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Hopkins Medicine Magazine - A Dying Dog, a Slow Elevator, and 50 Years of CPR

Hopkins Medicine magazine, Winter 2011

A Dying Dog, a Slow Elevator, and 50 Years of CPR

How a visionary Johns Hopkins team developed modern cardiopulmonary resuscitation--and how their successors now plan to make it smarter.

By: Ramsey Flynn
Date: February 18, 2011


William Kouwenhoven
1 2 3
William Kouwenhoven is among those featured in a 1962 film, still viewed annually by Hopkins medical students, that showcases CPR’s pioneering principles.

WHEN KRISTEN LINDEMAN and her three colleagues set out for a happy hour near their workplace last January, returning to work was among the last things on their minds. They all served as rehab therapists at Johns Hopkins Bayview Medical Center, which required annual tests in CPR. A tight social unit, the quartet sometimes talked about how—should anyone suffer an unfortunate medical event in their presence—they’d be ready to rock ’n’ roll as one.

As Lindeman’s troupe headed to the restaurant, a separate duo geared up for the same destination. Rose Johnson and roommate Chessa Marshall darted about their South Baltimore apartment, getting dressed for a girls’ night out. Once ready, the spirited pair slipped outside into the car and navigated north.

Both parties arrived at Canton’s Hudson Street Stackhouse slightly before 7 p.m. The two roommates took a table; the Hopkins quartet lined up at the bar.

At the table, Rose Johnson sipped a beer and briefly glanced away from her friend. When she looked back, she was puzzled to see Marshall wordlessly craning her neck toward the ceiling. When Marshall’s back arched suddenly, Johnson jumped to circle her arm around her friend and began lowering her to the floor. “I need help!” she shouted.   

At the nearby bar, Lindeman was about to take her first bite when she heard the noise. She turned to see a panicked patron cradling an apparently unconscious woman.

Lindeman and her colleagues moved in. “We’re therapists from Bayview,” Lindeman said to Johnson, who stepped aside as Lindeman’s team stepped in. “Tilt her head back to maintain her airway,” said one of the Hopkins crew to another.

* * * * * * * * * *

When Marshall’s back arched suddenly, Johnson jumped to circle her arm around her friend and began lowering her to the floor. “I need help!” she shouted.

* * * * * * * * * *

Johnson, herself an emergency nurse, was relieved to have the able team take over. Okay, she thought. We’re good.

“I don’t have a pulse!” one therapist shouted. Another therapist called 911 and asked the bartender to stop the music and brighten the lights. Still another quizzed Johnson about her friend’s medical history. Several people moved furniture to open a path for inbound EMTs. Patrons then formed a protective ring as one therapist started a rapid series of chest compressions. She kept pace by humming the Bee Gees tune “Stayin’ Alive,” just as she’d been taught. The song’s beat approximates the ideal 100 pushes per minute that could keep this woman from dying.

Less than 10 percent of the 250,000 people who annually suffer a cardiac arrest beyond the reach of an electronic defibrillator can be sustained long enough to make it to the hospital alive.
“Okay,” said Lindeman to the small group, as they focused on helping Chessa Marshall beat the odds. “Let’s go!”

******

AMONG THE LITANY of our institution’s discoveries, this one needs little hedging: Johns Hopkins is ground zero for modern CPR. Its genesis came to light in a seminal Hopkins-centric research paper that unleashed a global buzz in the summer of 1960—which means CPR recently marked its 50th birthday.

In what has become an annual rite at the School of Medicine, the story of CPR’s Hopkins origins gets retold to each incoming class. This now happens every September in the new Simulation Center auditorium, where center director Betsy Hunt guides her students through an archival black-and-white film from 1962 that showcases Hopkins scientists demonstrating CPR’s principles on laboratory dogs.

Gesturing next to the screen between pivotal sequences, Hunt describes how two scientists in the film are about to demonstrate their ability to restart the heart of a sedated dog induced with cardiac arrest. “See when they do the chest compressions?” she says, then narrates as the sequence shifts from the dog to a printed readout of the animal’s vital signs. “All of a sudden you get back a blood pressure,” she says, pointing her finger to a film clip showing the tracings, “and they see that the brain is getting perfused.

“And here,” Hunt adds, as one scientist prepares defibrillating paddles, “he’s actually going to shock the dog.” The shock is applied. The dog revives. The printout confirms the reversal. “So all of a sudden, the dog is back. So this is really, really exciting.”

