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Emily Silverman

You're listening to The Nocturnists: Conversations. I'm Emily Silverman. If you've ever been to an ICU, you've probably seen a ventilator. It's a machine that helps someone breathe through a tube that goes through their mouth and into their trachea or windpipe. These days, ventilators are really advanced. They can operate on close feedback loops, adjusting the amount of air and frequency of breaths based on what the patient's body needs. Working in the background, these devices are easy to take for granted. But how did ventilators come to be? Or further? How did intensive care units come to be with their hour by hour monitoring of patients and their tight nursing ratios? Today's guest Dr. Hannah Wuntch whisks us into 1950s Copenhagen so that we can learn about the origins of ventilators and the ICU. It was a time in place when the city was fighting a devastating polio epidemic, which she explores in her book The Autumn Ghost. I found this piece of history to be gripping, and love how Hannah guides us through the experiences of doctors, nurses, medical students, patients and families who are navigating this public health crisis and taking big risks with innovation. Hannah is a critical care physician and researcher at Sunnybrook Health Sciences Center. She's a professor of anesthesiology and Critical Care Medicine at the University of Toronto, as well as a Canada Research Chair. Before we dive in, let's hear Hannah reading an excerpt from her book, The Autumn Ghost.

Hannah Wunsch

August 1952, Copenhagen, Vivi. Vivi Ebert was just 12 years old, she was going to die. Near the end of August, Phoebe came home from school saying she had a headache and went to bed. The next day, she complained that she couldn't move her arms and legs well. On Tuesday, August 26, she had a fever, headache, stiff neck, and some paralysis. The telltale signs of polio. from other called an ambulance and Vivi was brought to the hospital. She already had weakness in one arm, but much more concerning she also had difficulty breathing. Since early July, the hospitals admitted many patients just like Vivi and almost all of them had died. As their symptoms worsened, the doctors and nurses knew she'd likely had only a few more hours or days at most to live. The polio epidemic that year in Copenhagen had begun with a trickle of cases in July. By the end of the summer, the disease was roaring through Denmark's capital and outlying regions, it was far worse than in previous years with more cases of paralysis and difficulty breathing than anyone had ever seen. There were daily news bulletins on the radio announcing the latest areas with outbreaks. Ambulances kept pulling up at the hospital hour after hour, day after day. By late August, there were 50 admissions a day, all with severe polio. The doctors and nurses would have focused on one key question: could the patient take a breath? For someone who was struggling to breathe there was little that could be done except to try to keep them comfortable. Henry Chi Alexandra Lassen, the chief of the blind and the only infectious disease hospital in the city, was a physician and an expert on polio. He had cared for hundreds of patients with the illness. But this strain of the virus seemed to be causing more cases than usual and was viciously deadly. By the time that he showed up, he and his team had already lost dozens of patients, many of them infants and children. Vivi was about to be next. The previous decades have been full of major medical advances. Antibiotics allowed for treatments of bacterial infections. The discovery of insulin meant that a diagnosis of diabetes was no longer a death sentence. And X rays provided a way to see inside the body. New vaccines had even been developed for infectious diseases such as diphtheria, and influenza. But in 1952, there was still little anyone could offer as treatment for patients with polio. And there was also no vaccine for prevention. Modern medicine was failing and polio was winning, that was about to change.

Emily Silverman

I am here with critical care physician, Hannah Wunsch. Hannah, thank you so much for being here today.

Hannah Wunsch

Thank you so much for the invitation to join you. It's a real pleasure. I'm a big fan of your podcast.

Emily Silverman

I loved the book. And I love this section at the end, where you talk about the inspiration for writing this book. And in it, you talk about how a lot of people have written a lot of things about polio, and how it usually focuses on the vaccine and the scientists and eradicating the disease and things like that. But that you felt there was another story that wanted to be told. So tell us about the angle that you took with this book. And what motivated you to bring this story into the public square.

Hannah Wunsch

Yes, it's a story I first heard about 20 years ago or read about, I should say, when I was a medical student, and I took a year off to get a master's degree in London, and I read a book about what's called The Rise and Fall of modern medicine. And there was a chapter on this polio epidemic in that book. And it just stuck with me because it was a very dramatic story. And it wasn't the vaccine story. And it was very much relevant to the field that I was interested in going into, which is critical care medicine, because it was really an origin story for my specialty. And so I kind of held on to that for many, many years and was intrigued by that. And then a number of other pieces kind of fell into place. I read Philip Roth's novel Nemesis, which is about polio in the 1940s and United States, and was intrigued thinking again about this disease that I never saw as an ICU doctor and hope never to see. But that was obviously so influential in so many people's lives in earlier decades. And then just became intrigued with the idea of wanting to share this very dramatic and fascinating different story about polio and the influence it has on modern medicine.

