– Scandinavians should be proud to have invented intensive care – News, Primary Health Service, Infections, Congresses
SSAI, OSLO (Dagens Medisin): In the 20th century, polio was one of the most feared diseases in Scandinavia. Before there was a vaccine against the disease, some cases of severe polio appeared every year. Occasionally there was a major outbreak. The epidemics often came in the autumn.
In Norway, polio epidemics peaked in 1951 with 2233 registered cases, in which 1563 patients developed significant paralysis. This outbreak led to 283 polio patients with paralysis being admitted just at Ullevål hospital.
But it was a major outbreak in Copenhagen in 1952 which led to several discoveries which helped to establish intensive care as a separate blanket.
This was stated by Professor Hannah Wunsch from the University of Toronto on Thursday during the conference Scandinavian Society for Anesthesiology and Intensive Care Medicine (SSAI) «Monitoring life».
She wrote the book about the polio epidemic in Copenhagen in 1952: «The Autumn Ghost – the battle against polio».
Mortality rate of 87 percent
Poliovirus is highly infected and virtually everyone who comes in contact with the virus becomes infected.
But for most people, the viral infection is a trifle. Either they are asymptomatic or they get mild symptoms in the airways or as nausea and diarrhea.
But no one gets serious disease, paralytic polio. The proportion can vary between 1 and 10 percent, Wunsch said.
The disease is most severe when the spinal cord or brain stem is attacked. In those who died of polio, the respiratory muscles had usually been paralyzed, which led to breathing problems, but also paralysis of the tongue and throat could be very serious.
At that time there were no respirators, they used a large device called «iron lung». The patients were placed in a chamber where negative pressure was created on the outside of the body, so that the chest and lungs expanded and the air flowed into the lungs. This worked well in some patients, but was less suitable in patients who had severe disease in the lung tissue itself, or collection of gastric juice which is very acidic and which is pressed up into the esophagus and passes into the lungs (aspiration). This can cause the lungs to be damaged and it also gives rise to infection which eventually became the most common cause of death in these patients.
In Copenhagen, however, they had only one such iron lung, and the number of polio patients increased day by day.
At Blegdam Hospital, they received 50 infected people daily, and every day 6-12 of them developed respiratory failure. By mid-August, 27 of 31 patients with the most severe form of polio – which affected the brainstem and / or spinal cord – had died. A mortality rate of 87 percent. About half were children.
– Then they were not even at the top of the epidemic, but legends were in despair, Professor Wunsch said.
Success
Superior Henry Cai Alexander Lassen called in for a meeting attended by, among others, anesthesiologist Bjørn Aage Ibsen, who had had practice at Massachusetts General Hospital in Boston. And Ibsen suggested a new approach, where one should rather blow air directly into the lungs of the patient. He wanted to use tracheotomy, which at that time was only used during surgery.
The next day came 12-year-old Vivi Ebert who had severe polio and severe prognosis. Ibsen tried to treat her and managed to stabilize her. She lived until she was in her late 30s.
This was a turning point. But since the pumping of the air into the lungs had to be done manually, there were no motor respirators, medical students were put to work, for which they were modestly paid, Professor Wunsch said.
Around 1,600 students worked in shifts for several months, and the overall result was striking. Before December 1952, the epidemic was coming to an end. By then, they had succeeded in reducing mortality from 87 percent to about 33 percent.
– There is much else that has reduced mortality to such an extent as a professor at the University of Toronto.
Published in The Lancet
Chief Physician Lassen published the findings in The Lancet in January 1953. And after the word came out and it is necessary for respirators to be clarified when there are many different ones on the market.
During some very hectic months in 1952, I had not learned much about polio from the Danish Games. They had also suggested that gathering patients with breathing problems made it easier to offer good treatment. This insight led to the first intensive care unit being able to receive its first patient in Copenhagen in 1953.
– When Sweden was hit by a polio epidemic in 1953, they had fans of the type “Engström” ready, Wunsch said.
– The experience from Copenhagen led to the establishment of intensive care units all over Europe, she added.
– You should be proud
The discovery from Northern Europe was also exported to the United States when Professor Michael Pinsky of the University of Pittsburgh told the story to The Society of Critical Care Medicine (SCCM) in the United States during the congress on Thursday.
– You in Scandinavia should be proud of the work that was done here. That led to what we have since done in the United States, said Professor Pinsky.
– The early research was done in Scandinavia. Not only have you started the field of intensive care, you also continue to lead the development. Thank you very much for that, he continued.
According to conference organizer Tor Inge Tønnessen, who is chief physician at Rikshospitalet and professor of anesthesia and intensive care medicine at the University of Oslo, not many people are aware of how important Scandinavia has been for the development of the field of intensive care medicine.
– There are far too few who know this story. I would think it was unknown to belong to her today. That is why we included it in the program this year, he told Dagens Medisin.
– I completely agree that this is something we should be proud of, he added.
Found SCCM
In addition to the previously mentioned Bjørn Aage Ibsen, Pinsky highlighted Danish Henrik Bendixen and Swedish Ake Grenvik as Scandinavians who moved to the United States and gained great importance for the development of the intensive care unit there. And Austrian Peter Safar who took the concept of having his own intensive care unit to Baltimore City Hospital, where he started the United States’ first «ICU».
The three were among the founders of The Society of Critical Care Medicine (SCCM) in 1970, and all had at one point served as president of the SCCM, said the professor, who has worked in intensive care throughout his career.
– Grenvik was one of those who started the debate about whether it is right to keep people alive just because we can. He also introduced the concept of brain death, Pinsky said.
For a lot of intensive treatment?
Professor Hannah Wursch said that this was also something of a concern for Chief Physician Ibsen. What if they failed to get patients off the ventilator because they could not live without it? It became more and more cases.
He talked about this in a radio interview in 1974, and was asked if the treatment actually prolonged the death process. “Yes, and often it would be more humane to give morphine, peace and comfort to patients who have no hope of survival,” Ibsen replied. When asked if he had done so, he answered yes.
This led to large headlines in the newspapers, with headlines such as “Will the superior who provides euthanasia accused of murder?”. It bothered him, Wursch said.
– What is a lot of intensive care is still a challenge. But we have become better at knowing when it’s time for finished treatment.
Postpolio syndrome and “long covid”
She also drew parallels between polio and covid-19 when it comes to the consequences of the disease being treated in the intensive care unit.
25-30 years after an acute polio paralysis, part of what is called postpolio syndrome (PPS) is affected.
– We do not know for sure what caused it. Is the polio virus left? Exhausted Neurons? Or an autoimmune response to the virus?
What is certain is that many polio patients who have apparently done well and have lived with normal physique for many years, have had major physical limitations many years later, she explained.
– They thought they had managed through polio, then they get into big trouble later. This is very scary when we to some extent know what “long covid” looks like today, but not others what it will look like in 20-30 years or what needs these patients will have then, Wursch said.
More from the congress: – Games are not good enough to seek help
Polio patients left in the intensive care units?
Although the vaccination has been a great success, the polio has not been completely eradicated.
There are still minor outbreaks and the vaccination is not as good anymore, she said.
– It may therefore be her we will again see polio patients in our intensive care units in the future. This is much more likely today even 20-30 years ago.
She also pointed out, among other things, climate change which can lead to e.g. malaria is emerging in new areas, and multidrug-resistant tuberculosis as increased threats today.
– This is something we will see more of in the future, she said.