Interesting and entertaining article about the early days of ACLS

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    This is an interesting article written by my colleague, Dr. Josh Grossman, on the history of ACLS; it is educational as well as entertaining.

    Feel free to write Josh with your comments @ ZJBG2@imail.etsu.edu


    |TITLE| A.C.L.S. – A Critical Care Nursing Issue
    |AUTHOR| Joshua Grossman, M.D., F.A.C.P. Clinical Assistant Professor, James H. Quillen College of Medicine
    |JOURNAL| Emergency Medicine


    “An army can be stopped but not an idea whose time has come” (1)

    |INTRODUCTION| Après avoir (after having) decided to write an article on Advanced Cardiac Life Support (A.C.L.S.) my first task was to select a title. Several options came to mind such as, “A.C.L.S. – a Critical Care Nursing Issue, “A.C.L.S. – History,” or “A.C.L.S. – Past, Present and Future,” or “A.C.L.S. – Where have we been? Where are we now? Where are we going,” or “A.C.L.S. – Facts and Folklore,” or “Why A.C.L.S?” or “Is A.C.L.S. for everyone?” In endeavoring to select a title from among these – or perhaps other choices - I thought of a text review I read - some decades ago - regarding the life and work of a physician who lived and served for decades among the peoples of an emerging nation; and, after forty years of service endorsed, “These folk have no written history. One must go to their elders to learn their history.” Well and good. That being said dare we ask, “Are any of our community organization(s) any different?” Further, is our A.C.L.S. any different?”
    |A.C.L.S. - HISTORY| The history of our A.C.L.S. appears to be inextricably linked to the history of our Intensive Care Units. A generation ago there were no Intensive Care Units and – and concomitantly no officially recognized or organized A.C.L.S.
    In those now bygone days – patients, predominantly men – commonly between the ages of 35 and 55 years-of-age – commonly sedentary – commonly abusing tobacco products – commonly somewhat mesomorphic – became abruptly and acutely ill with their “heart attacks” and – then as now with a period of some hours of denial-induced-delay - slowly made their way to a hospital where – after they arrived in the hospital approximately 2/3rd lived and 1/3rd died. What did we do? Simply put, we did the best we could – as reasonably ethical and prudent healthcare providers - with what we had available. Before the development of our Intensive Care Units, we used to place a {monitor – defibrillator} at their bedside along with an intravenous pole supporting a container of intravenous fluids to keep open an intravenous line for the route-of-administration of intravenous pharmaceuticals and a reasonably comfortable chair and we would spend the major portion of the nights at their bedside(s). Naturally from time to time we would trot off to attend to other patients but, for the most part, there – at the bedside – there we were and there – at the bedside - we remained. I distinctly recall sitting through the night with a 45-year-old man with an acute myocardial infarction and multiple re-occurring bouts of ventricular fibrillation asking him, “What does it feel like? What do you experience when I provide your defibrillation shock(s)? Is it like a burn?” His response, “No doctor, it is more like a punch in my chest,” paved the way for my understanding of our contemporary concept of providing a precordial thump (2) for a witnessed cardiac arrest. Will I always remember that night? He and I speaking softly between his cardiac arrests with ventricular fibrillation periodically re-occurring on his cardiac monitor and his successful repeated defibrillation(s) with the restoration(s) of his regular sinus rhythm, the soft light from his cardiac monitor screen barely illuminating our faces. He verbalized his understanding and he verbalized his appreciation of what I was providing and his understanding of my raison d’etre (rationale) for his having to undergo painful and repeated defibrillation(s) – six separate and distinct shocks – as the night - his long and difficult night slowed by. In the intervening years I have been humbly privileged to provide a precordial thump for witnessed cardiac arrest(s); that is, a single precordial thump, successfully – to restore a regular sinus rhythm - on two separate and distinct patients on two separate and distinct occasions. Major medical center revered, eminent chiefs-of-medicine resisted the development of intensive care units with the concomitant development of A.C.L.S. until they themselves developed their sudden abrupt cardiovascular crises and were privileged to spend their long-night-in-discussion with their respective chiefs-of-cardiology seated at their respective bedsides at which point in time they may well have experienced a paradigm shift, a radical shift in their perspective(s), to becoming increasingly receptive to and supportive of the development of both our contemporary intensive care units and our contemporary advanced cardiac life support.

