The Call to the Schools

The proven success on Vivi Ebert’s table creates an urgent new problem: how to scale this labor-intensive, life-saving technique for dozens of dying patients. At ten minutes past midnight on August 28, 1952, the telephone rings in the porter’s lodge of the University of Copenhagen’s medical faculty on Bredgade. The porter, a man accustomed to emergencies of academic rather than medical consequence—late examinations, disputed grades, students taken ill after celebrations—lifts the receiver and finds himself speaking to a hospital administrator whose voice carries the compression of someone who has not slept in days. The message is brief. The hospital needs students. All of them. Now.

By half past midnight, the porter has begun his rounds. The medical faculty occupies a warren of offices and lecture halls in a nineteenth-century building whose corridors smell of floor wax and formaldehyde. He moves through them with a list in his hand, waking the night watchmen, locating the telephones that connect to the residences where students sleep in attic rooms and converted servants’ quarters. The first calls go to the senior students, those in their final years who have already spent time in hospital wards and will require the least instruction. Then to the intermediates. Then, as the mathematics of the crisis become clearer, to the first-years who have barely learned to take a pulse.

The calculation is simple and brutal. Each patient requiring manual ventilation needs a hand on the rubber bag for every minute of every hour. A single patient consumes twenty-four hours of labor per day. Two patients, forty-eight hours. The ward at Blegdam already holds more patients than its single Emerson iron lung and some cuirass-type ventilators can serve, and new admissions arrive by ambulance through the night. The hospital administrators, working with Ibsen and the senior medical staff, have estimated that they may need to ventilate fifty patients simultaneously. Some will recover enough to breathe on their own within days. Others will require weeks. The arithmetic produces a figure that has no precedent in Danish medical history: perhaps fifteen hundred students, working in shifts around the clock, to keep the patients alive.

The hand-pump economy was born in that first night: human labor converted into the primary technology of survival.

At 1:15 a.m., a medical student wakes to knocking at his door in a boarding house near the university. He is twenty-three years old, in his fourth year of study, and he has spent the evening in the anatomical laboratory preparing for an examination he will now miss. The porter’s message, delivered through the landlady who holds the only telephone on the ground floor, tells him to report to Blegdam Hospital by 6 a.m. With a change of clothes and whatever books he might need to occupy himself during breaks. The landlady, a widow who has seen two wars and the German occupation, watches him pack his satchel with the expression of someone who recognizes the sound of a front line being established.

He is not given details. He is told only that his hands are needed, and that he will be shown what to do when he arrives.

The telephone lines continue their work through the night. The dental faculty, housed in a newer building near the university hospital, receives its own summons at 2 a.m. Dental students have no training in respiratory physiology, no experience with tracheostomy, no preparation for the management of paralyzed patients. Their inclusion in the call represents a widening of the net that betrays the desperation of the calculation: hands are hands, and the bags must be squeezed regardless of whose fingers close around them.

By dawn, the administrative machinery of the university has been repurposed entirely. Secretaries who expected to spend August preparing for the autumn term instead type lists of names and telephone numbers, cross-referencing student residences with estimated travel times to Blegdam. The dean of the medical faculty, a professor of pathology who has not practiced clinical medicine in fifteen years, finds himself conducting a military-style mobilization from his office, his desk covered in maps of Copenhagen marked with the locations of student boarding houses and the routes of the electric trams that will carry the summoned to the hospital.

The first students begin arriving at Blegdam Hospital shortly after 5 a.m., while the sky over Copenhagen is still gray with the summer dawn. They gather in the courtyard, uncertain where to go, their medical satchels and dental tool kits absurdly inappropriate to the task that awaits them. A hospital administrator meets them with clipboards and directs them to the lecture hall that has been commandeered as an assembly point. The hall smells of disinfectant and stale coffee. Someone has pinned a handwritten notice to the blackboard instructing silence, as patients sleep in adjacent wards.

The instruction begins at 6 a.m. With a demonstration that takes less than ten minutes. A senior nurse, her face marked with exhaustion, stands before the assembled students with a rubber bag connected to a mannequin. She squeezes. The chest of the mannequin rises. She releases. The chest falls. The rhythm is four seconds per cycle: squeeze for two, release for two. She explains the anatomy of the tracheostomy, the tube that enters the patient’s neck below the larynx, the connection to the bag, the importance of keeping the airway clear of secretions. She warns them about the signs of over-ventilation and under-ventilation, the changes in skin color that indicate too much or too little carbon dioxide being expelled. She tells them that they will work in pairs, one student squeezing while the other rests, and that they must maintain the rhythm without fail.

There is no time for practice on living patients. The first students are assigned to beds within the hour.

