- Email: [email protected]
James O. Elam MD, 1918–1995
Resuscitation 50 (2001) 249– 256 www.elsevier.com/locate/resuscitation
The Resuscitation Greats
James O. Elam MD, 1918–1995 Peter Safar * Safar Center for Resuscitation Research, Uni6ersity of Pittsburgh, 3434 Fifth A6enue, Pittsburgh, PA 15260, USA
James Otis Elam MD, was a pioneering anesthesiologist during the adolescence of this specialty in the 1950s [1 – 3]. He was a clinician and respiratory physiologist who made important original measurements on humans. Many colleagues remember him as an imaginative inventor and developer of devices that have helped those in anaesthesia. Health professionals and lay persons who are interested in first aid should remember Elam primarily for the fact that he was the first person to prove that exhaled air can be an adequate resuscitative gas [4]. I have a personal reason to thank him for having motivated me, through a chance encounter, not only to teach and practice, but also to research resuscitation, which became my lifelong pursuit [3,5]. I will remember him as a catalyst for research and development in resuscitation in the latter half of the 20th century, who influenced several colleagues. This laudatio of Elam as a ‘resuscitation great’ has input from Mark Lema, MD, Ph.D., present professor and chairman of Anesthesiology, University at Buffalo [2] and from Jim’s widow, Marjorie Elam, CRNA. Jim Elam was born on May 31, 1918 in Austin, TX. Sands and Bacon [1] remind us that he was born prematurely and needed external stimuli to start breathing. He had a creative and dynamic professional life and a family life that included five children with his first wife Elinor. In the 1990s, he suffered from a prolonged illness and died on July 10, 1995, in Valparaiso, Indiana, cared for by his wife Marjorie. Elam’s professional career took him from a bachelor of arts degree at the University of Texas in 1942, to an MD at the Johns Hopkins University School of Medicine in Baltimore in 1945, and via a rotating internship at the US Navy Hospital in Washington
* Tel: + 1-412-624-6735; fax: + 1-412-624-6736. E-mail address: [email protected] (P. Safar).
(Bethesda, MD) in 1945/1946, physiology training at the University of Minnesota in 1946/1947, internship and fellowship in surgery at Barnes Hospital of Washington University in St. Louis, Missouri, in 1947 –1949, to an anesthesiology residency at the Massachusetts General Hospital in Boston and the University of Iowa in 1949 –1951. In 1951 –1953, he served as a research assistant professor at the Barnes Hospital. From there he went to Buffalo, NY, where he became chief anesthesiologist (‘Chief Cancer Research Clinician’) of the Roswell Park Memorial Institute, now called Roswell Park Cancer Institute (and hospital), from 1953 to 1964 [2]. During his 11 years at Roswell Park, he rose to the rank of major in the US Army while finishing his Army obligations in 1954 –1956 at the Army Chemical Corps Medical Laboratories (Research and Engineering Command) at Edgewood, MD (near Baltimore). His earlier military obligation had been interrupted by his residency training. The combination of US Army-funded research from 1951 to 1970 (: $30,000 per year, present value over ten times this amount) and the opportunity to study anaesthetized patients at Roswell Park, created the environment for his contributions to anesthesiology and resuscitation in general, and to exhaled-air ventilation in particular. That research took place before the advent of institutional review boards, which now have to give approval for patient research. Before the 1970s, Elam and I and other resuscitation researchers studied patients and human volunteers by assuming personal responsibility and seeking approval only from our local peers. The decade in Buffalo came to an end when Elam became increasingly disappointed that the lack of medical students and anaesthesia residents at the Cancer Institute would prevent his innovations being disseminated and continued. Therefore, in 1964, he left Buffalo to become professor and chairman of the Department of Anesthesiology at the University of Missouri at the
0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 1 ) 0 0 4 1 3 - 0
250
P. Safar / Resuscitation 50 (2001) 249–256
Kansas City General Hospital. He again experienced disappointments and, in 1966, went on to become a professor of anesthesiology at the University of Chicago, working mainly in obstetric anaesthesia, from 1966 until his retirement in the mid-1980s. Retirement gave him the freedom to innovate and further develop his devices privately. The frequent change in locations reflects the restlessness of a creative individual.
