The document discusses the impact of the Surviving Sepsis Campaign (SSC) 2012 guidelines on the author's hospital. It notes that SSC 2012 revised the bundles based on analysis of over 28,000 patients. The new resuscitation bundle focuses on lactate measurement, blood cultures, antibiotics, and fluid resuscitation within 3 hours. The new septic shock bundle emphasizes vasopressors, central lines, and hemodynamic targets like CVP and ScvO2 to be achieved within 6 hours. The role of collaboration between specialties like ICU and ED is also emphasized.

1. The impact of SSC 2012 on the panning
and evaluation of my hospital's
performance
Critical Care Department - Hospital Vall d'Hebron
Barcelona, June, 10, 2013
Rui Moreno
UCINC, Hospital de São José
Centro Hospitalar de Lisboa Central, E.P.E.

2. DECLARATION OF POTENTIAL (REAL)
CONFLICT OF INTEREST

3. DECLARATION OF POTENTIAL CONFLICT OF INTEREST
• I am not an Anaesthesiologist
• I am not and Internist
• I am not a surgeon
• I am not a GP

4. DECLARATION OF POTENTIAL CONFLICT OF INTEREST
• I am not an Anaesthesiologist
• I am not and Internist
• I am not a surgeon
• I am not a GP
I AM AN INTENSIVIST!

8. THE PATIENT WITH SEPSIS NEED
TEAMS, NOT TRIBES!

10. Sepsis = Decomposition,
decay
Septic = Rotten
Σήψις

11. DEFINITIONS
Bone et al. Chest. 1992;101:1644;
Wheeler and Bernard. N Engl J Med.
1999;340:207.
SepsisSIRSInfection/
Trauma
Severe Sepsis
Sepsis with ≥1 sign of organ
failure
 Cardiovascular (refractory
hypotension)
 Renal
 Respiratory
 Hepatic
 Hematologic
 CNS
 Unexplained metabolic
acidosis
Shock

12. 800
1,000
1,200
1,400
1,600
1,800
2001 2025 2050
Year
300
400
500
600
SepsisCases(x103)
TotalUSPopulation(million)
Angus DC, et al. JAMA 2000;284:2762-70.
Angus DC, et al. Crit Care Med 2001;29:1303-10.
SEVERE SEPSIS IS INCREASING IN INCIDENCE
Severe Sepsis Cases
US Population

21. EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLY
ILL PATIENT
0%
10%
20%
30%
40%
50%
60%
70%
80%
0-1 2-3 4-6 7-10 11-15 16-21
Days in ICU before the study day
Infectionrate
N = 6010 1608 1857 1248 1176 742
(EPIC II, 2008)

27. INFECTION AND OUTCOME
0,0
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
45,0
Mortality,%
ICU mortality 13,9 32,2
Hospital mortality 18,7 41,8
No infection Infection
(Moreno et al. 2005 - data from the SAPS 3 study)

29. 0%
25%
50%
75%
100%
%ofpatients
0 2 4 6 8 10 12 14 16 18 20 22 24
SOFA score
Survivors Non-survivors
(R. Moreno, 1997)
EPIDEMIOLOGY OF SEPSIS IN THE CRITICALLY
ILL PATIENT

30. 1 OSF
2 OSF
3 OSF
0
20
40
60
80
100
1 2 3 4 5 6 7
ICUmortality(%)
Number of days in MOF
ORGAN FAILURE AND MORTALITY IN PATIENTS WITH SEPSIS
AND ORGAN FAILURE
(data from Moreno et al.)

33. DECLARATION OF BARCELA
2002

34. Surviving Sepsis Campaign: Timeline
Barcelona
Declaration
SSC Guidelines
2010
???
Guidelines
And bundles
Revision
2005
NEJM editorial
2004
2002
Guidelines
Revision
Phase III starts:
IHI partnership
2008 2012
Results
published
15,000 pts
20% RRR
2006
2012--

35. Surviving Sepsis Campaign
Guidelines for Management of Severe
Sepsis/Septic Shock
2004

36. Surviving Sepsis Campaign
Guidelines for Management of Severe
Sepsis/Septic Shock
2008

37. Surviving Sepsis Campaign
Guidelines for Management of Severe
Sepsis/Septic Shock
2012

39. Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly
Peter Q. Eichacker, M.D., Charles Natanson, M.D., and Robert L. Danner, M.D