Typically, this is also the moment when Hunt backs up in time to the late 1950s, to interject one of the most delightful details of traditional Hopkins-style serendipity. The moment draws on the legendary torpor of the 13-story elevators in Hopkins’ fabled Blalock wing.

Ah yes, Guy Knickerbocker allows today, “the notorious elevator thing.” In sitting down for an interview this past fall about CPR’s founding, Knickerbocker—one of the two men shown in Hunt’s archival video—displays his hallmark caution in accurately portraying a Eureka moment.

It was 1958, he explains, and he was a 29-year-old grad student working in the lab of Hopkins electrical engineer William Kouwenhoven, who’d already invented the first cardiac defibrillator. Knickerbocker, while conducting a series of ongoing tests on a laboratory dog during one of his lab chief’s brief absences, saw the animal’s heart unexpectedly slip into a nearly universally fatal form of ventricular fibrillation.

Normally, his lab associates would pull up the wheeled cart that carried their novel cardiac defibrillating equipment and shock the animal’s heart back into a proper rhythm. But this lab was on the Blalock wing’s 12th floor, and their cart was on Blalock 5. They’d long understood that no mammal could survive more than five minutes in V-Fib. With the chronically sluggish Blalock elevators now standing between them and the heart cart seven floors below, it didn’t take a rocket scientist to calculate that this dog was not long for this world.

With the lab animal’s life inexorably slipping away, Knickerbocker decided to test one of his growing suspicions. In the preceding months of experiments—with the lab dogs hooked up to the monitors—Knickerbocker had noticed that the dogs’ blood pressure readings spiked when he was forcefully pressing electrodes to the animals’ chests prior to defibrillation. Could those simple elevations constitute actual blood flow to a dying animal’s brain? If so, what would happen if the scientists methodically squeezed the animal’s rib cage to mimic the effects of an actual beating heart?

Retelling the story a half-century later, Knickerbocker can’t remember whether he himself began compressing the dog’s chest and then handed it off, or whether he simply asked an associate to do it. In any case, Knickerbocker clearly remembers that he next did what any other fit 20-something might do to bypass a handicapped elevator: He raced down the stairs.

But going back up with a 200-pound cart would be a different feat. As he rolled the cart up and pushed the elevator button, Knickerbocker understood it was going to arrive “in its own time.” And then, of course, there were the other people on the elevator making stops on interim floors.

Knickerbocker maintained a brisk pace where he could. Though no documents attest to the lapsed time, he believes the dog had been down for about 20 minutes.

Would such a patently doomed effort still be worth the fuss? Only one way to find out. Knickerbocker plugged in the apparatus, greased up the paddles—asked the man doing chest compressions to back away—and administered a single shock to the apparently lifeless beast.

Almost immediately, the dog’s heart lurched back, and then settled. Knickerbocker recalls it as “a spontaneous beat that required no substantive assistance.” The next morning, when he visited the animal, the dog behaved normally.

Knickerbocker debriefed one of his senior medical collaborators, cardiac surgeon Jim Jude. When Kouwenhoven returned, the trio began exploring the bigger questions: Was this event an anomaly, or could it be reproduced? If reproducible, what made it work? And if it could work in saving a dying dog, could it be applied to saving the lives of humans?

While this moment clearly launched the development of CPR’s formal use of life-saving chest compressions, a separate team of scientists was making headway with another key component to modern resuscitation. At the affiliated City Hospital in East Baltimore, anesthesiologist Peter Safar and associate James Elam were rapidly advancing the idea of using a living bystander to breathe air into the lungs of an unconscious patient confirmed in cardiac arrest. This would become known as “mouth-to-mouth resuscitation”—and the affiliated City Hospital would also one day become the Johns Hopkins Bayview Medical Center.

But in the late 1950s, these separate resuscitation groups shared only a basic understanding of each other’s parallel discoveries. It took the initiative of a city rescue leader to build the bridge. In a bid to improve his squads’ life-saving skills on the streets of Baltimore, fire department commander Martin McMahon, who headed up the department’s ambulance division, began asking if the city’s trailblazing scientists might share some of their latest findings.

First, McMahon’s rescue crews learned what they could from Safar’s group about rescue breathing. Then they trained in Hopkins’ technique of chest compressions. In their own way, McMahon observed, each approach seemed promising. Why not get everybody together and combine the two?