1. Respiratory physiology and anesthesiology Before his anesthesiology residency, while in Minnesota under the influence of physiologist Maurice Visscher, he used one of the first oximeters, an ear oximeter [6]. Designed by Glen Millikan, this device was then used by the US Air Force. He also used the ListonBecker (Model 16) infrared CO2 analyzer for research [7,8]. Elam was probably the first to use it in anaesthesia and resuscitation research. Excited by research in general, Elam continued some studies part-time during his residency in anesthesiology. Present-day anesthesiology board requirements preclude such a mixed experience of patient care, clinical research and laboratory research, although for workaholic, pioneering, young anesthesiology trainees like Elam, that experience was not uncommon in the 1940s– 1960s. Moreover, it was not unusual at that time to seek out colleagues of other specialties who had something new to offer. After his residency, when at Barnes Hospital, he was committed, under US Army funding, to study humans. The chairman of Surgery (anesthesiology was a division of the Department of Surgery) first accepted human studies, but later demanded that they be replaced by work on animals. Since this would be unrealistic and would have jeopardized his Army contract, Elam and collaborators Elwyn Brown, John Elder and Raymond Ten Pas, went to Roswell Park [2]. There, anesthesiology received departmental status. Elam’s team established a school for nurse anesthetists, which enabled him to continue focusing on his experiments in respiratory physiology. Physicians directed all of the anaesthesias administered by the nurses. His group then explored, for the Army, new valves designs, a flashlight laryngoscope and, most important, exhaled-air ventilation devices for nerve-gas-poisoned casualties (see later). They also acquired some patents. During his Army duty at Edgewood, he re-visited Roswell Park every week or two to study the data his associates had produced there. An effective synergy developed between Elam, who ‘dreamed and schemed’ and Brown, the practical engineer [2]. Elam himself was ahead of others in drawing attention to the elimination and monitoring of carbon dioxide [9]. Using the infrared CO2 analyzer, he described the ‘alveolar plateau’. Soon after his anesthesiology
training, based on closed-circle anaesthesia systems introduced by Sword, Waters, Adriani and others, Elam questioned the efficacy of the CO2 absorbers in use at the time. He designed a better system for CO2 absorption in anaesthesia circuits [10–17]. Elam and Brown greatly improved the CO2 absorber by making it larger, packing the granules better, using baffles, doubling the canisters and determining that the absorbers’ interstitial space should at least equal tidal volume [16]. His successors at Roswell Park wrote [2]: ‘‘Every anaesthesia machine over the last 30 years has used a carbon dioxide absorbence system essentially designed by these two physicians.’’ Elam and his collaborators also constructed a human respiration simulator, for various long-term ventilation experiments. That lung model was further developed into the Roswell Park ventilator, a bellows-in-box ventilator, powered by intermittent compression of the bellows by gas pressure in the box. This machine became the Air Shields Venti-meter Ventilator, which was in use throughout the 1950s, 1960s and 1970s [18]. They first used a windshield-wiper type power source obtained from the TRICO plant adjacent to the Cancer Institute. The ventilator could function by pressure or volume-cycling, with intermittent positive or positive– negative pressure patterns. The novel idea was that this bellows-in-box device was also useful for spontaneous breathing. The anesthetist, when squeezing the bag connected to the box, could monitor and control tidal volumes by watching excursions of the bellows connected to the anaesthesia circuit.
2. Exhaled-air ventilation Before Elam became an anesthesiologist, his interest in respiratory resuscitation was aroused by having been given responsibility for the care of paralyzed polio patients in 1946 in Minneapolis [4]. While assigned to the polio floor, when he temporarily ran out of tank respirators (the Iron Lung), Elam instinctively performed mouth-to-mouth or mouth-to-nose ventilation, sometimes for hours, he said. During his residency in Iowa City, under the direction of Stuart Cullen, when moving patients from induction areas to operating rooms, he again instinctively used mouth-to-tracheal tube ventilation, as I and other anesthesiologists had done quite routinely. Around 1952, when Elam was assistant professor of anesthesiology at Barnes Hospital, he found in the literature descriptions of over 100 manual (push–pull) methods of artificial respiration, but only brief mention of the mouth-to-mouth method for use in the newborn. He noted that no one had investigated the physiology of exhaled-air ventilation [4]. He and Brown embarked on studies of patients experiencing residual muscle
P. Safar / Resuscitation 50 (2001) 249–256
paralysis in the post-anaesthesia recovery room, under renewed succinylcholine paralysis. Elam demonstrated that mouth-to-mask or mouth-to-tracheal tube ventilation could maintain normal arterial blood-gas values, as recorded by the CO2 analyzer and tedious blood-gas analyses by the VanSlyke system. These first data on exhaled-air ventilation were published as a landmark paper in the ‘New England Journal of Medicine’ soon after his arrival in Buffalo [19] (Fig. 1). Elam documented that it requires ‘‘doubling the tidal volumes, because you are breathing for two’’. After Elam and I had met (in 1956), he published these blood-gas data in greater detail, in the ‘JAMA’ of 1958 [20], simultaneously with my data on airway control and the controlled comparison of direct mouth-tomouth with manual methods [21] and the data by Gordon on mouth-to-mouth versus manual methods in children [22]. Between 1953 and 1956, Elam’s breakthrough data [19] seemed to have been dormant, with no one in anesthesiology or first-aid circles paying much attention to them. Gordon [23] had earlier found in curarized adult human volunteers, that the prone back-pressure
Fig. 1. James Elam in the 1960s.
