The Birth of Intensive Care Medicine.
How a Danish doctor helped transform the care of critically ill patients
Until the middle of the 20th century, seriously ill patients were generally nursed on ordinary medical or surgical wards rather than in designated units with specially trained staff as they are today. Although there were several individuals such as Florence Nightingale and Harvey Cushing who laid the foundations, the first designated Intensive Care Unit (ICU) was only established seventy years ago. This transformation of patient care arose from an epidemic that swept across the Western world.
During the poliomyelitis (polio) epidemic of the 1950’s a Danish hospital was overwhelmed with patients requiring respiratory support. One of the most serious symptoms of polio was paralysis of the respiratory muscles. In order to keep affected patients alive, respiratory assistance was required by means of mechanical ventilation.
1950’s Ventilators
The most common ventilators at the time were known as iron lungs. These were enormous negative-pressure tank-like devices in which the person would lie while a vacuum-creating mechanism would force the lungs to expand. Patients suffering from polio were often required to spend several weeks or even months inside the iron lungs, until their respiratory muscles were strong enough to cope without assistance.
A similar but less cumbersome device was the shell ventilator, such as the cuirass respirator. This smaller, dome-like piece of equipment would be strapped to the patient’s torso with an electric motor producing negative pressure which forced the chest wall to move efficiently thus causing the lungs to expand and deflate.
(Image edited by author to show single picture only)
Crisis
In August 1952 only one iron lung and six shell ventilators were available for over 300 polio patients requiring respiratory support in Blegdam Hospital in Copenhagen. Rather than allowing the patients (many of whom were children) to die; the chief physician called an urgent staff meeting to discuss the crisis.
Björn Isben
An anaesthetist called Björn Isben came up with a radical idea. He suggested that instead of using the traditional negative-pressure devices for ventilation, patients could be kept alive with positive-pressure ventilation instead.
Inserting a tube into the patient’s airway (endotracheal intubation) and forcing air into the lungs was already common practice in the operating theatre at this time. Unconscious patients undergoing surgery were, however not the same as conscious patients requiring long-term ventilation over several weeks or months.
Isben was aware that attempting to insert or maintain endotracheal tubes in awake patients would be problematic; the tubes would be poorly tolerated and would likely cause severe discomfort, gagging and trauma. To prevent this, Isben suggested that tracheostomies were performed on the patients to enable the breathing tube to be placed into the trachea via the hole at the front of the neck instead.
Tracheostomies are secure, stable airways which are generally well-tolerated by patients, including infants and children. Today thousands of people who rely on long- term ventilation have tracheostomies in place. In the mid 1950’s however, the procedure was relatively rare and many of the medical and nursing staff would not have been familiar with this type of airway. I have included a YouTube video at the end of this article for anyone who wants to learn more about tracheostomies.
Isben’s plan was that the patients would be ventilated by staff pumping rubber bags by hand via the tracheostomies to inflate the patients’ lungs
Success
Despite some misgivings by senior staff, many of the polio victims received tracheostomies on Isben’s recommendation. To resolve the staffing problem, hundreds of medical and dental students were recruited to work in shifts hand-ventilating the patients to keep them alive. It is reported that the students were offered the equivalent of £1.50 a day for their efforts. Thanks to Björn Isben and his team, many lives were saved, with the mortality rate from polio in Copenhagen plummeting from about 80 per cent to about 40 per cent.
You can access images of the students with the patients here.
Vision
Isben was keen for the hospital to continue to offer this high staff-to-patient ratio permanently but with dedicated nurses rather than medical students. This was a radical concept at the time but Isben did not give up on his vision. Several months later, in December 1953, Blegdam Hospital officially opened the world’s very first intensive care unit. Initially, the unit cared exclusively for polio victims but eventually other patients requiring a high level of care were also admitted.
Other countries
Over the next few years, hospitals in other countries established their own intensive care units. The first one in the USA was at the University of Pittsburgh and opened in 1959. This is reported to have been the first ICU with 24-hour coverage by senior medical staff.
Significantly, the polio vaccine had been developed at this same university by Dr Jonas Salk. Its approval in 1955 and the subsequent vaccination campaign has been described as one of the most momentous medical and scientific achievements in history.
By 1961 Australia had already established Intensive Care Units in two hospitals whereas the UK and Canada did not open their first ICUs until several years later, in 1966.
Increase in demand for ICU beds
Despite the drop in the number of polio victims, the number of intensive care beds increased across the world, with ICUs accommodating patients suffering from many different conditions. Major developments in technology, pharmacology, medical knowledge and surgical techniques during the 1960s contributed to the rapid expansion of intensive care medicine as a speciality. Advances in cardiac, brain and transplant surgery resulted in many patients requiring intensive nursing and medical care in the immediate post-operative period.
The new technique of cardiopulmonary resuscitation (CPR) was introduced in 1960 with surviving patients often requiring a high degree of nursing and medical support. Another significant factor in the UK was the introduction of the first motorway with the new style and speed of driving leading to a significant increase in trauma patients.
Paediatric Intensive Care Units
The first ICU specifically for children opened in Sweden in 1955, in response to the polio epidemic. In other countries, most Paediatric Intensive Care Units (PICU’s) were established later; many developing in response to the rise in the number of children undergoing heart surgery. Many children with congenital heart defects were now able to receive corrective surgery thanks to the newly-developed cardiac bypass techniques and needed to be cared for post-operatively in dedicated units with teams of highly trained staff.
Over the last few decades, thousands of infants and children with a myriad of medical and surgical conditions have greatly benefited from the specialist care offered by PICU’s across the world.
Public Domain Image/Bill Branson/National Cancer Institute /Wikimedia Commons
The history of Neonatal Intensive Care Units has not been discussed here. For information about this please read my other article:
Thank you so much for reading to the end.
As promised, here is the YouTube video explaining tracheostomies.
