Scandinavia: Foundation of Modern Intensive Care Medicine

At the 2022 annual congress for the Scandinavian Society of Anesthesiology and Intensive Care Medicine (SSAI), Michael Pinsky, MD delivered three lectures, one of which drew the attention of Oslo journalist Leni Aurora Brækhus. His talk “European export of intensive care medicine to USA: The history of Society of Critical Care Medicine” and one by Hannah Wunsch, MD from the University of Toronto highlighted Scandinavia’s pivotal role in the growth of modern critical care medicine. Read the translated story from Dagens Medisin below.

Background: During the SSAI conference in Oslo on Thursday, June 9, 2022, Professor Michael Pinsky from the University of Pittsburgh and Professor Hannah Wunsch from the University of Toronto spoke about how the foundations of modern intensive care medicine were laid in Scandinavia in the 1950s.

Scandinavians should be proud to have invented intensive care
Scandinavian doctors who had to deal with polio outbreaks in the 1950s became pioneers in intensive care medicine, said an American and a Canadian professor during SSAI.

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, cases of severe polio appeared every year. Occasionally there were major outbreaks. The epidemics often came in the autumn. In Norway, polio epidemics peaked in 1951 with 2,233 registered cases, in which 1,563 patients developed significant paralysis. This outbreak led to 283 polio patients with paralysis being admitted to Ullevål hospital in Oslo alone.

But there was a major outbreak in Copenhagen in 1952 that led to several discoveries that helped to establish intensive care as a separate field, according to Professor Hannah Wunsch from the University of Toronto who spoke on Thursday during the conference Scandinavian Society for Anesthesiology and Intensive Care Medicine (SSAI) “Monitoring life.” She wrote a book about the polio epidemic in Copenhagen in 1952: “The Autumn Ghost - the battle against polio.”

Mortality of 87 percent
Poliovirus is highly contagious and almost everyone who comes in contact with the virus becomes infected. For most people, the viral infection is a trifle. Either they are asymptomatic or they get mild respiratory symptoms or nausea and diarrhea. However, some get serious illness, paralytic polio. The proportion can vary between one and 10 percent, Wunsch said.

The disease is most severe when the spinal cord or brainstem is attacked. In those who died of polio, the respiratory muscles had usually been paralyzed, which led to breathing problems and paralysis of the tongue and throat that could be very serious.

At that time there were no respirators, instead a large device called an "iron lung" was used. 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 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 had accumulation of gastric juice, which is very acidic and which was forced up into the esophagus and 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 iron lung increasing daily numbers of polio patients. 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. They were not even at the peak of the epidemic, but the doctors were desperate, Professor Wunsch said.

Superior Henry Cai Alexander Lassen called for a meeting, in which, among others, anesthesiologist Bjørn Aage Ibsen, who had had practiced at Massachusetts General Hospital in Boston, participated. Ibsen suggested a new approach where one should instead 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 12-year-old Vivi Ebert was admitted to the hospital with severe polio and very poor prognosis. Ibsen was allowed to try the treatment on her and managed to stabilize her. She lived until she was in her late 30s.

This was a turning point. Since the pumping of air into the lungs had to be done manually, there were no motorized 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 results were striking. By December 1952, the epidemic was coming to an end and they had succeeded in reducing mortality from 87 percent to around 33 percent.

"There is very little else that has reduced mortality to such an extent," said the University of Toronto professor.

Published in The Lancet
Chief physician Lassen published the findings in The Lancet in January 1953. And after the word came out, and the need for respirators became clear, there were many different ones on the market.

During some very hectic months in 1952, the Danish doctors had not only learned much about polio, they had also realized that gathering patients with breathing problems made it easier to offer good treatment. This insight led to the first intensive care unit, which received its first patient in Copenhagen in 1953.

When Sweden was hit by a polio epidemic in 1953, they had "Engström" type ventilators ready, Wunsch said. The experiences from Copenhagen led to the establishment of intensive care units throughout Europe, she added.

You should be proud
PROUD: Congress leader, chief physician and professor Tor Inge Tønnessen thinks far too few know that intensive care medicine was invented in Scandinavia 70 years ago and exported to the rest of the world. t is something to be proud of, he says.

The discoveries from Northern Europe were also exported to the United States, said Professor Michael Pinsky of the University of Pittsburgh when he told the story of 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 did 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 the audience here today. That is why we have 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.

Founded 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 USA and became very important for the development of the intensive care unit there. And Austrian Peter Safar, who brought 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 time the presidency 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.

Too much intensive care?
Professor Hannah Wursch said that this was also something that worried Chief Physician Ibsen. What if they could not get patients off the ventilator because they could not live without it? There were more and more such cases.

He talked about this in a radio interview in 1974 and was asked if the treatment in reality 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 said yes.

This led to large headlines in the newspapers, with headlines such as “Will a superior who provides euthanasia be charged with murder?” It bothered him, Wursch said. What is too much intensive care is still a challenge. But we have become better at knowing when it's time to end treatment.

Post-polio syndrome and long COVID
She also drew parallels between polio and COVID-19 in terms of the consequences of the diseases treated in the intensive care units. Twenty-five to thirty years years after an acute polio paralysis, part of what is called post-polio syndrome (PPS) is affected. We do not know for sure what it is due to. 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 severe physical limitations many years later, she explained. They thought they had moved beyond polio, then they get big problems later.

This is very scary when we to a certain extent know what ‘long COVID’looks like today but have no idea what it will look like in 20-30 years or what needs these patients will have then, Wursch said.

Polio patients back in the intensive care units?
Although vaccination has been a great success, polio has not been completely eradicated. There are still fewer outbreaks, and vaccine coverage is not as good anymore, she emphasized.

It may therefore be that we will again see polio patients in our intensive care units in the future. This is much more likely today than it was 20-30 years ago. She also pointed out, among other things, climate change that could lead to, for example, malaria appearing in new areas, and multi-resistant tuberculosis as increasing threats today. This is something we will see more of in the future, she said.