Discovery and innovation often come from humble beginnings and the intersection/collaboration of different sectors. For example, it was the Consolidated Electric Company of New York City that sought out a professor of engineering to study the effect of electrocution on human physiology. The working group that emerged from this need explored how electric countershock, applied directly to the myocardium, could halt electrocution-related fibrillation. Kouwenhoven, Howell, Vivien and others built multiple open-chest defibrillators and their work had the unintended consequence of pushing chest compressions into the mainstream.
Brought together by a utility company, under the guise of occupational safety, engineers and physicians developed a life-saving manoeuvre for use, initially, in the operating theatre then readily adapted for use anywhere there are two willing hands.
Open chest defibrillation, though not particularly accessible or portable, made sense at the time. Open chest cardiac massage was described by Niehaus in 1880. The first successful cases of its use were published by Ingelsrud in 1901 and Starling & Lane in 1902. By 1906 White performed a literature review and found 50 cases of open heart massage, whereby a staggering 70% had been associated with chloroform anaesthesia and occurred in the operating theatre. This was the original clinical challenge, chloroform toxicity resulting in apnea and cardiac standstill. Indeed, by the 1950’s there were mounting publications describing the use of open-chest massage, direct defibrillation and injection of cardiac stimulants for “cardiac arrest” treatment. The operating theatre allowed for immediate and skilled response to sudden cardiac arrest.
The challenge then, was closed-chest defibrillation. Getting back to the utility company; Edison Electric Institute requested that Kouwenhoven and colleagues develop a closed-chest approach to electrocution in linesmen. Occupational electrocution resulted in ventricular fibrillation. Kouwenhoven discovered that 20amps across the closed chest could stop fibrillation in the canine heart. When the electrode placement was further optimized (suprasternal notch and apex), only 5amps were required. Incredible discovery. It is unclear if others were close to this discovery or if this was already well known amongst other researchers.
It was in 1958, when studying closed chest defibrillation, that Kouwenhoven and Knickerbocker observed a rise in arterial pressure when heavy electrodes were applied to the canine chest wall. This is the often-reported moment chest compressions or external cardiac massage was discovered, but it is well known in the resuscitation community that closed chest compressions had been performed on numerous occasions prior. Stimulation and chest wall compression may have been a routine response to intraoperative misadventure from anaesthetic toxicity, like many medical innovations, it probably had not been disseminated.
Initially there were skeptics and critics of closed wall compressions- of course. In 1908 Pike et al. chest compression research in felines cast doubt on the technique and chest compressions in large dogs were deemed too laborious. However, their research continued, and with the help of early adopters such as Alfred Blalock at John Hopkins, over ten months 20 patients were resuscitated with “closed-chest cardiac massage”.
These cases were the impetus for the JAMA manuscript “Closed-Chest Cardiac Massage” by Kouwenhoven et al. which was effectively the Gladwellian “Tipping Point”. This was the first time that the manoeuvre was used outside the operating theatre allowing the authors to make the claim that “the real value of the method lies in the fact that it can be used whenever the emergency arises”. They also reported systolic blood pressures from 60 to 100mmHg and that the “chest of an unconscious adult was found to be remarkably flexible”.
Chest compressions had been used used intraoperatively for anesthetic toxicity. Most often the compressions were internal i.e. internal cardiac massage. But by the late 1800's there were case reports in the literature of closed chest compressions being used as well. A utility company collaborated with engineers and physicians to develop closed chest defibrillation and it resulted in the expanded role and utility of closed chest compressions. As is often the case with innovation, people from disparate backgrounds working together against a common challenge in a supportive and innovation nurturing environment, results in discovery.
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