Online Resource 2:
Interview with Prof. Björn Ibsen
The interview with Prof. Ibsen was conducted on July, 16th 2006 in Danish.
(Translation: Louise Reisner-Sénélar)
B.I.: First, I would like to emphasize that I was very young when I began at the “Rigshospital”. I then quickly realized that it would probably take me one hundred years before I could hold a job as a Senior physician, There were just so many colleagues who would be prioritized before me. I therefore turn back to Trier Mørch, at this time he was the only specialized Anaesthesiologist in Denmark and he had been trained abroad.
Thanks to his support, I trained for one year under Harry Beecher at the Massachusetts GeneralHospital in the United States. When I came back, I got hired as a so-called anaesthesia physician at the Rigshospital. I earned back then 50 crowns per anaesthesia. A little later I moved to the CommunityHospital where the surgical head doctor was Mikkelsen. He had two junior doctors of first grade called, Vandall and Roeg. Vandall had studied in the United States and disagreed with Roeg whether a recently operated patient could be treated with 10% NaCl. Roeg however, gave his patients by principle, 100-500 cm3 10% NaCl intravenously. One day, a patient in very bad condition was admitted and Mikkelsen asked me to take the patient over in order – as he said – to write down a procedure for the treatment. Just at that moment, I finished to set-up a 10 bed recovery room which had been formerly used as training room for the Nurses. So the room had a big blackboard on which I started to write down the measured values of the patients. Afterwards I added the values I estimated to come-up next day and asked Roeg to follow my example. My predictions proved to be more accurate and eventually the patient also recovered. Afterward, however, I had to listen to a typical surgeon remark: "If you would have followed the treatment I had recommended, the patient would have simply recovered faster. That’s how the intensive therapy began for me. Gradually, they left me in charge of the most affected patients and the recovery room developed slowly into a small intensive care unit.
3-4 Months after the polio epidemic the first position as professor of anaesthesia was created at the Rigshospital (Chief Physician). I was highly interested to get the position, but could not exhibit the same amount of scientific papers as my competitors. This was also due to the fact that I was very busy during the Polio were I spent a lot of time treating Lassen’s patients. When I asked Lassen to support my candidacy at the Rigshospital with a written recommendation, he turned off my request with the following sentence: "it’s always the generals who win battles, you should know that. If you had not worked for me, you would not have come up with theses solutions and treatments!”! In my memories, Lassen will always remain in connected to that sentence.
L. R-S.: You received finally the opportunity to start at the Kommunehospital?
Yes, I finally came to the CommunityHospital. This has actually not been simple: In the minds of many, Henning Poulsen’s candidature was highly favoured, until a vacancy as senior consultant including a Professorship was announced at AarhusCommunityHospital. During a four eye conversation I let Poulsen understand that I was not interested in the Aarhus job. Thereafter, Poulsen decided to go for Aarhus and I became senior consultant at the CommunityHospital.
At that time, it was so that for each patient whose blood values had to be tracked, a sensor and a wire had previously to be purchased and connected - with many time consuming adjustments – to our own amplifier and recorder. I could not accept this unnecessary loss of time and therefore asked an engineer, to develop an apparatus that could perform all measurements simultaneously.
What you could compete with the new apparatus?
Oxygen, carbondioxide and the other useful things. The apparatus was, however, so huge that it was easier to bring our patients to it than vice versa. At the same time more rooms were granted to my anaesthesia department allowing more patients to be admitted to the intensive therapy, that’s how the ICU actually started. Of course one could immediately come up with the question why I became chief physician of a new anaesthesia department.