251
arm-lift (Holger–Nielsen) method moved more air than the then widely taught prone back-pressure-only method (Schafer)— both techniques were studied with a tracheal tube. The views of my mentors of 1950, Comroe and Dripps [24] and similar data obtained using tracheal tubes by Nims et al. [25] in Dripps’ department, also questioned the efficacy of the Schafer method. Only the US Army took Elam’s work seriously. When Elam worked for the Army Chemical Corps, he found the chest- or back-pressure methods too weak to ventilate nerve-gas-poisoned animals. These animals developed bronchoconstriction, massive bronchial secretions, bradycardia and paralysis. At Edgewood, Elam worked side-by-side with John Clements, a brilliant civilian researcher at the Army Chemical Center (who pioneered pulmonary surfactant). Elam and Clements developed prototypes of valved mask-to-mask devices for intended resuscitation of nerve-gas-poisoned humans [27–29]. A gas filter could be put on the air intake for the rescuer. Clements recently recalled: ‘‘Adam Muir and I [26] found that the Holger– Nielsen method did not move any air in rhesus monkeys (with nerve-gas poisoning), and I designed a flow-valved, non-rebreathing mask-to-mask device that was effective enough to overcome severe bronchoconstriction and led to long-term survival [26].’’ The research and development of modern emergency resuscitation exploded after Elam and I met, by coincidence, in 1956. I described this event roughly as follows [3,5]: The spark that started my lifelong commitment to resuscitation research, including interest in pre-hospital first aid, was a chance contact with James Elam. It happened at the American Society of Anesthesiologists (ASA) meeting in October 1956 in Kansas City. For the previous 100 years, various chest-pressure arm-lift methods had been used; since the early 1950s, the back-pressure arm-lift method was favored, because of data obtained by Archer Gordon (then in Chicago) who used intubated curarized human volunteers [23]. Until that ASA meeting of 1956, I had not been aware of the 1954 publication by Elam [19] that documented normal blood-gas values in apnoeic patients during IPPV with mouth-to-mask or mouth-to-tracheal tube ventilation. On October 12, 1956, Eva (Safar) and I had supper with James Elam. This was the first time I talked with him. Elam asked to hitch a ride back to Baltimore with us. During that ride on October 13 and 14, 1956 from Kansas City via Chicago to Baltimore, I was inspired by his first published proof that exhaled air is an adequate resuscitative gas [19], and by his imaginative personality. Elam revealed to me that his results were not widely known. He gave me the impression during that trip that neither he nor others had challenged the current doctrine, and that first-aid agencies continued to adhere to teaching the back-pressure arm-lift method.
