The Development of Intensive Care Services at RAH

The appointment of Maurice Sando

The major development of the Department of Anaesthesia and the related services such as Intensive Care began when Dr Maurice Sando was appointed Director of Anesthesia in 1962. Progress in anaesthesia involving the use of muscle relaxants and intermittent positive pressure ventilation of the lungs (IPPV) over the preceding decade had improved its safety and the safety of surgery. Other advances in the field of resuscitation included the introduction of external cardiac massage (cardiopulmonary resuscitation, CPR) and ventricular defibrillation and the availability of cardiac and other monitoring. Cardiothoracic surgery had evolved following the development of extracorporeal circulation enabling the repair of various congenital cardiac defects and the introduction of coronary artery replacement grafting.

Anaesthetists contributed to major resuscitation in addition to their traditional roles and the RAH Anaesthesia Department, under the direction of Maurice Sando played a major part in providing acute resuscitation services. It was eventually renamed the Department of Anaesthesia and Resuscitation. Later this evolved to Anaesthesia and Intensive Care.

Establishing a recovery ward

The immediate postoperative period (i.e. first few hours carries the greatest risk of postoperative breathing difficulties, inadequate pain control and sudden bleeding and so a special Postoperative Recovery Ward proposed by Dr Graham Marshall, Director of Anaesthesia during the 1950s, and it was the first in the country. It was adjacent to the operating theatres on the western side of the old theatre block, level 4. Above it (level 5) were Coombs and Ritchie, the post-operative wards where major cases were nursed for the first few days.

The Recovery Ward also became the place where prolonged resuscitation was conducted, because of additional nursing staff and the rapid availability of medical officers from the nearby operating theatres and Anesthesia Department. Because of such use it became a de facto Intensive Care Unit, but that term was not used at that time (early 1960s). The principal admissions for such prolonged resuscitation at that stage were from poisonings. Barbiturates were commonly available and many people in suicidal gestures were taking huge doses, with resultant profound and prolonged coma. The treatment adopted was to provide good general care plus respiratory care and ventilatory and circulatory support. Patients were treated as though they had given themselves a prolonged anaesthetic. Endotracheal intubation and ventilators were used, often for several days. This differed from the previous custom of using stimulants, which could produce convulsions and cardiac depression.

The developing role of nursing in these cases became apparent, such as the supervision of IV pain control, use of inotropes, complex IV hydration regime and adjustment of ventilator settings as prescribed by the medical staff. Lung secretions were aspirated and the lungs were artificially humidified. It was the beginning of what was later formalised as Intensive Care nursing.

Road trauma admissions were common, and proportionately more severe than currently, because there were no seat belts. Crushing chest injuries were very common and the process of providing heavy pain relief and supporting patients on the ventilator until the lung condition was resolved was frequent. This was producing better results than earlier methods of surgical stabilisation of severe chest injuries.

The Tetanus problem

Tetanus was prevalent, due to imperfect immunisation programmes. Tetanus cases had traditionally been managed in a special section of Flinders ward, on the general medical unit of honorary physician Dr Chris Sangster. It was carpeted; the nurses wore sneakers and blinds were drawn to avoid direct sunlight, because bright light and loud noises, such as dropping trays, could trigger intense spasms, when the patient’s back arched like the Sydney Harbour Bridge, with the head on one end of the bed, and heels on the other. Sedation used was not very successful and mortality was over 50%. However in the mid 1950s Drs Maurice Sando (then a registrar) and Jim Lawrence published a pioneering series on the use of muscle relaxants to break the agonising and life threatening spasms. Eventually the introduction of muscle relaxants with what were in effect intensive care methods cut mortality to less than 5% in the Royal Adelaide Hospital.

Cardiac arrest teams

Drs Maurice Sando and Peter Hetzel had established cardiac arrest teams, comprising an anaesthesia registrar, coronary care registrar and an Intensive Care Unit nurse plus a trolley carrying the first “portable” defibrillators (weighing around 15 kg), to respond to in-house emergencies. When staff in metropolitan private hospitals began to ask in increasing numbers for onsite assistance with major emergencies, he encouraged departmental staff such as Fred Gilligan to put together another emergency kit for such responses.

The need for an ICU

The Recovery Ward, primarily for postoperative patients, was becoming rapidly overrun with such patients needing prolonged resuscitation. A new building was planned, to be called the North Wing, with a site for a definitive Intensive Care Unit. Maurice Sando was awarded a Churchill Fellowship to go abroad for three months, to study Intensive Care developments. He then combined with Dr Peter Hetzel (Cardiology) and Neville Martin (Director of Biomedical Engineering) to design an ICU with 11 beds (wards Q4A and Q4B) alongside a six bed Coronary Care Unit (Q4C). The electronic monitoring system served each bed. The continuous waveform displays were state of the art. Telectronics, an Australian company, constructed the equipment.

The new unit was opened in the early ‘70s and the electronic hardware was used for over ten, when the second generation was installed. Subsequently it became obvious that ten years was the maximum before much superior electronic systems and software emerged.