Emily Silverman

I like how you describe this as an origin story of the entire field of critical care, and also to an extent to the field of anesthesiology, or at least a piece of that history is rolled in there. And I think that'll become apparent to the listeners as we move on in our conversation. But first, because blessedly polio isn't really around much anymore, maybe you could take a second to just tell us what is polio. And then tell us about this outbreak in Copenhagen, which is the setting for most of this book.

Hannah Wunsch

Yes, unfortunately, polio has been in the news a little bit recently, sadly, but it is a disease that most people don't know much about. It's a virus. So it's called an enterovirus. And it's transmitted by the oral fecal route. So contaminated feces that then get ingested in some way. That's the classic form of transmission. And it's an interesting virus, because really, we don't hear much about polio up until the 1900s and the late 1900s. We know it was there in the population, but it wasn't causing paralysis. And then we start to see these epidemics. The most famous one, the United States was the first outbreak that occurred in 1894. So it gives you a sense of how late it was before anybody was really aware of polio. And then you start to see worsening epidemics in the 20th century. And that's when it really becomes this disease, it starts to scare people, because of the paralysis it leaves. Now it's a bit like COVID in that many, many people contract it never know they've had it move on with their lives and are just asymptomatic throughout. Some portion of people develop symptoms, but often it was just kind of another childhood illness- few days of fever, headache, feeling lousy, and then it would pass. And so it was really a very unlucky few, again, similar to COVID, in terms of the unlucky ones who ended up with respiratory failure. But for those unlucky ones, the virus would attack the nerves in the spinal column, primarily, and cause usually motor paralysis. So weakness of the limbs, and if you were very, very unlucky weakness of the respiratory muscles, and if you were even more unlucky, weakness of the muscles that are used to swallow the bulbar muscles, and that was called bulbar polio.

Emily Silverman

And the excerpt from the book that you just read painted a little bit of a picture of this outbreak in Copenhagen, but maybe you can tell us more about this outbreak. What about this particular flare up of the disease in this time and place gave rise to all of these changes in how we do medicine?

Hannah Wunsch

So the outbreak that was of interest to me in particular was one that happened in 1952 in Copenhagen and particularly centered around this one infectious disease hospital. It was the only infectious disease hospital in the city called the Blyde M hospital. It was a bad year for polio across many places in the world, but particularly bad in Copenhagen and they were seeing an epidemic like they've never seen before. They were seeing dozens of admissions a day starting in mid to late July. And polio is an interesting disease in that the US it was always described as the summer plague because it would flare up in the summer months and then disappear. In the Scandinavian countries further north, it tended to peak in the autumn. And so they knew in July and August that they were only at the beginning of the epidemic, and it was really like nothing they'd seen before. And the particular strain they were seeing did cause a lot of respiratory paralysis and bulbar polio. So it was more kind of vicious than many strains were. And so they were seeing a lot of people die. And what was particularly problematic was that they only had one iron lung in the entire city, which was used to support people who are having trouble breathing. But on top of that, because there were so much bulbar polio associated with this strain, the iron lung actually wasn't that helpful for patients with bulbar polio. And the mortality rate with that from the disease was still about 90%, which is pretty much exactly the mortality rate they were seeing in those patients in the hospital.

Emily Silverman

You mentioned COVID earlier, and I have COVID on the mind right now, because a book just came out called Lessons from the COVID War. And I was one of 34 authors on this book, but it was put together by an American diplomat, Philip Zelikow, who was the director of the 911 Commission. And one of the sections of the book that really struck me in which I was thinking of as I read your book, was some of the confusion that we had about COVID and transmission, and how it really took us too long to figure out that it was transmitted the way that it is, which is airborne, and so on, and so forth. And Phillip really calls this an intelligence failure, framing it more through military metaphors. And so that was fresh in my mind. And then when I got to the part in your book, about people trying to understand how polio was transmitted, I was interested to see that there was a similar set of setbacks, you could say, or confusion about how it was transmitted that had to do with Flexner, and his monkeys. And so I was wondering if you could speak a little bit to the intelligence failure, really, of why it took us so long to understand how polio moves from one person to another?