252
P. Safar / Resuscitation 50 (2001) 249–256
Elam recalled later [4] that he did try to persuade Army physiologist Bruce Dill (research director at Edgewood), Army generals, and the Red Cross ‘‘to recognize the method of Elisha. I even told them that Elam was a biblical name and that I (Elam) might be a prophet disguised as a major.’’ I do not know whether this happened before or after we met. Dill, who recognized that the Schafer method would be ineffective for nerve-gas casualties, created the US Army contract for Elam on artificial respiration. Dill promoted the first Army conferences of investigators for artificial respiration and originated the first National Academy of Sciences (NAS) conferences on this subject. Dill, Elam and Dripps probably recommended funding of my first research proposal to the Army in 1956. I further recalled [3] that when Elam, in October 1956, told me about his results [19], it occurred to me that anesthesiologists’ know-how in handling upper-airway obstruction had not penetrated beyond the operating room. On that fateful car trip, I proposed that we conduct the following needed studies and documentations: (1) A study of upper-airway soft-tissue obstruction on curarized adults. (Elam had used a mask, a pharyngeal tube and a tracheal tube in his landmark study [19], but had not explored backward tilt of the head, which I considered crucial.) (2) A controlled study in which ventilation volumes and oxygenation produced by the ‘push –pull methods’ would be compared with those produced by direct mouth-to-mouth inflations, using both methods on the same apnoeic adult curarized volunteers and on patients, without the use of a tracheal tube, pharyngeal tube, or mask, with each subject serving as his own control and mouth-tomouth ventilation performed by lay persons. Elam agreed that this should be done. I suggested that we do it together at the Baltimore City Hospital where I was chief anesthesiologist. He attended the first two or three experiments in December 1956 [30,31] and then moved to Buffalo and continued on his own. Elam and I maintained some communication thereafter until his death. When Elam left the Army to return to Roswell Park, Brown took his research position in the Army. I thank Jim also for having brought me in touch with John Clements, who gave valuable advice for our human volunteer experiments [31]; John the pianist and his wife Margot, a superb professional singer, made classical music with the Safars and other medical amateur musicians in Baltimore. Our preliminary [30] and definitive data [31] from the human volunteer experiments in 1957 and my first documentation of the failure of manual methods of artificial ventilation [32]; the mechanisms of upper-airway soft-tissue obstruction in coma and need for backward tilt of the head, jaw thrust, and open mouth [21,33 –35]; and the efficacy and techniques of exhaledair ventilation without adjuncts [20– 22], were received as a bombshell in the US and Europe.
On March 8, 1957, the NAS held a meeting in Washington DC, chaired by Julius Comroe, concerning artificial respiration for children. Elam and I presented the data of our first experiments on adult volunteers. Mouth-to-mouth ventilation was recommended for children but not yet for adults. At that meeting, Archer Gordon learned about our preliminary results on adults [30] and gathered similar data on anaesthetized children and adults [22]. On May 10, 1957, Dill gathered Army researchers in Denver; Elam’s and my data were hot topics. On November 3, 1958, after our definitive data had been published [20–22], the NAS held its second meeting on artificial respiration, chaired by visionary surgeon Sam Seeley. Backward tilt of the head with direct mouth-to-mouth ventilation was decided upon as the preferred method of artificial respiration. The recommendation applied to adults as well as children. Within 1 year, medical associations, the Armed Forces and the American and International Red Cross organizations changed from the manual methods to the exhaled-air methods of artificial ventilation. In 1960, Elam was honored by the US Army Chemical Center with an Award of Achievement and by the New York Medical Society with its highest honor, the Albion O. Bernstein Award of Distinction for Contributions to Medicine. He was honored by the American Heart Association as one of the pioneers of CPR. As was to be expected, there were controversies. Elam had recommended mouth-to-mask ventilation and had produced a green plastic pocket mask. To my knowledge, this never came to market. I introduced blowing through an S-shaped Guedel-type oro-pharyngeal tube. We agreed that use of devices should be restricted to health care professionals. After Elam had returned from Baltimore to Buffalo, he enticed Henning Ruben of Denmark into collaborating with him. Ruben had earlier introduced the self-refilling bagvalve-mask unit, a breakthrough in resuscitation devices [36]. Gordon and I recommended to try blowing into the mouth first [21,22] because of frequent nasal obstruction [33– 35], while Elam and Ruben recommended to blow into the nose first [37]. ‘Mouth first and nose second’ became the national [38] and international guidelines [39]. Elam popularized exhaled-air ventilation in the state of New York and beyond by writing manuals and making teaching films. After the first volunteer experiments at Baltimore City Hospital, Elam produced a film that included a medical student paralyzed with succinylcholine on whom he demonstrated the various ventilation methods, accompanied by ear oximetry. Elam was also sought after in the early years as a lecturer because of his message and impressive speaking style. Airway control became step A of CPR. Ruben and Elam [40–42] confirmed my head-tilt data [21,33–35]. Elam tried to minimize gastric insufflation and regurgi-
P. Safar / Resuscitation 50 (2001) 249–256
tation by blowing into the narrower nasal passage, which reduced pharyngeal pressure [37]. I found gastric distension to be self-limiting [21] and documented expiratory nasal obstruction as a greater obstacle [33–35]. Exhaled-air ventilation [20– 22] became step B of CPR. I combined steps A and B with step C, external cardiac massage, re-discovered by Kouwenhoven et al. [43], into basic life support (BLS) [44,45] and added advanced and prolonged life support for the cardiopulmonary-cerebral resuscitation (CPCR) system [39,45]. Elam continued to promote exhaled-air ventilation together with me [46,47] and reported on actual cases of successful resuscitation [48]. He became co-initiator (with Gordon, Jude and Safar) of the first American Heart Association CPR-Emergency Cardiac Care Committee [49]. Elam joined me in advising Laerdal in the creation of the Resusci-Anne manikin [50]. He also advised the Ambu Company of Denmark concerning resuscitation devices. Elam served on the first American Society of Anesthesiologists acute medicine committee that I had initiated [51]. Later, Elam co-initiated, with Jude and me, the first Wolf Creek Conference of CPR Researchers [52]. At that conference in 1975, Elam contributed imaginative ideas on bag-valve-mask O2 ventilation [53], intrapulmonary administration of CPR drugs [54], the esophageal– pharyngeal airway [55], esophageal electrocardiography [56] and esophageal defibrillation [56].
