Philip Drinker and that damn machine: the dark side of life-support since the iron lung
I walk in to Mr. W’s room to say hello. He is 73 years old and has been in the hospital for 3 months, ever since he was diagnosed with COVID-19 and developed pneumonia. He smiles at me when I introduce myself but cannot speak because every breath he takes is with the support of the mechanical ventilator at his bedside. He is no longer contagious, but he is still critically ill, stuck on the ventilator, weak and struggling to take even one breath by himself; he doesn’t even have the strength in his arm to wave when I say hello, but I note the twitch of movement at his wrist as he tries.
In June, 2021, as the third wave of COVID-19 was ebbing in Toronto, I was taking over the care of patients in one of our ICUs. In the unit were a large number of patients who were technically “COVID survivors,” having come through an episode of acute respiratory distress syndrome (ARDS) that is the hallmark of severe COVID. Yet weeks to months later they were all still in the ICU, still dependent on a machine for their breathing, and still without any certainty as to whether or not they would ever get better. This condition of chronic organ failure (in this case the lungs), with a weakened immune system leading to recurrent infections, and a range of other complications such as kidney failure, low blood pressure, gastrointestinal bleeding, severe weakness, and delirium, is a well-known entity in the ICU. We call it persistent (or chronic) critical illness [1].
This entity is not the same as long COVID [2], although some of the symptoms may be the same. The big difference is that these are not individuals who can survive on a regular hospital ward, let alone at home. It is a twilight existence, as these people are alive — some fully alert — but the body is too fragile to survive outside the cocoon of whirring machines and dripping medications providing life support, and the attention of a nurse at the bedside 24–7. They are tended to day after day, week after week. The patients, their families, nurses, doctors, and other care providers all hope that these bodies will heal — just enough so they can breathe on their own; just enough to fight off the next bout of pneumonia. How long can this last? Many weeks, months, and sometimes years.
Newspapers have been filled with vivid descriptions of those in the throes of severe acute COVID, battling ARDS in ICUs around the world; the majority of these individuals will be dead or discharged from the hospital within a month [3]. There are also mounting testimonies of the terrible suffering of those with “long COVID”; the myriad debilitating symptoms that plague many who had supposedly recovered. But what is less discussed is that we are also creating an army of sufferers who are trapped in this state of persistent critical illness, tucked away in ICU beds around the world. Some patients have even described it as a “state worse than death” [4].
For most of history, the inability to breathe on one’s own always led to death. Oxygen therapy was introduced at the end of the 19th century. But if the body was too weak to take a breath, there was nothing more to be done except keep them comfortable. All of that changed in 1928.
By the 1920s, poliomyelitis had firmly taken hold as an epidemic disease. A virus that in the prior century had barely been a whisper of a problem, was now causing terror, leaving paralysis and death in its wake. Doctors had little to offer — bedrest was the mantra of the era. William Osler as far back as 1892 advocated doing not very much, stating “the child should be put to bed and the affected limb or limbs wrapped in cotton” [5]. Children (and adults) struck down by polio lay immobilized, day after day. But the most devastating of all was not even the inability to move, it was the paralysis of the respiratory muscles; the medical profession remained helpless to support those who lost the ability to breathe. James L. Wilson, a resident physician at Harvard during the 1920s described the despair of caring for polio patients in this condition: “Of all the experiences that the physician must undergo, none can be more distressing than to watch respiratory paralysis in a child ill with poliomyelitis — to watch him as he becomes more and more dyspneic, using with increasing vigor every available accessory muscle of neck, shoulder and chin, silent, wasting no breath for speech, wide-eyed and frightened, conscious almost to the last breath” [6].
Philip Drinker did not set out to change care for patients with poliomyelitis, or peoples’ relationship to machines. He was a Professor of Industrial Hygiene at the Harvard School of Public Health. Drinker had also been appointed to a newly formed commission at Rockefeller Institute in 1926 charged with improving methods of resuscitation from gas poisoning and electric shocks. Around this same time Drinker’s brother Cecil, along with a colleague Louis Agassiz Shaw Jr., was tinkering with a method to measure the breathing of different animals, including a cat, by placing an anesthetized animal inside a metal box attached to a manometer — a device to measure pressure [7]. The cat was sealed in except for the head and they could then measure how much air was going in and out of the lungs by looking at a U-shaped tube half-filled with water; when the cat inhaled, the water level changed, showing how much air had entered the cat’s lungs. Drinker was intrigued and paralyzed the cat and then pumped air in and out of the box by hand using a syringe, keeping the cat alive for a few hours. By sucking air out of the box, he created a vacuum, forcing air down the cat’s trachea and into the lungs; by pushing air back into the box, the rib cage, and therefore the lungs, were pressed inward by the pressure, causing the cat to exhale. The two — Drinker and Shaw — began to experiment more with cats, showing they could keep such animals alive indefinitely.
