A Legacy: Ake N. Grenvik, MD, PhD, MCCM
July 10, 1929 – September 5, 2021
Critical care medicine was in its infancy in 1968 when Ake Grenvik moved with his wife and four children from Sweden to Pittsburgh for a one-year fellowship in critical care medicine.
Perhaps Ake was in the right place at the right time? More likely, he was the right person for the moment.
Ake was a perfectionist with indefatigable energy. A transformative thinker with a prescient ability to see the big picture, he was also a master of the details. He pre-rounded before 4 am rounds with the night fellow. He interviewed and wrote detailed summaries of every fellowship candidate. He noticed a golden opportunity for intervention and pushed repeatedly to create a Condition C for ‘crisis’ to intercept imminent patient declines. The Condition C saved lives and grew into the Rapid Response Team spearheaded by his colleague Michael De Vita.
His one-year fellowship in Pittsburgh snowballed into a 41-year career that shaped significant parts of the field of critical care medicine. A book is needed to do justice to Ake Grenvik’s legacy. For now, we offer a glimpse of his incredible career through four vignettes: fellowship education, brain death determination, liver transplantation, and the Society of Critical Care Medicine.
Special thanks to Ali Al-Khafaji, Joe Darby, Sandra Kane-Gill, Jason Moore, Michael Pinsky, David Powner, and James Snyder for their recollections of Ake Grenvik.
A Fellows’ EducatorAke Grenvik was the original multidisciplinary critical care fellow. He was a cardiothoracic surgeon with a PhD entitled ‘Respiratory, Circulatory and Metabolic Effects of Respirator Treatment’ from Uppsala University. His fellowship classmates at UPMC were all anesthesiologists; a matter that Ake rectified by doing a one-year anesthesiology residency during fellowship.
“Only four years out of fellowship and Ake is the program director. Then over the next 20 years he moves the program from this embedded year in an Anesthesiology residency to this wonderful multidisciplinary program that we have now,” said Jason Moore, MD, MS, who is Division Chief of the adult Multidisciplinary Critical Care Training Program (MCCTP). “Ake and Peter Safar germinated the idea of formal training in Critical Care Medicine with people learning from the different backgrounds of their colleagues.”
In their 1977 paper ‘Critical Care Organization and Education’ in Anesthesiology, Peter Safar and Ake Grenvik opined that “CCM is a multidisciplinary endeavor that crosses traditional departmental and specialty barriers, since no one physician possesses the full range of all skills and knowledge that ICU patients require.”
Drawing upon their experience in training more than 100 fellows by 1977, their paper championed the need to expand fellowship training programs to meet ICU manpower needs, improve standards, and foster research. Tenets that are still applicable more than 40 years later.
An innovator and early adopter of new practices, Ake understood the value of a diverse training cohort. He backed board certification for trainees and embraced evidence-based medicine, patient safety, and simulation training in "New aspects of critical care medicine training" in a 2004 issue of Current Opinion in Critical Care. With vision and boldness, Ake nurtured a program that would be replicated around the world by his trainees.
He was a hands-on program director, who hosted summer pool parties and winter holiday parties at his home for the fellows. Ake interviewed every candidate and wrote a lengthy summary of each right down to the level of eye contact displayed. He also had an innate sense of when to back a hunch.
In the mid 1980s, emergency medicine-trained David Crippen was looking for a critical care fellowship without any luck. One of David’s friends in neurological surgery recommended him. Ake interviewed David and agreed to give him a shot when no one else was interested. David joined two others as the first EM cohort to join the UPMC MCCTP and the concept of emergency training for critical care medicine gained momentum. (A single trainee with EM credentials graduated from Ake’s program in 1977 and in 1980).
“I owe Ake Grenvik virtually all of my professional life,” said David Crippen in his tribute to Ake Grenvik. David retired from UPMC in 2017.
At the heart of today’s fellowship at UPMC are three core principles: a collaborative culture of faculty from multiple training backgrounds, common working and learning environments for fellows, and programmatic flexibility in clinical rotations to meet the needs of different specialties. The program continues to evolve yet still retains its Ake ethos.
A Visionary for Brain Death Determination
Ake Grenvik knew better than most how to sustain life. He was, after all, recruited by the father of cardiopulmonary resuscitation, Peter Safar. Ake also understood when it was time to let go. He was a member of a national group that introduced ‘letting die’ and ‘terminal weaning’ to the critical care lexicon.
He valued mechanical ventilation for keeping critically ill patients alive so they could heal. But he also foresaw a need for guidance on ventilated patients with irreversible loss of all brain function. At Presbyterian University Hospital (PUH) in Pittsburgh in the late 1960s, Ake was involved in a checklist protocol for the certification of death by neurologic criteria, and later he was one of the first in the nation to attempt to standardize the neurologic examination for determination of brain death.
In 1977, his Critical Care Medicine review with David Powner and James Snyder recommended hospital-level guidelines until a legal definition of brain death could be established. Ake was a member of the 1981 President’s Commission that developed ‘Guidelines for the Determination of Death.’ The guidelines fell into two categories: when respiration and circulation have irreversibly ceased (no assessment of brain function needed), and when neurologic criteria are used to assess if brain function has irreversibly ceased in artificially ventilated patients.