Hannah Wunsch

It's a great question. So you know, the reality is, if we think it took a long time to figure out COVID, it took decades for them to figure out what was going on with polio. And you allude to the fact that there was a real problem that happened early on, in fact, they had figured out or someone had figured out quite early on near the turn of the century, how polio was transmitted. But it was a Swedish group of scientists. And it just sort of got lost in the noise of scientific presentations and discovery, no one quite knows why. The other piece that really set things back was that you alluded to Flexner, who was the head of Rockefeller Institute, and did polio research. And he had chosen to use a certain type of monkeys rhesus monkey for research into polio, and monkeys were one of the few animals that actually could contract polio. And so they were needed for a lot of the research. And he then chose a specific strain. And these two things combined, he happened to have chosen a monkey that did not behave the way humans do, or other monkeys do in terms of being able to contract polio through this normal oral fecal route, they really had to have a kind of injected into their spinal system or brain in order to get it. And that wasn't a problem in the laboratory, they could do that it was a very quick and easy way to induce polio. But it led them to decide that polio might be transmitted through the nose, because that was very close to the nerves in the brain, and that this was the most likely route of transmission. The other problem was then that everybody else copied him because he was this kind of all powerful figure. Nobody thought to try other strains of polio, nobody thought to use different monkeys for a very long time. And so this really set back the field because people didn't recognize that there was a problem with this model that he was using. So it was really not until the 1940s that people realize that okay, this looks like it's oral fecal, but then there was an even bigger problem of getting people outside of scientific circles to understand that and recognize that and of course, transmission of information was very different back then. So you alluded, there were all kinds of theories that were floated particularly in the first few decades of the 20th century. And there was one huge epidemic in 1916 in the United States centered around New York City, where they killed tons of dogs and cats, as some people were convinced they were the cause of transmission. They were swatting flies. They were, as we did wiping down surfaces, everything and anything was tried. And if you talk to people who lived through the polio era, they all talk about their parents keeping the windows closed during the summer time, and sweltering in their houses at home, convinced that somehow keeping out the bad air was going to keep polio out of their lives. And so it's really remarkable it's even people from the 40s and 50s, whose childhoods were during that period will tell you about that vivid memory.

Emily Silverman

It's just so interesting to me that the answer was there all along in these Swedish researchers' paper and how it's really not enough to discover, quote unquote, truth, you have to discover it. But then it has to penetrate the consciousness of the medical community and the consciousness of the public. And those are two very different things. There's almost like the research on the one hand, but then the dissemination on the other and just how important PR is when it comes to science communication.

Hannah Wunsch

During the research for this book, I became very aware how much every breakthrough was sort of a relearning, rediscovery of concepts and ideas that someone had floated before. And I became very wary of saying things were the first because you discover that somebody had invariably published something about it, or tried it or showed something worked often decades or even centuries earlier. So yes, medical research and discovery is this weird, fascinating mix of amazing breakthroughs that are really on the backs of many, many, many other people's ideas that come before. And then to your point, the whole dissemination issue, once even the scientists have decided they're in agreement about something or the physicians to get the general public on board is a whole different aspect to it too.

Emily Silverman

So we have this terrible disease that paralyzes the body, and all doctors can really do unfortunately is watch them die. And then we get the iron lung. So tell us about the iron lung and how that came to be.

Hannah Wunsch

The Iron Lung came about 1928 through the work of two scientists, professors at the Harvard School of Public Health, Philip Drinker and Louie Agassi Shaw. Louie Agazi Shaw was doing some experiments with a cat, one of the things he was interested in is whether cats could breathe through their skin, which amazingly in 1928, they weren't sure about. And he used a device that basically encased the cat's body and allowed them to suck the air out of the encasement to measure how much the lung volume was, what's called a seismograph. And Philip Drinker was interested in resuscitation and realize that this was potentially a means to help someone to breathe. And he then later was exposed to polio patients on the wards at Boston Children's Hospital and realize that not only might it be useful for resuscitation of workers and accidents, but actually, probably its main use would be for polio patients. And so he very quickly developed what became the iron lung, really synonymous with polio care. And it's what's called negative pressure ventilation. So again, it seals the body in the head sticks out at one end. And then air is sucked out from the canister, and This forces the lungs open, pretty because it creates a negative pressure and then the air rushes in through the mouth and into the lungs to fill that space. And it's important to know that this is actually physiologic, this is the way we breathe, we just don't do it by having something suck our lungs open, other than our muscles and our diaphragm that pushes down. So it was seen as a huge advance of care. It was a huge advance in care, because it really allowed for the first time for them to intervene on patients who had respiratory polio. And many people survived because of it.

Emily Silverman

But they're big, and they're heavy, and they're expensive. And so was it really more of an American thing because as you said, this hospital in Copenhagen, they did have one iron lung, but it wasn't enough. And so they really had to look to other technologies. Their hospital was also recover recovering from the Nazi occupation of the city. And so talk to us a little bit about like, we have this iron lung technology being developed in America. But back in Denmark, like where are we? And is this technology accessible, and maybe tell us about the impact of the war on the hospital and how that affected the way that these technologies were being developed and adopted?