Nursing staff to match

It progressively emerged that nursing the critically ill needed to develop as a post-basic specialty. There were very few such nursing specialties at the time (around 1970). Theatre Nursing was one. Matron Irene Kennedy supported the concept and she allocated Ms Honor Morris, who had a considerable reputation as a nurse educator and developer of education programs. She and Dr Fred Gilligan constructed the first post-basic ICU nursing course, initially of six months duration, and later extended to twelve months. It was designed with major emphasis on the basic sciences involved, with especial reference to acute life threatening illnesses: additional anatomy and physiology involving the major body systems – CNS, respiratory, cardiovascular, renal and haemopoietic systems, and elements of biochemistry. Psychiatric components were also involved. The relevant pharmacology of the multitude of drugs used was added. This was superimposed on the need for meticulous conduct of basic nursing care. There were medical lecturers from all the relevant specialties such as cardiologists, renal physicians, respiratory physicians and haematologists. Dr Fred Gilligan chaired the educational committee initially until after a few years it was passed it over to a nurse.

The academic program involved several hours of lectures a week: one day was set side for study when the students were freed from their ward work. It was aimed to make many lectures like a tutorial with questions and answers frequently involved. A number of those who graduated subsequently progressed very far in the health system including Kaye Challinger, Leslye Long, Jan Fletcher and Heather Schubert to name a few. But Honor kept a very tight schedule, with clearly defined aims and objectives. She organised the examiners to set examination questions and to conduct oral examinations. The aim was to inculcate independence of thinking, and the ability to use clinical judgment based on the basic sciences.

Key ICU medical staff

Anaesthetists initially staffed the ICU on a rotational basis but it was evident a core of intensive care specialists was needed and the ICU grew progressively independent of the anaesthesia service, as intensive care began to emerge as a separate specialty. Dr Fred Gilligan was appointed Director in 1977 (having been Deputy Director since 1974) and was supported by Drs David McCleave (later to enter private practice), Lindsay Worthley, Steven Hagley and later Toby Thomas, until the development of the Intensive Care service required an increasing number of ICU consultants.

Dr Sando unfortunately became unwell and died in 1984 from cardiovascular disease, without realizing his aim to establishing a Professorial Chair in the Department.

The widening role of the ICU

Intensive care practice required considerable attention to the rapidly changing biochemical status of patients. This was aided by the development of automated biochemical and haematological analysis. The multidisciplinary approach of intensive care was illustrated by the early encouragement of IMVS staff such as clinical biochemists, microbiologists and haematologists to attend daily clinical conferences, such as Dr David Thomas, Roy Pain, Trevor Steele, Eileen Lim and others such as nutritionists.

This had benefits in the development of total parenteral nutrition (TPN) and enteral nutrition services. Several scientific papers were published, including studies of the toxic effects of xylitol, a substance once used in parenteral nutrition, and the results of early cases of legionnaires disease in Australia. Extension of ICU services involved the supervision of many patients on general wards who required TPN because they were unable to take food by mouth. several patients improved to the point when they could be discharged and lived for several years on home TPN. These were supervised by Dr L Worthley. Similarly there were a small number who were unable to breathe without artificial ventilation, but could be discharged home, though requiring occasional visits to supervise progress.

The scope of intensive care practice continued to widen. Swan-Ganz flotation catherisation of the pulmonary vessels enabled cardiac output and pulmonary vessel pressures to be directly measured. The development of continuous haemofiltration services enabled slow progressive dialysis, an improvement on the use of intermittent haemodialysis. Fibreoptic bronchoscopy facilitated difficult intubation and direct assessment of lung pathology, and the emergence of ultrasound techniques enabled vessel identification further assessment of cardiac output. Tracheostomies could now be performed in the ICU.

Apart from such bedside techniques, organ-imaging procedures such as CT and MRI scanning produced much-improved information on the critically ill.

Specialist medical education

It became evident there was a need to develop a specialist medical educational program, as intensive care developed into a specialty separate from anesthetics and from the divisions of medicine (cardiology, respiratory medicine etc), though it incorporated components of all those mentioned. Lindsay Worthley developed a series of lectures and tutorials, which were very successful, and over some years these evolved into a program nationally accepted by the Colleges and Faculties responsible for training in this area, notably the Faculty of Intensive Care of the College of Anaesthetists and the sections of the Royal Australasian College of Physicians.

These measures attracted an increased number of medical staff from interstate and overseas joining the staff for specialist training.

A university department

Deputy Directors Fred Gilligan, Sally Drew and John Russell had been working, together with a formal committee to facilitate the creation of an academic department of anaesthesia and intensive care. Eventually the University and the Hospital agreed and in 1988 Dr Bill Runciman from FMC was nominated as Professor of Anaesthesia and Intensive Care and his appointment was associated with the development of an increased emphasis on formal research.

This provided considerable impetus to the Department, and funding was obtained to progressively increase the number of consultants and registrars necessary to cope with the 24 hours-a-day patient management needed and also to provide staff for the retrieval service.

The bulging ICU

During the late 1980s, it became evident the rising ICU caseload could not be contained in its present location. Progressively, the postoperative ward in the western section of level 4 of the north wing (Ward S4), became incorporated into ICU. Around this time, redevelopment of the whole RAH site had been planned and a new adjacent wing was built to become a new ICU entirely.

Changing directors

In 1991 Dr Gilligan was appointed Director of the rapidly expanding retrieval service and Dr Toby Thomas became Director of ICU. With the completion of the new Gerard wing, ICU was housed there with an increased number of beds. In 2006 Dr Rob Young became ICU Director and Dr Peter Sharley Deputy Director, when Dr Thomas was asked to undertake the development of ICU services at the Lyell McEwin Hospital.