40. New Policy to deal with Potential Conflicts of Interest

41. GRADE PRO: Guideline development process
• Prioritize problems (and define specific question(s)
• Perform systematic review
• Summarize the evidence in evidence profiles (summary of
findings tables)
• Judge which outcomes are critical
• Judge overall quality of evidence
• Judge balance of benefits and downsides
• Generate recommendation
• Judge strength of recommendation

42. 42

43. 43

44. 4.5 potentials for a mishap per operation

45. NURSING WORK
Gets IV bags,
Checks
orders in binder
13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00
Hangs IV
IV push Oral meds,
topical
cream
Checks
updates
in computer
Hangs IV
Planning for
new shift
Checks
orders in
binderHangs IV
Hangs IV
Hangs IV
Oral meds
IV push
Oral meds
Insulin
Hangs IV
Pain med
Checks
updates
in computer
Topical
cream
Other RN
needs binder
Nursing home
assessment
Narcotic keys
Staffing
IV pump alarm
Fingerstick
machine
calibration
Hand off
assessment
IV pump alarm
Narcotic meds
too many to
put in cart
Narcotic keys
Other RN
leaves floor
Signature for
narcotics
Move patient
to new bed
Water for
patient
New nursing
assistant
arrives
MD asks to tape
down IV
LPN she is
covering
Children on
floor
Patient risk of
falling
Other RN
returns
Hang IV
for her
Pain med
request
BP machine
problems
Dinner
Patient
moved up in
bed
Water for
patient
Fingerstick
machine
IV pump alarm
Beds
Weigh
patient
Staffing
Other RN
dinner
Hang IV
IV pump alarm
Cart
Wife of patient
Emily S. Patterson PhD

47. Surviving Sepsis Campaign
Guidelines for Management of Severe
Sepsis/Septic Shock
Version 2012

73. Direct medical costs

74. van Beeck et al. J Trauma 1997;42:1116
TRAFFIC INJURIES
0 10 20 30 40 50 60 70 80 90
0
10
20
Age in years
MillionsofUS$
Male
Female

75. van Beeck et al. J Trauma 1997;42:1116
OCCUPATIONAL INJURIES
0 10 20 30 40 50 60 70 80 90
0
1
2
3
4
5
Male
Female
Age in years
MillionsofUS$

76. DOMESTIC INJURIES
0 10 20 30 40 50 60 70 80 90
0
10
20
30
40
50
60
70
80
90
100
Age in years
MillionsofUS$
van Beeck et al. J Trauma 1997;42:1116
Male
Female

77. 2000
2200
2400
2600
2800
3000
3200
3400
3600
1990 1991 1992 1993 1994 1995
Totalexpenditureinacutecare-MillionEuro
Years
Denmark
TOTAL EXPENDITURE IN HEALTH CARE

78. Direct medical costs

79. IF WE WANT TO AVOID A DISASTER
OUR FOCUS SHOULD BE ON
THE EVALUATION AND OPTIMIZATION
OF THE SERVICES WE PROVIDE

80. HOW (UN)RELIABLE IS MEDICINE?
• 10-1 means that 1 to 9 times out of 10 the intended actions fail to
produce the desired results or are defective. An example is if I
have a 80% compliance with giving appropriate DVT prophylaxis
there are 2 defects in our process in every 10 patients
• 10-2 means that 1 to 9 times out of 100 the intended action or
results fail or are defective. An example is if I have 96%
compliance with giving appropriate DVT prophylaxis there will be
4 defects in our process in every 100 patients

81. Average
Percent
High
Income
Zip
Codes
Low
Income
Zip
Codes
Expected
in One
Year
Diabetic Eye
Exams
47,9 53,2 44,9 100,0
Hgb A1c
Monitoring
55,9 59,5 50,9 100,0
Mammography
Screening
46,7 50,8 39,8 100,0
Colon Cancer
Screening
9.0 (45%) 10,3 8,0 20,0
Influenza Vaccine 46,5 50,8 41,5 100,0
Pneunococcal
Vaccine
8 (80%) 8,7 7,3 10,0
Pham HH. Delivery of
Preventive Services. JAMA
2005; 294:473-481

82. WHAT ARE OUR EXPECTATIONS OF RELIABILITY IN OTHER
INDUSTRIES?
1. How many of you would put up with your automobile not
starting two out of ten starts?
2. How many of you would fly commercially, if airplanes
crashed or abandoned the trip one out of every ten flights?
3. How many of you would frequent a restaurant that served
contaminated food three times out of every ten meals?

