Preface
“That cold Irish evening, through the dark mist of my final Guinness, I started writing this book. It is not a book filled with joy – indeed, there will be sadness – but there is always hope. I will take you on a journey to the light and the dark places that critical ill patients visit. Even in death, glimmers of the future can reflect in the smallest of spaces. I will borrow the bodies, the lives and the families of real patients I have met, and I will use them to shed light into these deep cracks where life meets death…”
“We will experience the inner workings of the physical ICUs well as my mind as a doctor working within it. You will experience the sounds, smells, and sights of the most dramatic area of the hospital. We will travel through the main organ systems of the human body, find out how we can keep people alive without a pulse, and what happens when a patient becomes brainstem dead. I will share with you the highs and the lows that patients, families and healthcare staff witness through the course of fighting human fragility. While the lows can be dark, I am privileged to support patients and their families while they stand at the brink of their existences. Through this lens, I am reminded daily of the beauty of life…”
Extracts and Excerpts from the Preface, quote Dr Matt Morgan, January 2019
Welcome to the World of Intensive Care Medicine
It was a beautiful and sunny August evening in Copenhagen as Vivi danced in her garden after returning home from school. She was a happy twelve-year-old girl, with sandy-golden hair and apple-red cheeks. Life was tough since her parents had separated; her mom struggled to make ends meet working as a hatmaker. She watched her daughter through the window, dancing barefoot on the grass as she giggled and smiled to herself. Forty-eight hours later, Vivi was about to die. This is the story of the people, practices and technology which allowed her instead to live. Her journey was the first step along a sixty-five-year-long journey that now enables us to enjoy life in the face of devastating critical illness. This is the story of how intensive care can save your life. Vivi didn’t notice the moment earlier that day when a water droplet landed on her hand. Nor did she know that a million copies of the deadly poliomyelitis virus were in that water droplet as she rubbed her eyes at night. As her mother’s lullaby sent her to sleep, the virus started its work. It travelled from her hands to the cells in her mouth, before passing through the cell membranes.
As the sun went down, the virus infected her tonsils, the lymph nodes in her neck and finally her intestines. By the morning Vivi had a head ache which stopped her from dancing. Her mom’s cool hand felt Vivi’s hot head and rubbed her stiff neck. The next day Vivi struggled to fasten buttons on her summer dress. Her fingers moved clumsily at the end of two heavy, weak arms. After being taken to the local Blegdam Hospital, she stopped responding to her name, as breathing became rapid and shallow. Soon Vivi met the man who would save her life. He was the world’s first intensive care doctor, Dr Bjorn Ibsen.
Dr Ibsen was a 36-year-old anaesthetist when he met Vivi. It was clear to him that she was suffering from acute severe polio. Twenty-seven people had already died of the disease in just the first two weeks of the Copenhagen polio outbreak in 1952. Before its end, more than three hundred people would contract polio, a third with the severe respiratory failure that Vivi was developing, with 130 people dying as a result. Dr Ibsen knew that the so-called iron lung – the last machine that could save Vivi – was already in use. This machine was Vivi’s only last chance of surviving the illness that had caused her respiratory muscles to become too weak to turn the air around her into breath. The iron lung created an airtight seal between a patient’s chest and the outside world, allowing a powerful air pump to make a vacuum that would suck out the chest wall and cause air to flow into the lungs through the windpipe.
Dr Ibsen felt helpless as he watched Vivi’s breathing become even shallower. The buildup of dissolved carbon dioxide gas in her bloodstream, normally removed by breathing, pushed her blood pressure ever higher and depressed her consciousness so much that much she could no longer stop her saliva from choking her. Dr Ibsen decided to do something radical that would change medicine for ever.
In an operating theatre, Dr Ibsen’s job as an anaesthetist was to administer powerful drugs that would render a person unconscious and then to use other drugs to stop all muscle contractions, including those of the breathing muscles. Only under these circumstances could a surgeon safely perform complex operations that required still and controlled access to the inside of the human body. To keep a patient alive in the meantime, Dr Ibsen would need to breathe for his patients by inserting a plastic tube into the trachea, or windpipe. Although normally inserted through the mouth or nose, occasionally a tube would be inserted directly into the trachea through the front of the neck – a procedure known as tracheotomy. For Dr Ibsen, Vivi’s condition mirrored that of the patients he cared for every day. The difference here was that the muscle weakness was caused by the polio virus acting directly on the motor nerves and spinal cord that normally supplied Vivi’s muscles with instructions. However, the solution was the same, and at 11.15 a.m. on 27th August 1952 Dr Ibsen took Vivi to the operating theatre, organised an emergency tracheotomy, attached her pipe in her trachea to an inflatable bag that he then squeezed, forcing air into the lungs using positive pressure.