3. Chicago and semi-retirement With rescue breathing as the climax of his professional career, one can consider Jim Elam’s years at the University of Chicago (from 1966 to 1980), a professorship at the University of Texas Southwestern Medical School in Dallas (in 1981– 1983) and his semi-retirement in Valparaiso, Indiana (from the mid-1980s to the 1990s) as a continuum (Fig. 2). Starting in the 1970s, he had turned his attention to new airway-control devices. His conception, design and promotion of devices spanned many years. Most of the recently invented devices have so far not become commercially available. One reason was the bureaucratic demands and delays posed by institutional review boards against human trials, which since the 1980s have been essential to bring devices to fruition. Another reason for some of his inventions having remained dormant may have been a lack of publications. Since the 1960s he had tried the use of soft rubber nasopharyngeal tubes in both nasal passages as an alternative to tracheal intubation [57,58]. Reportedly, more than 1000 patients at the Lying-In Hospital in Chicago received this airway in operating rooms between 1966 and 1970. Connecting one nasopharyngeal tube directly to an anaesthesia or resuscitation system
253
Fig. 2. James Elam in the 1980s.
was not new. Reducing airway resistance by doubling the tube was new. The nasopharyngeal tube connected directly to the anaesthesia circuit did not become a widely accepted method for prolonged general anesthesias, since anesthesiologists and nurse anesthetists felt that patients were safer with a cuffed endotracheal tube. When in Chicago, Elam also made contributions to anaesthesia method [59–61]. He promoted sound principles when he sought new approaches and devices: (1) As alternative to tracheal intubation, he developed a pharyngeal airway with a pharynx-occluding balloon [62], which actually became a forerunner for the laryngeal mask airway (LMA) designed and published by Brain. (2) He designed a double-barreled plastic tube to be inserted into the mouth without a laryngoscope, with one barrel as a conduit for a tracheal tube and the other for a nasogastric tube. The idea was that people without medical knowledge could safely intubate blindly and decompress the stomach at the same time. This was a forerunner of the ‘Combitube’. (3) He wanted to develop a non-distensible manual bellows ventilator for use in nerve-gas-poisoned stiff lungs, as he initiated it in the 1950s with the Army. (4) His further work with the Air-Shields ventilator focused on an assist/control mechanism that would allow patients to regulate their own spontaneous breathing volume and rate [63].
