History of Cardiopulmonary Resuscitation - Modern Resuscitation - The Development of Emergency Medical Services

The Development of Emergency Medical Services

The extensive international readership of the Lancet helps explain why Pantridge's idea spread so rapidly to other countries. Within 2 years, similar physician staffed MCCU programs began in Australia and Europe. The first program in the United States was started in 1968 by William Grace out of St. Vincent's Hospital in Greenwich Village in New York City. The program was a clone of the Belfast program and utilized specially equipped ambulances with physicians on board to provide advanced resuscitation care directly at the scene of cardiac emergencies. Calls for medical emergencies in which chest pain was a complaint were passed on from the police 911 operator to the hospital. There an ambulance would fight New York traffic to arrive at the scene. Grace described the rather full ambulance and how it was sent:

"The personnel includes an attending physician, resident physician, emergency room nurse, ECG technician, as well as a student nurse observer, in addition to the driver and his assistant. This team is summoned from various points in the hospital to the emergency room by a personal paging system which each member of the team carries. This team has four and one half minutes to get to the emergency room, obtain their equipment and board the ambulance. Anyone who is not there within this time is left behind."

In a scientific report of the St. Vincent's program, Grace described the experience with the first 161 patients (ref). Only two instances occurred in which the physician did not make the 4½-minute deadline and the ambulance left without the physician. The ambulance reached the scene usually within 14 minutes, plus of course the 4½-minute pre-response time. One call took 25 minutes owing to heavy traffic. Among the first group of patients seen by the MCCU were three patients treated for ventricular fibrillation. One of the three survived.

Grace took an innovative concept, imported from overseas, and made it work in his community. Physicians with defibrillators rushing through the city to reach a non-breathing, unconscious person whose heart had stopped were quite unusual by 1968 standards. However, the program was limited in vision, and although it could work in some communities, it was not nationally applicable. An evolution in prehospital emergency care was needed. Pantridge, Geddes, and Grace had broken the conceptual block of keeping resuscitations confined to hospitals. Now someone had to break a conceptual block that kept resuscitation in the hands of physicians. This called for a major change the personnel allowed to perform resuscitation.

The evolution from physician-staffed mobile intensive care units to paramedic-staffed units in the United States occurred independently and almost simultaneously in several communities. Two communities that led the way were Miami and Seattle, but others included Portland, Oregon, Los Angeles, and Columbus, Ohio. These communities were a major evolutional advance compared to the Belfast or New York City programs. Not only were paramedics used instead of physicians, but from their inception the programs were established to deal with the problem of sudden cardiac arrest. Pantridge's program was established primarily to reach the victim of MI fast and thereby prevent mortality in the vulnerable early stage of this event. Thus cardiac arrest was successfully treated only if it occurred as a complication of MI and only if the ambulance was already at the scene or en route. The new paramedic programs were far more nimble than physician-based programs and were specifically designed not only to treat the early stages of MI, but also to attempt resuscitation for sudden cardiac arrest wherever and whenever it occurred. Reversal of death itself would be a major purpose and goal of the new paramedic programs. Beck’s vision of treating “hearts too good to die” was becoming real.

Eugene Nagel, became aware of Pantridge's work in 1967. He believed that the physician-staffed model of prehospital care was not going to work for the United States in general or for Miami in particular. Physicians were too expensive to sit around fire stations waiting for calls, and if they had to be picked up in hospitals, it would take too long to arrive at the scene. When Nagel or his colleague James Hirschman, rode on the ambulance themselves they could, of course, defibrillate and provide medications, but they could not be present on all shifts. Nagel became convinced it was time to move away from a program using physicians to one staffed by paramedics.

Nagel moved incrementally. He did not think he could initially sell the idea of paramedics working alone, even if they had authorization to perform medical procedures signed by physicians. So instead his first step was to establish a radio link and telemetry between the paramedic fire fighters and the hospital. Nagel's had a hidden agenda in promoting telemetry. For Nagel it was the Trojan horse that gained him access through the legal impediments stopping fire fighters from defibrillating patients and administering medications. Nagel reasoned that if the fire department could send the ECG signal to the hospital via telemetry, then the fire fighters (with special training) could be authorized by the physician to administer needed drugs and procedures before arriving in the emergency department. He believed a paramedic at the scene was a legal extension of a physician. He recalled later, "We saw telemetry as the key to extending our treatment to outside the hospital where hitherto trying to legislate it was the dark side of the moon in those days. The telemetry looked like it might be the 'open sesame' to doing some treatment pre-hospital."

Nagel hoped to find support from the medical community; instead he only encountered discouragement. The theme of opposition to innovation seems a recurring one. Nagel recalled this opposition, “It was a rare doctor that favored us doing any of this stuff — very rare. We had incidents in the street when we were just sending an ECG, where doctors on the scene would tell the firemen to quit fooling around and haul the victim in.”