Hannah Wunsch

There's a few things to your point that it was really an American technology, the United States, mostly because of Franklin Delano Roosevelt, who himself had what was probably polio, had founded the National Foundation for infantile paralysis and its fundraising arm the March of Dimes, that was really flush with money to support research and care for your patients. And so they had the money to buy a lot of iron lungs to move them around the United States to where outbreaks were occurring. And to your point, they were very heavy, they were cumbersome. Nurses hated them, of course, because in order to create a seal, to allow the lungs to be sucked open, you can't have any breaks in that seal. And it becomes very, very challenging to nurse patients. So that was a huge limitation of the iron lung. And then the last limitation was the fact that for the form of polio, that was the most severe bulbar polio, it actually was not very helpful, because it just sucked all the secretions in the back of the throat that someone couldn't swallow down into their lungs. And so there was still 90% mortality from that type of polio. And then on top of that, you've got countries like Denmark, like much of Europe where they're really war torn, and they don't have a lot of money into your point they were recovering from in Denmark, Nazi occupation. And so they did have access to an iron lung and what are called some Kairos respirators. They're basically a miniature version that strapped over the chests that are not very successful. And then they also use something called a rocking bed, which is a crazy if you ever see the images or films of this, it's literally someone was strapped to a bed that rocked forwards and backwards, up and down to force the diaphragm with gravity to go up and down with the idea of this one sort of help support someone's breathing. It looks quite miserable, although it was described as not so bad, actually to be in. But none of these things were very successful for bulbar polio. There wasn't a lot anyone anywhere could do in the circumstances they were in in Copenhagen. And then it was a lot of coincidences, and a lot of bright people in the right place at the right time that led to this breakthrough occurring, rather than just sitting and watching everybody die.

Emily Silverman

I love the scene of Lassen. I think his name is am I pronouncing that right? Yes,

Hannah Wunsch

that's correct Lassen, at least that's my pronunciation the Danes may differ.

Emily Silverman

So Lassen is the head doctor at this infectious disease hospital, just outside of Copenhagen. And the polio epidemic is raging. They're having daily crisis meetings in his office, everybody's depressed, everybody's in a state of despair. And then one of his friends says to him, "Hey, there's this guy across the street at the other hospital. And he practices something called anesthesiology. Maybe we should invite him over here and see what he has to say about all this." And in this moment, it's kind of a threat to Lassen and his ego because Lassen is this big, fancy doctor and this other guy across the street, he's like a nobody. And so he has to sort of weigh the shame of inviting in this interloper against the potential benefit of whatever this person might have to offer. So tell us a little bit about that moment like that decision of should we invite this guy in and maybe he has the answer or an answer.

Hannah Wunsch

One of the things about European medicine at the time was that it was incredibly hierarchical. Professor Henry chi Alexandra Lassen, you know, chief of the Blight M Hospital was a real force in the city and was not someone to be messed with. He had an underling, someone he actually clearly did respect and supported, who was one of his senior trainee doctors, a guy named Mogens Bjornbow and apologies to Danish speakers out there, because that's my very American pronunciation of his name. And it's still a little bit of a mystery as to how and why Bjornbow had put all the pieces together to recognize that Ibsen, this colleague of his who was an anesthesiologist might be able to help. But he did and a little bit of that it goes back to two years earlier when he'd actually met Ibsen's wife on a ship traveling back to Copenhagen from the United States. And she had mentioned that her husband was finishing up training in anesthesia at Mass General Hospital in Boston. And he remembered this years later in the spring of 1952, when he actually had a baby with tetanus, who he was struggling to care for. And he invited Ibsen, this anesthesiologist who was working in a different hospital to come see if he could help with the sedation and with the breathing, and together, they've kind of worked over this baby for four or five days, and the baby died. But Ibsen had used some of his techniques, the sedation and also doing what's called a tracheostomy, putting a tube through the throat into the trachea, to help the baby to breathe better. And and clearly, Bjornbow was just impressed by him and his thinking. And so he started badgering Lassen to invite this guy over. And as you say, Lassen resisted at first, he first brought in a colleague of his who was sort of the same level, a professor, who he asked from another hospital kind of consultant and really didn't have anything to offer. And so, you know, to Lassen's credit, and I think it is important to acknowledge that he eventually did say, "Yeah, bring this guy over, and I'll hear what he has to say." And so I think it is important to recognize that in this very hierarchical world, that there was this moment when He shifted and allowed this to proceed.

Emily Silverman

I love it. It's just there's so much drama here. It's such a great story. And I think some of that is a testament to your storytelling skills in this book, but, but they invite them over and they show him, "Okay, here's the people who are kind of sick. Here's the people who are really sick. Here's the people who are on death's door about to die." And then they take them to the morgue. And they say, here are the people who are dead. And then Ibsen comes up with a hypothesis. And the hypothesis is that "I actually don't think there's anything wrong with these people's lungs, I actually think that this is a muscle issue." And that kind of went against the prevailing again, it's similar to the transmission question with the monkeys, and is it through the nose? Or is it through the fecal oral route, like he was able to show up to the situation, naive with fresh eyes. So talk a little bit about that moment where he changed the way that we think about end stage polio,

