|Hart First Response|
History of Resuscitation
This text was originally taken from the webpage: http://gema.library.ucsf.edu:8081/Originals/wallace.html which no longer exists! (Submitted to GEMA on 10/29/96)
Author: Lieutenant Michael J. Wallace
REMT-P Largo Fire Department Pinellas County Emergency Medical Services
It seems almost inconceivable that our industry is only thirty years old. We have seen many changes over the years. From "Johnny and Roy" on television, we have evolved to field use of thrombolytics to dissolve clots and paralytics to aid in rapid sequence induction for endotrachealintubation. It seems we have become a "high tech, low touch"occupation. History of our profession is not taught as part of thenational curriculum because how we came to be is not deemed to besignificant. Maybe by looking back, we can improve our vision of thefuture.
The first apparent attempt at resuscitation interestingly enough wasrecorded around 800 BC. The first resuscitation was Elisha's mouth tomouth. "...And he went up, and lay upon the child, and put his mouthupon his mouth, and his eyes upon his eyes, and his hands upon hishands; and he stretched himself upon the child; and the flesh of the child waxed warm."1 This first recorded event has been the gate through which all of us have traveled.
Very early in our history, people realized that the body became coldwhen lifeless and connected heat with life. In order to prevent deathfrom taking the person, the body was warmed. The use of warm ashes,burning excrement, or hot water placed directly on the body were allemployed in an attempt to restore life.
In the 1500's it was not uncommon to use a bellows from a fireplace toblow hot air and smoke into the victim's mouth, a method that was usedfor almost 300 years.2 In the 1700's a new method of resuscitation wasused. This "new" procedure involved blowing tobacco smoke into thevictim's rectum.
Other methods were developed in the 1700's in response to the leadingcause of sudden death of that time, drowning. Inversion was tried, apractice developed in Egypt almost 3,500 years ago again became popularin Europe. This method involved hanging the victim by his feet, withchest pressure to aid in expiration and pressure release to aidinspiration.
Another resuscitation method comprised placing the victim across atrotting horse. It was thought that the rhythmic compressions of thevictim's chest as the body bounced would restore breathing. Sometimethis method was modified to replace the horse with a barrel. Thepatient was placed over the barrel and rolled back and forth to compressand release pressure on the thorax. At times the victim was placedinside the barrel which was then rolled.
In response to the increasing numbers of drowning during this timeperiod, societies were formed to organize efforts in resuscitation.England's Royale Humane Society was founded in 1774. Although it wasthe most famous, it was not the first. It was preceded by the DutchSociety for Recovery of Drowned Persons, established in 1767. Dutchrecommendations included: 1) warming the victim (which sometimesrequired transporting the body to a different location) by lighting afire near the victim, burying him in warm sand, placing the body in awarm bath, or placing in a bed with one or two volunteers; 2) removingswallowed or aspirated water by positioning the victim head lower thanhis feet and applying manual pressure to the abdomen, vomiting wasinduced by tickling the back of the throat with a feather; 3)stimulation of the victim, especially the lungs, stomach and intestinesby such means as rectal fumigation with tobacco smoke, or the use ofstrong odors; 4) restoring breathing with a bellows; 5) bloodletting.3These and other methods had been applied for years as documented in thereport of Anne Green's hanging, resuscitation and recovery in 1650.4Other methods included physical and tactile stimulation in an attempt to"wake up" the victim. Yelling, slapping, even whipping were used toattempt to resuscitate.5
In the late eighteenth century, death was mostly seen as caused byinfectious diseases or accidents. Cardiovascular disease was not fullyunderstood or appreciated. By far, the most common accident wasdrowning. "Rescue Societies" were established throughout Europe and theUnited States to deal with this problem. The purpose of these societieswas to recommend resuscitation techniques. They issued annual reportslisting resuscitation attempts and outcomes.
