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Introduction
Dr. Kathryn McGoldrick: Welcome. I'm Dr. Kathryn McGoldrick. I'm with the AnesthesiaWeb. And in my other life, I'm Professor of Anesthesiology at Yale and Vice President of the Board of Trustees of the Wood Library. Our distinguished guest this afternoon is Dr. Peter Safar, who founded the Department of Anesthesiology and Critical Care Medicine at the University of Pittsburgh, and is chair emeritus now. Dr. Safar is going to be our distinguished Wright Memorial lecturer this year at the American Society of Anesthesiology annual meeting. He has the daunting task of reviewing the wonderful innovations in resuscitation that have occurred during the last millennium. And with that as background, I'd like to ask Dr. Safar what he considers to be the most dramatic advances that have been made in the last 500 years.
The Early Days
Dr. Peter Safar: Before the 1500s, which was the time of Enlightenment, the Renaissance, there was not much to talk about. And since then, the willingness to resuscitate in situations of sudden terminal state, like shock, or cardiac arrest, or clinical death has existed. The ability didn't come about until around 1900, a hundred years ago. And then much, but not all, knowledge on the present steps of what we call modern cardiopulmonary cerebral resuscitation, CPCR, existed. But nobody put it together. Lots of researchers, laboratory researchers, clinicians, and rescuers in the field, even in the same area, didn't communicate. Domineering professors resisted change, and the techniques for measuring the efficacy, the physiologic potentials of these techniques, didn't exist. So nothing happened then, very little, for the next 50 years, between 1900 and the 1950s, except for traumatologic resuscitation, which was pioneered by Anglo-American anesthesiologists and surgeons in World War II, not by the other side. So that brings us to what I call the Magic 1950s for resuscitation medicine, by resuscitation medicine — you as a professor of anesthesiology and I now just as a resuscitation researcher — distinguished but not extinguished.
“The Magic ’50s”
Dr. Peter Safar: I want to remind the colleagues in our base specialty that most of this was all created out of anesthesiology. That's important to remember. So now we are in the 1950s, and the ABCs of CPR came together. It was extended with advanced and prolonged life support and so on. I think in addition to fluid resuscitation for traumatic hemorrhagic shock out of World War II experience, we now have to look at the sudden cardiac death cases, half a million a year in the United States. The steps: (A) airway control, (B), breathing control, mouth-to-mouth and other techniques, and (C) external, rather than only internal cardiac massage, meaning emergency artificial circulation. As number two, we call it basic life support steps, ABC of resuscitation. Number three would be defibrillation. Number four would be cerebral resuscitation potentials, not yet implemented, at least in guidelines, although some people are using it anyhow. And this is brain resuscitation attempts with hypertensive reperfusion and mild hypothermia. Drugs so far, minimal effects. Hypothermia, maximum effects. And number five, the whole field of intensive care, meaning critical care medicine, long-term life support. Now, all these five, we happen to, in our research groups in Pittsburgh, contribute to initiate some, contribute to others, all four of the five, not defibrillation.
Autobiography…
Dr. Kathryn McGoldrick: I should mention for the benefit of our audience that Dr. Safar recently published his autobiography. It's available from the Wood Library in our Careers in Anesthesiology Series.
And I found it fascinating to read about starting with (A) airway, the really remarkable innovations Dr. Safar made there, and the resistance he encountered. For example, in the early 1950s, the approved, if you will, or customary method of establishing the airway, and ventilating the patient, was to use back pressure arm lift methods. And Dr. Safar showed that this was not efficacious, that the way to do it was with head tilt, and mouth-to-mouth. Perhaps you'd like to expand on that, because I thought that was fascinating, how you went about proving that.
Dr. Peter Safar: There were actually, if you then add the big question still unanswered in the mid-'50s about emergency artificial circulation, without opening the chest. Because open-chest CPR existed since the turn of the century, but it was used predominantly, almost only, in operating rooms. But for anyone to start emergency oxygen transport to vital organs, mostly brain and heart, anywhere, within seconds, it required not only backward tilt of the head, first step, (A), airway control, and mouth-to-mouth ventilation, but also artificial circulation. This combination, really, was triggered by chance events. Steps (A) and (B) through a chance getting-together of a Dr. Elam and myself, step (C), a chance rediscovery -- because this all was known around 1900, by an electric engineering Ph.D. student, actually a postgraduate research fellow, Dr. Quickebacher, at Johns Hopkins. And then we put this into a system, and extended the system, and added intensive care, and worked on brain resuscitation, because CPR wasn't enough, there has to be another "C" in it for hearts and brains too good to die.
Dr. Kathryn McGoldrick: I thought it was fascinating when in your book you pointed out that some of the initial studies on the airway had been done in animals. And people didn't appreciate the difference between the human airway, and dogs.
Dr. Peter Safar: Yes. Thanks for bringing this up now. There are some colleagues who don't go in their literature search beyond earlier than Medline. And the only human data on airway control and ventilation, under chest pressure only for circulation, are from the 1960s. So they miss that. Now they think all you have to do is push on the chest, and you can bring people back. But the data are voluminous from the early years that this ain't so. And the combination of ABC is still physiologically a fact which cannot be disputed. Even if you would say that somebody who drops dead suddenly from ventricular fibrillation will have pink aortic blood for long, long time, the moment you start circulating it with pushing on the sternum, in one half to one minute, it's black. Because it goes through tissues where oxygen is absorbed. So you are ending up with the (A) and (B) being necessary, anyhow.