Hannah Wunsch

The prevailing wisdom, and it is one of these things where sort of it gets ingrained in people that they just gets passed down. Their idea was at a certain point, polio just overwhelmed the body, and in particular, that it hit the brain, and that it hit the kidneys. And that when people had reached the stage where they looked like they had high blood pressure, and they were sweating in their part was going too fast. But these are all signs of the virus overwhelming everything. And a very kind of nihilistic view of it. And so what Ibsen recognizes, and this is, again, one of those weird moments that they chosen the right guy at just the right moment. Not only had he worked at Mass General, where he felt there was less of a hierarchy and that he felt that he could speak and that he experienced this kind of more open environment of testing out of ideas, which he had felt that this was important to his ability to stand up to someone like Lassen, he also had been spending time in the operating room playing around with a device called the carbo visor, which measured exhaled carbon dioxide. And he recognized that his patients in the operating room when he stopped ventilating them, and he could measure the carbon dioxide afterwards that it built up in the body. And this was a hypothesis that they just weren't being ventilated enough, that they were not breathing enough. And seeing the lungs in the morgue of the couple of small boys who had died. Uh, he said, basically, the lungs looked fine. And that he just wished that he could have ventilated these patients. And that's exactly what he proposed was to do what's called positive pressure ventilation, as opposed to what the iron lung is, which is the negative pressure ventilation, to do a tracheostomy and blow air directly into the lungs and flooding them like a balloon. It was something he knew to do in the operating room, but it really was not used outside of the operating room or for any prolonged period of time in care of patients at that time.

Emily Silverman

Can you say a few words about anesthesiology at this point, because I was really interested to learn that it hadn't really carved itself out as a respectable field at this point, and how it was sort of like the surgeon would snap and say, "Anesthesiologists, you know, come come do whatever I say" and that they were they didn't really have a lot of respect or autonomy. So can you just say a few words about that.

Hannah Wunsch

If they were lucky, and they even had an anesthesiologist because what's really remarkable is that anesthesia as a specialty in Denmark was not even recognized until the very early 1950s. And there were really only half dozen, if that, trained anesthesiologist in the city. And so Ibsen himself describes the state of anesthesia when he was training in the 30s and 40s. You know, literally, it might be a medical student or nurse, the assistant in the office who might be giving the anesthesia, it's pretty terrifying. And there was slow recognition that this was actually a real skill that required medical expertise, and that the safety of it really could be improved by ensuring that there were skilled anesthesiologist in the room. So it was an ongoing battle to establish themselves as a needed new specialty. At the time, things were a little more advanced in some areas, such as in the United States. That's one of the reasons he'd gone to travel to Mass General to train where they actually already had an established program for anesthesia. But he was really amongst the pioneers in Denmark for convincing the surgeons that they needed to have anesthesiologist caring for their patients because of the complexity of anesthesia.

Emily Silverman

So he's down in the morgue, he's looking at these lungs, he's floating this hypothesis that maybe these end stage symptoms are actually from CO2 retention, or hypo ventilation, and then Lassen says, "Okay, take a patient", and they give him a patient and tell us what happens because in some ways, for me, that was one of the biggest climaxes of the book, just such a heart wrenching experience to watch Ibsen with that patient. Tell us a little bit about that. And also, what was it like to because you built that scene so vividly in this book? I guess there's sort of a question under the question, which is one what happened and then two, how do you know-- was this all documented?

Hannah Wunsch

Yeah, so remarkably, we have the medical record of the first patient that they tried this on. And Lassen basically said to him, you get one shot, I'll give you a patient to try this on to demonstrate to us that your idea works that we don't need iron lungs, and that this positive pressure thing you're talking about is going to work. And this is where we get to return to Vivi Ebert, because she was the patient 12 years old, who really was about to die on August 27 1952. Lassen and his team rounded on her, and he examined her and basically pointed her and said, she's the one. And so they wheeled her into a side room, and they did a tracheostomy on her and then Ibsen took over her care. And it was not straightforward. They ran into problems, he actually had trouble ventilating her, he had made a mistake, he was worried she would die if he gave her any anesthesia. And so he had asked the surgeon to do it under local anesthesia instead, which he did you mean the tracheostomy that tracheostomy, yeah, to get the tube in the throat. And so he was able to do the surgical procedure. But he got into a bit of bleeding because she wasn't fully asleep and was moving around. And so this causes what's called bronchospasm, where the muscles lungs just sort of constrict and become impossible to open up. It's every anesthesiologist's nightmare. And everybody kind of left the room because they just didn't want to see another child die of polio, which is what it looked like was happening. And so there's this dramatic moment when he makes the decision to actually give her anesthesia and put her to sleep so we can break the bronchospasm and risk causing her death. And luckily for him, and for the rest of us, it worked. And he's able to stabilize her and everybody comes back from lunch expecting her to be dead. And instead, she's actually pink and breathing, and looking comfortable. And so it's really, you know, I hate to be called the M word in the ICU a miracle moment. But, you know, this was a disease that was bulbar polio, it really was close to 100% mortality. So they knew what was her fate without this intervention. And so to see somebody stabilized and safe, who they expected to die that day really must have been pretty miraculous. So yeah, so it kind of gives me goosebumps thinking about it. And there's a few ways we know what happened. One is the physical records that Gibson took very detailed notes over the course of her care that first day, minute by minute, practically. I have an English colleague, who's a nephrologist, who actually did write a book that was published in Danish, maybe 15 years ago. And so he actually had the luxury of interviewing some of the individuals that were there before they died. And so I was able to also rely on his descriptions of what had happened, because he was able to get detail that obviously wasn't in the chart. So lucky in that regard. He was very generous with his notes and his manuscript.

