The international crisis due to COVID-19 includes reports of the shortage of ventilators. These are the backbone of modern intensive care, used to support the patient's breathing during the worst parts of the illness.
Nowadays we take this for granted, but not so long ago this was a radical new way of treating patients. One particular contribution to the development of intensive care happened in Newcastle in 1955.
The 50s were a time of rapid medical and scientific progress around the world. In Newcastle Hospital there was a dynamic group of young staff and a somewhat 'radical' culture of innovation and willingness to try new ideas, both clinically and organisationally.
It was also a time of difficult medical challenges, some of which have thankfully disappeared.
In 1955, a 22-year-old married woman was admitted to Royal Newcastle Hospital with clinical tetanus, a complication following an attempted 'backyard' abortion using a syringe. She had repeated tetanic spasms and convulsions, which could not be controlled by all standard treatments, including heavy barbiturate sedation.
After 18 hours, the desperate and courageous decision was made to manage the patient by paralysing her using curare. A tube was then placed in her trachea (windpipe), and a small hand-operated bellows used to blow air in and out of her lungs (ventilation).
This intervention was based on recent reports from Denmark on the management of acute polio patients, and some cases of tetanus that had been ventilated for some days. In Australia, however, ventilation outside the operating theatre with the use of curare was virtually unknown.
The doctors involved then had to work out what to do using basic clinical anaesthetic principles, solving problems as they worked to support the patient for as long as she took to recover . . . if she recovered.
Initially the patient was ventilated by hand, with doctors taking turns to control the bellows. The senior anaesthetist (Ivan Schalit) then assembled a mechanical ventilator from anaesthetic apparatus, household and laundry appliances. This was an ongoing challenge involving trial and error for the next week. He was assisted by a non-medical friend (Rod Earp Sr.) who was "handy" with mechanical things.
Senior anaesthetist Ivan Schalit assembled a mechanical ventilator from anaesthetic apparatus, household and laundry appliances.
The bellows were controlled by lever and gears from his son's Meccano set. An electric motor was obtained by adapting a small household 'clothes press' used for squeeze-drying small towels etc. Using this apparatus, and with the medical team solving problems as they occurred, the patient was then ventilated artificially for 25 days. Years later, Schalit's wife Nina gracefully recalled: "Fortunately, the patient survived....Unfortunately my clothes press did not."
Tracheotomy was performed on day two, and this was the patient's airway for 51 days. Sedation, intravenous fluid balance, nutrition, humidification, respiratory care, and management of the primary pathology (sepsis and tetanus) all had to be dealt with.
Initially, many of the hospital's doctors felt the treatment was an inappropriate intervention in a hopeless case. The ultimately successful outcome, however, attracted wide attention, and became one of the 'legends' of the hospital.
The legend includes the clinical meeting afterwards where the case was discussed - with the patient invited along and presented to the medical audience (unusual for the time). Ironically, the patient later complained to the hospital about her tracheostomy scar.
The case was reported in the Medical Journal of Australia, and gained international interest.
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Many of the hospital's nurses worked with the patient during her long stay in hospital. The experience gained in this case became the basis for many subsequent cases requiring prolonged ventilation. In retrospect, it can be seen as the birth of intensive care in Newcastle.
Ivan Schalit is remembered as a 'Gentleman of the Old School' who delighted in his work and teaching. Warren Gunner, his first trainee, went on to establish the intensive care unit at St Vincent's Hospital in Sydney. He rediscovered the photos of this case in 2005, shortly before his death.
Heroism and innovation by our hospital staff continues in the current crisis. Meanwhile, Rod Earp's grandsons have adapted their gin distillery in Carrington to make urgently needed hand-sanitiser.
Today, we understand more, have better drugs and equipment, and routinely manage cases much more physiologically complex than this one. But while we achieve more, it is by standing on the shoulders of giants.