Book Review

Life in the Balance: Emergency medicine and the quest to reverse sudden death

N Engl J Med 1997; 337:206-207July 17, 1997

Article

Life in the Balance: Emergency medicine and the quest to reverse sudden death
By Mickey S. Eisenberg. 304 pp. New York, Oxford University Press, 1997. $27.50. ISBN: 0-19-510179-0

Sudden death outside the hospital as a result of ventricular fibrillation, the subject of Life in the Balance, was irreversible until the 1950s. Until then, complete airway obstruction (a common byproduct of coma), apnea, and the absence of a pulse outside the hospital meant certain death. Despite occasional anecdotes since antiquity about attempts to reverse sudden death, most people accepted it as an act of God. The Enlightenment in the 18th century brought a willingness to reverse sudden death. However, the ability to do so outside the hospital was lacking until the 1950s, with the advent of external cardiopulmonary resuscitation (CPR) and its delivery through community-wide systems of emergency medical services.

Life in the Balance is an exciting, detailed medical detective story concerning the history of selected topics related to resuscitation. As the author notes, ``The journey recounted here from biblical to modern times is far more than a simple tale of people and events.''

Eisenberg divides his book into five parts, focusing on sudden cardiac death from ventricular fibrillation. The book is best read from cover to cover, because the prologue presents a case report describing the recent successful resuscitation of a middle-aged man from sudden cardiac death at home. This case is referred to repeatedly throughout the book, with speculations on why the man would have been doomed in earlier times.

Part I, ``The Quest,'' includes delightful historical anecdotes. Part II, ``The Breath of Life,'' primarily concerns the development of step A (airway control) and step B (breathing control) in modern CPR. This section describes how in the 1950s, with scientific experiments on humans, Elam showed that exhaled air is useful resuscitative gas, and tells how I documented airway control by a backward tilt of the head and jaw thrust, the failure of ventilation by chest-pressure arm-lift methods, and the superiority of direct exhaled-air ventilation. Part III, ``The Pulse of Life,'' recounts efforts to induce artificial circulation, step C, by chest compressions, apparently first used on patients in the 1890s by Maass of Gottingen. External cardiac massage was not adopted and remained forgotten until it was rediscovered in the late 1950s at the Johns Hopkins Hospital. Kouwenhoven, a professor of electrical engineering at Hopkins from the 1930s until his death in 1975, studied electrically induced ventricular fibrillation and immediate defibrillation. In 1958, Kouwenhoven's engineering fellow, Knickerbocker, made the crucial rediscovery by chance. Jude, a surgeon, documented the efficacy of chest compressions in patients. In 1959, I put steps A, B, and C together as ``basic life support'' and added ``advanced and prolonged life support'' for teaching and implementing a systems approach.

In ``The Birth of CPR,'' Eisenberg raises the question of credit. He concludes that ``all five [Elam, Safar, Kouwenhoven, Jude, and Knickerbocker] are the inventors of CPR.'' He meant that we are all the inventors of basic life support. There is more to it than steps A, B, and C, and what ultimately counts is the discoveries that are made, recognized, and implemented, not so much who introduced or reported a new idea first.

Part IV, ``The Spark of Life,'' includes fascinating anecdotes about early searches for electrophysiologic phenomena and uncontrolled ``clinical trials'' with electric stimulations, which Eisenberg calls ``electroquackery.'' The recent development of effective external (portable) electric defibrillation is described. Part V, ``The Way Is Found,'' concerns the delivery of CPR through mobile intensive care units in Belfast and the United States. The epilogue poses the question, ``Is it worthwhile?'' I agree with the author's views. The ethical dilemmas of resuscitation medicine, however, are very complex and deserve a separate book.

At the end of the book is a glossary, as well as notes with some references for each chapter. A list of selected readings refers the reader to related literature but does not include all the landmark articles that should be listed in a scientific book on resuscitation. Also at the end of the book is a useful ``Community Survival Checklist.''

Eisenberg writes with eloquence, humor, clarity, and a minimum of jargon. However, the book omits several important topics. It focuses exclusively on ``respiration, circulation, defibrillation, and emergency medical services.'' Resuscitation medicine, however, is concerned with the reversal of all acute dying processes. Although the book includes Beck's concept of ``hearts too good to die,'' it neglects the concept of ``brains too good to die,'' which makes restoration of the human mind the ultimate goal of resuscitation. The book does not mention Negovsky of Moscow, who studied, starting in the late 1930s, the pathophysiology of acute dying processes, their reversibility, and post-resuscitation disease. The battery-powered portable capacitor discharge defibrillator was pioneered by Gurvich in Negovsky's laboratory in the mid-1940s. In addition, the book does not consider prolonged intensive-care life support, which is required for patients to survive coma after CPR. Also excluded is Eisenberg's own pioneering work since the 1980s on the scientific evaluation of community-wide CPR efforts.

Downplayed is direct heart pumping (open-chest CPR), which according to Stephenson, saved many lives in hospitals during the first half of this century. Open-chest CPR (by physicians), which produces much better perfusion pressures than sternal compressions, is now being reconsidered for ultra-advanced life support, even outside the hospital, in cases in which external CPR is not successful. Portable emergency cardiopulmonary-bypass equipment and procedures are also being developed.

The mobile cardiac care unit introduced in Belfast in the mid-1960s brought cardiology fellows to heart-attack (not heart-arrest) victims in attempts to prevent cardiac arrest. Credit should also be given to the mobile general intensive care units, which were initiated earlier, first in Prague and Moscow. These units brought physicians to the scene to resuscitate patients from terminal states or clinical death. Although the results of prehospital CPR attempts are still suboptimal, systems of emergency medical services in the United States have been partially effective, because of national guidelines for ambulance design and equipment, technicians' training, and the organization of emergency medical services. These guidelines were developed in the 1960s by the Emergency Medical Services Committee of the National Research Council and were pilot-tested and implemented first in Pittsburgh, by ``unemployable'' African Americans of the Freedom House project under the medical direction of Donald Benson in the 1960s and Nancy Caroline in the 1970s.

There were two major setbacks in the development of modern resuscitation. In the mid-1800s, exhaled-air ventilation was abandoned in favor of chest-pressure arm-lift maneuvers, which were taught for 100 years until proved ineffective. And around 1900, most but not all of the steps of CPR (or cardiopulmonary-cerebral resuscitation) were known, but this knowledge remained dormant for 50 years. Eisenberg speculates on several causes of these setbacks. It is important to know the causes in order to avoid similar setbacks in the future.

This delightful book is essential reading for health care professionals involved with acutely life-threatening conditions. It is also absorbing reading for others, including any educated layperson who is interested in sudden death or the history of medicine.

Peter Safar, M.D.
University of Pittsburgh, Pittsburgh, PA 15260

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