Emily Silverman

Total goosebumps moment, and so well rendered in the book. So you got to read the book. But so it works. And someone says, "Well, what do we do now?" And they say, "Well, this is the new standard of care."

Hannah Wunsch

I think it was Lassen who really called the shots there. And so he's the one who saw that this was working and said, right, we're gonna do this with everybody who's in this situation. But there was one problem. They didn't have ventilators. So they could put these tracheostomies into people and they had this idea that positive pressure ventilation was going to keep them alive, but they had no machines to hook them up to and so they called on the medical students of the city to come in the hundreds, and ultimately over 1000 medical and dental students to sit at the bedside of these patients and hand ventilate them 24 hours a day.

Emily Silverman

Someone said we need an army of hands. And again, it's kind of impossible not to draw parallels with COVID. But I'm remembering during that first wave when a lot of medical students graduated early, and thinking about how they showed up to the hospital to volunteer and help and serve. And I spoke to a few of these medical students and I asked them like, Well, what did they have you do? And a lot of them just talked about how it was electronic health record work. It wasn't necessarily super hands on clinical work. They were picking up slack in other ways, but not these medical students. So can you talk to us a little bit about the toll that this took on these volunteers, and eventually they did get paid. It wasn't no longer a volunteer gig after a while. But talk to us about the physical toll and the emotional toll and like, what is it like to just squeeze a bag 20 times a minute, for eight hours? And if you screw up, someone dies?

Hannah Wunsch

Yes. Luckily, and well put. Yeah, I mean, I think the world has changed, right, there was a lot of concern about putting medical students, current medical students in harm's way. And having been exposed to COVID, when we didn't really understand it very well. Interestingly, back in 1952, there was still the risk of contracting polio themselves. Infection control was something they tried to do, and they were as careful as they could be. But certainly putting students in a room with acutely ill polio patients risked harm to them. And remarkably, in that particular epidemic, nobody who was in direct patient care got polio. But beyond that risk of infection, which when I talked to them, and from prior records, they kind of said they didn't fully seem to care about. But they did care very much about the risk to their patients of screwing up. And there are descriptions of harrowing events when tubing got disconnected, or an oxygen tank sort of exploded around them. And easily it was the Wild West because nobody had ever done anything like this before. And they were given very little training. You know, some of them say five minutes, some said 30 minutes, but pretty much that was it. And many of them really had never even been near patients before. Some of them were first year, second year medical students. And so this was their first time involved with patient care, and they were put into the deep end. And there's also not only the stress of that they talked about their hand cramping, they talk about their fear of falling asleep. But also then, of course, in the aftermath, because although it was incredibly successful as an intervention, not everybody survived, and they did witness the deaths of patients, many of them children that they've come to know and really care about.

Emily Silverman

I just have to take a moment to read this excerpt from Niels Stevenson, the first year medical student who talks about how one night he's caring for a little boy and then he notices that the oxygen is running out and he says, using a wrench the old cylinder could be released from the reduction valve with a gentle hiss and the new full cylinder trundled over on its base before connecting up again. But this night, and without warning, my short white coat snagged onto the tubing and the bomb started listing heavily. There was nothing I could do to stop the large cylinder crashing to the floor alongside the bed. The noise was tremendous and all along the corridor startled faces turned in my direction. On impact, the reduction valve had been sharply distorted and the gauge smashed, the cylinder falling to one side and disconnecting started to release a powerful stream of pressurized air. To my shock, that heavy bomb lived up to its name and driven by the fast flow of gas spun around and scattered around the room like a jet fighter, I leaped onto the bed, scooping up the boy and carried him outside, leaping over the spinning bomb. I sat on the floor outside the room for a few seconds, sweating, panting and swearing, until suddenly realizing that he was now gradually turning blue with a lack of oxygen. By chance, a technician in a side room was preparing a new cylinder and without delay, the child was connected up again, within 10 minutes. And after clearing out the debris, he was back in his bed and seemingly miraculously, totally unharmed.

Hannah Wunsch

There's a lot of harrowing stories like that. And there's one story of one of the medical students who actually had to put his mouth to the tracheostomy and blow air in himself because of an issue with the tubing and such connected. And that was the only way that he could keep the child alive for a brief period. And just that heroism rate of risking his own life with someone who's infected with polio and doing that, and it is really remarkable. I was lucky enough to get to meet two of those medical students when I traveled to Denmark to do research for this book. And that, to me is truly the high point of the research experience was getting to shake their hands and hear their stories. One of them has unfortunately died and will not get a chance to read the book, which makes me very sad. But I was pleased to be able to tell them that I would be widely sharing their story because they've they've lived with these stories and these memories for many, many years and they're very proud of what they did. And it clearly shaped their lives in all kinds of different ways. One of them actually became an anesthesiologist because of her experience working.