Published in London in 1788, a physician named Charles Kite published apaper in the then current medical literature entitled "An Essay on theRecovery of the Apparently Dead". This document describes the majorcause of sudden death in that day, drowning. The essay also describeswhat some consider the first successful defibrillation. The data usedin Kite's essay was from the initial annual reports of the Royal HumaneSociety. The essay was awarded a silver medal by the society in 1788.
Kite did not discuss sudden cardiac death as we know it today. It wasprimarily a study of drowning, which at the time, was the equivalent ofsudden death. Many parallels can be drawn between drowning as itoccurred in the eighteenth century and sudden cardiac death in thetwentieth century. Both conditions are the most common known cause ofsudden death in their respective time frames. Both require rapidintervention on the part of bystanders and rescuers. Although thecondition of drowning does not require rapid defibrillation as doessudden cardiac death, Kite's essay did attempt to define when aresuscitation would not be successful by suggesting the application ofan electric shock to the body. If no muscular contraction occurred, itwas concluded that death was irreversible.
Kite's essay describes a portable device designed to apply electricshock to victims of collapse. The device did in fact have many of thecomponents of a modern defibrillator, including a capacitor as a meansto store energy, a way to adjust the charge and two electrodes to beplaced across the chest.
Kite relates the story of a 3 year old girl who fell out of a secondstory window and "was taken up to all appearance dead". A doctor wholived opposite the place of the accident tried to revive the child withelectricity. Twenty minutes passed before the doctor could apply theshocks. The shocks initially ineffective when placed on various partsof the body but "on transmitting a few shocks through the thorax, heperceived a small pulsation" and the child began to breathe. After fourdays of coma, the child revived to normal health. Although unlikelythat this child was in V-Fib, she was more likely deeply unconsciouswith a brain injury and the shocks stimulated her to a level of apparentresuscitation.
Kite documents the first analysis of resuscitation as well with 125cases of successful resuscitation of drownings and 317 cases ofunsuccessful resuscitation. Kite concluded that the most importantfactor in success leading to "recovery of the apparently dead, is thelength of time that elapses before the proper remedies can be applied."
Like scholars of today, Kite recognized the need for immediate action tosave the life of someone suffering from cardiac arrest. Although hisresearch methods were crude and his data was not the "clean" data we cancollect today (his "down time" and "response times" were from memory ofthe bystanders), he forged a path to the future by providing a model tocopy and a method to collect, analyze, and improve the way we care forpatients today.
Other resuscitation techniques evolved outside of the traditionalWestern European medicine. In the 1800's the Russians buried the victimupright with his head and chest exposed and splashed water on his face.6An early attempt at what Russian science referred to as "reanimatology".
In 1811 research by Benjamin Brodie resulted in the abandonment the useof fumigation after his researched demonstrated that four ounces oftobacco would kill a dog and one ounce would kill a cat.7 In 1829, Leroyd'Etiolles demonstrated that over distention of the lungs by bellowscould kill an animal, so this practice was discontinued. The warming ofthe victim's body became the focus of resuscitation. Interestingly, inthe same paper that warned about the use of bellows a method of manualventilation was described applying pressure to the chest and abdomen. 8In 1831, Dalrymple suggested that side-to-side compression of hevictim's chest, either by hand or by two operators pulling on the endsof a wide bandage placed under the victim's back and over his chest.9
Also in the 1800's Napoleon's personal physician Dominique Larrey, madegreat strides in the care of traumatic injuries specifically to aid inthe war effort of Napoleon. He conceived the first "ambulance volantes"which made possible the rescue and resuscitation of many of the woundedin battle and which in effect led to the development of the modernambulance service as we know it today.