Well, it happened like this: There was no independent anaesthesia department. We, the anaesthesiologist, worked under the Chief physicians from surgery or internal medicine. The Chief Physician of the Department of Internal Medicine was already very old and one of his former senior consultants, Kurt Iversen was Chief physician at the SundbyHospital. One day, he admitted a patient in a very poor condition, and asked if he could deliver him over to me. It was then clear to everyone that it would have been absurd to send the request to the Chief Physician of the Department of internal Medicine. to take over the treatment of that patient. Because of that, I eventually got appointed Head of the Department of Anaesthesia and Intensive Care at the CommunityHospital and SundbyHospital. ... Well, that was more or less all about it! Is that enough information for you? Would you still like to know more? There is not really much more than that!
Fig. 1: Prof. Dr. Björn Ibsen.
May I ask you some questions about the polio epidemic? Why did Lassen choose to contact you for the job?
Well yes, why did he come to that idea? Let me recall... …Oh Yes! My wife and my children had accompanied me to the USA. My wife returned a month before me to Europe and on the ship she incidentally met Mogens Björneboe, who thereby also became aware of me. Björneboe was employed at the Rigshospital. In March 1952 he had to treat a child with congenital tetanus. He did already know that curare had a relaxant effect on muscles. Well, since I was the only anaesthetist that he knew at that time, he asked me if the spasms of the child could be treated with curare. I anaesthetized the child and treated it with curare, tracheotomy and artificial ventilation. The patient still lived 3 weeks under this treatment.
When the first polio patients were admitted at the end of July, early August, Björneboe started wondering if patients who were suffering from muscle weakness could also be possibly ventilated and treated with curare. He spoke to Lassen. Lassen asked me to a meeting with him and his team on a Saturday in his office at BlegdamsHospital. I explained to the group that the whole mystery lays in the fact that patients with shortness of breath tend to lack oxygen. You eventually become cyanotic and get blue lips and fingernails. If you start treating the cyanosis only with oxygen through a nasal catheter – which was quite common at that time - the consequence was that the patient did not ventilate enough which eventually resulted in hypercapnia (excessive carbon dioxide levels) with the corresponding symptoms. I pointed out to Lassen and his colleagues that the goal should be to normalise the level of carbon dioxide, and then maintain the level low.
The info has meanwhile circulated and it is of course widely known nowadays that oxygen deficiency should lead to the ventilation of the patient in order to expel the carbon dioxide. It was then proposed that I should demonstrate my theory on the following Monday on a suitable patient.
My plan was, first, to tracheotomise a polio patient and ventilate her through a tube in order to reduce her carbon dioxide levels. Unfortunately, a colleague lost a lot of time during the Tracheotomy. When eventually it came to my turn, I got confronted with bronchospasm and panicking, making the intubation impossible. The state of the patient worsened continuously. In order to save her, I administrated 100 mg of Phenobarbital intravenously and consequently she became unconscious, which now gave me the opportunity to ventilate her and suck all the mucus, accumulated in her lungs. ... That I could save the patients’ life with such a simple method, was one of the most incredible moments of my life. When I initially gave the patient the phenobarbital, many colleagues decided to leave the room thinking that my demonstration had failed and the patient would die. When they came back – quite incredulously - I was able to demonstrate that I could control her level of oxygen and carbon dioxide over the ventilation. We had our first polio patient under control. And then she survived.
The patient was lucky to get under your treatment.
Yes, when I came, 31 patients were exclusively treated with oxygen. 27 of them died. After the first treatment of this patient the mortality rate went down from 92% to about 25%. This was a convincing demonstration.
Were all patients tracheotomised or were there also people who simply got intubated orally?
No, in general they were tracheotomised. I have no memory of patients who were living several months with an endotracheal tube.
Did you learn your methods at the Massachusetts GeneralHospital?
Yes, there was an ear-nose-throat department. I came there to anaesthetize patients, who had a tracheotomy. And I learned how easy it was to ventilate a patient with safe and free airways
You also read the Bowers and Bennet paper?
Yes, I read an article that described similar methods. I think it was the one you mentioned.
Were the Patients intubated during the anaesthesia at the Massachusetts GeneralHospital?
Yes.
What method was used at that time in Denmark?
We used the Guedel tube.
And the patients were ventilated?