Willing to take a position, Ake’s 1983 Critical Care Medicine editorial, ‘Terminal weaning: discontinuance of life support therapy in the terminally ill patient’ led to significant debate among the medical as well as legal, ethical and religious communities. In 1995—the same year the American Academy of Neurology released an update to its first guidelines—Ake, David Powner and Joe Darby (now a professor of Critical Care Medicine and Neurosurgery at UPMC) published the PUH brain death protocol in the Textbook of Critical Care.
More than 50 years after Ake Grenvik’s first foray into brain death determination, The World Brain Death Project, which included professor Marie Baldisseri from the Department of Critical Care Medicine, published a special communication in JAMA in 2020. This consensus statement of recommendations “…provides the minimum clinical standards for the determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances.” It has widespread endorsement from international societies and would lead to greater consistency within and between countries. However, we still await the development of official and legal standardized protocols and procedures for determination of brain death/death by neurologic criteria.
Liver Transplant Success … a Dotted Line to Ake GrenvikThirty-three years ago, Ake Grenvik wrote about ‘Ethical dilemmas in organ donation and transplantation’ in Critical Care Medicine. Not only had Ake lived through an explosive growth of transplantation surgery in the early/mid 1980s—in particular, liver transplants at UPMC under Thomas Starzl—but he was acutely attuned to the ethical issues of his time as well as those on the horizon, including organ shortages and technological advances promising artificial organs and live-donor transplants.
Ake’s clinical practice was rooted in empathy, and he believed in a peaceful death. When in 1981 the first 13 liver transplant patients all died, Ake saw patients suffering and attendings emotionally distressed. He requested a moratorium to determine why the patients died.
The review showed correct post-operative processes were in place, however, crucial steps needed after hours were delayed by three or more hours. The interprofessional staffing model was changed with pathology, radiology and pharmacy all moving to 24/7 availability. The 14th liver transplant patient survived. Transplantations boomed in Pittsburgh and Ake ensured the four separate eight-bed liver transplant ICUs could also work around the clock. Some years, UPMC had more liver, heart and lung transplantations than any other center in the world, Ake stated in his autobiography.
Transplant deaths in ICUs are now rare. Advances in transplant ICU care, immunosuppression drugs, organ procurement processes, and live-donor transplants all keep risks low.
“That just doesn’t happen anymore. Surgeons have mastered the complicated organ transplant process and we have mastered the pre-op and post-op care of transplant patients,” said Ali Al-Khafaji, MD, MPH, who is medical director of the Transplant Intensive Care Unit at UPMC Montefiore Hospital.
Dr. Al-Khafaji recalled a time with Dr. Starzl, who was checking on one of his patients in the Transplant ICU. Dr. Starzl commented that he would probably not have been in the position to do so many successful transplants without Ake and his transplant team managing their post-operative care.
SCCM Founding Member, PresidentAt the 1968 FASEB meeting, three critical care legends—Peter Safar, Max Henry Weil and William Shoemaker—took a stroll along the Atlantic City boardwalk and agreed that the intensive care field needed a dedicated society. A year later in Los Angeles, Ake Grenvik was one of 28 ICU physicians who became the inaugural members of the Society of Critical Care Medicine.
Max Henry Weil was elected the founding president, followed by Peter Safar and William Shoemaker as the second and third presidents. Ake was an officer of the society, elected to the editorial board of the newly launched Critical Care Medicine journal, and became the 7th SCCM president in 1976. SCCM membership increased rapidly as did attendance at the society’s annual meetings.
Ake spearheaded a national movement to establish board certification in critical care medicine. Despite the inclusion of members from the four specialty boards most involved in critical care—ABA, ABIM, ABP and ABS—the many months of negotiations failed to reach an agreement on a common certification. Nevertheless, the outcome was a success with separate subspecialty certifications established within the four boards.
In 2012, the American College of Critical Care Medicine honored Ake by inviting him in to join the inaugural class to be inducted as a Master Fellow in Critical Care Medicine. The MCCM distinction “honors members who have distinguished themselves by achieving national and international professional prominence by virtue of personal character, leadership, eminence in clinical practice, outstanding contributions to research and education in critical care medicine, or years of exemplary service to SCCM, ACCM, and the field of critical care medicine in its broadest sense.” Ake met every qualifier.
Ake stated in his autobiography that the Society of Critical Care Medicine was founded for “those interested in intensive care problems regardless of medical background.” That interdisciplinary spirit persists with president-elect Sandra Kane-Gill, DPharm, MS, hailing from the University of Pittsburgh School of Pharmacy.
“Dr. Ake Grenvik had a vision to formally recognize critical care medicine as a medical subspeciality in the United States. He expressed this concept during his address as the 7th president of the Society of Critical Care Medicine in 1977. He continued to lead the formation of critical care medicine by developing the first guidelines for critical care units with Peter Safar and heading the Division of Critical Care at the University of Pittsburgh,” said Dr. Kane-Gill. “As a visionary and founding member of SCCM, Dr. Ake Grenvik and his colleagues forged a path for the critical care medicine multidisciplinary team, and we will be forever grateful.”