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An Investigation of the Development of Intensive Care of Adults in England and Wales

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An Investigation of the Development of Intensive Care of Adults in England and Wales 1 AMDG An investigation of the development of intensive care of adults in England and Wales. Thesis submitted in accordance with the requirements of the University of Liverpool for the degree of Doctor of Medicine Alfred Anthony Gilbertson June 2011 2 3 Acknowledgements I am indebted to my wife for her patience and understanding, particularly during the last three years. My supervisors, Dr Sally Sheard and Professor Geoff Gill have shown me how to research and write history and I hope my thesis does them justice. This study would have been impossible without the generosity of those I have interviewed. Everyone who has been approached has agreed to help, mostly by agreeing to be interviewed and for the few for whom that has not been possible, by supplying useful written information. I must also thank my friends who have seen little of me in this last year and my daughters Nicola Gilbertson, Virginia Prout and Caroline Jackson and my friend the Rev. John Lynn who have acted as sub-editors and corrected my scripts. Mrs Sue Corbishley at the Liverpool Medical Institution has never failed to find an article or book I needed, calling on resources which would have been inaccessible without her help. Finally I am deeply indebted to Dr Graham Kemp, Faculty of Medicine Director of Postgraduate Research, who arranged for my thesis, unusual in its being a historical investigation, to be accepted for the degree of Doctor of Medicine. 4 Contents Acknowledgements 3 Contents 4 List of figures and tables 6 Glossary 8 Abstract 9 Chapter 1. Introduction 10 Chapter 2. Methodology 20 SECTION 1. INTENSIVE CARE BEFORE 1952 Chapter 3. Surgical origins of intensive care 32 Chapter 4. Emergence of respiratory support in poliomyelitis 58 Chapter 5. Professionalisation of anaesthesia 81 SECTION 2. THE EARLY YEARS OF MODERN INTENSIVE CARE 1953-1963. Chapter 6. Intensive care of infectious diseases after 1952 93 Chapter 7. Intensive care beyond infectious diseases. 123 SECTION 3. THE EXPANSION OF INTENSIVE CARE 1964-1980. Chapter 8. Staffing and accommodation 141 Chapter 9. Post-operative and general intensive care 159 Chapter 10. The influence of renal dialysis units and coronary care on intensive care 186 5 Contents (continued) SECTION 4. INTENSIVE CARE COMES OF AGE, 1980 - 2011 Chapter 11. The specialisation of intensive care medicine 196 Chapter 12. The development of the nursing profession and the specialisation of intensive care nursing 207 Chapter 13. Conclusion 228 Bibliography 238 Appendix 1. Use of copyright material 257 Appendix2. Invitation to potential interviewees. 259 Appendix 3. List of interviewees 260 6 Figures Page: Figure 1. Radiograph of right-sided pneumothorax.......................................... 33 Figure 2. Negative pressure chamber for operations in the chest (Sauerbruch 1904)................................................................................................................. 34 Figure 3. Early 20th century Jackson Pilling laryngoscope with bulb holder which slides into a groove in the laryngoscope tube to illuminate the larynx.................................................................................................................. 40 Figure 4. Diagramatic [sic] sketch of carbon dioxid [sic] filtration system................................................................................................................ 46 Figure 5. Anaesthetic circuit used for ventilation of the lungs in Copenhagen by Ibsen in the 1952 poliomyelitis epidemic...................................................... 76 Figure 6. Notifications of poliomyelitis between 1956 and 1970...................... 94 Figure 7. Tetanus cases in England and Wales between 1970 and 2008........... 118 Tables Table 1. Comparison of survival in patients treated in a respirator and in similar patients for whom a respirator was not available. Compiled from data in Langdon, 1934…………………………………………………………...... 68 Table 2. Management of respiratory paralysis in Copenhagen before the poliomyelitis epidemic in 1952-3…………………………………………...... 74 Table 3. Results of treatment of respiratory paralysis 1948-1950. (compiled from data in Lassen 1953……………………………………………………. 75 Table 4. Patients requiring ‗special treatment‘.(Compiled from data in Lassen 1953 …………………………………………………......................... 77 Table 5 Anaesthesia in 4 hospitals of different type during 6 months of 1930……........................................................................................................... 91 Table 6. Diagnosis, treatment modalities and survival/mortality for patients treated at Ham Green Hospital Bristol in the 12 months before (Ward) and the 12 months after (ITU) the opening of the intensive care unit……………. 