As late as 1856, manual ventilation was given low priority,concentration was on maintaining body heat.10 These were the samerecommendations as provided by the Dutch nearly 100 years earlier. Asignificant change in priorities occurred when Marshall Hall challengedthe conventional wisdom of the Society. His contention that time waslost transporting the victim; that the restoration of warmth withoutsome type of ventilation was detrimental; that fresh air was beneficial;and that if left in the supine position, the victim's tongue would fallback and occlude the airway. Because the bellows were no longer anoption, Marshall Hall developed a manual method in which the victim wasrolled from stomach to side 16 times a minute. In addition, pressurewas applied to the victim's back while the victim was prone (expiratoryphase). Tidal volumes of 300 ml to 500 ml were achieved and soon becameadopted by the Royale Humane Society.11 12 European methods used laterin the century included stretching the rectum, rubbing the body,tickling the throat with a feather, waving strong salts, such asammonia, under the victim's nose. In 1892, French authors recommendedtongue stretching. This procedure was described as holding the victim'smouth open while pulling the tongue forcefully and rhythmically.13During the next 50 years, different techniques of manual ventilationwere tried and compared, the push pull method, the Eve Tilting method14, each was compared and reviewed. Even the U.S. military conducted areview of current resuscitation techniques.15
In 1923 the only comment on "counter shock" was by Dr. Drinker whocondemned it. He reported a case in which a lineman was accidentallyelectrocuted. The patient was dropped, his feet were pounded, and/or hewas punched. Such attempts to revive patients eventually fell intodisfavor. Today the only remaining procedure, a reminder of days past,is the precordial thump, the last remnant of beating patients to restorelife.16
Dr. Peter Safar began experimenting with mouth to mouth respirations asearly as 1958.17 The next major step in resuscitation was closed chestmassage which was introduced in the 1960's by Dr. Kowenhoven, Jude andKnickerbocker.18 The stage was set for the emergence of a newanimal...the paramedic. All that was needed was the political impetus.
In 1966 the now famous document titled "Accidental Death and Disability:The Neglected Disease of Modern Society." was released by the NationalResearch Council and the National Academy of Sciences. This combinedcommittee publicized that "there are no generally accepted standardsfor the competence or training of ambulance attendants".19 Severalmonths later, the American Medical Association (AMA) conducted anational conference in which this study was widely cited. Theconference ended with a number of recommendations regarding the minimumlevel of training that all ambulance personnel should have.
The greatest influence on the state of emergency medical care in theUnited States could arguably be a foreigner named J. Frank Pantridge, aphysician in charge of the Department of Cardiology at Belfast's RoyalVictoria Hospital. He came to realize that time was the greatest factorin treating out-of-hospital episodes of acute myocardial infarction. In1963, Dr. Pantridge noted that more than 60% of the young andmiddle-aged males who died from this form of heart attack died withinone hour of the onset of symptoms. In addition, he noted that more than90% of the early deaths resulted from ventricular fibrillation and thatpatients with mild infarction incurred the same risk of ventricularfibrillation as those in whom the infarct is larger. To Pantridge thesolution was simple, start treatment before the patient is admitted tothe hospital. Dr. Pantridge along with Dr. Geddes succeeded increating the first vehicle equipped with coronary care equipment fromthe hospital's coronary care unit, including a physician. Thus thefirst pre-hospital care was established, albeit with physicians, notwith non-physician surrogates. The streets of Belfast became "theplace" to have an out-of-hospital cardiac arrest.
The first "paramedics" were actually trained in Miami by Dr. EugeneNagel. Dr. Nagel became a physician after a successful career as anelectrical engineer. An avid scuba diver, he met several members of theMiami Fire Department while diving. In conjunction with the FloridaHeart Association, Dr., Nagel was able to develop the first portabletelemetry unit which could be used by specially trained "rescuefiremen." These devices used phone lines to transmit the electricalsignal to the hospital for interpretation by the "base physician". Theentire unit weighed an incredible 54 pounds.