******

JUST PAST 7:30 P.M. at the Hudson Street Stackhouse, things are growing tense: The young woman on the floor has yet to breathe on her own. The therapist pushing on her chest begins counting out loud, cuing Kristen Lindeman to the right moments to apply mouth-to-mouth.

“Twenty-four! Twenty-five! Twenty-six! ....”

Meanwhile, one Hopkins therapist has posted herself outside to signal the arriving EMS crew. In moments, the three-person ambulance team arrives with equipment and attaches probes from their portable defibrillating device to the woman’s chest.

Once the leads are in place for the crew’s automatic electronic defibrillator, the device gathers data and erupts with a piercingly robotic voice: “Shock advised.”


The crew unleashes the shock. Chessa Marshall’s chest lifts up and then back with involuntary muscle contractions. No pulse, so they resume chest compressions even more vigorously.

The EMS team carefully transfers the young woman onto a gurney to maneuver into the ambulance. Johnson nervously takes a seat up front, then steals a glance through a small window into the cab to see the EMS crew continuing to work on her friend. The man applying compressions is a big guy, seemingly all arms, intensely pressing her friend’s lifeless chest. Johnson can see that the man’s actions are Chessa’s only lifeline. Dear God. 

******

AS WILLIAN KOUWENHOVEN and Guy Knickerbocker extended the new ideas further into their Hopkins research on laboratory dogs through 1959, cardiac surgeon Jim Jude carefully explored ways to apply the principles to humans. As was sometimes the case in Hopkins’ clinical wards, patients with acute heart conditions would suffer a cardiac arrest. This typically posed an urgent dilemma to their attending physicians: Should they race for the heart cart and hope to get there in time, or should they take the more drastic measure of quickly cutting into the dying person’s chest to rhythmically squeeze the heart by hand, thereby buying time before the heart cart arrived with its potentially lifesaving shock?

Armed with the emerging observations on laboratory dogs, Jude proposed to his young colleagues a meantime approach. “While you’re debating whether to open a patient’s chest, why don’t you do this?” Jude then demonstrated the chest compression technique that his research colleagues were successfully applying with dogs up on Blalock’s 12th floor.

The tactic took hold. Within months, the Hopkins practice of cracking the sternums of arrested patients dropped to near zero.

* * * * * * * * * *

“While you’re debating whether to open a patient’s chest, why don’t you do this?” Jude then demonstrated the chest compression technique being successfully applied with dogs on Blalock’s 12th floor.

* * * * * * * * * *

The nascent CPR tactics also soon debuted on the nearby streets on a day in 1960, when 68-year-old Bertie Bish thought he had simply overeaten. He lay down on the sofa in his East Baltimore home, complaining of chest pains. Minutes later his wife sent out the urgent call for a heart attack in progress.

When fire department commander McMahon’s two-man ambulance squad arrived, they quickly concluded they were fatally late: Bish was gone, his body lifeless. But the crew had just been introduced to these newfangled resuscitation techniques. Why not try them?

Crewmen Hubert Cheek and Marvin Burkendine initiated both rescue breathing and chest compressions. Cheek continued the efforts as Burkendine drove them to the nearby Hopkins ER. Admitting doctors there called Jude, who naturally deployed the magical shock of Kouwenhoven’s defibrillating paddles. Against expectations, Bish’s heart resumed its own pace. As the evening unfolded, his skin “pinked up” with the flush of new life.

A grateful Bertie Bish marked the event’s anniversary for years thereafter, making personal phone calls to McMahon and Jude for giving him his second life.

“So this was one of these kernels of CPR’s transition into the field,” says Jude today.

While both Jude and Knickerbocker agree that the 1960 Bish event added clear momentum to their efforts to publish the growing findings (indeed, the group had submitted a draft paper to the Journal of the American Medical Association), the era’s deepening Cold War also played its part. In the spirit of East-West scientific collaboration beyond the Iron Curtain, a group of Soviet medical scientists paid a visit to the Hopkins resuscitation scientists around the time of the Bish incident.

As the American hosts regaled their Soviet visitors with their latest research, Knickerbocker—who had been studying the Russian language—thought he heard one of the Soviet scientists urging his compatriots to share the happy news with others as soon as they got back home. Knickerbocker’s sense was quickly confirmed by a translation of the talks.

