Dr. Frank Pantridge – Father of modern EMS?

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Dr. Frank Pantridge- Father of modern EMS?                                                                            

Dr. Ronald D. Stewart

“Well, if that is so, if that is what is happening in Belfast, we are seeing only the tip of the iceberg; we must go out and get these people!”1

This determined declaration made in 1964 by Dr. Frank Pantridge, the equally determined chief cardiologist at the Royal Victoria Hospital in Belfast, Northern Ireland, could well be considered the rallying cry which gave birth to what we now know as modern Emergency Medical Services (EMS). Dr. Pantridge, who founded the cardiac service at that hospital in 1951, was reacting to the information brought to his attention by his chief resident at the time, Dr. John Geddes. Dr. Geddes, researching a focus of study for an advanced degree in medicine following his internship, had pointed out to his chief that most of these people—that is, citizens who suffered myocardial infarct—were dying within the first hour of the onset of their symptoms. The suggestion by John Geddes that they should consider reaching out beyond the walls of the hospital resonated with his chief, Dr. Pantridge. They just had to figure out a way to “go out and get these people.” And because of this, over the last 50 years we have seen a system emerge, Emergency Medical Services (EMS), dedicated to the public good and the saving of lives.

 

Beginnings…

Frank Pantridge was born in Hillsborough, County Down, about 20 km. or so from Belfast, the province’s capital city. Amid the sectarian culture and religious strife that often became part of his young life, Frank Pantridge was, as long as he cared to remember, a “mediocre student and more-than-occasional rascal.”2 Even in his early life he showed the grit born of his independent character dismissive of social rules and rigid customs. Following his medical training in Belfast, he volunteered for the British Army and was called up in 1940 and, barely escaping a court-marshal for insubordination, found himself in the oppressive heat of Singapore just before the invasion of the Japanese, its capitulation, and the beginning of the long years as a prisoner of war. As one of the few physicians in the slave labour camps constructing the Burma railway, he worked in every way to ease the desperate plight of the Australian and British soldiers, despite his having contracted several diseases related to malnutrition, parasites and maltreatment. He was liberated in September of 1945, eventually making his way back to his beloved Ulster to ‘breathe the free air of County Down.”2 His stubborn and feisty character served him well in wartime, and at least partly explains his survival against all odds, but it also fed a lifelong resentment of war, the rigidity of military life, and an abhorrence of administrators and often colleagues whom he thought pompous, unimaginative and incompetent.3 Such was the man who picked himself up after the war, took up a residency at his alma mater and later was appointed physician-in-charge of the new ‘cardiac unit’ from which he, along with John Geddes, later launched the “flying squad”, lighting the fuse which exploded round the world as mobile intensive care units which were gradually broadened in scope and fashioned into modern EMS systems.

 

Frank Pantridge began practice when cardiology had only begun to be recognied as an area of special attention, both in clinical treatment as well as an important field of research. Along with John Geddes he pushed the limits of this new specialty beyond the walls of the hospital and clinic at a time when people were living longer, revealing at mid-20th century cardiovascular disease as the greatest killer of adults. Pantridge immediately recognised the importance of the data brought to him by John Geddes who cited a study in 1948 indicating that most of those dying from acute myocardial infarction (AMI) succumbed within an hour of the onset of symptoms and often did not reach medical care.4 In fact, most of them died suddenly and without warning. Weighing this evidence, and from their own observations, the two clinicians pondered several basic facts as they understood them:

 

  1. That most deaths from AMI were sudden, and most were from ventricular

fibrillation (VF);

This was demonstrated and reported on as far back­ as 18895, and confirmed when continuous electrocardiographic monitoring was introduced in 1961.6,7

 

  1. That most deaths from AMI occurred outside hospital:

The early studies in the fifties and later demonstrated that most people (85 per cent) suffering an AMI died within the first hours of an attack, and sudden death would most likely be due to ventricular fibrillation.8,9,10 Both Geddes and Pantridge were part of the British National Health Service which, as its foundation, had a network of general practice (GP) physicians who commonly made house calls. Most physicians, however, had only rudimentary knowledge of AMI and even less, of its treatment. The “Belfast experiment” attempted to change that as well, with Dr. Pantridge and his group spreading the word about their novel approach to selected groups of GP’s as part of their “flying squad” program. Both clinicians agreed that earlier care might lead to less damage to the heart muscle, a reasonable but relatively new concept which added to their desire to get to the patients sooner than later.11

 

  1. That defibrillating these patients QUICKLY was of paramount importance—the sooner the better:

Both clinicians, Pantridge and Geddes, were convinced that VF was more likely successfully terminated when a shock was delivered as soon as possible after the onset of VF and that the “new” CPR was a “stopgap” measure only.