Over the last thirty years our profession has continued to expand uponthe basic precepts established three decades ago. Occasionally we findour methods to be of less use than previously thought. Occasionally wefind new techniques that are more successful than others. One constantremains: The need to provide early intervention in time criticalemergencies has proven to be the one effective tool in combating traumaand cardiac arrest.The next thirty years appears to be concentrating on cerebralresuscitation. More than 50% of patients who regain spontaneouscirculation die as result of neurologic damage, and more than 20% of thesurvivors sustain severe neurologic sequelae.20 21 22 Even today, thesame Peter Safar who pioneered research in manual ventilation is nowlooking at cryogenic preservation of the cerebral tissue during cardiacarrest. It is not unthinkable that paramedics will arrive at the sideof a patient found to be in cardiopulmonary arrest, slip on what appearsto be a motorcycle helmet, infuse liquid nitrogen into the helmet tohelp preserve brain tissue and continue resuscitation until a return ofspontaneous circulation is achieved, thus preserving brain tissue.
If you can imagine it, it can happen. If you measure it, you can changeit. The future of EMS is unclear and the waters are uncharted. What anexciting time to belong to this profession!
2 Perkins JF: Historical development of respiratory physiology;Handbook of Physiology: Respiration. Washington DC; AmericanPhysiologic Society, 1964; 1-62
3 Luckhardt AB: Official "edict" by the City of Zurich, Switzerland,1766 A.D., on the methods of resuscitation to be employed on drowned andasphyxiated persons. Br Med J; 1982; 285; 1792-1793
4 Hughs JT: Miraculous deliverance of Anne Green: An Oxford case ofresuscitation in the seventeenth century. Br Med J; 1982; 285;1792-1793
5 Karpovich PV: Adventures in artificial respiration. New York,Association Press, 1953
6 Karpovich PV: Adventures in artificial respiration. New York,Association Press, 1953
7 Keith A: Three Hunterian lectures on the mechanism underlying thevarious methods of artificial respiration practiced since the foundationof he Royale Humane Society in 1774. Lancet 1909;1:745-749, 825-828,895-899
8 Keith A: Three Hunterian lectures on the mechanism underlying thevarious methods of artificial respiration practiced since the foundationof he Royale Humane Society in 1774. Lancet 1909;1:745-749, 825-828,895-899
9 Karpovich PV: Adventures in artificial respiration. New York,Association Press, 1953
10 Hall M: Asphyxia, its rationale and its remedy. Lancet1856;1:393-394
11 Fletcher FD: Dr. Marshall Hall's method of treatment of asphyxia.Med Times Gaz 1857; 15:513
12 Jenning JCS: Dr. Marshall Hall on asphyxia. Med Times Gaz1856;12:525
13 Laborde JV, Billot C: Application du procede de traction de lalangue, ou procede de la langue auu traitment de l'asphyxie par les gazdes egouts-deux succes. Bulletin de l'Academie de Medicine1892;28:718-723
14 Eve FC: Actuation of the inert diaphragm by a gravity method.Lancet 1932;2:995-997
15 Dill DB: Manual artificial respiration. US Armed Forces Med J1952;3:171-184
16 Standards and guidelines for cardiopulmonary resuscitation (CPR) andemergency cardiac care (ECC). JAMA 1980;244:453-509
17 Safar P: Ventilatory efficiency of mouth to mouth resuscitation JAMA1958;167:335-341
18 Kouwenhoven WB, Jude JR, Knickerbocker CG: Closed chest cardiacmassage. JAMA 1960;173:1064-1067
19 Reprinted by the U.S. Department of Health, Education, and Welfare.Public Health Service Publication No. 1071-A-13. Sixth PrintingSeptember 1970
20 Myerburg RL, Conde CA, Sung RJ, etal: Clinical electrophysiologicand hemodynamic profile of patient's resuscitation from prehospitalcardiac arrest. Am J Med 1980;68:568-576
21 Norris JR, Chandrasekar S: Anoxic brain damage after cardiacresuscitation. J Chronic Dis 1971;24:585-590
22 Willoughby JO, Lech BG:
Relation of neurological findings aftercardiac arrest to outcome. Br Med
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