Despite the air of collegiality, lab chief Kouwenhoven felt a protective instinct. He took up his concerns with Hopkins surgical chief Alfred Blalock. “Al, you heard what those Russians said. They’re going to go home and claim that they invented this,” Kouwenhoven reportedly said.

By then, editors at JAMA had been sitting on the Hopkins draft manuscript for nearly a year. Blalock made a personal call. The paper suddenly leapfrogged to the fore, securing a prominent slot in JAMA’s July issue.

So the genie was out. Just two months later, in September 1960, both the Kouwenhoven and Safar groups shared their complementary findings at the annual gathering of the Maryland Medical Society. More presentations soon followed, along with books and instructional videos. The lifesaving basics of CPR easily translated around the world.

As the years passed, the pressure mounted to further shorten the time between the onset of a patient’s cardiac arrest, the start of CPR, and the initiation of the defibrillating shock. By 1979, biomedical engineers had developed a portable cardiac defibrillating device that emergency crews could take with them into the field. Through the ’80s and ’90s, biomedical engineers distilled the devices down to a level where they could be mass-produced, when they became known more popularly as automated electronic defibrillators, or AEDs.

More recently, with the help of CPR evangelists like Hopkins chief of medicine Mike Weisfeldt—who took a national leadership role in advocating the distribution of AEDs to public locations throughout the U.S.—the simplified devices have become nearly ubiquitous in aiding the rise of what is now known as “bystander” defibrillation. Through field studies, says Weisfeldt, it became clear that “a layperson could defibrillate” a dying person back to life.

******

SHORTLY AFTER the ambulance pulled into the same emergency room that had saved the life of 68-year-old Bertie Bish a half century earlier, Rose Johnson watched intently as her own Hopkins ED colleagues received her friend Chessa Marshall, who had just turned 28.

Marshall remained unconscious but was breathing on her own. Yet even as the medical team continued to swirl around them, Johnson was already starting to wonder if her roommate’s brain was still okay beneath the spell of anesthesia. If she came out of this, would Chessa still be Chessa?

******

IT'S HARD TO ARGUE with a technique so clearly proven to preserve human lives that previously would have been lost, yet that is precisely the sort of impolite inquiry that adventurous researchers must embrace when they want to make a good idea better.

Prior to the dawning of CPR in 1960, people who suffered cardiac arrest outside of a hospital almost never survived. In the years since then—and especially when combined with the growing availability of AED technology—CPR and defibrillation are now believed to save about one person each day somewhere in the world. Even that figure is hard to confirm, but one nagging reality has long fallen below the radar: A very high percentage of CPR survivors suffer lifelong neurological impairment resulting from oxygen deprivation to the brain.

Most immediately, researchers have looked for ways to make long-standing CPR protocols more useful, carefully gauging the efficacy of varying tools and techniques—especially with expanding the availability of AED units and their ease of use—to further shave precious seconds in restoring healthy oxygenation to the brain. From multiple fronts, they’re inching closer.

This past fall, researchers announced the results of two long-term studies showing that bystander chest compressions alone provide outcomes equal to those where rescuers tried to combine both compressions and rescue breathing. Compressions without rescue breathing—or “hands-only CPR”—has proven valuable, says Hopkins’ Weisfeldt, because a viable level of oxygen-rich blood remains in the lungs in the first minutes after cardiac arrest; it just needs to be circulated.

Adding to the decreasing emphasis on rescue breathing, says Weisfeldt, are two key factors: One, he says, is that few people know how to administer rescue breathing without long interruptions for chest compressions. And, he says, many would-be rescuers are reluctant to place their mouths over the mouth of another person, especially a stranger.

In November, the American Heart Association adapted this new thinking into its protocols. In most adult cases, the guidelines now call for initial chest compressions only. The exceptions are for infants with obstructed breathing, drowning victims, and adults with breathing conditions in addition to cardiac arrest.    

But even with such fine-tuning, a growing number of resuscitation experts are steering still more attention to new tools.

“The majority of CPR survivors exhibit significant loss of neuronal function,” says Hopkins neurointensivist Romer Geocadin. Oxygen deprivation can prompt a wide spectrum of injury, he says, including to the brain’s delicate hippocampus structure (where memory is most centered), and to the cortex’s gray matter, an especially susceptible brain region that governs thought processing and executive functions.