84. HEALTH CARE RELIABILITIES
(Un)Reliability Outcome/Process
10-1
Beta blockers and ASA in Acute MI
HgA1c tested at least 3 times every 2 yrs Mammograms,
Immunization
Lower Vt in ALI Patients.
10-2
Serious adverse events in hospital
Deaths in high risk surgery
10-3
Neonatal mortality
General surgery deaths
10-4 Deaths in routine anesthesia
10-5 Blood Banking
10-6 ?

85. 10.3 10.5 10.3 9.6 8
7.7 6.9
2 2 2 2
12
21
31
0
5
10
15
20
25
30
35
1996 1997 1998 1999 2000 2001 2002
Median Vt ml/kg % of ARDS Patients Recieving 6 ml/kg Vt
ARDS Network Paper Published NEJM May 2000
Death deceased from 40% to 31% p= 0.007
(Am J. Respir & CCM 2004; 169 supp:A256)

86. 10.3 10.5 10.3 9.6 8
7.7 6.9
2 2 2 2
12
21
31
0
5
10
15
20
25
30
35
1996 1997 1998 1999 2000 2001 2002
Median Vt ml/kg % of ARDS Patients Recieving 6 ml/kg Vt
ARDS Network Paper Published NEJM May 2000
Death deceased from 40% to 31% p= 0.007
Two Years after publishing the evidence,
‘7’ of 10 patients are NOT receiving best
care
(Am J. Respir & CCM 2004; 169 supp:A256)

87. TIDAL VOLUME IN THE ICU’S
0
2
4
6
8
10
12
Luhr 1999 Esteban 2000 Esteban 2002 Esteban 2002 ALIVE 2004 SAPS3
mL/kg
(João Gouveia et al. Data from the SAPS 3 study)

88. PEEP IN THE ICU’S
0
2
4
6
8
10
12
14
Luhr 1999 Esteban
2000
Esteban
2002
Esteban
2002
ALIVE 2004 SAPS3
cmH2O
(João Gouveia et al. Data from the SAPS 3 study)

91. We demand the right to make bad
choices.

92. Bad choices yield bad results

93. 4.5 potentials for a mishap per operation

94. NURSING WORK
Gets IV bags,
Checks
orders in binder
13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00
Hangs IV
IV push Oral meds,
topical
cream
Checks
updates
in computer
Hangs IV
Planning for
new shift
Checks
orders in
binderHangs IV
Hangs IV
Hangs IV
Oral meds
IV push
Oral meds
Insulin
Hangs IV
Pain med
Checks
updates
in computer
Topical
cream
Other RN
needs binder
Nursing home
assessment
Narcotic keys
Staffing
IV pump alarm
Fingerstick
machine
calibration
Hand off
assessment
IV pump alarm
Narcotic meds
too many to
put in cart
Narcotic keys
Other RN
leaves floor
Signature for
narcotics
Move patient
to new bed
Water for
patient
New nursing
assistant
arrives
MD asks to tape
down IV
LPN she is
covering
Children on
floor
Patient risk of
falling
Other RN
returns
Hang IV
for her
Pain med
request
BP machine
problems
Dinner
Patient
moved up in
bed
Water for
patient
Fingerstick
machine
IV pump alarm
Beds
Weigh
patient
Staffing
Other RN
dinner
Hang IV
IV pump alarm
Cart
Wife of patient
Emily S. Patterson PhD

97. Revised SSC Bundles
• Based on 2012 SSC guideline Revision
• Utilizing analysis of 28,000 pt in the SSC
database
• New software to be developed
• No industry funding utilized in revising guidelines or
bundles