106 7 Tables (continued) Table 7. Treatment and mortality in poliomyelitis in the Western Fever Hospital; December 1954- January 1956…………………………………….. 109 Table 8. Diagnostic categories and treatment of cases treated in the Respiratory Unit of Southampton General Hospital between August 1958 and September 1960………………………………………………………… 125 Table 9. Neurological cases treated in the Respiratory Unit of Southampton General Hospital between August 1958 and September 1960. Diagnosis and survival………………………………............................................................. 126 Table 10. Number of consultants in anaesthesia at various dates since December 31, 1949 (Great Britain)…………………………………….......... 150 Table 11. Career pathways in critical care nursing……………………………………………………………………….. 222 8 Glossary Cuffed endotracheal tube An endotracheal tube which has its end surrounded by an inflatable cuff which ensures that it is an airtight fit in the trachea to allow the lungs to be inflated and prevent secretions running down from the throat into the lungs. Endotracheal tube A tube which can be inserted through the mouth and glottis into the trachea ICU Intensive care unit INPR Intermittent negative-pressure respiration. Usually supplied by an iron lung. INPV Intermittent negative-pressure ventilation of the lungs (previously called INPR). IPPR Intermittent positive pressure respiration IPPV Intermittent positive-pressure ventilation of the lungs (previously called IPPR). Iron lung. Also called a tank- or A cabinet which encloses the patients limbs and trunk. cabinet respirator The head is outside the cabinet, protruding through a hole in the end-plate and resting on a pillow. Sub-atmospheric pressure is applied intermittently (12-14 times per minute) to expand the thorax of a paralysed patient and suck air into the lungs through the mouth. (G)ITU (General) Intensive therapy unit NHS British National Health Service Polio Poliomyelitis SpR Specialist registrar, a grade of physician in training. Recently used for specialist nurse practitioner. Trachea Windpipe Tracheostomy, previously A surgically created opening in the trachea through which tracheotomy a tube can be placed to inflate the lungs UK United Kingdom of Great Britain and Ireland US United States of America 9 Chapter 1. Introduction Abstract The development of adult intensive care in England and Wales has been researched using primary and secondary literary sources and the oral history of participants in intensive care in England and Wales from soon after its inception until the present (2011). The development of theory has been inductive. In 1952 Bjørn Ibsen, a Danish anaesthetist, treated patients with bulbo-spinal poliomyelitis (polio) with a regime based on intubation of the trachea (windpipe) and intermittent positive-pressure ventilation (IPPV) of the lungs. This resulted in a reduction of mortality of about fifty percent in patients in Copenhagen with this condition. This dramatic result is considered to have initiated the development of modern intensive care throughout the world. The significance of this event is re- evaluated: IPPV was not new. It was in common use in anaesthesia in 1952. It was not more successful than treatment in advanced negative-pressure cabinet respirators in use in the United States. The use of IPPV in paralytic polio was not inevitable. Nevertheless, IPPV did have advantages that made it generally preferable in intensive care. It was applicable to a wider range of conditions which cause respiratory failure, the equipment required was much less expensive and generally available than advanced cabinet respirators and it allowed unrestricted access to the patient. Ibsen‘s contribution was to bring an anaesthetic technique into use in an infectious disease unit and later into intensive care units. He also extended the applicability of IPPV by combining it with the use of relaxant drugs. The development of respiratory support techniques in the 40 years before 1952 is described and it is argued that some of these earlier practitioners should be credited with having practised what would later be called intensive care. For a decade after the introduction of IPPV in paralytic polio and tetanus its use in the United Kingdom was largely by infectious disease physicians, sometimes in collaboration with anaesthetists. The development of the specialty of anaesthesia to a point where anaesthetists were able to become the major participants in intensive care after polio and tetanus had become rare after 1963 is described. Intensive care is not simply a matter of connecting a patient to a mechanical respirator: The part played by nurses in the US and the UK in establishing intensive care units is stressed. Oral histories have shown that medical participation was for many years often by one or two enthusiastic
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