Advice
Dr. Kathryn McGoldrick: Well, Dr. Safar, you've had such a distinguished career, and as you look back on it, do you have any professional or personal regrets; anything you would have done differently?
Dr. Peter Safar: I would say no , or, well, everybody regrets certain things he/she did. Your question is stimulating me into getting back to what our colleagues in anesthesiology should keep in mind as they are approaching the end of their residency. There is a very sad thing going on in this country (strangely, not abroad) and that is the clinician-scholar, clinician-scientist, is becoming a threatened species. And one thing I regret was that at the end of some very short surgical and pathology training, I had a short residency, what was then the required time, with Dr. Drips in Philadelphia, in anesthesiology. And I would have liked to, and should have, then gone into what an academically-oriented doctor would now seek to do, but doesn't, because of financial reasons, and that is several years of full-time research under very high-level guidance. I couldn't do it because of visa reasons. Since I was an ex-Viennese Yankee. What I should have done before or after Peru is to be in full-time research as a fellow. And I was a chief from the beginning, because at that time anesthesiology leadership positions were available all over the place. Everybody was looking for somebody to run the department. And if you were clinically known to be safe, have some leadership talent, and academically oriented, you could be a chief overnight. And that was a mistake. So I have a message is for our colleagues who are finishing their specialty training to think about an academic career which requires, whether or not they will be live researchers later; this is not the point. You're a much better clinician and leader if you go through a rigorous experience as a research fellow, but it depends on the mentor, these have to be top-notch mentors. And to do that, not fully thinking about money.
Dr. Kathryn McGoldrick: What values would you like to pass on, see promulgated and carried from one generation to the next, in medicine in particular, or anesthesiology more specifically?
Dr. Peter Safar: There is still a measure of art which should be preserved. There has been too much switch into technology-dictated case management. And the usual thing people recommend, but it's not always done, is compassion. And reason. We have to also accept futility, and pull out, but then again, with titration, help people in the end stages of life, and there is no chance ...
Dr. Kathryn McGoldrick: Right .
Dr. Peter Safar: ...to come back with a good brain.
Dr. Kathryn McGoldrick: Yes.
Dr. Peter Safar: And, oh, there are many other suggestions which, interested viewers of this program can find in my memoirs. Integrity. Openness, honesty,...
Dr. Kathryn McGoldrick: Yes.
Dr. Peter Safar: ...whether it's clinical or research activities. And sharing. Not hiding in order to get a patent.
Dr. Kathryn McGoldrick: Right. I take it, from reading your book, that you're really not too kindly disposed toward the idea of patents. Is that fair to say?
Dr. Peter Safar: No, I'm just an old-timer. When I grew up and my parents were physicians in Vienna, Austria, highly respected, it would have been unthinkable for the doctor to be involved in a patent. You just don't do this! Because it holds back the implementation of something new which could be immediate, immediately, if you don't bother with patents. I can tell you there have been some experiences we had with industry I consider role models, like the Laerdal company. I have never gotten a penny personally from them. There was friendship, the same missions, and that's the way it went. There was never a lawyer, a contract, a patent involved... nothing.
Dr. Kathryn McGoldrick: And the Laerdal company, for the benefit of our listeners, manufactured the Resuscitation Anne for you, correct?
Dr. Peter Safar: Yes, that came about through a coincidence, again. Many of these things in acute medicine came about through coincidence. I was to present the first steps (A) (B) of CPR data for the first time in Europe, in 1958, at the Scandinavian Anesthesiology Congress. I mentioned that we have tried in the States to make this or that potential interested in creating a realistic mannequin for practicing steps (A) and (B) of resuscitation for lay trainees, every trainee. This was immediately picked up by a Scandinavian anesthesiologist, Lind, who said, "Oh, I know a puppet-maker in Stavanger, Norway. I'll bring you together." So just a few weeks later, Mr. Laerdal showed up at Bolluma City Hospital, and I told him what we need ...
Dr. Kathryn McGoldrick: And the rest, as they say, is history.
Dr. Peter Safar: And the rest was a Resusci®Anne Mannequin, which became then Recording Mannequin, which became later, and this is now going into big simulators.
Dr. Kathryn McGoldrick: Yes. Very exciting.
Dr. Peter Safar: And we were just a catalyst by making Mr. Asmund Laerdal, who was a genius, and his son, too, Torre Laerdal, who took over after Asmund's death. They are examples of industry we deal with should be industry with social conscience, and not putting all this nonsense of secrecy and patenting into the forefront.
Conclusion
Dr. Kathryn McGoldrick: Well, thank you so much, Dr. Safar, for sharing your wisdom and insight with us this afternoon. I know you're an extremely busy man, and I appreciate this so much. Dr. Peter Safar, and I'm Dr. Kathryn McGoldrick with AnesthesiaWeb.