It should not be surprising that the medical directors of the various paramedic programs would remember the first resuscitation in their city. Nagel vividly recalled the first save of the Miami paramedic program. The collapse occurred near Station 1, on the fringe of downtown Miami, where the good part meets the bad part. He reminisced:

"There was a guy named Dan Jones who was then about 60 years old, who was a wino who lived in a fleabag in the bad part of town. Jones was well known to rescue. In June of '69 they got a call—man down—it was Jones. They put the paddles on him, he was in VF, started CPR, zapped him, he came back to sinus rhythm, brought him in to ER and three days later he was out and walking around. In gratitude, about a week later, he came down to Station 1, which he had never done before, and he said he would like to talk to the man who saved his life. They told me they had never seen Dan Jones in a clean shirt and sober, both of which he was that day. He would periodically come to the fire house and just say hello and he seemed to be sober. In my talks in those days I said this was the new cure for alcoholism. That was our first true save."

Pantridge's article also energized Leonard Cobb in Seattle. He knew the Seattle Fire Department was already involved in first aid and therefore approached the Fire Chief, Gordon Vickery, to propose a new training program to treat cardiac arrest. The fire department already had one of the United States' first computerized systems for documenting first aid runs. Cobb realized that this system could provide scientific documentation for the efficacy (or lack thereof) of Pantridge's suggestions and suggested to Vickery that they pool their knowledge and resources. Cobb and his colleagues then provided instruction and training in cardiac emergencies including cardiac arrest to volunteer fire fighters. The program became operational in March 1970, nine months after Nagel's first save in Miami. The mobile unit—and there was only one at first—was stationed outside the Harborview Hospital emergency department. As Cobb himself points out, the mobile unit was not the real innovation. Rather, it was the concept of a tiered response to medical emergencies. The idea was "that we would get someone out there quickly"—via the fire department's already existing mobile first aid units—"and then a secondary response would come from the mobile intensive coronary care unit." The beauty of the tiered response system was the efficient use of fire department personnel, which allowed aid personnel to reach the scene quickly (on an average of three minutes) to start CPR. Then a few minutes later the paramedics arrived to provide more definitive care such as defibrillation. In this way the brain could be kept alive until the electric shock converted the heart to a normal rhythm. After stabilization the paramedics would transport the patient to the hospital.

The Seattle paramedic program did more than pioneer paramedics and promote the tiered response system. It was the first program in the world to make citizens part of the emergency system. Cobb knew from data the program had collected that the sooner CPR was started, the better the chances of survival. He reasoned that the best way to ensure early initiation of CPR was to train the bystanders. Thus Cobb, with the support of Vickery, began a program in 1972 called Medic 2. Its goal was to train over 100,000 people in Seattle how to do CPR. Cobb recalled how the idea was first proposed:

One day he said, "Look, if it's so important to get CPR started quickly and if firemen come around to do it, it can't be that complicated that other folks couldn't also learn—firemen are not created by God to do CPR. You could train the public." I said, "That sounds like a very good idea." Shortly afterwards things started.

Cobb decided to use an abbreviated course of training. "We weren't going to do it by traditional ways where they had to come for 20 hours (of training). So they had to do it at one sitting—how long will people participate?—well, maybe three hours and that's pretty much the way it was.” Cobb cautiously did not state how long it would take to train 100,000 people. He had no idea. In fact it took only a few years and by the 20th anniversary of the citizen training program over half a million people in Seattle and the surrounding suburbs had received training in CPR.

Some people were sceptical about mass citizen training in CPR; indeed, many felt the potential for harm was too great to allow such a procedure in the hands of laypersons. The skeptics also had the support of national medical organizations. The alarmist voices were stilled by some fortunate saves. Cobb recalled one resuscitation soon after the citizen training program began. "In March 1973 there were these kids playing golf at Jackson Park. They came across a victim a quarter of a mile from the clubhouse." The man was unconscious and not breathing; later it was confirmed that he was in ventricular fibrillation. "But these kids had taken the course over at the local high school. Two or three of them started doing CPR and the other kid ran off and phoned the fire department. Shortly they came with the aid car and Medic 1 screaming over the fairways." Cobb concluded, "They got him started up again. He survived; he's alive today . That was a very convincing story. I didn't mind it being written up in the Reader's Digest."

The decade of the 1960s started with the development of CPR. By the end of the decade, paramedic programs were operating in Miami and Seattle (and Portland, Columbus, and Los Angeles). A common denominator to all the cities was a physician who saw the problem of out-of-hospital cardiac deaths, decided not to accept the irreversibility of death, and started doing something about it.

Read more about this topic:  History Of Cardiopulmonary Resuscitation, Modern Resuscitation

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