    |A.C.L.S. – CRITICAL CARE| A generation ago, our early intensive care units were primarly and predominantly utilized by our patients afflicted with cardiovascular crises. A five bed intensive care unit might well – on any given day or night – contain and provide critical care for three individuals suffering with an acute myocardial infarction and one individual hospitalized because of premature pacemaker failure – the latter identified by the sutures on his (or her) forehead – placed when his pacemaker failed causing him (or her) to faint (abrupt slowing of his ventricular rate with an abrupt reduction in cardiac output causing cardiac syncope) and fall down and hit the pavement; although afterwards, clearly endorsing, “Doctor I did not fall. The pavement came up and hit me!” The fifth bed was generally kept open and unoccupied in anticipation of the next patient-in-cardiovascular crisis in need of emergent care. As A.C.L.S. was in its infancy, cardiac pacemakers were “in infancy” as well. The early – and I do mean the earliest of our temporary pacemakers – were somewhat challenging as:
    1. Our temporary pacemakers contained vacuum tubes – necessarily so in our pre-transistor era – meaning that our vacuum tubes produced a “warm-up-delay” of several seconds just as our now historic –sometimes varnished wood – World War II vintage Philco Radios
    2. Further our earliest temporary pacemakers – prior to the development and availability of our contemporary direct-current external battery packs - were plugged into our wall electric socket(s) just as our standard television sets and our standard lamps are now plugged into our wall electric socket(s) producing the risk of accidental electrocution. We knew of that risk-of-accidental-electrocution but there was fundamentally no other way to provide pacemaker care at that point in time. That was the standard of care at the time.
    A generation ago Doctor Marcus Welby – portrayed by veteran screen actor Robert Young – when asked to provide care for a patient with a stroke might well endorse to the family of the stroke-victim, “There is nothing you can do;” and/or, “We cannot be certain of anything right now.” That may well have changed, probably representing changes in our perspectives on “stroke.” A “stroke” is – in more contemporary terminology known as a “cerebrovascular accident,” and even more contemporary terminology known as a “brain attack.” Much can be done and needs to be done in a reasonably timely manner; or, in the classic language of our Elizabethan era, “’Tis done when ‘tis done, ‘twere well ‘twere done quickly!” (3) Just as our cardiology colleagues may well endorse, “Time is muscle (meaning heart muscle pumping function),” so too our neurology colleagues may well endorse, “Time is brain tissue (meaning the potential for restoration of our cognitive, verbal, motor, sensory, and sensory-motor integrative functions).”
    Reasonably timely transport of our stroke-victim (cerebrovascular accident-victim) to our emergent care center(s) where computerized axial tomography can be swiftly accomplished accompanied by reasonably timely neurological consultation(s) is now reasonable and prudent for our contemporary brain-attack survivor(s).
    What of our efforts and endeavors to provide external cardiac pacing? A generation ago, our external cardiac pacemakers were briefly introduced and then fell out of favor as it was said that, “They just caused too much discomfort, too much pain.” But, as the decades past, our external pacemakers came back (were re-introduced into our intensive care units and re-introduced into our advanced cardiac life support protocols and our algorithms) and are now quite respected – and are now able to sustain heart rate of our patient until an intracardiac pacemaker wire can be floated into place in the right ventricle. The issue of pain and discomfort – with each and every external pacing shock – may well be somewhat ameliorated by intravenous opioids (perhaps morphine 2 – 4 milligrams intravenous administration) thereby increasing patient satisfaction – always a reasonable and prudent provider goal. (4)


    |A.C.L.S. – PER NURSING| With the establishment of our intensive care units – staffed 24 hours a day; seven days a week by our trained critical care unit healthcare providers the focus of our Advanced Cardiac Life Support appears to have shifted from physician – healthcare providers to nursing - healthcare providers. (5) I initially learned my initial Basic Cardiac Life Support (B.C.L.S.) from a nursing – healthcare provider team. Then – later - I went on to learn my initial Advanced Cardiac Life Support (A.C.L.S.) from another nursing – healthcare provider team. Further, still – later, I obtained my Advance Cardiac Life Support (A.C.L.S.) instructorship training from another nursing – healthcare provider team. Our nursing dedication, enthusiasm, and focused intensity of purpose has empowered the teaching of Advanced Cardiac Life Support to become available to virtually any and all healthcare providers serving in critical care units, emergency rooms, operating rooms, as well as general medical, and general surgical units as well. Further, A.C.L.S. is available to our surgical subspecialty colleagues and with some modifications – as P.A.L.S. – Pediatric Advanced Life Support – is provided by our adolescent, pediatric, and neonatal providers as well. We A.C.L.S. instructors are necessarily somewhat challenged to make our A.C.L.S. materials in general and our twelve – lead scalar electrocardiograms somewhat more acceptable to our allied healthcare colleagues who may have had minimal-to-none formal training in electrocardiography prior to our A.C.L.S. provider programs. We A.C.L.S instructors need to work hard so that all of our A.C.L.S. provider student – candidates will come to understand that our twelve – lead electrocardiograms represent a two – dimensional representation of a three – a dimensional object (our heart). When that concept is presented and appreciated, the rest of our twelve – lead diagnostic electrocardiography and concomitantly cardiac rhythm - recognition and cardiac - arrhythmia – recognition, necessary for correct diagnosis and treatment of cardiac crises, may well then be viewed as reasonably straight – forward.
    |A.C.L.S. – “WAR STORIES| Our icing-on-the-cake, the piece`-de-resistance (culinary classic French meaning: main dish) of A.C.L.S. are the “war stories,” that may well be told and re-told (related) whenever our A.C.L.S. providers gather to either re-certify as A.C.L.S. providers and/or to become our A.C.L.S. Instructors. Since A.C.L.S. necessarily often involves electricity, so too, these “war stories,” may well involve electricity as well. Consider these three.
    1. The depressed farmer who – while working on his electric fence - accidentally electrocuted himself into unconsciousness When he, “came to,” he felt ever so much better with his concomitant mood-elevation; and, as a result he elected to deliberately, “Give himself a little juice – representing another electric shock from his electric fence,” whenever he again felt depressed – although finally he sustained an electric shock in his vulnerable period of his cardiac cycle (“R” on “T” phenomenon) developed ventricular fibrillation, was successfully resuscitated, and he lived to tell the tale. (6)
    2. The cardiologist who – rather than seek the services of an electrician - while he himself was working on his electric lamp in his office – accidentally electrocuted himself into ventricular fibrillation; and then stripped open his shirt, and he scooped up his defibrillator - paddles, and cardio-converted himself back in to a restored regular sinus rhythm with a single defibrillation shock from his very own office defibrillator. (7)
    3. The junior-high-school Halloween soccer-team-pranksters-youths who wired their school principal’s automotive twelve-volt battery to the drain pipe(s) of their school-teachers urinals producing interesting post-voiding somewhat noxious urinary bladder-shocks that were observed and reported to be somewhat electrifying. (8)

