The accidental inventor of chest compressions
The slim, modest gentleman in his late seventies didn’t look like a betting man. But according to Guy G. Knickerboker, PhD, M.S.E., he wouldn’t have laid money on the fact that CPR wouldn’t have worked in humans.
In 1958, Knickerboker, a 29-year old graduate student at Johns Hopkins University, was part of a research team working in a surgical lab for William Kouwenhoven, the principal investigator and electrical engineer involved in a long-time study of the effect of electricity on the heart. The research was funded by Edison Electric Institute to help electric companies treat employees who had been electrocuted. At that time, the electrical companies were losing hundreds of linemen a year to accidental electrocution. Other workers, including television repairmen and telephone industry employees, were also subject to high-voltage exposures that resulted in occupational deaths and injuries. “Our target was that the person would come back and be alright,” Knickerboker says. “Look what turned out!”
The day chest compressions were born
As luck would have it, Kouwenhoven was not in town that Saturday in 1958 at the John Hopkins University lab when “closed-chest resuscitation” was discovered. Knickerboker and a couple of the younger researchers stumbled on what would become the foundation for chest compressions. The labs used dogs that had been anesthetized and intubated as the test subjects for the defibrillation technique. Their hearts were stopped and paddles were applied to the chest wall to deliver the shocks.
The paddles replaced an early defibrillator design that used electrodes controlled by knife switches. That version was scrapped when Kouwenhoven, who was holding the copper electrodes to the chest wall of the dog, asked the researcher controlling the switch, “Are you ready?” The researcher heard, “Ready” and threw the switch, giving Kouwenhoven part of the shock. “I am thankful I wasn’t there that day,” Knickerboker says.
A new paddle design put control of the shock in the hands of the person administering the shock. Both paddles had to be placed with enough force to ensure that the defibrillator would fire, Knickerboker explained. While pushing on the animal’s chest one day, he noticed a blip in the arterial pressure. “It didn’t strike us immediately that it was important,” he says.
That Saturday, while Kouwenhoven was attending a conference, Knickerboker and his fellow researchers had prepared the dogs, but they had failed to secure the defibrillator, a heavy transformer in a box. When they were ready for it, they realized it was being used on patients who were seven floors below. (Knickerboker notes that without the influence of governmental agencies that oversee such things now, the sole defibrillator was used on both patients and lab animals.) The only way to move the unit down to the lab was to use the building’s notoriously slow-moving elevator.
He estimates it took approximately 20 minutes to retrieve the defibrillator. In the meantime, he and a colleague performed chest compressions on the dog until the machine could be plugged in and powered up. “It was a duration that had no reasonable expectation of recovery,” he says. To their surprise, it worked. The dog was not only revived, but it survived.
“It was an “˜aha’ moment,” he says.
Closed chest massage on humans
Kouwenhoven and his team had been joined by James Jude, MD. While Jude was on assignment at Johns Hopkins to work on a cardiac hypothermia project, he had seen the work Kouwenhoven was doing. After a six-month duty at the National Institute of Health, Jude returned to Johns Hopkins as a cardiac resident, responsible for post-operative care in the cardiac care ward. He convinced the staff to consider using closed-chest massage and defibrillation for patients who re-arrested. According to Knickerboker, Jude told the staff, “You are always going to procrastinate about whether you open the chest. While you are procrastinating, do this.”
“That was the transition,” Knickerboker says. “Pretty soon, they weren’t opening the chest. It was striking how quickly that turned. Jim’s presence there was significant.”
In 1960, Kouwenhoven, Jude and Knickerboker published their findings in the Journal of the American Medical
Association.¹
Alerting the public
Almost simultaneously to the close chest massage breakthrough, Peter Safar, MD, chief of anesthesiology across town at Baltimore City Hospital, had perfected the mouth-to-mouth resuscitation method along with James Elam, MD, and published the book, ABC of Resuscitation. “From that side, the ventilation issue would be covered,” Knickerboker says. CPR was born.
Until this time, Kouwenhoven’s group had only minimal contact with Safar. Hospital personnel who were trained to perform these procedures were trained separately. No one had thought to put the two techniques together until Captain Martin McMahon, chief of the Baltimore City Fire Department Ambulance Service and a progressive advocate for patient care, heard of closed chest massage. McMahon had been badgering Safar to teach his crews mouth-to-mouth resuscitation. “So when McMahon got wind of closed chest massage, we traveled to that squad,” Knickerboker says.
About a week after that first CPR session, a crew that included two members who had attended the training was called to a home a couple blocks from Johns Hopkins Hospital for a cardiac arrest. “Their first impression was very typical: DOA,” Knickerboker says. But they figured they had been trained, so they’d give it a try. They used both mouth-to-mouth resuscitation and closed chest massage, just as they’d been taught. To everyone’s surprise, they got a pulse. They also radioed ahead to get the defibrillator in place. The patient survived to return to the hospital every year for the rest of his life to tell Jude “thank you” and “happy birthday.”
A weekly television show in Baltimore picked up the story, and for the first time, the public was exposed to CPR. Soon, the Maryland Heart Association began the first official CPR classes, training physicians to teach the technique. They, in turn, traveled the U.S. teaching other physicians. It wasn’t long before instructional videos were being made and distributed.
A legacy of science
Knickerboker stayed at Johns Hopkins until 1972, when he left Maryland for Pennsylvania to join the ECRI Institute, formerly the Emergency Care Research Institute. As a Senior Project Engineer, he was responsible for engineering and clinical evaluation of high technology medical equipment used primarily in surgery.
In 1976, he was promoted to chief scientist, overseeing the scientific quality of the research, hazard investigations and product evaluations for the Institute’s Health Devices Group. He was actively involved in the evaluation of surgical lasers and other high-tech surgical devices, with an emphasis on safety. In 2000, he retired from the ECRI Institute.
Knickerboker still maintains his enthusiasm for what was accomplished that day more than 50 years ago. “There’s still an element of awe,” he says. “It’s just astounding to see the various branches. I couldn’t imagine there’d be this much research still going on.” He could have bet on it.
References
- Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA.1960;173(7):94—97. doi:10.1001/jama.1960.03020280004002