Emily Silverman

So eventually we get machines.

Hannah Wunsch

Yes, mechanical students, they call them.

Emily Silverman

Yes, mechanical students. I'm glad we don't call them that anymore. So we get the machines, the sky's the limit at this point. So talk about Ibsen, because Ibsen moved on from polio in a lot of ways and realized and recognized that there are so many different clinical scenarios where supporting the breathing can be helpful. And so tell us a little bit about what happened to him, and how this technology really just blew open medicine into a new era.

Hannah Wunsch

Once they realized they needed something to replace the students, there were a lot of people actively at work on creating new ventilators, the mechanical ventilators. And they did exist, they just existed in a few spots where people were experimenting with them in operating rooms. And so to your point, this was a total change in focus for how a ventilator could be used. And Ibsen the next year moved on to a different job, he got a position as an anesthesiologist in the municipal hospital nearby. And he was tasked first with creating a kind of recovery room where he could provide this sort of high level support, but really only during the daytime and only to sort of select post operative patients. And he had his experience from the operating room, he had his experience from the polio epidemic. And he just had a vision, which was that he could combine all of this to care not only for those with polio who needed respiratory support, but for anyone who needed respiratory support, and started taking in medical patients, made sure it was staffed 24 hours a day. And in December of 1953 is when he admits his first medical patient. And really, that kind of marks the the modern era of intensive care, because he put all of these pieces together. Now, polio was actually the perfect disease to start with. And I say that because it does only affect the muscles, and it doesn't affect the lungs themselves. And it's a lot harder to ventilate someone adequately and safely when the actual lungs had been damaged. So it was actually perfect that they could start with a disease where the only thing wrong was that the muscles were paralyzed. And if you blew air in the lungs, they would oxygenate perfectly, they would exchange carbon dioxide perfectly, and you can kind of mess up with it, and it wouldn't actually hurt the patient. So you can pull it a little too much, you could throw in a little too little, and they'd still be okay. That becomes a lot harder when you start dealing with patients who have pneumonia, or cystic fibrosis or all these other diseases where the actual lung is impacted. But it was soon recognized that mechanical ventilators could be used to support many of these individuals who were struggling to get them through an acute event where the lung was themselves were damaged. So that piece along with actually a lot of other pieces that came from things like World War Two and resuscitation medicine, development of CPR, and that's form of resuscitation dialysis machines that could support the kidneys, all of those things came in not because of the polio epidemic, per se, but through other events. And so that really all came together in the mid to late 1950s. As ICU start to get opened elsewhere, as people realized that this is a really needed piece of medical care in hospitals. Important to recognize even now, this is only the case in high and middle income countries and that less developed countries still struggle to have the resources to provide what we would consider a full intensive care. But there is this incredible metastasis, maybe the wrong word to use, but in terms of development of intensive care, as people look to what has been done, and one of the founders in the United States, Peter Saffer, actually referenced the Copenhagen polio epidemic and said, we saw what they had done. And that was really the impetus for recognizing that we could do this in the United States.

Emily Silverman

So important to recognize the parts of the world that are still underresourced and do not have access to this technology. Toward the end of the book, you also address the flip side of that question of almost a question of too many resources, or a darker side of this technology. You know, if you have all of these different forms of life support, that opens a whole other can of worms in terms of ethics and end of life. And you know, when do you turn the machines off? Or when do you choose not to use the machines and Ibsen himself you describe was a bit haunted by the ethical implications of what had been created. And in this conference in London in 1969, he says, "At the beginning of intensive therapy, it was a problem to keep the patient alive. Today, it has become a problem to let him die." So tell us how Ibsen landed on this issue, and then maybe tell us a little bit of about his own personal death and how he chose to die or how he did die, because I actually thought that was a really beautiful and poetic death.

Hannah Wunsch

Ibsen definitely lived long enough to see the full arc of modern medical care. When he was born at the start of the 20th century, there was really nothing on offer, not even an iron lung available for support of polio patients. And he lived into the 21st century and saw real high tech interventions become available. But as early as the late 1960s and early 1970s, he working in his own ICU became very aware of this issue that we now had this technology that had been created. That could kind of indefinitely keep people in what I sometimes describe as kind of a twilight zone, or sometimes described as prolonging death, because we're able to functionally keep people's hearts beating and bodies circulating blood, but we can't get the body to heal. And so they are stuck on machines, they are stuck not just on machines where you know, plenty of people live with ventilators at home and live full lives, but stuck needing all of the equipment and accoutrements of intensive care and unable to leave the unit. And he really wrestled with this as we still do. Now, everybody has a different definition of what constitutes a quality of life. And so that's always important to recognize, but even though ethically, withdrawing support and not starting support are kind of viewed the same. Emotionally, it's very, very different. And it becomes often very challenging for families and patients themselves to sort of say, to stop something that has been started. And that's what he saw was getting stuck in this place of endless support. He didn't have an answer for it, we still don't have an answer for it. And each case is individual, but it is what I sometimes call the dark side of intensive care. In terms of Ibsen's own death, he managed to have a very different death than what he witnessed in the ICU. He essentially got dressed very early one morning, went out into his garden, and was just found there, very peacefully dead by his family. And it was very much the type of death that he had expressed to his children that he would choose that he did not want all the fancy devices and interventions that come with intensive care. Now, some people are luckier than others, some of it is luck that he ended his life this way. But it is a stark contrast to the type of care he conjured for the world that he ended in such a peaceful death in his own garden.

