History of Cardiopulmonary Resuscitation - Modern Resuscitation - The First Out of Hospital Defibrillation

The First Out of Hospital Defibrillation

For civilians, ambulance service for many years was merely a means to bring the patient to the hospital. In a few cities, interns rode ambulances as part of their training but provided no medical care at the scene. During the 1930s and 1940s municipal fire departments in some cities (including Los Angeles, Columbus, Baltimore, and Seattle) began to provide rescue, first aid, and resuscitation care. In 1966 the United States National Academy of Sciences and the President's Commission on Highway Safety issued reports decrying the unevenness of ambulance personnel competency and the lack of standard procedures. The commission described the carnage resulting from traffic accidents as the neglected disease of society. The subsequent National Highway Safety and Traffic Act of 1966 authorized the Department of Transportation to establish a national curriculum for prehospital personnel, which led to the training of emergency medical technicians (EMTs).

EMTs did much to upgrade the general performance of ambulance services throughout the United States. Their 80-hour course and certification, which included CPR, ensured that proper care would be provided to victims of motor vehicle accidents and other emergencies. Thus they could provide artificial ventilation and closed-chest massage at the scene and en route to the hospital.

However, EMTs were neither trained nor authorised to provide definitive care for cardiac arrest. They could not provide defibrillation; intravenous medications; or advanced airway control, such as endotracheal intubation. EMTs saved few, if any, victims of sudden cardiac arrest, largely because cardiac arrest occurred mostly in people's homes. The time required for EMTs to arrive and transport the patient to the closest emergency department was too long for resuscitation to be successful. Not even letter-perfect CPR can save a life if it takes too long for defibrillation and other advanced procedures to occur.

In 1965, Frank Pantridge turned his attention to this vexing problem of heart attacks and sudden cardiac death. His sensitivity to the problem came from two sources. First, personnel in the emergency department of the Royal Victoria Hospital in Belfast frequently commented on the number of patients coming in dead on arrival (DOA). Second, Pantridge had recently read a telling study in a medical journal that indicated that among middle-aged or younger men with acute myocardial infarction (MI), more than 60% died within 1 hour of the onset of symptoms. Thus the problem of death from acute MI had to be solved outside the hospital, not in the emergency room or the coronary care unit. "The majority of deaths from coronary attacks were occurring", he wrote, "outside the hospital, and nothing whatever was being done about them. It became very clear to me that a coronary care unit confined to the hospital would have a minimal impact on mortality." He wanted his coronary-care unit in the community.

Pantridge's solution was to develop the world's first mobile coronary-care unit, or MCCU. He staffed it with an ambulance driver, a physician, and a nurse. Pantridge encountered numerous obstacles to the creation of the MCCU. He dealt with them in his typical direct fashion, with determination to succeed and transparent contempt for politicians and any authority figure who opposed him. Even his cardiology colleagues were skeptical. "My noncardiological medical colleagues in the hospital were totally unconvinced and totally uncooperative," Pantridge said. "It was considered unorthodox, if not illegal, to send junior hospital personnel, doctors, and nurses outside the hospital." Pantridge's new program began service on January 1, 1966.

John Geddes was a resident in cardiology at the Royal Victoria Hospital in Belfast and worked on Pantridge's service. As junior member of the team it was Geddes' responsibility, which he shared with four other residents on the service, to ride on the newly christened ambulance when it was called into service.

Why did this breakthrough in cardiac care occur in Belfast, of all places? Geddes thought he knew the answer:

"I would say two reasons. One was Pantridge himself. He is a remarkable personality who is very persuasive. He can persuade people to do things, and . . . actually make them enjoy doing things that he has made them do because they are successful. So there was his tremendous enthusiasm behind the system. Then there was the fact that the layout of the hospital was flat and it was quick and easy to get to people and resuscitate them. I didn't realize this at the time, but I subsequently visited hospitals in various parts of England. They had slow elevators and so on, and you could never move around the hospital quickly with any kind of emergency apparatus."

The success in the hospital wards made them believe success in the community would be possible. So it was the combination of a hospital's architectural layout and a physician's driving and persuasive personality that provided the impetus for this breakthrough. But one cannot discount the resuscitation infrastructure already in place: mouth-to-mouth ventilation, chest compression, and portable defibrillation. Without each of these three elements the Belfast program would have been a waste of time and effort.

The team reported the initial results of their program in the August 5, 1967 issue of The Lancet; their findings on 312 patients covered a 15-month period. Half the patients had MI and there were no deaths during transportation. Of ground-breaking importance was the information on 10 patients who had cardiac arrest. All had ventricular fibrillation; six arrests occurred after the arrival of the MCCU, and four occurred shortly before arrival of the ambulance. All 10 patients were resuscitated and admitted to the hospital. Five were subsequently discharged alive (ref). The article has historical importance because it served to stimulate pre-hospital emergency cardiac care programs throughout the world. As an historical footnote, August 1967 is exactly 200 years to the month from the founding of the Amsterdam Rescue Society. The rescue effort that began in 1767 in Amsterdam as an attempt to resuscitate drowning victims (the sudden death of the 18th century) finally culminated two centuries later in Belfast with a successful way to achieve resuscitation for cardiac arrest (the sudden death of the 20th century).

The Belfast system was established to reach patients with acute myocardial infarction. The resuscitated patients were those whose hearts fibrillated after the ambulance was at the scene or en route. The system reacted too slowly to resuscitate persons who fibrillated before the call was placed. In 1966, it was assumed that most cardiac deaths in the community were the result of acute myocardial infarction. It was not appreciated that ventricular fibrillation can occur without myocardial infarction and have only seconds of warning—or none at all.