Cannon's fighting speeches for a legal

Many of the people I knew from the International Club in London

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1.5 Potential Conflicts/Weaknesses

1.7 Data Collection and Analysis

1.8 The Future

2.2 Changing Landscape: The Fourth Industrial

2.3 Precision Delivery in Healthcare

2.4 Critical Care: A Risk-Based Specialty

2.5 ovel Capabilities with Improved Data

2.6 Current Risk Prediction Applications in Critical Care