Emily Silverman

This book was such a ride, it was such a ride, reading it, and I have no doubt writing it. And so I'm curious for you, Hannah, you're a critical care physician. What did writing this book do for you? Or what did you take away from the experience, or how has the process of pulling out these stories changed you as a physician or as a person?

Hannah Wunsch

Well, we need a whole other podcast for that. There were a lot of people, I wanted to write this book for, a lot of different people, I really wanted to write it for all the critical care practitioners out there, and to have it be my gift to them to help the world to recognize what it is that they do all day, and the sacrifices they make to do it. And to honor their origins and their daily lives. I wanted to write it for all those who have dealt with polio and have dealt with the aftermath of polio and the paralysis and difficulties that that brings to their lives. And I was really gratified I did have one polio survivor who read it, who told me that she would never, never wished to have had polio, but she felt part of a bigger story and an important one having read my book, and that was just the best feedback I could ever receive. Because I was really pleased to think that I could give that to that community of survivors. And then we haven't really talked about the vaccine. But of course, the ultimate quest was to try to get rid of polio and eradicate it. And we haven't fully done that. But we have somewhat, and of course, I think that telling the stories of the polio survivors themselves was important because I think it's important to remind people and have those stories so people can understand what life was like when polio was still a threat and what it meant to get polio, and hopefully, to remind people of the importance of vaccination not just for polio, but for many diseases, we live in a world- where we've been up until COVID- quite lucky not to have to deal very much with infectious diseases that are life threatening or life altering. And I fear we're in a world now where that reminder is very much needed as people are questioning vaccines.

Emily Silverman

I'm curious, have you found that many of your colleagues in the critical care space, do they know this origin story? Or not really? Do people have a sense of the arc of the larger story that they're a part of?

Hannah Wunsch

One of the reasons I wanted to write this story was because I discovered a lot of people didn't know it. A lot of the old timers did. But younger generations, not so much. And some of that is that the older physicians actually knew these people. And so it was not part of history for them, but part of their lives. And as that has faded, fewer and fewer, no. So yeah, I'm also pleased that to be able to share the origin story with the individuals in my field. And so that's been really gratifying. And for me, it was a journey, I did not major in history, I had no background in historical research. It was a real roller coaster learning how to do that type of research. It was exciting and a much needed break for me from a normal type of research I do, which is epidemiology and health services research. And certainly those tools were useful in some of the research I did, but learning to deal in archives, learning how to interview people, and get information above and beyond sort of just the medical history, ask the right questions to really get all the detail that was needed to fill out a book and make it come to life. That was fun, exciting, different. And I'm also very grateful to my colleagues who allowed me the time to do that just step away from some of my responsibilities to be able to write the book.

Emily Silverman

Well, it's tremendous. I really enjoyed reading it. And I love the inscription in the front too, for your family and friends who have been there through the hard times, but also for all those who have ever held a life in their hands. And so, if that's you listening, and even if it's not, I highly recommend that you pick up this book. It's called The Autumn Ghost, How the Battle Against A Polio Epidemic Revolutionized Modern Medical Care. And the author is critical care physician, Hannah Wunsch. And it's been so much fun chatting with you today. Thank you for coming and sharing this book with us.

Hannah Wunsch

Well, thanks so much appreciate your reading it. I appreciate the opportunity to come talk about it. And I hope that others find meaning and interest in the book as they read it too.

Emily Silverman

Thanks for listening. This episode of The Nocturnists was produced and edited by Jon Oliver and produced by Carly Besser. The Nocturnists Executive Producer is Ali Block, and our Chief Operating Officer is Rebecca Groves. Our original theme music was composed by Yosef Munro, and additional music comes from Blue Dot sessions. The Nocturnists is made possible by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit CMAdocs.org. The Nocturnists is also sponsored by the California Health Care Foundation, and from donations from listeners like you. Thank you so much for supporting our work. If you enjoy the show, please help others find us by telling your friends about us posting your favorite episode on social media or leaving us a rating and review. To contribute your voice to an upcoming project or to make a donation, visit our website at thenocturnists.com. I'm your host, Emily Silverman. See you next week.