Online Resource 1:
Extracts from the patient record of Vivi E. (1952)
The first patient that Ibsen treated with the new method on August 26th 1952 was a 12-year-old girl, who got admitted directly from home to the BlegdamsHospital. I was lucky to re-discover the patient record, which now gives us the opportunity to follow Ibsen’s Treatment of Vivi E. between August 27th and 28th as recorded by Dr. Ibsen himself.
To my knowledge this is the first time that extracts from this record have been published. The patient’s record shows that the patient was suffering from fever, headache and a stiff neck (meningitis) since August 25th. By the time of the admission she was showing a slight paralysis of the upper extremity and respiratory complaints. On August 27th at 9.45 a.m., a doctor, who signed with "BJ" - Perhaps Dr. Björneboe - examined her. "BJ" wrote that the patient's condition had deteriorated since admission. The respiratory movements of the chest were barely visible, the patient was also very anxious. Her blood pressure was 150/100. At about 10am, an X-ray showed a left lung atelectasis. The right lung was normal.
At 11.15am a tracheotomy was performed under local anaesthesia (this comes from a note of the ENT department). It was vainly tried to aspirate the excess mucus from the lungs. The record does not indicate when Ibsen was called in, but, from his own account, we know that he was present when the patient was tracheotomised and that he took over the treatment shortly afterwards. What follows is a direct translation from the Danish medical records of that day (Most entries are not handwritten by Ibsen, which suggests that he asked a colleague to fill the chart, while he was busy with the treatment):
12.10pm: About half an hour after the tracheotomy:
Attempts were been made to aspirate the atelectasis in the left lung, but the secretions could barely be sucked out, consequently an insufflation with positive pressure and 100% oxygen was attempted. It became difficult to support the breathing immediately after the tracheotomy, due to bronchospasm, but now it is getting easier. The respiration of the patient is insufficient and she is turning cyanotic when not supported with oxygen.
The situation now: fairly good [skin] colour at 100% oxygen in the "to and fro" absorber system with much anxiety and sweat, wet and cold and cold.
Blood pressure 150, pulse 94, respiration frequency 44
12.30pm: urethra catheter in the right bronchus. Condition has become worse very restless, kicking.
Blood pressure 130, heart rate [not noted].
12.40pm: patient wet and cold and worsening condition, blood pressure 120, pulse 84, Respiration 38, less bronchospasm. Oxygen saturation at 80%. When removed from oxygen: the patient gets immediately restless.
12.48pm: The oxygen saturation is 72%. The patient is it now so bad that we have to give oxygen.
12.49pm:100% oxygen.
12.50pm: 160 blood pressure, oxygen saturation 81-82%. Lab: pH 7.32, 23.2 [Bicarbonate].
12.52pm: oxygen saturation 84%.
12.54pm: Respiration [Illegible], 100% oxygen.
12.55pm: Patient very restless. CO2 6 ½%.
12.57pm: We need to stop the oxygen in order to suck out the lungs. The patient is immediately and severely cyanotic and her condition is bad. She gets 100% oxygen again.
Blood pressure 150, pulse 94, respirations 40; always restless. Jerks with her arms. 6% CO2. Patient unconscious.
01.02pm: CO2 7 ½%. Started active support of breathing.
01.06pm: CO2 7%.
01.17pm: patient still very restless. 130 blood pressure, pulse irregular 88.
We have rising carbon dioxide and are now in a situation where we can not perform the ventilation because of her spasms and agitation, therefore we administer Pentothal 100 mg.
01:32pm:[In Ibsen's Handwriting] patient immediately calm and much easier to treat
Pulse 146, blood pressure 80.
The patient is immediately warm and dry
01.35pm:[In Ibsen’s Handwriting] CO2 3.5 [%]. Skin warm and dry. Blood pressure 70.
01.36pm:[In Ibsen’s Handwriting] pulse 146. All spontaneous movements stopped.
01.37pm: CO2 4 [%]. Easy to ventilate. Blood pressure 100
01.38pm: Awake again. CO2 4 ½ [%] . Spontaneous respiration started again.
01.45pm:[In Ibsen’s Handwriting] Pentothal 100 mg.
Blood pressure 90th Pulse 120
01.50pm:[In Ibsen’s Handwriting] blood pressure 90th 120th P
01.57pm:[In Ibsen’s Handwriting] CO2 3 [%].
01.57pm:[In Ibsen’s Handwriting] while a blood sample was taken from the Arteria Femoralis , the patient became a little restless.
3% CO2, blood pressure 90 Pulse [not noted].
She is awake and wet and cold.
02.02pm:[In Ibsen’s Handwriting] termination of the CO2 measurement.
[Laboratory] [pH:] 7:47, [bicarbonate] 24.2.
