Extreme Medicine (14 page)

In 1952 there was no drug or vaccine that physicians could set against polio. When outbreaks hit major cities, they created tragedies of the grandest proportion. Thousands were infected and many hundreds left paralyzed or dead. Clinicians in general became nihilistic in their attitudes to the disease. Medicine, it seemed, had little or nothing it could offer.

But there was a distant hope—that the respiratory system could be supported artificially with ventilators, as a temporary bridge to survival, while the virus ran its course. For this the world of medicine would turn to the fledgling specialty of anesthesia.

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D
URING AN INTERVIEW FOR A JOB
with a cardiothoracic unit, an anesthetist was once asked by a rather pompous surgeon what she thought her role was within the surgical team. “Oh, that's easy,” she replied. “It's like an aircraft. I fly the plane, and you do the in-flight entertainment.” Apparently she still got the job.

There's much more to the art of anesthesia than injecting a drug and making the patient count backward from ten. Anesthetists fly human physiology as pilots fly planes. While you're awake and conscious, your physiology is largely under automatic control, just like a passenger airliner on autopilot. The intricacies of your cardiovascular and respiratory systems are held neatly in balance with your kidneys, gut, liver, and the enormous complexity of your brain. Your body's autopilot—its system of autonomic control and feedback loops—is pretty good at the job. In health it keeps things running on an even keel, night and day, beat to beat, even when you're asleep. Evolution has allowed thousands of biological processes to be seamlessly integrated and orchestrated under automatic control, so that you can go about your business and do the stuff of conscious thought without having to be bothered by pesky things like stopping to remember to make yourself breathe or keep your heart beating with the right rate and force.

But the unconsciousness of anesthesia is something other than sleep. It's a little bit like rebooting that autopilot midflight and giving the aircraft over to someone else for manual control. In the same way that the captain of the plane takes over control to gently navigate around bad weather, so the anesthetist must wrest control of physiology from the patient in order to navigate the hazards presented by surgery, injury, and disease.

This ability of anesthetists to support and replace the function of organ systems artificially was vital to the creation of the new specialty of intensive-care medicine.

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T
HE SCALE OF THE 1952
D
ANISH
polio epidemic was unprecedented. In Copenhagen over three thousand people were infected, among whom more than a third showed signs of paralysis. The number of these patients suffering with respiratory failure was higher than in any other European outbreak. Copenhagen boasted several large municipal hospitals, but there was only one, the five-hundred-bed Blegdam Hospital, that was equipped to deal with infectious diseases.

Toward the end of the summer, the polio epidemic was in its fullest throes. Henry Cai Alexander Lassen, professor of epidemiology at Blegdam, charted the progress of the outbreak and was shocked by the tidal wave of disease and death that flowed through the hospital's doors. Among the facility's staff, there was frank desperation; the disease appeared to defy any conventional treatment. In the first three weeks of August, thirty-one patients suffering with paralysis of the muscles of breathing and swallowing were treated at Blegdam. Despite the hospital's best efforts, all but four died. Desperate for a measure that might turn the tide against the virus, one of Blegdam's physicians, Mogens Bjørneboe, recalled the work of an innovative young doctor named Bjørn Ibsen, who was interested in anesthesia and artificial ventilation. Ibsen was a freelancer among the hospitals in Denmark, and Bjørneboe had worked briefly with him earlier that year in treating and ventilating a newborn suffering with tetanus. The child did not survive, but the intervention itself appeared to Bjørneboe to have worked, at least briefly. Ibsen was promptly summoned.

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T
HREE YEARS EARLIER,
in 1949, Bjørn Ibsen had traveled to Boston to train as an anesthetist at Massachusetts General Hospital. He spent a year there and returned to Denmark with new skills and insight. He was nothing if not unconventional. He chose anesthesia over more traditional careers—a bold move in a world that wasn't yet ready to acknowledge that this was a specialty worthy of the attention of qualified doctors.