254
P. Safar / Resuscitation 50 (2001) 249–256
Elam’s US patents and developments between 1952 and 1983 included CO2 absorbers, ventilators, valves, masks, airways, sensors, a tracheal tube double-cuff, and a cuff monitor. Between 1947 and 1984, he published about 120 works, including peer-reviewed papers, reports, books and abstracts. During Elam’s retirement, we honored him as visiting professor at the opening of the International Resuscitation Research Center facility at the University of Pittsburgh in 1980. After that, we met occasionally at resuscitation conferences sponsored by the American Heart Association. In January 1994, I invited Jim to the May 1994 International Conference of Resuscitation Researchers in Pittsburgh. Elam had to decline because of health reasons: ‘‘too many diagnoses including cardiac myopathy and diabetes … When you asked me why I was still working on gadgets, the answer is that in retirement, with no access to patients, developing better equipment was about all I could do. For example, regurgitation during resuscitation … we should be concerned about it … if I could attend your symposium, I would report on my recent project which utilizes (combines) a conventional endotracheal tube, an Ewald (esophago-gastric) tube, and the method of rapidly establishing (inserting) both before aspiration occurs. I have arranged for clinical testing of the method by others. I shall send you the results when the project is done.’’ Sadly there was no follow-up because, according to his wife Marjorie, he became increasingly ill. At Roswell Park, he had a godfather for his research and development in surgeon and Institute Director George Moore [2]. Thereafter, he lacked such support. In the early 1990s, feeling that time was running out, Jim re-visited Roswell Park in attempts to obtain patients for trials of his novel devices. I believe that airway and ventilation methods and devices would have been further improved had Elam succeeded during the 1970s and 1980s in translating his ideas into prototypes, testing in patients, publishing results and bringing some of the devices to the open market. Helping inventors like Elam should be among the important roles of academic medical centers. Industry and academia may have (incorrectly) perceived him more as a gadgeteer than as a visionary, which I believe he was. Jim’s wife, Marjorie Elam of Valparaiso, Indiana, wrote to me after his death: ‘‘Jim died around 10:00 pm on July 10 (1995). He had suffered what seemed to be a small stroke, in addition to kidney failure, chest pain, and diabetes. … He died very peacefully. Life had become a struggle. His son Michael lives in Los Angeles, son Peter in Minnesota, son David in San Francisco, daughter Joann in Chicago, and daughter Susan in Boston.’’
4. Conclusion James Elam started as a patient-focused respiratory physiologist and became a visionary inventor of devices that improved the safety of general anaesthesia and contributed to more effective resuscitation methods. He has been called charismatic, determined, innovative and ingenious [2]. His most important contribution was to the noble endeavour of emergency respiratory resuscitation: the documentation that exhaled air can be adequate for artificial ventilation. This sparked the development by others of modern external CPR and beyond. Elam’s influence on me and on others, and our subsequent influences on resuscitation researchers who followed, with cross-fertilization between them, which will continue for decades to come, reminds us that each one of us represents one or more links in the chains of human evolution. Elam was a strong link from which modern CPR, cerebral resuscitation (CPCR), trauma resuscitation, emergency medical services and critical care medicine developed during the latter half of the 20th century. Jim Elam helped put the Roswell Cancer Institute in Buffalo on the map [2]. His legacy has been summarized in several documents on the history of modern resuscitation. I would like to conclude this laudatio by quoting Sands and Bacon [1]: ‘‘James Elam, from his early work on CO2 homeostasis, leading to the first human capnograhic tracing, leading to the modifications of the soda lime canister, to his recent work on an airway that laymen can use to intubate victims of cardiac arrest outside the hospital, Elam has always strived to improve the quality of life of his fellow humans. Battling through hardships of his own … including debilitating osteoarthritis necessitating multiple hip replacements and ultimately confinement to a wheelchair, Elam persevered.’’ References [1] Sands RP, Bacon DR. An inventive mind. The career of James O. Elam, M.D. (1918 – 1995). Anesthesiology 1998;88:1107 –12. [2] Peppriell JE, Bacon DR, Lema MJ, Ament R, Yearley CK. The development of academic anesthesiology at the Roswell Park Memorial Institute: James O. Elam, MD, and Elwyn S. Brown, MD. Anesth Analg 1991;72:538 – 45. [3] Safar P. From Vienna to Pittsburgh for anesthesiology and acute medicine. Careers in Anesthesiology. Autobiographical Memoirs. Vol. V, American Society of Anesthesiologists, Wood Library-Museum, 2000. (Wood Library Museum, 515 Busse Highway, Park Ridge, IL 60068). [4] Elam JO. Rediscovery of expired air methods for emergency ventilation. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:263 – 5 Chapter 39. [5] Safar P. From back-pressure arm-lift to mouth-to-mouth, control of airway and beyond. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:266 – 75 Chapter 40.
P. Safar / Resuscitation 50 (2001) 249–256 [6] Sleator W Jr, Elam JO, Elam WN Jr, White HL. Oximetric determinations of cardiac output responses to light exercise. J Appl Physiol 1951;3:649 –64. [7] Luft K. Methode der Registrieren gas Analyse mit Hilfe der Absorption ultraroten Strahlen ohne spectrale Zerlegung. Z Tech Phys 1943;244:97. [8] White JU, Liston MD. Performance of double beam recording infrared spectrophotometer. J Soc Am 1950;40:93 –101. [9] Brown EB, