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Founding father of intensive care and hero of the 1952 Copenhagen polio epidemic
The specialty of intensive care started in Copenhagen in 1952, when Bjørn Ibsen got a relay of doctors to manually ventilate a dying 12-year-old patient with polio.
Ibsen was working as a freelance anaesthetist as there were no staff posts. The son of a salesman, he had been educated at Øregård Gymnasium in Copenhagen, obtaining his baccalaureate in 1933, and Copenhagen University, qualifying in 1940. In his final year he gave his first anaesthetic, using the then standard equipment of a bag of ether, tongue forceps, and a mouth opener. Anaesthetics were delivered under the surgeon's supervision by a nurse or student.
At a Jutland hospital he trained in radiology, surgery, pathology, and gynaecology. He won a biochemistry prize in 1944. The hospital's only anaesthetic equipment was an Ombredanne inhaler, an ether device. He went to Massachusetts General Hospital in 1949 for specialist anaesthetic training. His wife, Ingrid, a nurse, accompanied him on the outward boat journey; on the ship back she met Mogens Bjømboe, deputy to Hans Christian Larssen, head of the Blegdams Fever Hospital. This was to prove a formative contact.
Danish hospital culture was formal and hierarchical, with surgeons at the top. At Massachusetts General Hospital the atmosphere was relaxed, residents having a refreshing combination of clinical freedom and good training. From legendary names, including Harry Beecher, Ibsen learnt the underlying principles of gas exchange in the lungs.
Ibsen returned to Copenhagen in 1950 as a freelance anaesthetist. His relationship with the surgeons was uneasy. However, a thoracic surgeon initiated a series of WHO training courses in anaesthetics, bringing in great names from around the world, which Ibsen greatly appreciated.
In 1952 at Blegdams Fever Hospital, Mogens Bjømboe was temporarily in charge when a baby with tetanus was admitted. Remembering his meeting with Ingrid Ibsen on the ship, he sent for Bjørn Ibsen. They jointly decided to paralyse the baby with curare to abolish the tetanus spasms and ventilate by hand. The baby did well until it was transferred to the standard regimen of controlling the spasms with sedation, and died; but a lesson was learnt.
A few weeks afterwards, Copenhagen had one of the world's worst polio epidemics—2899 cases in a population of 2m. Fifty or more patients a day were admitted to Blegdams Hospital. Too weak to cough, many patients drowned in their own secretions. Larssen, the chief physician, sought Ibsen's advice.
Ibsen had recently anaesthetised a patient with a tracheostomy and discovered how easy it was to intubate a patient who already had a free airway. He had learnt in Boston that inadequate ventilation caused carbon dioxide retention with hypertension and sweating, and recognised these symptoms in patients with polio. Patients were dying not from kidney failure but from carbon dioxide retention. He proposed that patients were given a tracheostomy with an airtight seal, which would keep saliva out of the lungs, which could be cleared of secretions and ventilated with positive pressure. He proposed adding a carbon dioxide absorber and used equal parts oxygen and nitrogen in case ventilation became inadequate.
Larssen was sceptical but relented when he saw a dying 12-year-old quadriplegic girl with a collapsed left lung gasping for air and drowning in her own secretions. Ibsen did an immediate tracheostomy and inserted a cuffed tube, attaching a to and fro absorption system, which gave good suction. Bronchospasm and secretions still made it impossible to reinflate the lungs. Desperate, he gave her pentothal to stop her struggling. She stopped breathing and collapsed, and he found that in this state he could inflate her lungs.
Returned to the tank ventilator, her underventilation returned and she became cyanotic. Oxygen improved her colour but her carbon dioxide continued to rise. She was taken out of the ventilator, and manual ventilation improved her again. The lesson was obvious.
Ibsen and Larssen moved patients needing ventilation to dedicated wards. Surgeons, anaesthetists (including the 20 WHO trainees), and medical and dental students were trained to aspirate secretions and perform manual ventilation in shifts of six hours. At the height of the epidemic, 70 patients were being manually ventilated. In all, 1500 students put in a total of 165 000 hours, and mortality plummeted from 80% to 25%.
Other countries took note, and the British Journal of Anaesthesia suggested that a similar scheme should be adopted in the United Kingdom. Thus began the concept of intensive therapy.
After the epidemic subsided, a Kommunehospital surgeon appointed Ibsen to organise an anaesthetic service there. A year later, in 1954, he was appointed consultant anaesthetist, in charge of his own department, with the same salary as his surgical colleagues. This gave Ibsen the financial security that enabled him to pursue his interest in intensive therapy. With the realisation that having intensive treatment facilities for different diseases was a waste of resources, the first intensive therapy unit was opened under his supervision in the Kommunehospital on 1 August 1953. It was copied around the world. His interests progressed to monitoring and, when acute medicine was moved away from the hospital in 1975, towards pain management.
Ibsen was on the editorial board of Acta Anaesthesiologica Scandinavica from its inception in 1961. He was awarded the Danish poliomyelitis medal and anaesthetic medal, and the Purkinje medal from Czechoslovakia. He was a corresponding member of the Society of Anaesthetists of Great Britain and Ireland, and was the first honorary member of the European Resuscitation Council. He wrote two textbooks on anaesthetics and intensive care in Danish (1950 and 1959), From Anaesthetics to Anaesthesiology in 1965, and a memoir, Gensynsglæde (“The Happiness of Reunions”), in 1990. His wife died in 1984.
A full account of Ibsen's work is given in Anaesthesia and the Practice of Medicine: Historical Perspectives, by Keith Sykes and John Bunker (RSM Press 2007), to which I am indebted.
Bjørn Ibsen, anaesthetist and intensivist, Rigshospitalet, Kommunehospitalet, and Anaesthesiology Centre, Copenhagen (b 30 August 1915; q Copenhagen 1940), d 7 August 2007.