He returned to Copenhagen in 1950 to find his former tutors scornful of his experience. The University Hospital of Copenhagen regarded Ibsen's sojourn abroad as though it were time spent in the wilderness. “You have been away from the fountain of life for one year,” remarked a professor of surgery. “Let us hope you can catch up with what you have missed.” Despite these verbal assaults, Ibsen thought that the anesthetist might find a role well beyond the walls of the operating theater. After all, the experience of resuscitating a patient bleeding to death from a brisk hemorrhage or managing the life-threatening side effects of primitive anesthetic agents gave the anesthetist fraternity an appreciation of real-time applied physiology that was otherwise lacking in medical practice.

But Ibsen—having witnessed isolated cases of polio and with firsthand experience of the slow suffocating death that it brought—was most interested in the anesthetist's ability to take over a temporarily compromised organ system.

During the polio epidemic in Copenhagen, the most fortunate among the patients were treated with artificial ventilators called iron lungs, which assisted breathing by helping the patient's chest expand. These devices were half-cylindrical vacuum chambers, large enough to accommodate an adult. They were constructed so that a patient could lie sealed inside with only the head protruding through a hole in the top, sealed around the neck with rubber. The pressure inside the cylinder, and therefore inside the patient's lungs, could be reduced to below that of the outside air, creating a partial vacuum in the patient's chest and sucking air into his or her lungs through the mouth and nose. In this way the iron lung devices mimicked the normal mechanism of the lungs, using reduced pressure inside the chest cavity to suck air in from outside. This became known as negative-pressure ventilation.

Ibsen realized that iron lungs were effective but cumbersome, expensive, and, when it came to the hospitals of Copenhagen, in desperately short supply. Their use was severely rationed, and during the polio outbreaks, doctors had the unenviable task of deciding who, among the dozens of victims, should be given this chance of life and who should be left to die. So scarce was the resource that even when the iron-lung ventilators were employed, they were often used too late to make a difference.

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W
HILE THE WORST CASES OF POLIO
in the Copenhagen epidemic were proving almost invariably fatal, Ibsen was nevertheless confident that the skills and knowledge he had acquired while in the United States could save lives. Ibsen believed that the early failures seen at Blegdam were partly attributable to clinicians' poor understanding of both the disease and its effect on human physiology.

No one seemed sure why these patients were dying. The sickest patients were drowsy and febrile, to the point where some of the doctors assumed that polio was causing infection and inflammation of the brain.

But Ibsen disagreed. The drowsiness and rapid heart rate, he believed, were not the result of encephalitis caused by polio but the consequence of high levels of carbon dioxide accumulating in the bloodstream.

In addition to bringing fresh oxygen into the body, the lungs are also responsible for expelling carbon dioxide. Deficient levels of oxygen in the bloodstream can, in part, be treated by increasing the amount of oxygen inhaled. The expulsion of carbon dioxide from the lungs depends much more heavily upon the rate and depth of breathing. Ibsen measured the levels of carbon dioxide in the bloodstreams of the sickest polio patients. Levels of oxygen appeared to be normal in these patients, but carbon dioxide had, in contrast, accumulated to many times its normal level.

Artificial ventilation was the answer, Ibsen was sure of it. He had taken great interest in the work of Dr. Albert Bower and his colleagues in Los Angeles, who had described their ventilation of polio sufferers with iron lungs and how this had reversed their prognosis from 90 percent mortality to nearly 80 percent survival in less than four years. If the Danish polio patients suffering with paralysis of the muscles responsible for breathing and swallowing could be similarly ventilated, then perhaps they could hope for the same success rates.

But iron-lung machines were bulky and hugely expensive—about the same price as the average 1950s family home. Blegdam Hospital possessed only three.

