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A US$1-million gift for critical care research in Toronto has been donated by Dr. Barrie Fairley, one the founders of the Respiratory Unit at Toronto General Hospital (TG), a precursor to today's Medical-Surgical Intensive Care Unit (MSICU).
The lead donation, together with $100,000 from Critical Care Canada Forum, and future fundraising commitments, will create a $2-million endowment for the first H. Barrie Fairley Professorship in Critical Care.
The professorship is a joint project with UHN and the University of Toronto (U of T). A search committee is being struck to select the inaugural holder.
The gift coincides with the 60th anniversary of Critical Care at TG. Both are being celebrated today at the University Club of Toronto. A plaque honouring Dr. Fairley will be placed in the MSICU at TG.
Dr. Fairley, 91, joined TG in 1955 as an anaesthesiologist, and had an illustrious career as a clinician, medical leader and researcher in the physiology and management of respiratory failure. He retired in 1994 as Chair of the Department of Anesthesia at Stanford.
"I wanted to give something back to the place which springboarded my career," he says fondly on the telephone from his home in San Diego, California. "It was important for me to create the opportunity for researchers to be able to further their career and be productive in their research.
"Many people helped me, and I want to do the same for the next generation of talented critical care researchers."
Dr. Fairley was welcomed at TG, as he had special training in anesthesia for cardio-thoracic surgery at the highly-regarded Brompton Hospital in London. He arrived in Canada from London after buying a £50 steerage passage on the lowest deck in a Cunard liner, since at that time his U.K. salary was £960 a year.
Dr. Fairley was the first non-Canadian to be appointed to the Department of Anesthesia at TG.
"Things were very different than today's highly technological, sophisticated critical care units," he recalls. "There were no such units back then, and we had to start from scratch.
"There was no blueprint of how to begin."
There were no mechanical ventilators, no piped gases and oxygen tanks were only delivered to the wards by orderlies upon request, he continues. Any ventilation was done manually by the hand of an anesthesiologist squeezing a rubber bag connected to the endotracheal tube of a patient in the operating room.
Patients with respiratory difficulties were usually treated in a ward, encased in iron lung tank respirators – a "coffin-like container" with their heads sticking out from one end, and an air-tight seal around their necks, explains Dr. Fairley. These were widely used between the 1930s and 1950s by patients whose breathing muscles had been paralyzed by polio. Complications were common and deaths were frequent.
Dr. Fairley and three colleagues – Dr. Richard Chambers, Neurology, Dr. Colin Woolf, Pulmonology, and Dr. Hugh Barber, an ear, nose and throat specialist – had a different vision of how to treat patients with respiratory issues.
Deemed too junior to present their recommendations for a specialized respiratory unit to TG's Medical Board, a senior cardiologist as chair of the Respiratory Paralysis Committee presented them on their behalf in 1957. They were based on four principles that are still the foundation of any intensive care unit (ICU) today.
The main ones include: patients need a designated area for their care; nursing care must be provided by permanent and specially trained staff; and ventilation using intermittent positive airway pressure would be the preferred method of respiratory support.
Unlike the iron lung, this means that a machine takes over the patient's breathing, and a mixture of air and oxygen is pushed into a patient's lungs by an endotracheal tube or a connection through the windpipe. This improves the levels of oxygen and carbon dioxide in the blood.
Upon approval from the TG Medical Board in 1957, one of the first Respiratory Failure Units in Canada was established, a forerunner of ICUs in Canada. It was run by an interdisciplinary team of the original four junior physicians who first planned it, along with a thoracic surgeon for consults, physiotherapists, and higher nurse-to-patient ratios than in other units.
"The nurses were first-rate," remembers Dr. Fairley. "We helped train them, and they understood how to handle the equipment, how to closely observe the patients, and how to prevent aspiration by suctioning and clearing the trachea on a regular basis.
"We worked so closely as a team. They understood us and we understood them. We had confidence in each other. That's what made the unit work so well."
As the intrepid team began to take on patients other than neurological ones, they "evolved, stumbled upon occasion and achieved success on others, and hopefully made a few contributions," summarizes Dr. Fairley, who later became the first director of the Respiratory Failure Unit.
In fact, the survival rate of the first 100 patients treated in the new and specialized unit rose to 75 per cent, a much higher rate than previously.
Dr. Fairley also made important innovations in developing the first mechanical ventilator alarm, standardizing blood gas measurements, and developing a system of ambulance transportation between hospitals. That system included an anesthesiologist and the necessary equipment to provide respiratory support during the journey to retrieve a patient, ensuring that patients in respiratory distress were less likely to die en route to TG's Respiratory Unit.
He also organized teams to respond quickly to patients having heart attacks.
When a Code Blue is called in today's hospitals, a team of clinicians (sometimes called a "code team") rush to the specific location with a resuscitation or "crash" cart and begin immediate resuscitative efforts on patients. The cart that they wheel with them has a set of trays and drawers with medications and emergency equipment.
When Dr. Fairley organized hospital teams in the 1960s to better respond to cardiac arrest patients, he, along with a colleague in cardiology, made sure that each floor of the hospital had a small suitcase or box stocked with simple equipment such as suction catheters, an Ambu bag or manual resuscitator, oxygen tank, as well as syringes and some drugs. Each box rested on a kitchen tray which, when turned upside down, could be used as a back support for the patient during chest compressions.
"We improvised all the time," chuckles Dr. Fairley, as he recounts efforts to create a "vigorous program" to train new physicians at the beginning of the year on this new technique.
Dr. Niall Ferguson, Head of Critical Care Medicine at the UHN and the Sinai Health System, agrees that innovation and creativity still remain the hallmarks of the MSICU at TG.
He says critical care at the U of T is known internationally as a powerhouse for critical care medicine – recently ranking second in the world behind only Harvard University for its research output.
At TG, the critical care group is particularly known for its strong research on acute respiratory distress syndrome (ARDS), a severe form of lung injury and inflammation that can result in life-threatening reductions in oxygen and the need for prolonged support on mechanical ventilators.
About 40 per cent of these patients die from this illness in the ICU, and it is estimated that there are more than 17,000 Canadian cases per year.
Landmark studies led by TG Critical Care Specialist Dr. Margaret Herridge have described how critical illness impacts surviving patients and family caregivers will help us modify long-term outcomes for both, points out Dr. Ferguson, and inform the development of a family-centred, rehabilitation program after critical illness.
Other research led by TG Critical Care Specialists Drs. Eddy Fan and Lorenzo Del Sorbo, among others, focuses on the critical care of transplant patients, and how best to use mechanical ventilation and extracorporeal life support. The ICU at TG has become a provincial resource in the use of ECMO technology for ARDS patients, increasing the chances of survival in the majority of cases.
The TG ICU has pioneered efforts in helping patients move, stretch and exercise as early as possible, engaging families as partners in care during bedside reports by nurses at the end of each shift, and using art as a means to remember a dying family member, adds Dr. Ferguson.
"We welcome Dr. Fairley's gift because we encourage high-quality research within a culture of inquiry, mentorship, collaboration, and relevance to the patient and family members," says Dr. Ferguson. "We are grateful to Dr. Fairley for his generosity and wisdom in helping clinical care researchers fulfill their aspirations in helping our patients."