This is the opposite of how humans normally breathe. Take deep breath in right now and feel the large muscle in your abdomen, your diaphragm, pushing down while simultaneously the muscles between your ribs contract, pulling them upwards and outwards. Together this creates a negative pressure in the layers between the elastic lungs and the inside of the ribcage. This pressure is transmitted to the lungs, pulling them outwards, dropping the pressure in the 500 million tiny air sacs inside, and thus drawing in air. This is the moment when air becomes breath. Instead, though, Dr Ibsen was squeezing a bag to push air into the lungs, much like what happens if you hang your head out of a fast-moving car’s window and open your mouth. After one breath, Vivi’s chest went up and then down. The second breath was easier than the first, and by the tenth breath her heavy eyes opened and she saw through life’s windows once again.
It is often the simplest ideas in life that lead to the most profound change. This was one such moment. To sustain and not just save a life, Dr Ibsen needed to take the next important step – to create a safe place in which to keep Vivi and gather a team of people to care for her by squeezing the bag until her respiratory muscles had recovered. No one knew how long this might take. In fact, it took a team of medical students working shifts of up to eight hours each, continuously squeezing the bag – not too hard, not too softly – for months in a small temporary hospital ward to keep Vivi alive.
This was the world’s first intensive care unit, requiring over 1,500 volunteer medical students to squeeze Vivi’s bag and then the bags of countless other patients day in, day out for six months during the Copenhagen polio epidemic. Finally, in January 1953, the bag was replaced with a dedicated mechanical ventilator that would breathe for Vivi.
Against the odds, and despite being unable to move from the neck downwards, Vivi survived. Seven long years after becoming ill, she left hospital and moved into a newly built apartment complex with her mother that allowed her to live attached to her breathing machine twenty-four hours a day. Vivi was an extremely happy, lively and brave young lady. She had a passion for reading, using a stick in her mouth to turn the pages of her favourite books, and she would paint jewellery by using a paintbrush held between her teeth. She often travelled to family parties, always accompanied by heavy batteries strapped underneath her wheelchair to power her mechanical lungs, and her beloved Border collie, Bobby would help her pass the time while looking over the skyline of Copenhagen from the twelfth-floor apartment block. In time Vivi formed a special bond with one of the male carers, and the pair fell in love and were soon engaged, finding respite from the reality of Vivi’s situation by spending long summer days together at a family summer house along with her dog Bobby.
Despite years of Vivi’s years of extensive rehabilitation ands care, the ongoing burden of disability that often accompanies survival; form critical illness prevented her from regaining her full independence. Yet Vivi did not let the challenges she faced cast a shadow over what she had been gifted. Her mom had her daughter back, Vivi had her life back, and Dr Ibsen never looked back. Nor would medicine.
“The emergency department is colloquially known as the hospital’s ‘front door’. It is the main route of entry for patients arriving by road or air ambulance, for patients self-presenting in an emergency or even for patients rolled out from a speeding car as I once witnessed. Those whose measurements of their physiological signs – including heart rate, blood pressure and conscious state – lead to them being assesssed as critically ill are taken directly to an area called ‘resus’ in the emergency department. Short for ‘resuscitation’, this zone has individual patient bays ideally set up to care for the sickest of patients in an efficient, timely manner. Each area in resus has emergency drugs on stand-by, equipment to put you onto a life-support machine close at hand, and a high ratio of staff all trained and ready to save your life. It is like a miniature ICU that needs to act fast but only for a short period of time. Some doctors specialise in treating patients at this stage of their journey and call themselves resuscitationists. Intensive care doctors will visit resus when critically ill patients are referred to them.
Resus is often the most exciting and dangerous point of care for patients as they arrive from the tangled outside world, covered in dirt, blood and jeans and with little prior information to go on. “If you panic, they panic and others panic – and panic has never saved a life.”
Source: Critical – Dr Matt Morgan
Photo Credit:
Scriveners Online© 