The Birth of Critical Care

Bjorn Ibsen, a Danish Anesthesiologist, had a problem. In the 1900s polio, once a quiet endemic pathogen, evolved into epidemics in Europe and North America. During the 1940s and 1950s the disease paralyzed or killed over 500,000 people every year. Lockdowns, similar to the COVID-19 lockdown in 2020, frequently occurred to stop the spread of the virus. The modern polio vaccine did not exist yet. In early 1952 Copenhagen was preparing for an unusually large polio epidemic. The problem was they didn’t have enough staff, money, or equipment. They were desperate for a solution.

Polio is a neurological disease. Its scientific name, poliomyelitis, is a combination of the Greek words “polio” meaning grey, “myelo” referring to the inside of the spinal cord, and “itis” meaning inflammation. Literally the virus causes inflammation of grey neurons located in the anterior (front) of the spinal cord. The virus is transmitted via fecal-oral route. It replicates in the gastrointestinal (GI) tract of its human host, then spreads to its next victim when the host touches other people or objects without proper hand hygiene. When inside its host it replicates in the GI tract then moves to the spinal cord, where it causes inflammation of motor neurons responsible for voluntary movement of the extremities.

In severe cases the virus can move up the spinal cord into the brainstem, called “bulbar polio”. Bulbar refers to the cerebellum, pons, and medulla; structures at the base of the brain. This disables the nerves responsible for moving the diaphragm and the victim suffocates. The paralysis usually improves over the course of 2 weeks;  however victims may have residual paralysis of their lower extremities. Since 1928 the iron lung, a rudimentary ventilator, was used to breathe for bulbar polio patients until their paralysis improved. Unfortunately for Dr. Ibsen the iron lung had several practical limitations: it was expensive, difficult to maintain, required a dedicated experienced operator, and patients’ secretions were difficult to manage; they sometimes aspirated into the lungs causing a severe chemical pneumonia. And there was only 1 iron lung in the whole city of Copenhagen. Every day 50 patients were admitted to Blegdam hospital and 6-12 of them developed bulbar polio. In the first three weeks of the Copenhagen epidemic 27 of 31 patients with bulbar polio died, an 87% mortality rate. Half of them were children.

Luckily Dr. Ibsen had a plan. First, polio patients who developed the severe bulbar form would be given tracheostomies. Tracheostomies are literally a “stoma”, Greek for “hole” in your trachea. Through the hole a plastic tube, called an endotracheal tube (endo means inside) would be inserted. The plastic tube was connected to a bag mask valve, a rubber bag that could be squeezed to force air through the endotracheal tube into the patient’s lungs. Ventilation could be achieved with easy management of secretions reducing the incidence of aspiration pneumonia close to zero. The bulbar polio patients were organized into a new ward: medical students squeezed the rubber bags for 24 hours a day in 6-8 hour shifts under supervision of doctors and nurses. At the height of the epidemic it had 105 beds. Furthermore he used recent advances in respiratory physiology to measure blood pH (indirect measure of carbon dioxide in the blood) in order in order to optimize their ventilation. From August to December 1952 about 3000 patients were admitted to Blegdam hospital for polio and 345 developed bulbar polio. The mortality rate decreased from 90% to 25% due to Dr. Ibsen’s innovative polio treatment. His use of positive pressure ventilation, organization of patients based on severity of disease, and efficient distribution of labor is considered the world’s first intensive care unit. Dr. Ibsen was the world’s first intensive care physician.

The first US polio epidemic occurred in 1894. 14 years later, in 1908, the cause of these epidemics was identified as poliovirus. The iron lung was invented in 1929 to prevent death from bulbar polio. For the first 42 years of polio outbreaks scientists did not have a way to study the virus; then in 1936 Dr. Peter Olitsky and Albert Sabin grew the virus in human embryonic brain tissue. This was the first time the virus was cultured. Later in 1949 Drs. John Enders, Thomas Weller, and Frederick Robbins grew poliovirus in embryonic skin and muscles cells. Finally in 1952 Dr. Jonas Salk and his team at the University of Pittsburgh invented the inactivated polio vaccine. By 1961, after 9 years of vaccination campaigns, only 161 cases were reported in the United States. 67 years had passed between the first polio outbreak and an effective vaccine.

Many people do not realize the March of Dimes, a charitable organization devoted to improving the health of mothers and babies, was founded by President Franklin Delano Roosevelt in 1938 as “The National Foundation for Infantile Paralysis” to raise money for polio treatment and research. He was afflicted by a paralytic illness at age 39, presumed to be polio, rendering him paraplegic. The name “March of Dimes” was coined by Eddie Cantor, an American entertainer. He popularized a fundraising campaign where anyone could buy a pin for a dime the week before FDR’s 56th birthday in January 1938. Within a week the White House received 40-50,000 letters and about $85,000 in dimes; $1.5 million in 2020 dollars. Over the next 20 years the foundation spent $233 million on polio patient care. About 80% of American polio patients received medical care because of the foundation alone. Because of his leadership in polio treatment and research, in 1946 the US mint placed FDR’s face on the dime, a design still present today. Go find a dime in your pants pocket! See for yourself!

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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