But the most devastating post-CPR injuries, says Geocadin, afflict the lower regions of the brain that govern essential arousal systems. This can cause coma.

“If you lose blood flow to your brain enough to alter your consciousness,” says Geocadin, “you have sustained neuronal injury. And once you have sustained neuronal injury, your brain will never be the same again.”

* * * * * * * * * *

“Are survivors happy that they were resuscitated?” asks Geocadin. “Because if they are resuscitated to the point of severe disability, what have we gained?”

* * * * * * * * * *

With most CPR survivors sustaining life-altering disabilities, says Geocadin, the dilemma becomes hard to ignore: “Are survivors happy that they were resuscitated?” he asks. “Because if they are resuscitated to a point of severe disability, what have we gained?” The mixed results, he says, call for an even more intense focus to improve outcomes.

In his quest to improve “survivorship,” as he calls it, Geocadin outlines the challenges. Chief among them is reliable data. “How many survivors are impaired and to what extent?” he asks. “We don’t know. But I would venture to say that none of them is 100 percent.” Without reliable methods for gauging a CPR survivor’s quality of mental status, Geocadin says, the medical community has settled on a prevailing claim that up to 20 percent of survivors are deemed cognitively “normal.” But even many of those, Geocadin says, say they don’t feel altogether the same. 

“High-quality CPR is key,” says Geocadin, “but it’s also just the beginning.”

To tackle the mounting challenge of brain damage, Geocadin is among a growing group of resuscitation scientists committed to pushing the frontiers of slowing down the metabolism of a person resuscitated from cardiac arrest by dousing them with a bucket of ice.

More clinically, the technique is called therapeutic hypothermia. (Geocadin’s work in this area, with colleague Nitish Thakor, was detailed in our Spring/Summer 2009 issue. See “The Big Chill.”) By quickly chilling down a patient in cardiac arrest, says Geocadin, rescuers can reduce the brain’s demand for oxygen, further reducing the risk of neuronal death from oxygen starvation.

The benefits of cooling after devastating brain injuries have been observed for a long time, but its clinical applications are still advancing. With mounting studies supporting the value of rapid cooling amid oxygen deprivation, says Geocadin, it’s only a matter of time before therapeutic hypothermia takes its place in the optimal protocols for CPR.

It might look like this: If Geocadin was in an airport and saw a traveler collapse, he would first confirm the man had no pulse. In short order, he would then ask a bystander to call 911 and to quickly seek a defibrillator. After starting chest compressions, he would also ask someone to seek out a bucket of ice from the nearest vendor. If the traveler could be successfully defibrillated, Geocadin would pour ice over his patient—and make sure follow-up chilling at the hospital was kept in place for at least 24 hours.

The basic idea has gained traction in several trials, Geocadin says. If the right protocols come to fruition, he believes, “we could actually undo some of the injury.”

******

HOURS AFTER LEAVING the Canton restaurant that fateful night last January, Kristen Lindeman was reheating her dinner at home when the evening’s drama began to sink in. The woman she’d worked to save had seemed the same age as Lindeman and her colleagues. Did the woman make it? Did Lindeman and her colleagues and the EMS crew and everyone else in the rescue chain get all the details right?

“I wonder which ER she went to,” Lindeman said to a friend the next day. “I just want to know if she’s alive.”

With only a time frame and the young woman’s first name to work with, Lindeman started working through her Hopkins network. When her queries finally got close enough, a voice on the phone line chirped: “Actually, her father’s right here. Do you want to talk to him?”

At the bedside in the coming days, Chessa Marshall’s loved ones hovered closely as she regained consciousness. Her first words emerged slowly but clearly enough. When it came time for basic orientation questions, she stumbled only by saying “Bush” instead of “Obama.”

Just two weeks after the episode, a beaming Marshall and her mother paid a special visit to Bayview to thank Lindeman and her fellow therapists. To Lindeman, the patient looked smashing. The only evidence of a medical intervention was an invisible pacemaker that Marshall called “an insurance policy” against a recurrence of an episode that physicians have deemed a lingering mystery.

The visit “was surreal,” Lindeman says now. “She was much taller than I remembered her in person. Obviously she looked healthier. It was nice to see that we really did help someone. We really, truly saved a life.”

******

REEL STORY: To view a video celebrating the 50th anniversary of CPR, featuring interviews with key Hopkins pioneers, visit: http://media.hopkinsmedicine.org/##/search/CPR/

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