02.18pm:[In Ibsen’s Handwriting] Blood Pressure 90, pulse 116
It is now obvious that the patient is in a state of apnoea with almost controlled breathing - awake - warm - dry – she is quiet - no facial mimics.
02.25pm:[In Ibsen’s Handwriting] blood pressure 100, pulse 92
02.50pm: stopped [In Ibsen’s Handwriting] stopped with 100% oxygen, back to 21%.
02.55pm:[In Ibsen’s Handwriting] blood pressure 90, Pulse 112
03.05pm:[In Ibsen’s Handwriting] glucose intraveneous 800 [ml].
A vein was exposed on the left ankle.
Positive pressure ventilation with atmospheric air. Oxygen saturation 83%.
During a short break without ventilation, oxygen saturation 83% → 75%.
03.20pm:[In Ibsen’s Handwriting] transition to pure oxygen. The saturation increases within 30 sec from 83% to 87%.
03.19pm:[In Ibsen’s Handwriting] oxygen saturation in the interval of 15 seconds: 88%. 87%. 86%. 86%. 86%.
Intervals of 30 seconds: 87%. 86%. 86%. 86%. 86%.
03.15pm:[In Ibsen’s Handwriting] blood pressure 100
03.20pm:[In Ibsen’s Handwriting] oxygen saturation 83% → 88% (within 15 sec.)
03.22pm:[oxygen saturation] 90%. Patient sweats significantly.
04.00pm: blood pressure 110, Pulse 120
04.01pm: respiration almost ? with 100% oxygen. Blood gas analysis:
pH 7.37, CO2 28.3 [%] .
04.10pm: The oxygen meter can not be set at 50%. Is set at 100% and 80% of initial value.
04.15pm: Blood pressure 110. Oxygen saturation set at of 80%. Display: 74% →
78%. Pulse 108
04.16pm: blood pressure 120, respiration 48
04.18pm: blood pressure 110
04.26pm: Respirator [a cuirass respirator]is placed. [Negative pressure in bar:] -15 Frequency 24, Oxygen saturation 80 [%].
In less than a minute: 70%. Oxygen is administered: 77%.
Oxygen is taken away. In less than a minute: 80% → 72%.
Poor synchronisation with the respirator.
Blood pressure 150.
Oxygen is provided again. Within a few seconds [oxygen saturation] 80%.
Blood pressure 120 Oxygen via nasal catheter.
04.30pm: Blood pressure 110, pulse 124.
Oxygen is taken away. The respiration of the patient does not follow the respirator.
04.39pm: oxygen saturation 68%. Oxygen injection over ventilation bag.
After 1 min oxygen saturation up to 77%.
04.37pm: blood pressure 130, pulse 104
04.39pm: Sweats, somewhat restless.
04.40pm: blood pressure 125
After a few minutes the oxygen meter went down to 73%.
Still not in synchronisation with the respirator.
04.53pm: Again Carbovisor: blood pressure 130, wet and cold.
04.55pm:[The patient has now] extrasystoles: CO2 3.7% oxygen saturation 70%.
04.58pm: CO2 4.5%, blood pressure 135.
05.06pm: oxygen saturation 63%. No oxygen for a minute;
Oxygen saturation 54%.
05.08pm: CO2 4%.
05.09pm: Blood pressure 125 Pentothal 100 mg. CO2 4.5%, oxygen saturation 66%.
05.11pm: CO2 3,8%.
05.12pm: Still retching, still not synchronised with the respirator.
Spontaneous respiration: [the frequency] 32 Oxygen is taken away.
Oxygen saturation 50%. We go on to pressure ventilation with oxygen (+ own breathing).
Oxygen saturation 50% -> 65% in 15 sec
05.35pm: oxygen saturation 85%!
06.18pm: Phenol 10 mg.
07.15pm: blood pressure 160, Pulse 120
Sweating, grimaces appear, seems absent. Suction. Oxygen with positive pressure.
07.40pm: Blood pressure 140
07.45pm: assisted with 100% oxygen 2 minutes ago.
Good complexion. Blood pressure 120, pulse 140
07.50pm: blood pressure 110 ...... [Illegible]. Still very nervous therefore, 100 mg Pentothal i.v. to allow blood gas sampling: pH 7.39.
08.02pm: blood pressure 120. Removal of the respirator. Manual
positive pressure ventilation.
08.05pm: Atmospheric air. Blood pressure 110
08.07pm: Respiration 36. Nearly apnoea. Moves all four extremities.
07.13pm: [probably meant 08.13pm ?] CO2 4%. Appears warm and dry at the same time and is more or less with respiratory failure.
Auscultation of the lungs: weak breath sounds on the left.
After vigorous ventilation and insufflation clear breath sounds can be heard also left and the sweating has ceased. The patient is quiet – now atmospheric air is sufficient (ventilation).
Ibsen believed that the left lung was insufficiently ventilated by the respirator – and that this is the reason why the condition of the patient deteriorated at 07.15pm.