98. Revised SSC Bundles
• Management bundle dropped
• IPP: High compliance at outset of study
• No significant change in compliance
• Glucose:
• Clouded by controversy
• Steroids:
• OR > 1.0 in SSC analysis
• rhAPC:
• Significant OR for survival but after the results of
PROWESS-SHOCK was withdraw from all markets

105. Sepsis Resuscitation Bundle
(To be started immediately and completed within 3 hours)
• Serum lactate measured in 3 hours.
• Blood cultures obtained prior to antibiotic administration.
• Minimize time to administration of broad-spectrum
antibiotics with a maximum of 3 hours.
• In the event of hypotension and/or lactate >
3mmol/L, deliver a minimum bolus of 30 ml/kg of
crystalloid (or colloid equivalent) within 1 hour.

106. Septic Shock Bundle
(To be started immediately and completed within 6 hours)
• Apply vasopressors for hypotension not responding to initial
fluid resuscitation to maintain mean arterial pressure (MAP) >
65 mm Hg.
• In the event of persistent arterial hypotension despite volume
resuscitation (septic shock) and/or initial lactate > 4 mmol/L
(36 mg/dl):
• Insert central line
• Achieve central venous pressure (CVP) of > 8 mm Hg.
• Achieve central venous oxygen saturation (ScvO2) of > 70%.

107. Role of Collaboration
ICUED

110. SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN
THE WASH
• From the data they obtained, Dr. Vincent and colleagues
make a number of observations:
• First, sepsis occurs frequently, being reported in almost 40% of
patients in the ICU
• Second, the frequency of sepsis varies markedly between
countries, and countries with higher frequencies of sepsis have
higher mortality rates among all patients admitted to the ICU.
• Finally, they report that the presence of a positive cumulative
fluid balance over the first 72 hrs from the onset of sepsis is,
among other variables, independently associated with higher
ICU mortality.
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554)

111. SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN
THE WASH
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )

112. SOAP AND SEPSIS-ANALYZING WHAT COMES OUT IN
THE WASH
• Data demonstrate that the mortality rate from organ failure
was the same for patients with severe sepsis as it was for
those without sepsis, suggesting that organ dysfunction,
rather than infection per se, is the key.
• What could account for these findings?
• ...difference in case-mix and ICU admission threshold
• ...the higher mortality rate in the ICUs with higher sepsis
prevalence might be a marker of overtaxed resources in
the ICU or during pre-ICU care
• ... it is tempting to speculate that baseline differences in
antibiotic use between ICUs may have contributed both to
the differences in the reported frequency of sepsis and to
the mortality rates observed.
Warren Lee & Niall Ferguson. Critical Care Medicine2006; 34:552-554 )

113. (Crit Care Med 2006; 34:211–218)

114. FINDING OUT WHAT WE DO IN THE ICU
Mitchell M. Levy, MD, FCCM
• This task force represents a change in focus, not only for
SCCM in particular but for the field of critical care in general.
• ...for a long time, SCCM, along with other critical care
societies, focused on the model of critical care delivery.
• Regardless of the model of critical care delivery, the most
important aspect of critical care is the quality of care patients
receive in a given ICU.
• For many years, the assessment of this quality was based
on measuring and reporting outcomes of care.
• Now, finally, there is a growing understanding that paying
attention to the details or process of care is the truly
essential aspect of quality measurement in the ICU.
(Crit Care Med 2006; 34:227–228)

115. FINDING OUT WHAT WE DO IN THE ICU
Mitchell M. Levy, MD, FCCM
• Curtis et al., at the direction of SCCM, have provided
clinicians in critical care units with a blue-print or mirror for
self-examination. The next step is for critical care clinicians
to look into that mirror and decide whether or not we like
what we see.
(Crit Care Med 2006; 34:227–228)

117. NEGOVSKY IBSEN SAFAR
WE HAVE STRONG SCIENTIFIC
FOUNDATIONS TO OUR SPECIALITY

118. FROM REANIMATION TO INTENSIVE CARE
MEDICINE
REANIMATION INTENSIVE CARE
INTENSIVE CARE MEDICINE

119. 20 years ago Dr Bill Knaus acknowledged:
• It ’ s the human resources of the ICU
TEAM, their organization and
distribution, and how we apply technology
consistently, NOT the genius of
individuals or the treatment “ magic
bullet ” that leads to EFFICIENT and
EFFECTIVE ICU.
Knaus et al Annals Int Med 1986: 104.410

120. DISEASES THAT MADE THE ICU
Polio: Mortality 60% to 20% ??? (but just in
2 or 3 countries)
Tetanus: Mortality approaches Zero
Guillian-Barré syndrome: Mortality approaches Zero
Acute organophosphate poisoning: almost disapeared
Most of the mortality relates to co-morbidity and
complications of ICU treatment.