Once they had finished experimenting on cats, and with the human-sized version complete, Drinker and Shaw moved on to experimenting on themselves. Drinker may have been originally thinking about using his new vacuum-sealed box for resuscitation of electrocuted workers, but his mind shifted to polio after he walked through the wards of Boston’s Children’s Hospital and had a “harrowing experience.” His sister said “he could not forget the small blue faces, the terrible gasping for air,” of children with polio and realized that this new machine might help them to breathe [8].
Bertha Richard was 8 years old. She was born in New Brunswick, Canada, and came with her parents, Alexander Richard, a construction worker, and Madeline Richard née Leger, to live on 94 Chestnut Street in Waltham, Massachusetts [9]. Bertha had been sick for three days, developing a fever, headache and stiffness of the neck and back. By the time of her admission to Boston’s Children’s Hospital on Friday, October 12, 1928 she had weakness of her left arm and difficulty breathing [10]. She received a spinal tap which confirmed the already clear diagnosis of poliomyelitis. Knowing full well she was going to deteriorate further, the pediatrician taking care of her called Drinker and Shaw who had been developing a new wheeled their new contraption over to the Children’s Hospital and left it in the little girl’s room. By the afternoon of October 13th her breathing was worse and she was placed in the new machine. They tested it out at low pressure and she did well. They took her back out, as they felt she didn’t really need it yet. But Berthe was clearly on the decline, as first the muscles of her chest and neck had become paralyzed, and soon her diaphragm as well. By the next morning at 6 a.m. she was struggling to breathe again, with the telltale blue lips and fingers showing a lack of oxygen in her body. She was put back into the iron lung, this time with an increase in the vacuum pressure up to 30 cm of water with a dramatic improvement in just 15 minutes. When she was able to speak, she asked for ice cream. Philip Drinker was so relieved he started to cry [8]. The residents took turns sitting with her day and night, including Dr. Wilson. But pneumonia overwhelmed her, and she died at 8 a.m. on October 19th. Despite the death of Berthe Richard, the experiment was deemed a success. She had been kept alive, breathing with the machine’s help, for 122 hours.
Almost a year later, another patient received the support of the new-fangled device, Barrett Hoyt, a Harvard student. He was an assistant hockey manager for the varsity ice hockey team, and an undergraduate just a year away from finishing his degree when he was admitted to the nearby Peter Bent Brigham Hospital with polio on September 13th, 1929 [11]. He was gasping and choking when placed into the giant tube; within a few minutes of support from the machine, he made the simple, relieved statement, “I breathe” [8].
Suddenly respiratory failure was not a death sentence. The Drinker and Shaw respirator, shortened to the Drinker respiratory (leaving poor Shaw a bit out of the limelight), and then dubbed the “iron lung” by a reporter,8 was about to become synonymous with the treatment of poliomyelitis. Drinker always grumbled that it was that “damn machine” that he was known for [8].
Barrett Hoyt spent four weeks in the iron lung, and a year battling polio — graduating from Harvard in 1930 instead of with his class in 1929. He went on to work for many years for the Liberty Mutual Insurance Company in Boston, and was even able to play golf. He died in 1972 [12]. That damn machine gave him an additional 44 years of life. The relationship between human and machine had been irrevocably changed.
With Hoyt everything went according to plan. However, before the iron lung was deployed, doctors were worried. What happened, they wondered, if someone couldn’t live without it long-term? When it was known that the new machine was first ready for use, some of the physicians at Boston Children’s hospital stood around on the lawn in the court of the Children’s hospital discussing the “moral justification” for using the machine, worried about such scenarios [13]. The idea was that it would provide temporary support while the nerves and muscles regenerated after acute polio, and would eventually allow a patient to breathe again on their own. But what if that didn’t happen? Were they about to create an army of “cripples”? In society at that time, disability was both part of life for many people, and yet also shunned, with little support for those who were severely disabled, and certainly no system in place to care for anyone who was dependent for life on a machine; the concept was something out of science fiction.
