How the Modern ICU Was Galvanized By a Polio Epidemic
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How the Modern ICU Was Galvanized By a Polio Epidemic

; Hannah Wunsch, MD, MSc

Disclosures

August 15, 2023

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This transcript has been edited for clarity.

Eric J. Topol, MD: Hello. This is Eric Topol for the Medscape Medicine and the Machine podcast. We have a phenomenal guest today: Professor Hannah Wunsch from the University of Toronto, who authored a book called The Autumn Ghost. I had the chance to review her book in the June 6 issue of Nature. Welcome, Hannah.

Hannah Wunsch, MD: Thanks so much. It's such an honor to be on your podcast.

Topol: In The Autumn Ghost, how you were able to go back in history 70 years, in Denmark, and dig up all this stuff about polio? It's hard enough to do currently. But you did it in detail. You included photos of some of the kids who were hit, poetry that some of the patients wrote, the news clippings, going back to 1952 and thereabouts, the interphysician warfare, the egos. How did you do it?

Wunsch: It was a bit of a treasure hunt. I loved it for that. You start scratching the surface and digging, and you never know what threads you're going to get to pull and where they might lead you. For me, the real thrill was getting to find the people who were there, who were eyewitnesses, and also digging up film footage. You can't see that in the book, but I used it as resource material. There is film footage of the epidemic.

The Danes are famous for their great archival material, and records in general in their city archives. They had a book of all of the deaths in 1952 in the one hospital where these events took place. Paging through that, I could reconstruct so much of this. But at the end of the day, it was getting to talk to people who were there.

Topol: Wow. That was the Blegdam Hospital in Copenhagen?

Wunsch: Yes. It's pronounced "Bly-dam" in Danish. It was the infectious disease hospital for the city of Copenhagen and the surrounding areas and became the epicenter for this now famous polio epidemic in 1952.

Topol: Are you of Danish descent?

Wunsch: Not at all. I don't speak a word, and I'm terrible with languages. So, I would say in many ways, the hardest thing for me was not speaking with people, because everybody there speaks English but [I was] dealing with archival material in Danish.

You'll appreciate this as someone who loves artificial intelligence (AI). I was able to read huge swathes of material in Danish with Google Translate; I was much more careful with anything that ended up in the book, in which case I asked people to help me translate. So, my interest in the events there, and in Denmark and Copenhagen, was through the events of this epidemic and my interest in the medical history.

Topol: How long did it take to do all the research?

Wunsch: I think it was 3-4 years in total. In a weird way, I was helped by COVID because, although we were very busy in the hospital — I work in the ICU — there were also long stretches of downtime when I was at home, not doing normal activities. And a lot of older people became familiar with Zoom.

So I was able to do a lot of interviews with people during the COVID lockdown, because everybody was at home with nothing else to do. And people who wouldn't have been facile with that sort of technology before the pandemic were able to hop onto Zoom and allow me to interview them. I was able to do a fair amount of preparation work before I even went over to Copenhagen to do research in person. It was an odd silver lining to COVID.

Topol: We're going to talk a bit more about the parallels between COVID and polio, but before we do that, what I didn't know was the world of the intensive care unit (ICU) and how it was basically born because of polio. I had no idea.

As you portrayed it, it was remarkable what they discovered about positive pressure ventilation. Back then, all these medical and dental students were hand-ventilating the patients around the clock because there was no such thing as a mechanical ventilator. Something like 50 of these students would be breathing for the patients, basically, with an early Ambu bag or whatever.

I had no clue about all this. Or that it was thanks to polio that we have such a thing as an ICU, an appreciation for blood gases, mechanical ventilators, the interdisciplinary team, the respect for anesthesiologists. Can you take us through that? I don't think a lot of people really know how this all came together.

Wunsch: Even in my own specialty, which is critical care medicine, a lot of people didn't know this story, which is the origin story for the specialty. To put it into context, other people and factors at play were also pushing things in this direction. It's important to recognize that although I tell sort of a single story, it's never quite that simple.

But in the early 1950s, one of the things I had to appreciate and understand was just how little there was to do for people who were critically ill. There were iron lungs for people who had polio with respiratory failure. But with bulbar polio — difficulty swallowing, all of that — it was 90% mortality for those patients.

I stumbled on this story in a book called The Rise and Fall of Modern Medicine 20 years ago. It tells this story as an important pivotal moment in medical history when there's a major epidemic of polio in Copenhagen. They've seen a lot of polio over the years, but nothing like this. It was a particularly virulent strain, and it was just hitting an enormous number of people. By the time the epidemic was over, 1 in 200 boys aged 1 to 4 had been paralyzed by polio. The hospital had one iron lung, but they also recognized that iron lungs were not the solution because so many patients had bulbar polio.

The book is about early innovation, but it's also about modern innovation and the important factors involved for something to occur, like this major leap in figuring out how to keep people alive. In this case, it was bringing in an anesthesiologist by the name of Bjørn Ibsen.

At that point in time, anesthesiology was barely a specialty in Denmark. Anesthesiologists had been recognized only a year or two earlier, and they certainly were not involved in the care of polio patients. That was the domain of infectious disease doctors, maybe neurologists, but certainly not anesthesiologists.

Ibsen was the one who came in and suggested, Let's do a tracheostomy on your patients. I think carbon dioxide retention is killing them. If we take the techniques of the operating room, where we keep people alive with ventilation, and apply them to patients with polio, I think I can save many of your patients.

So, the crux of the story is what it took for them to let him try this. You alluded to the involvement of ultimately 1200 medical and dental students when they realized they had a technique that worked — positive pressure ventilation — but they didn't have ventilators yet. It still gives me shivers every time I imagine being one of those students sitting at the bedside. They did it in 6- to 8-hour shifts, 24 hours a day, for months. At one point, they kept 70 patients alive this way. It's a great story, but it's also an important story for people to understand how recently we didn't have these basic interventions that we consider part and parcel of modern medicine.

Topol: The transformation of modern medicine by polio is so incredibly well captured. I want to read a couple of passages because this is a Medicine and the Machine podcast. The machine here is mechanical ventilation and related life support.

Ibsen said, "That I could save the patient's life with such a simple method was one of the most incredible moments of my life. We had our first polio patient under control."

And then later, "The legacy of these polio patients continues in the care provided to millions of patients with a wide array of medical conditions across the globe who breathe with the help of mechanical ventilation and receive the complex multidisciplinary care delivered in ICUs worldwide." That is the story you told that is just so extraordinary.

Now I want to connect the dots, because what you didn't do was just get into the tech stuff. You brought out the humanity. That blew me away, because you had pictures and stories of the patients. You included poetry written by Rosa Abrahamsen, opening many chapters with it, and tracing her life. Another patient who was central was Vivi Ebert.

She had bulbar polio and was able to live 20 years longer, from age 12 to 32, because of the support she had. With so many patients, you brought out the humanity of what this meant. This was what made the book quite extraordinary to me. It wasn't just technology and innovation and the polio story. It was how you so vividly portrayed these people.

Wunsch: When you work in the ICU, you always have to be careful that you do remember that these are human beings in the beds. There is so much technology surrounding them that it's easy to see the tubes and the machines and think about everything that's going on around the individual. I think the biggest struggle we've had is to ensure that we continue to remember that we are caring for individual humans in those beds.

That's true of all medicine. I know that something you care about deeply is how we keep that humanity in the role of physicians. To me, there is nothing more fundamental in terms of a connection than the idea of sitting at the bedside, literally having that life in your hand, in terms of hand-ventilating someone and that connection to a patient.

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