122. DEVELOPMENT AS A CHALENGE
• Education and training of new professionals.
• Training in Intensive care of other professionals.
• Better much between resources and workload.
• The flux of patients within the hospital: admission and
discharge policies, readmissions.
• Patient safety: prevention of adverse events.
• Organisative aspects: leadership, communication, team-
work.

123. Current and projected workforce requirements for
care of the critically ill.
Angus D et al. JAMA 2000 : 284; 2762-70

124. RETIRE FROM ICU CARE AT 77 YEARS:
(Angus et. Al, JAMA 2002)

125. 0
50
100
150
200
250
300
350
400
2001 2006 2011 2016 2021 2026 2031
Year
At 2006 rates
Modelling trend
ICNARCIntensiveCareNationalAudit&ResearchCentre
160% increase in demand
over 10 years.
Projected ICU Bed Day Requirements
Rowan K et al

126. INTENSIVE CARE IS NOT ABOUT
MACHINES
IT IS ABOUT PEOPLE
IT IS ABOUT ORGANIZATION

127. 12

129. 12

130. NUMBER OF INTENSIVE CARE BEDS PER
100.000 INHABITANTS
Portugal
USA
França
UK
Canadá
Bélgica
Alemanha
HolandaEspanha
0
5
10
15
20
25
30
0 2 4 6 8 10
13
nºdecamasdeMedicinaIntensiva
por100.000habitantes
Países
(Data from Wunsch et all, 2008)

131. NUMBER OF INTENSIVE CARE BEDS PER
100.000 INHABITANTS
Portugal
USA
França
UK
Canadá
Suécia
Holanda
Espanha
Croácia
Bélgica
Alemanha
0
5
10
15
20
25
0 2 4 6 8 10 12 14
Trinidá e Tobago
13 Países
nºdecamasdeMedicinaIntensiva
por100.000habitantes
(Data from Adhikari et al., 2010)

132. 13

133. • ≈2 millions
Total n° Acute Care Beds
• ≈ 60.000
Total N° IC Beds
• ≈3%
IC Beds/AC Beds %
Acute and intensive care beds in Europe…….

134. (Andrew Rhodes &
Rui Moreno, 2012, ICM)

135. Acute care beds
Acute care hospital beds
/ 100,000 population.
Total number of ICU and
IMCU care beds
Total Adult ICU and
IMCU beds / 100,000
population
Adult ICU beds as % of all
acute care beds
%>65
Andorra 188 224 6 7.1 3.2 13
Austria 48446 635 1833 21.8 3.4 18.2
Belgium 50156 456 1900 17.3 3.8 18
Bulgaria 57460 766 2154 28.7 3.7 18.2
Croatia 15629 353 650 14.7 4.2 16.9
Cyprus 2813 350 92 11.4 3.3 10.4
Czech Republic 91068 865 1227 11.6 1.3 16.3
Denmark 17124 308 372 6.7 2.2 17.1
Estonia 5096 380 262 19.5 5.1 17.7
Finland 12442 231 329 6.1 2.6 17.8
France 232821 358 10540 16.2 4.5 16.8
Germany 469791 575 23,890 29.2 5.1 20.6
Greece 44411 392 680 6 1.5 19.6
Hungary 41574 416 1374 13.8 3.3 16.9
Iceland 1169 367 29 9.1 2.5 12.7
Ireland 12202 272 289 6.5 2.4 11.6
Italy 201932 333 7,550 12.5 3.7 20.3
Latvia 11833 531 217 9.7 1.8 16.9
Lithuania 17061 526 502 15.5 2.9 16.5
Luxemberg 2511 491 127 24.8 5.1 14.9
Netherlands 56085 337 1065 6.4 1.9 15.6
Norway 13639 277 395 8 2.9 16
Poland 156662 410 2635 6.9 1.7 13.7
Portugal 31722 298 451 4.2 1.4 18
Romania 108611 507 4574 21.4 4.2 14.8
Slovakia 32560 599 500 9.2 1.5 12.8
Slovenia 7656 373 131 6.4 1.7 16.8
Spain 124194 269 4479 9.7 3.6 17.1
Sweden 26131 278 550 5.8 2.1 19.7
Switzerland 28096 357 866 11 3.1 17
United Kingdom 147809 237 4114 6.6 2.8 16.5