Drinker recalled that “after a few years we had a number of cases in which the patients could be kept alive in a respirator and could not live out of it and this was a pretty dreary prospect, so that one man…James L. Wilson…urged strongly that the attendants on respirator cases make every conceivable effort to get the patient out of the machine as soon as possible and try to use it sort of orthopedically rather than therapeutically, that is, get him by the critical stage and from then on use the respirator as a method for exercising lungs. This is pretty grim and pretty tough on the patient but the alternative of living in one of these respirators permanently was also very disquieting” [14]. However, as the iron lung was used on more and more people, such a transition out of the iron lung was not always possible. With their vacuum-driven iron monster, Drinker and Shaw also created the first humans dependent for life on a machine.
As the use of modern mechanical ventilation broadened over the decades from supporting those who had polio to include those with many forms of critical illness such as bacterial pneumonia, stroke, trauma, meningitis, and now COVID-19, the aftermath of such diseases leaves individuals not just dependent on a machine for breathing, but with a suppressed immune system, other organs in failure, skin breakdown, bleeding stomach ulcers, blood clots, and a whole host of medical problems that continue on and on. It is a precarious existence that is far from what Professor Drinker grappled with when he expressed those early concerns regarding dependence on his breathing machine; it is a dependence on the ICU itself.
In some parts of the world there are no individuals who are persistently critically ill. It is a state, or syndrome, created by technology itself. Regions, such as many low income countries, that do not have the resources for acute organ support, let alone prolonged organ support, never have such patients. Without any mechanical ventilation available in large swaths of the world, respiratory failure is still an automatic death sentence, as has been seen in the huge death toll in remote parts of places like India during COVID-19. However, even in some high-income countries where everyone has full access to the latest, cutting edge intensive care, such patients rarely exist. For example, in Sweden, they rarely provide organ support beyond the acute period and will make the decision to stop life-support after a few weeks at most, rarely if ever having patients make that transition from acute to persistent critical illness [15]. The choice is baked into the culture — an expectation of both physicians and patients that these decisions regarding life support are best. However, it is also a system that removes the decision-making from patients and their families as to whether or not to continue with life-support; this decision is made solely by the medical team (although with input from the patient and family).
In places such as the US or Canada, these decisions regarding life-support rest primarily with the patients or families themselves. Of course, many patients and/or families prefer not to remain on life-support for an extended period and will choose to transition away from aggressive treatments and the use of machines after some period of time (and for others, any time spent on life-support is too much time). For some who remain with persistent critical illness, it is a religious imperative that life, in any form, be continued. For others, it is the continued hope that with more time, and more treatment, the body will strengthen again and allow them to wean from the ventilator, and regain independence or at least the ability to leave the ICU and hospital and spend time at home. And for a third group who understand that there is no possibility of recovery, it becomes a choice of the current existence in the ICU, rather than the alternative of death. It is fundamentally a cruel choice. Life in an ICU is a state of limbo, and invariably involves painful procedures — needle sticks, cleaning of wounds, suctioning of the airway. The distress is experienced by the patients themselves, but also by family members who visit day after day (or in COVID times aren’t even allowed to visit) and those providing care at the bedside. It is a Faustian bargain to buy just a bit more life. At times we are prolonging dying rather than saving life, as it is clear that there is no chance of returning to survival outside of an ICU. We have no tools to heal an entire body when it is so irreparably broken. We offer time, nutrition and supportive care. Studies that have looked at patients considered “difficult” to wean from the ventilator have found that some will go on to be liberated, but certainly not all, and up to half will be dead within a year [16,17]. The magic bullet that takes dying bodies and makes them live again has not yet been invented.
Almost 100 years ago Drinker and Shaw fundamentally changed the relationship between human and machine and made possible a symbiosis that saved Barrett Hoyt and literally hundreds of millions of people after him. But they also unleashed new technology that creates agonizing choices for patients, families, and clinicians and a tortured existence for some. We cannot and should not forget about this additional impact of COVID-19: a whole new wave of people, hearts aching, dealing with the uncertainty and challenges of persistent critical illness. Philip Drinker and his colleagues understood from the very beginning the potential dark side of his machine and we are still grappling with its legacy.
This article is a longer form version of an article published online on August 20, 2021 in First Opinion in STAT.
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