 

  1. That defibrillators, available in 1965 and weighing up to 170 kg, had to be made smaller and lighter:

Pantridge, with his background in electrocardiography, was determined to build a defibrillator which would be PORTABLE because he believed that it was wrong to assume that the patient would be taken to the defibrillator, which was then the usual procedure. Pantridge was alarmed too by the increasing energy levels being used by manufacturers and researchers; not only did he recognise the potential for myocardial damage, he was unconvinced that “bigger is better.” Determined to prove his theory, he set about to show that lower energy levels were quite able to defibrillate.12 With the help of Dr. Geddes and Alfred Mawhinney, an electrical engineer in Belfast, the “Pantridge Defibrillator” was devised and weighed only 3.5 kg. Within the year it was clinically put to the test in America as well by Dr. Richard Crampton, and ended up featured on the front page of the New York Times.13

 

  1. We have to go TO the patients rather patients come to us:

Pantridge was skeptical that coronary care units were the answer to reducing the toll of coronary disease in a community. Although grouping patients into a special area in a hospital allowed for observing their clinical course by nurses who became expert in spotting trouble, and enabling continuous monitoring of the electrocardiogram, those that reached hospital and CCU’s alive represented “only the tip of the iceberg.”11 The answer was to break the “rules” and head out into the streets and homes of the city, a revolutionary concept which changed medical practice, saved lives and preserved myocardial tissue!

 

The “flying squad” mobile coronary care team was launched on New Year’s Day, 1966 from the Royal Victoria Hospital. Pantridge and Geddes had cobbled together a physician-led team of nurse, medical students and an ambulance “driver,” a rather debilitated ambulance found on the hospital grounds, and various pieces of medical equipment, including a defibrillator which weighed about 75 kg. Soon after that, however, the new “Pantridge Defibrillator” had been constructed and no longer did the “prehospital team” have to struggle to answer the calls placed to the CCU by GP’s making house calls.

                       

The explosion…

The proof of the success of their new system was announced the following year, in the British journal The Lancet14 and the explosion was heard—but slowly at first—around the world. In the 15 months of the “flying squad” program 312 patients were seen at home or work and half were proven to have had an AMI. All patients were treated at the scene, or, if they deteriorated en route the ambulance was stopped until the team stabilized them. Ten patients suffered cardiac arrest before the arrival of the team or shortly after; all were resuscitated and 50 per cent left hospital neurologically intact. There were no deaths in transit. Significant as well was the notable reduction in cardiogenic shock and heart failure in patients coming to their CCU.

 

A New York cardiologist, William Grace, happened upon the Lancet article and booked immediately to go and see what exactly was this “Belfast experiment” which he read about as well in Time Magazine.15 Returning to New York, he was determined to start one of his own.16 One of his colleagues, Dr. Richard Crampton, as well became a Pantridge disciple and in his new practice at the University of Virginia a “Belfast” program was set up using a local ambulance company as part of the physician-nurse team.17 Dr. Crampton’s efforts were reported on the front page of the New York Times after his team attended a patient having a heart attack in Virginia—former President Lyndon Baines Johnson.13

 

But the job wasn’t finished yet. Early on in the development of the “flying squad” Pantridge had proposed to the developer of the implantable (internal) automatic defibrillator, Dr. Michel Mirowski18, a defibrillator which could sense ventricular fibrillation across the chest wall and deliver a defibrillating shock. Dr. Mirowski was adamant that it couldn’t be done.11 Frank was all the more determined to push for it, and he frequently prodded researchers to hurry up and get on with it. Dr. Pantridge unhesitatingly predicted that these “automated defibrillators” would actually replace fire extinguishers in public buildings, since “people’s lives are more valuable than property.

 

The legacy of J. Frank Pantridge…

The list of his innovations and achievements is long and have not faded in the 50 years since the “flying squad” took to the streets of Belfast. We have built on each of them, changed them according to the lessons learned since he left us in 2004. Time has mellowed our memories of the occasional crusty and abrupt reprimand which often disguised a basic shyness if not perhaps his infrequent feeling that he perhaps wasn’t always right.