07.25pm:[Probably meant 08.25pm] 100 mg of Pentothal.
09.00pm: Has vomited 200ml in total over the whole day.
10.15pm: ...... [Illegible] 200 ml (absorber is connected).
10.20pm: Pulse 120, blood pressure 120.
11.30pm:Pulse 120, blood pressure, 120. Has been repeatedly been sucked. Spontaneous respiration.
Date: 28 / 8
00.10am: pulse 84, blood pressure 160. Sleeps quietly.
00.12am: The patient was administered: glucose 800 ml water and 200 ml of blood
00.12am: Glucose Water 1000 ml is appended. The absorber does not work and will be dismantled. Oxygen with high flow (12-15 L / min) is administered without absorber.
00.25am: Pulse 120, blood pressure 115.
02.10am: Pulse 120, blood pressure 130
02.30am: Blood pressure 120. From 02.00 am till 02.30 am oxygen was given and from 02.30 am on atmospheric air again.
02.55am: Blood pressure 120.
03.15am: Pulse 120, blood pressure, 120.
03.45am: Blood pressure 115.
04.00am: Blood pressure 125.
04.25am: Pulse 125, blood pressure 140.
04.30am:[In Ibsen’s Handwriting] after problems with ventilation, the patient got this regurgitation movements again, but no spontaneous chest movements. After brief hyperventilation with pure oxygen she got thorax movements again but with regurgitating movements.
Spontaneous thoracic movements: 38/Min.
Blood pressure: 150
05.05am: We get this regurgitation not under control.
Blood pressure 200. immediately after suction. Arms wet and cold.
05.07am: Blood pressure 160. Pulse 108 - irregular.
05.17am: Blood pressure 130. 2x suction.
05.18am: Blood pressure 120. pulse 160, warm, dry.
05.20am: Blood pressure 110, nausea away.
05.22am: Blood pressure 100, pulse 152. Pulse regular.
(from 05.05am on ventilated with 100% oxygen).
05.25am: she is feeling better after the oxygen was administered. We try again with atmospheric air.
05.30am: blood pressure 90. Pulse 120
06.00am: blood pressure 100. Pulse 160
06.30am: Atmospheric air.
06.35am: blood pressure 135, Pulse 112
06.40am: blood pressure 115, Pulse 128
Perfectly calm, warm and dry but something ...... [illegible].
Visit on 08/28th: yesterday at 11 o’clock: tracheotomy inf[erior].
The patient has since been ventilated with atmospheric air and intermittent positive pressure. The patient's condition is satisfactory.
Has been drinking, urinated. No bowel movement.
Received blood transfusion [total] 200 ml, consistent with type A Rhesus + and glucose 5% (until this morning, 1300 ml) than intravenous Infusion.
Evening: temperature still remains high. Is conscious. Is warm and dry. blood pressure 120.
The left bronchus is aspirated, as the X-ray shows Atelectasis to the left.
B.J.
In the following days the patient remained relatively stable, except for a further attempt to connect her to the respirator. The attempt failed. The condition of the patient worsened immediately and the doctors had to turn back to manual positive pressure ventilation.
It would take several days before the organization to full manual ventilation of the patients was operational (according to Ibsen it took 8 days) [1]. Until September 10th Vivi was feed through a gastric tube. In September, she also began with the physiotherapy and breathing exercises. Until January 1953 she was manually ventilated 24/7. There followed a very lengthy recovery. Again and again she developed atelectasis that was treated with bronchoscopy and antibiotics. She was still dependent on artificial ventilation. Over the following years, different models of respirators were tried. The technology improved as new models were developed. It was not until 1955, that a respirator entered the market which could support ventilation satisfactorily. Only by then, the manual positive pressure ventilation was no longer necessary at intervals. Vivi E. remained, according to the record, dependent on artificial ventilation for the rest of her life.
When she was released From Blegdams Hospital in 1959 (!), she was bound to a wheelchair because of quadriplegia. She could speak, and scroll through a book with a stick in her mouth, but needed help for eating and the daily nursing. Vivi’smother was trained in the use of the respirator and Vivi was released to her own home where she lived with her parents. In June 1971 she was again admitted to the BlegdamsHospital with diabetes and a severe pneumonia. She died after 2 ½ days in the hospital from pneumococcal sepsis.
She was 31 years old.
The following photocopies are from Vivi E.’s medical record found at the Muncipal Archives in Copenhagen
Fig. 1: the front of the medical record Vivi E..
Fig 2: First page of the medical record Vivi E.
Fig. 3: The page from the medical record of 08.27 E. Vivi with Ibsen’s entries.
References.
1. Ibsen B (1975) from anaesthesia to anaesthesiology. Personal experiences in Copenhagen during the past 25 years. Acta Anaesthesiol Scand Supp 61: 1-69.