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Critical Concept

The intensive care unit at Dartmouth- Hitchcock Medical Center celebrates its 50th anniversary this year. It was a pioneering concept back in 1955. And DHMC has remained a leader in critical-care medicine ever since.

By Laura Stephenson Carter

Total chaos. That's how John Sibley, M.D., describes what taking care of critically ill hospital patients was like until the mid-1950s. Acutely ill patients would be scattered on different floors throughout the hospital. "One person waaaay over there, and another one waaaay over there, and another one waaaay over there," he says. Sibley, who was a resident at Dartmouth in the 1950s and is now an assistant professor of community and family medicine emeritus, spreads his arms wide for emphasis.

"And you need an oxygen over there . . . and we need another one over here," he continues. But when a floor's supply of oxygen canisters was exhausted, the staff had to scramble to get more. He acts out what such a scene would be like: "'Get it from the basement.' 'Yeah, but it will take half an hour, you know, because we have to [take] the elevator, and it's very, very slow.' It was crazy," Sibley says.

Not only did chaos prevail, but less seriously ill patients suffered if they had the misfortune of sharing a room or ward with someone who was really sick. They were understandably anxious, might have trouble sleeping, and could even be ignored by medical staff.


Top: Drs. Howard Corwin, Stephen Surgenor, David Glass, and Andrew Gettinger in today's ICU. Above: Nurses and other staff who manage the unit.

"The other bed in that room might be somebody whose blood pressure is around 60 over nothing and barely conscious, or semiconscious, or going out," recalls Sibley. "The nurses are running around and trying to get his blood pressure up and get oxygen and so forth. And then the [non-acute] patient says, 'Can I have an aspirin?' The doctor or nurse says, 'I haven't got time.'"


A painting (by Joseph Dwaihy, DMS '06, and Sara Dykstra) based on a photograph of DHMC's first intensive care unit, circa 1955.

To make matters worse, the best-trained and most experienced nurses weren't always the ones who tended to the sickest patients. Some nurses hadn't been taught how to keep accurate intake and output records, do urine sampling, measure specific gravity and pH, cope with endotracheal tubes or respirators, or do a myriad of other things necessary to care for people who were critically ill. But, says Sibley, everyone understood that "this is the way it is—you do the best you can."

Everyone, that is, except for the late William Mosenthal, M.D., a surgeon at Mary Hitchcock Memorial Hospital. In the late 1940s, Mosenthal began thinking that there had to be a better way to manage the needs of acutely ill patients. By 1955, MHMH had one of the first intensive care units in the country.

Until recently, it was thought that Dartmouth's was the very first ICU in the nation, but it's become clear that there were varying definitions of what constituted an ICU in the early part of the 20th century. Johns Hopkins claims that it developed the first ICU in the world—a postoperative neurosurgical unit—in 1928. Massachusetts General Hospital in Boston established a burn ICU in 1942 to treat victims of the Coconut Grove nightclub fire. And many hospitals had polio wards in the '40s and '50s that some considered ICUs. However, Mosenthal's ICU may have been the first to concentrate nursing care and medical equipment in one place for critically ill surgical and medical patients.

The idea of concentrating nursing care for the seriously ill was even a century older. In 1854, Florence Nightingale wrote about the benefits of establishing a separate area of the hospital for patients recovering

from surgery. From 1899 to the 1940s, American nurses treated people with yellow fever in isolated quarantine camps. And during World War II, shock wards were established to resuscitate and care for soldiers who had been injured or had undergone surgery.

Mosenthal's Dartmouth colleague, Arthur Naitove, M.D., now a professor of surgery emeritus, suspects the military may have been "what gave Bill the idea of the effectiveness of having a unit that concentrated on giving care to the acutely ill people who desperately needed good care and couldn't be left alone." Indeed, Mosenthal served in the U.S. Army from 1944 to 1946. But he himself said that it was during the latter part of his residency in general surgery at Roosevelt Hospital in New York, from 1946 to 1948, that he first gave serious consideration to the idea of intensive care.

"The concept of a special-care unit really germinated as far as I was concerned in my residency in New York, after the war," he said in a 1988 interview with the late Louis Matthews, M.D. "The war was a tremendous stimulus to advances in medical care. Antibiotics were coming in, and things like fluid, electrolyte, [and] acid-base balances were becoming more and more and more important. We were doing more and more pretty large-scale surgery." Soon, Roosevelt's surgeons began sequestering their sickest patients in a small four-bed room that each ward had. "We drifted into the habit of putting our very sick patients in there," Mosenthal said. When "we made our own rounds, we'd go in there first and spend the most time, instead of going from here over to there, down to the end, back over here."

In 1948, Mosenthal joined the faculty of DMS. Shortly after his arrival, he proposed the idea of a hospital-wide special care unit at a fourth-Monday clinical staff meeting. "The proposal was well received by many of the staff and provoked considerable discussion," Mosenthal wrote in a 1992 letter to neurosurgeon Ernest Sachs, M.D. "I remember that Dr. Bowler [a founder of the Hitchcock Clinic] encouraged me to proceed with the idea, but put action on the back burner. The need was not as acute then as it was soon to become. . . .

"During the next several years, sophisticated and complicated advances

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Laura Carter is the associate editor of Dartmouth Medicine magazine. Sadly, William Mosenthal, M.D., who established the MHMH intensive care unit in 1955, died in 2003—well before Carter began work on this feature. However, she was able to draw upon not only recollections from many colleagues who worked with Mosenthal but also materials in Dartmouth's Rauner Special Collections Library, including a taped interview with Mosenthal that was conducted in 1988 by the late Louis Matthews, M.D.

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