The ward that receives them has been transformed overnight. Where there had been six cuirass respirators and the single Emerson iron lung, there are now rows of beds occupied by children and young adults whose breathing has failed. Each bed has been equipped with a tracheostomy tube, a rubber bag, and a mounting system to hold the bag when the student’s hands require rest. The students are paired and assigned to specific patients, given schedules that rotate them through six-hour shifts with two-hour breaks, and instructed to find the senior nurse immediately if their patient’s color changes or if the bag develops a leak.

The fourth-year medical student is assigned to a twelve-year-old girl whose name he is not told. She has been paralyzed by the bulbar form of the disease, her respiratory muscles destroyed by the virus’s attack on the brainstem. Her eyes are open and moving, tracking his face as he approaches the bed. He has never seen a conscious patient who cannot breathe. The sensation is disorienting: she is alive, aware, completely dependent on the pressure of his fingers against the rubber bag that rises and falls at her shoulder.

He begins to squeeze.

The mathematics of the operation reveal themselves gradually through the morning. Each student works six hours on, two hours off, in continuous rotation. This means that three students are required for each patient around the clock. For fifty patients, one hundred fifty students per shift. With three shifts covering the twenty-four hours, the total approaches the estimated fifteen hundred—though the actual number fluctuates as students fall ill, as some prove unable to maintain the physical demands, as the patient census rises and falls with admissions and deaths.

The hospital’s administrative staff, meanwhile, confronts a parallel crisis of logistics. The rubber bags, obtained from anaesthesia supplies and modified for continuous use, wear out under the strain. The connections to the tracheostomy tubes, never designed for weeks of continuous operation, develop leaks that must be patched with adhesive tape and ingenuity. The students require feeding, somewhere to sleep between shifts, a system for tracking their hours and ensuring that no patient is left without a hand on the bag. The administrator who began the morning distributing clipboards finds herself by noon directing the conversion of a storage wing into a dormitory, requisitioning mattresses from throughout the hospital, organizing a kitchen to produce meals at all hours for workers who cannot leave their posts.

The dental students present a particular challenge. Their training has prepared them for the mechanics of the oral cavity, for the precision work of drilling and filling, for the management of patients who can follow instructions and breathe on their own. Nothing in their education has suggested that they would spend six-hour shifts compressing a rubber bag to keep a stranger alive. Several, in the first hours, faint at the sight of the tracheostomy wound or the realization that their patient’s consciousness depends entirely on the rhythm they maintain. They are reassigned to less acute cases, to the fetching of supplies, to the documentation of vital signs—tasks that free the more resilient for the bags.

By noon on August 28, the system is functioning after a fashion. Fifty students squeeze bags in the main ward while fifty more rest in the improvised dormitory and fifty more prepare to relieve them. The senior medical staff move among the beds, checking blood gases drawn by Poul Astrup’s technicians, adjusting the ventilation rates for patients whose carbon dioxide levels remain too high or too low. Ibsen himself has not slept since the operation on Vivi Ebert; he moves through the ward like a man walking underwater, his attention fragmenting across dozens of patients whose survival now depends on machinery he has improvised and labor he has conscripted.

The afternoon brings new complications. The first students to complete a full six-hour shift report to the assembly hall with hands that cramp and wrists that tremble. The physical demand is greater than anticipated: not the absolute strength required, which is modest, but the absolute consistency, the maintenance of an identical pressure and rhythm hour after hour. The students who have rotated through describe the sensation of dissociation that sets in after the first two hours, the way the patient’s chest becomes an abstraction, the way one’s own breathing falls into synchronization with the bag’s rhythm and then, dangerously, diverges from it.

A system of massage and hot-water treatment is improvised for the students’ hands. The hospital’s physiotherapy department, previously concerned with the rehabilitation of polio survivors, finds itself treating the hands of those keeping the acute patients alive.

The evening of August 28 brings the first deaths under the new system. Not all patients can be saved by ventilation alone; some have suffered too much neurological damage, some develop pneumonia from the tracheostomy, some prove resistant to the rhythm that others survive. The students who have been squeezing bags when their patients die experience a particular trauma: the chest that has been rising and falling under their hands suddenly still, the rhythm they have maintained for hours becoming irrelevant in an instant. A protocol is established for these cases. The student is relieved immediately, given tea and a place to sit away from the ward, assigned to non-patient duties for the remainder of their shift. There is no formal debriefing, no psychological support—the machinery of crisis allows no time for it.

