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This article was written by Teghan Mear from New Zealand Resuscitation Council for the Council of Ambulance Authorities' First magazine.

On 16 September 2020, we celebrated the 60^th anniversary of the combined research of Kouwenhoven, Knickerbocker, Jude and Safar saved millions of lives through the creation of Cardiopulmonary Resuscitation (CPR). 

Lifesaving techniques date back to the middle ages with a number of inventive methods being used to save a life.

From flagellation to burying in snow, the science and techniques to save lives has evolved throughout time, many of these techniques using either chest compressions or ventilation. However, it was not until the late 1950s when two groups of researchers in the city of Baltimore, Maryland combined their findings that the foundations for modern CPR were made. 

Peter Safar was born in Vienna, Austria in 1924 to a family of physicians, his father an ophthalmologist and his mother a paediatrician. During the political turmoil of the 1930s and the eventual Nazi occupation, Safar because of his non “Aryan” heritage was sent to a labour camp in Bavaria and would’ve been drafted if it was not for his tenacity. Safar found that if he rubbed tuberculin cream into his eczema sores they would become inflamed and noticed by army physicians.

Once he successfully avoided being drafted, he began medical school in Vienna and in 1949 was awarded a surgical fellowship at Yale University. Instead, Safar completed an Anaesthesiology residency at the University of Pennsylvania after the realisation that “surgery would not advance without better life support and you learn life support in anaesthesiology.”   

In 1956 Safar met James Elam who had determined in his research that expired air ventilation was capable of maintaining normal blood gases in patients. This meeting trigged a series of studies which informed Safar’s now famous paper on mouth-to-mouth resuscitation in the Journal of the American Medical Association in 1958. Safar’s experiment determined that mouth-to-mouth ventilation was superior to the manual Holger-Nielson. During a presentation at the Scandinavian Society of Anaesthetists meeting in Norway, Safar met Bjorn Lind who knew Asmund Laerdal – a Norwegian toy-maker. A collaboration began after Lind told Laerdal about this new resuscitation technique which resulted in the development and production of “Resusci Anne” in 1960.   

During this same time period in the 1950s a team of electrical engineers at John Hopkins University in Maryland, were working under William Kouwenhoven. The engineers were trying to improve the external defibrillator, which Kouwenhoven had developed for both internal and external defibrillation in 1933. One day Guy Knickerbocker, a 29-year-old graduate was working in the lab and one of the animal model dogs went into cardiac arrest.

Normally when this happened, they would use a defibrillator to shock the dog's heart back into rhythm - but that day they were in the lab on the 12th floor and the equipment was on the fifth floor. The notoriously slow elevators in the building meant they would never get the defibrillator to the dog in time, the team began chest compressions.

It was noted that adequate circulation could be maintained for up to thirty minutes by pressing on the dogs chest wall. The dog and the slow elevator led to the re-discovery of the chest compression; which had been originally discovered in 1878, however internal cardiac massage was preferred until the Johns Hopkins discovery.

Shortly after this finding, thoracic surgeon James Jude began clinical human trials which supported the concept of external cardiac compressions. 

The two research groups then joined together when Safar combined the techniques of establishing airway, applying mouth-to-mouth ventilation and external cardiac compression. This led to the “ABC’s of Cardiopulmonary Resuscitation” (airway, breathing and circulation).   

The formal combination of chest compressions and mouth to mouth resuscitation took place on 16 September 1960, when Safar, Jude, and Kouwenhoven presented their findings at the Maryland Medical Society and published their research that year on twenty cases of in-hospital cardiac arrest in the Journal of the American Medical Association. In this presentation of Closed chest cardiac massage, Safar stressed the importance of combining artificial respiration and artificial circulation, stating that the two techniques of mouth to mouth ventilation and external chest compression “cannot be considered any longer as separate units, but as parts of a whole and complete approach to resuscitation”.   

The presentation was clear, chest compression buys time until the external defibrillator arrives on the scene “Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed is two hands.”   

Mass training of CPR became the next challenge for the researchers, tragically Dr Safar’s interest became personal after the death of his 12 year old daughter from a severe asthma attack. In 1968 the Pulse of Life Video educating and demonstrating the ABC’s and CPR is produced by Dr. James Elam, Dr. Peter Safar and Archer Gordon using a Resusci Anne. 

In Australia and New Zealand, we were early adopters of using CPR especially in Surf Lifesaving. Millions of people have been equipped with the life skills of CPR and millions have been saved because of this innovation. In the 60 Years since CPR was created research and scientific consensus is continually updated by the International Liaison Committee on Resuscitation (ILCOR).

The New Zealand Resuscitation Council and The Australian Resuscitation proudly collaborate as the Australian and New Zealand Committee on Resuscitation (ANZCOR) and we work with our colleagues and resuscitation councils from around the world providing guidelines to improve health outcomes around the earth. 

On World Restart a Heart a Day we join with our global community to celebrate the last 60 years of empowerment to save lives.