136. Total size of Population
Gross Domestic Product (GDP)
($millions)
Gross Domestic Product (GDP) per
inhabitant ($)
Total expenditure on health as a %
of GDP
Andorra 84082 2893 34,407 7.7
Austria 8404252 377,382 44,904 8.6
Belgium 11007020 467,779 42,498 8.2
Bulgaria 7504868 47,702 6,356 4.4
Croatia 4425747 60,834 13,745 7.8
Cyprus 804435 23,174 28,808 6.0
Czech Republic 10532770 192,030 18,232 6.9
Denmark 5560628 309,866 55,725 9.8
Estonia 1340194 19,253 14,366 5.3
Finland 5375276 239,177 44,496 6.8
France 65075310 2,562,742 39,381 9.2
Germany 81748892 3,286,451 40,202 8.9
Greece 11329618 305,415 26,957 5.8
Hungary 9986000 130,421 13,060 5.2
Iceland 318452 12,594 39,548 7.9
Ireland 4480176 206,985 46,200 7.2
Italy 60626508 2,055,114 33,898 7.4
Latvia 2229641 24,013 10,770 8.1
Lithuania 3244601 36,370 11,209 7.8
Luxemberg 511840 54,950 107,358 4.1
Netherlands 16654979 780,668 46,873 5.5
Norway 4920305 412,990 83,936 8.1
Poland 38200037 469,401 12,288 5.3
Portugal 10636979 229,154 21,543 5.7
Romania 21413815 161,629 7,548 5.4
Slovakia 5435273 87,450 16,089 6.0
Slovenia 2050189 47,733 23,282 6.8
Spain 46152926 1,409,946 30,549 7.0
Sweden 9415570 458,725 48,720 8.2
Switzerland 7866500 527920 67,110 6.8
United Kingdom 62435709 2,250,209 36,040 8.2

137. (Andrew Rhodes & Rui Moreno, 2012, ICM)

138. (Andrew Rhodes & Rui Moreno, 2012, ICM)

139. (Andrew Rhodes & Rui Moreno, 2012, ICM

140. (Andrew Rhodes & Rui Moreno, 2012, ICM)

141. (Andrew Rhodes & Rui Moreno, 2012, ICM

142. WE HAVE ARRIVED

143. DEVELOPMENT
AS AN
OPPORTUNITY

144. • Intensivist model
(closed) reduced
mortality. (OR: 0.71
95%CI 0.62-0.82)
• Intensivist model
(closed) reduced
length of stay
Pronovost et al. JAMA; 2002-2151
Physician staffing patterns and clinical
outcomes in critically ill patients.

145. Most Positive Factors Most Negative factors
Intellectual stimulation Lack of leisure time
Treating acutely ill patients Stress among faculty
Application of complex
physiology
Treating chronically ill patients
Procedure orientated Inconsistent with my personality
Dealing with end-of-life issues Dealing with complex ethical
issues.
Attitudes and Perceptions of Internal Medicine Residents
Regarding Pulmonary and Critical Care Subspecialty Training.
Lorin S et al. Chest 2005 : 127; 630-6.

146. “Beauty comes first. Victory is
secondary. What matters is joy.”
Sócrates Brasileiro
Sampaio de Souza Vieira de
Oliveira

147. 14

148. STRESSED INTENSIVISTS ?

154. “The physician must be able to tell the antecedents, know the
present, and foretell the future- must mediate these things, and have
two special objects in view with regard to disease, namely, to do
good or to do no harm.
The art consists in three things- the disease, the patient, and the
physician. The physician is the servant of the art, and the patient
must combat the disease along with the physician.”
Hippocrates, in Epidemics, Book 1, section 11

155. Gràcies