    |A.C.L.S. – IN OUR COMMUNITIES| At our American Heart Association meeting in Orlando, Florida held during the week of November 10 – 14, 2003 we both recognized, welcomed and hailed our contemporary expansion of our A.C.L.S. – based technology from our hospitals – emergency rooms, critical care units, operating suites – to our communities – “Sports facilities, shopping centers, entertainment venues – just to name a very few.” Approximately 1,500 automated external defibrillators (A.E.D.’s) have been distributed to approximately 993 sites. The bottom line appears to have been endorsed by Virginia Commonwealth University – Richmond, Virginia Professor Joseph Ornato, “The bottom line is that we believe defibrillators in public facilities will double survival if there are trained teams to use them.” (9)
    And our community-based-teams are available to use our A.E.D.’s! Happy stories are coming in. University of Utah Professor of Epidemiology Clay Mann endorses, “In one case at a fitness center, a 41 year old man walked on a treadmill while his wife swam in the pool nearby. Suddenly he collapsed with cardiac arrest, and two women working the front desk had him hooked to the defibrillator within a minute. He was shocked twice and woke up before his wife arrived from the pool. He is doing just wonderfully!” (10)
    All contemporary A.C.L.S. provider courses include instruction in the use of the automated external defibrillator (A.E.D.). Our community newspapers now display photos – provided by Phillips Medical Systems – that include:
    1. The definition or portable defibrillators as, “Devices that deliver an electric shock to people whose hearts stop.”
    2. Step-wise instruction is published in the news papers as follows:
    A. First determine that the person (victim) is not breathing and there is no pulse.
    B. Next turn the defibrillator on.
    C. Next place one pad on the upper right chest and the other pad on the lower left chest.
    D. Next plug the cord into the A.E.D. and wait for the A.E.D. to check for the presence or absence of a heartbeat.
    E. Next, if the victim has no detectable heartbeat; then, the A.E.D. will indicate that a shock is needed.
    F. Next, if, and when, a shock is needed the “voice” of the A.E.D. will endorse, “Shock advised.”
    G. If and when advised to shock, then the rescuer will then press the shock button to provide and deliver the defibrillation shock.
    H. Next, if needed, the “voice” of the A.E.D. may recommend (prompt) additional defibrillation shocks. (11)

    In sum, the “wheel” seems to have come full circle, defibrillation developed initially by biomedical engineering research teams and used for a generation by hospital-based critical care providers and by hospital-extender teams (paramedics) is now increasingly well established in our communities.


    |REFERENCES|
    1. Victor Hugo, Les Miserables
    2. Miller J, Tresch D, Horwitz L, Thompson BM, Aprahamian C, Darin JC.
    The Precordial Thump,
    Annals of Emergency Medicine
    1984; 13:791 - 4
    3. Sir William Shakespeare, Macbeth
    4. Furman, Seymour, The Early History of Cardiac Pacing,
    Pacing and Clinical Electrophysiology
    2003. 26 (10), 2023 – 2032
    5. Stewart JA., Beyond Code Teams: Early Defibrillation by Nurses for in-Hospital Cardiac Arrests,
    Journal of Emergency Nursing,
    1992; 18(6): page 491.
    6. – 7. – 8. Personal communication
    9 - 10. – 11. Published report from our annual meeting of our American Heart Association (A.H.A.) – Orlando, Florida – Public Defibrillators Increase Cardiac Arrest Survival Odds,” Wednesday November 12, 2003, The Johnson City Press, Page 7A, Johnson City, Tennessee
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