No, In the surgery room ventilation was rare. Only in an emergency. Patients
were breathing spontaneously and were evidently not relaxed..
What type of monitoring did you have in the surgery room, when you started
in anaesthesia?
Well, we had nothing more than a blood pressure monitor and we could
count the pulse.
But you were interested in monitoring?
Yes, I received a huge apparatus ...I do not know what else to tell...... I can only stress that it was my idea to monitor patients during the driving in the ambulances, when they sent over from other hospitals. We got once a call from the island of Bornholm for a 14 year old girl with polio, she should be sent over by aircraft. Lassen and I flew over to pick the patient up. It was interesting, because in the surgery room there were 39 colleagues, who were curious to watch us, as we tracheotomised and ventilated. When I saw the patient, she was lying with her head up and the legs down, her head was bent far back.
She was very cyanotic at her lips and fingernails. I looked under her blanket and saw that her toes were already purple. The patient had no polio, but "Transversmyelitis'”. When I simply laid her vertically she immediately became better. She did not need to be tracheotomised and survived. Had she been anesthetized and tracheotomised before, we would have never realized that it was totally unnecessary. It's just nowadays hard to imagine how our world looked like at that time.
Could you tell more about the transport system?
We modified some ambulances in order to create enough space for an accompanying person - a doctor – who could monitor and eventually ventilate the patient.
And that was new?
It was new that a doctor was accompanying the patient. I can remember quite well how it came to it. At that time, a patient [a 7-year-old boy] was transported by ambulance from Hornbæk to us. I brought an oxygen bottle and a face mask and waited in the courtyard for him. The ambulance finally arrived and we opened the doors just to realize that the patient had already ceased breathing. The boy was laying there alone with his mother in the
ambulance. I rushed to intubate and ventilate him and finally he got saved in the last minute. But then I asked myself: "Why was it not done before leaving Hornbæk?". That’s how it started, from that moment on during the ambulance service the patient was always accompanied by a Blegdam physician.
You also instructed countless medical students to ventilate in a very short time frame. How did you manage this?
It was simply necessary and there were not enough physicians with these skills.
Who advised the students in the ventilation techniques?
We decided by mutual agreement. We actually had no time for formal teaching methods. All this came later
The student organization of that time still exists today. I myself have been spending several nights with patients in intensive care.
I think we have now discussed the main issues. What was dramatic was when I administrated 100mg Phenobarbital to a dying patient, I manage to ventilate her and eventually saved her.
Later, you were interested in intensive therapy, shock treatment, fluid therapy?
Shock treatment. I have written an extensive book about shock. I found the subject very interesting.
Why?
Well because I could contribute to enhance the treatment. Originally, the treatment theory was that if a disease was causing low blood pressure, the blood pressure had to be raised. That was the old shock treatment. I realized that I had to focus my interest on the blood flow. So I developed a treatment in which the blood got diluted in order to increase the blood flow. As a basis for my treatment, I used to measure the skin temperature, you should maintain the treatment until the big toe was warm again. And that was actually it: you had to perform a treatment, which was focussing on the enlargement and filling of the vessels. This led to increase the blood flow which could be was determined by a temperature increase: If the feet were warm; the patient was no staying under shock any longer.
It just sounds so simple and logical. Today we have so many advanced methods that sometimes you forget the big toe touch, in order to examine how the patient is doing.
Yes, that was my method. I can not avoid feeling myself sometimes surprised about all the things I have found out.
That is certainly a great personal satisfaction, to have contributed so much.
Well, one has to remain prudent enough not to turn it into complacency.
Did you have connections with Germany in your career?
No, I have no memory of it. Maybe there was one or two Germans in my trainings. But I do not know with certainty.
Do you remember what sort of diseases you got confronted with at your intensive care unit in the first few years?
Mostly there were patients with respiratory complaints. And actually, it does not matter what is the source of the patient’s gasping. You simply have to bring his breathing back in order.
Thank you very much for the interview.