The night of August 28-29 operates as the first full test of the system’s endurance. Students who have never worked through a night maintain their posts while the ward darkens around them, illuminated only by the night-lights above each bed and the glow from the corridor where the senior nurses make their rounds. The sound of the bags, the soft rhythmic compression and release, becomes the ward’s new atmosphere, replacing the mechanical heartbeat of the iron lung with a more varied, more human percussion. Each bag has a slightly different tone depending on its wear, its connections, the particular rhythm of the student who squeezes it. The aggregate effect is of a room filled with breathing, as if the building itself had become a lung.

In the administrative offices, the calculations continue. The patient census has stabilized at approximately forty-five requiring continuous ventilation, with new admissions matching the rate of deaths and recoveries. This still requires nearly fourteen hundred students in continuous rotation, a figure that exhausts the available supply of medical and dental students and begins to draw from the veterinary faculty, from the nursing schools, from any institution whose students possess hands and can follow a four-second rhythm. The university’s rector, consulted by telephone at his summer residence, authorizes the suspension of all non-essential instruction for the duration of the crisis. The autumn term, scheduled to begin in September, is postponed indefinitely.

The physical plant of Blegdam undergoes further transformation. Corridors are lined with beds for patients who require less intensive ventilation, who can survive with intermittent assistance or who are recovering enough to breathe spontaneously for increasing periods. The operating theaters, their scheduled cases cancelled, become emergency stations for the insertion of new tracheostomies as patients deteriorate. The hospital’s laundry, overwhelmed by the sheets and gowns required for infection control, requisitions additional staff from the municipal services. The mortuary, its capacity exceeded, arranges for rapid transfer of bodies to the municipal facilities.

By August 30, the system has acquired a name among the staff: the “hand-pump service,” or in Danish, “håndpumpetjenesten.” The term carries both the practical description and a certain grim humor, acknowledging that what has been created is not a medical technology in the conventional sense but a human-powered infrastructure, a temporary bridge between the inadequacy of existing machines and the possibility of patient survival.

The students themselves begin to develop techniques and traditions. The pairs working each bed establish their own rhythms of conversation and silence, learning when their patient can hear them and when the effort of listening interferes with the work of breathing. Some patients, those whose paralysis is less complete, learn to signal with their eyes or with slight movements of their fingers—requests for suction, for adjustment of position, for the reassurance that the bag is still there. The students keep notebooks, against regulations, recording the peculiarities of their patients, the moments of connection, the hours of tedium. These documents will later become a crucial source for understanding what was created in the crisis, though at the time they represent only the individual response to an institutional demand.

The physical cost accumulates. Students report to the infirmary with blistered palms, with carpal tunnel syndrome, with psychological symptoms that have no name in the diagnostic manuals of 1952. The hospital’s senior staff, themselves working beyond endurance, develop a hierarchy of triage for the students as well as the patients: those who can continue, those who require lighter duties, those who must be sent home regardless of the labor shortage. The replacement rate becomes a constant anxiety; each student lost to exhaustion or illness increases the burden on those who remain.

Yet the system held. Through the first week of September, the mortality rate among ventilated patients stabilized at approximately 20 percent. The figure compared favorably with the 90 percent mortality previously associated with bulbar polio treated in iron lungs. It also meant that one in five of the young people whose chests rose and fell under student hands would still die, and that the survivors would face months of rehabilitation, permanent disability, or late complications the medical staff were only beginning to understand.

The institutional adaptation extends beyond Blegdam. The University of Copenhagen, its normal functions suspended, becomes an extension of the hospital’s administrative apparatus. Professors who have not practiced clinical medicine in decades find themselves organizing student schedules, negotiating with municipal authorities for additional resources, representing the crisis to a public that follows the epidemic through newspaper reports of increasing alarm. The Danish government, initially hesitant to acknowledge the scale of the disaster, authorizes emergency funding and the requisition of supplies. International attention begins to focus on Copenhagen as a test case for the management of polio outbreaks, with medical delegations arriving to observe the hand-pump system and report to their own authorities.

The Engström respirator, developed in Sweden and used for the first time in Blegdams Hospital during this outbreak, offers a partial mechanization of the process. It proved a success and by 1953 had superseded the iron lung throughout Europe. But in August and September 1952, the machines are too few and too late. The positive-pressure ventilator has the advantage that the patient’s airways can be cleared of secretions and the pressure regulated more precisely than with manual bags, but each machine can serve only one patient and the manufacturing capacity cannot meet the immediate demand. The students remain essential, their hands filling the gap between the proven technique and its mechanical implementation.

By the first week of September, the student army was assembled at Blegdam, and the human-powered system it had improvised would be tested through the months to come.

The success on Vivi Ebert’s table had created an urgent new problem: how to scale a labor-intensive, life-saving technique for dozens of dying patients. The call had gone out. The students were assembled. What remained to be seen was whether the system they had built in a single night could hold.