 

But was he “the father of modern EMS”? His accomplishments would suggest so:

  • The first mobile intensive care unit system;
  • Early recognition and emphasis that early care reduced infarct size; “tissue is

time, time is tissue”;

  • The first portable defibrillator, without which not much could have happened;
  • The idea for and development of the automated external defibrillator (AED);
  • His defence of the very idea of prehospital care;
  • His leadership and teaching which reached around the globe.

And so, when all is said and done, if he was not the “father of EMS,” he certainly delivered the baby, nurtured it and lived to see it grow to adolescence. His statue sits proudly in the city of Lisburn, now part of Belfast; the statue displays his defibrillator, and the inscription on it reflects a motto which hung on the wall of his office for many years:

 

People can be divided into three groups:

                        Those who make things happen,

                        Those who watch things happen, and

                        Those who wonder what happened.”

 

There is little doubt J. Francis Pantridge fit into the first.

________________________________

 

REFERENCES

  1. Eisenberg MS. Life in the balance: emergency medicine and the quest to reverse sudden death. New York: Oxford University Press; 1997.
  2. Pantridge JF. An unquiet life: memories of a physician and cardiologist. Antrim: Greystone Books; 1989.
  3. Baskett TF, Baskett PJF. The resuscitation greats: Frank Pantridge and mobile coronary care. Resuscitation 2000 Aug 24; 48:11-104.
  4. Yater WM, Traum AH, Brown WG, Fitzgerald RP, Geisler MA, Wilcox BB. Coronary artery disease in me eighteen to thirty-nine years of age. American Heart Journal 1948 Oct; 36(4):481-526.
  5. McWilliam JA. Cardiac failure and sudden death. British Medical Journal 1889 Jan 5:i:6-8.
  6. Julian DG. Treatment of cardiac arrest in acute myocardial ischemia and infarction. Lancet 1961; ii:840-44.
  7. Julian DG, Valentine PA, Miller GG. Routine electrocardiographic monitoring in acute myocardial infarction. Medical Journal of Australia 1964;i:433-36.
  8. Fulton M, Julian DG, Oliver MF. Sudden death and myocardial infarction. Circulation 1969; 40 (suppl IV):182-91.
  9. Goldstein S, Moss AJ, Greene W. Sudden death in acute myocardial infarction. Archives of Internal Medicine 1972 May; 129:720-24.
  10. Bainton CR, Peterson DR. Deaths from coronary heart disease in persons fifty years of age and younger: A community-wide study. New England Journal of Medicine 1963 Mar 14;268(11):569-75.
  11. Pantridge JF, Wilson C. A history of prehospital coronary care. Ulster Medical Journal 1996 May; 65(1):68-73.
  12. Pantridge JF, Adgey AAJ, Webb SW, Anderson J. Electrical requirements for ventricular fibrillation. British Medical Journal 1975;ii:313-15.
  13. Altman LK. Portable heart unit is developed. New York Times 1975 Aug 11;1 (col.1-3).
  14. Pantridge JF, Geddes JS. A mobile intensive care unit in the management of myocardial infarction. The Lancet 1967;ii:271-73.
  15. Immediate Counterattack. Time Magazine 1967 Sept 1; 32(Col.1-2).
  16. Grace WJ, Chadbourn JA. The mobile coronary care unit. Diseases of the Chest 1969 Jun;55(6):452-55.
  17. Crampton RS, Aldrich RF, Gascho JA, Miles JR, Stillerman R. Reducation of prehospital, ambulance and community coronary death rates by the community-wide emergency cardiac system. American Journal of Medicine 1975;58(2):151-65.
  18. Mirwowski M. Prevention of sudden arrhythmic death with implanted automatic defibrillators. Annals of Internal Medicine 1982;97:606-8.

 

About The Author

Dr. Ronald Stewart is a medical graduate of Dalhousie University and began his practice along the north coast of Cape Breton Island. He trained in emergency medicine in Los Angeles and became the first director of the City and County EMS system. Following a decade at the University of Pittsburgh where he was chief of the department and Medical Director of that city’s EMS system, he joined the staff at Sunnybrook (U of T) and returned to Nova Scotia to his alma mater. Following a career in government as Minister of Health, he returned to Dalhousie Medical School and continues as Professor Emeritus in Emergency Medicine. He is a member of The Order of Canada, the Order of Nova Scotia and holds three honorary degrees.

 

Author’s titles

Professor Emeritus, Medical Education, Dalhousie University;

Professor of Emergency Medicine, Department of Emergency Medicine, Dalhousie

University;

Adjunct Professor, Emergency Medicine, University of Pittsburgh

Author’s Email: ronald.stewart@dal.ca