A cheaper, more widely available alternative would have to be sought. Here Ibsen fell back upon his experience in the operating room. He knew that patients could be ventilated by passing a tube into the trachea, connecting a rubber bag to the end of the tube, and then allowing oxygen to run into the assembly. When squeezed, the bag would push fresh oxygen into the lungs, thereby inflating them. When released the elastic recoil of the lungs expelled air laden with carbon dioxide through a valve. This method of ventilation moved air into the lungs by applying positive pressure from the outside rather than trying to replicate the work performed by the respiratory system in generating negative pressure within the chest. Ibsen was sure that this would work outside of the operating room, too. The scheme required little equipment and so could offer a lifeline to dozens of patients rather than the few who could be serviced by the handful of iron lungs that the hospital possessed. But Ibsen's method would first have to be demonstrated and proved before his physician colleagues would accept it. He would not have to wait long for the opportunity.

Just a few days after Ibsen first arrived at Blegdam Hospital, he was referred the case of a twelve-year-old girl whose limbs and chest were paralyzed and who could not swallow. Breathless and unable to deal with the saliva in her mouth, she was choking on her own secretions. Her case was nearly identical to that of the twenty-seven patients who had died in the previous month. Without intervention, it seemed certain that she, too, would die.

Ibsen took her to the operating room and persuaded a surgeon to perform a tracheostomy, making a hole in the neck, around an inch below the Adam's apple, which could admit a breathing tube.

The surgery proved difficult. They had injected a local anesthetic agent into the skin where the incision had been made, but the girl was agitated and fought against the medical team. The surgical wound bled back into her airway, soiling her lungs and adding to her distress. By the time the tracheostomy was complete and Ibsen's rubber breathing tube had been inserted through the new opening, she was in extremis, with Ibsen wrestling to retrieve the situation. His colleagues, who had gathered to observe his efforts, assumed that they were merely witnessing the futile efforts of a physician to revive yet another patient dying of poliomyelitis. One by one they turned their backs and left the room.

Ibsen had to think quickly. The girl on the operating table before him was suffocating. The tube connecting her lungs to Ibsen's rubber bag was in place and free of obstruction. But she was now distressed and fighting against Ibsen's efforts to squeeze air into her lungs. With no air entering or leaving her chest, the oxygen in her bloodstream was dwindling while carbon dioxide was on the rise. If she was to survive, he would have to stop her from fighting against him and take over her breathing completely. Ibsen injected sodium thiopental, an anesthetic agent, and within seconds her body had gone limp. Now for the first time able to squeeze air into her lungs, Ibsen could make headway. Asleep and unable to resist Ibsen's efforts, she was finally breathing—albeit artificially and with his assistance. The color returned to her face, and as the carbon dioxide fell, her heart rate stabilized.

Ibsen's physician colleagues returned to the room, incredulous that he had rescued a child who a few minutes earlier had been so clearly at the point of death.

The hospital wasted no time. Ibsen's technique was adopted, and within eight days, the wards were filled with patients being ventilated using this technique. Armies of medical students and nurses were recruited to assist in the task; standing by bedsides, squeezing bags in shifts, day and night, they provided artificial ventilation to dozens of patients at a time.

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U
P UNTIL THE MIDDLE OF THE
twentieth century, medicine was mostly about the treatment of chronic illness: consumption, cancer, syphilis, arthritis, and the like. Short, severe illness was generally fatal. Survival was rarely attributable to heroic medical intervention. With the exception of a few genuine medical emergencies that could be solved with a knife, there was little that the art of medicine could put in the way of critical illness. The idea that medicine might be in the business of buying the patient time by supporting their vital organs against the onslaught of overwhelming disease was almost entirely alien. But Ibsen's pioneering work in the field was to have far-reaching consequences. What Ibsen started by organizing patients into intensive wards of care during the Copenhagen polio epidemic came to underpin the frontiers of modern medicine. In time, intensive care allowed us to stretch and protect human physiology well past the previously accepted limits of survival—paving the way for more ambitious surgeries and more aggressive medical therapies.

And poliomyelitis was by no means the last viral epidemic to threaten the world.

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O
N
M
ARCH 11, 2003,
C
ARLO
U
RBANI
was on his way from Hanoi to Bangkok, attempting to relax after what had been a frenetic and exhausting fortnight.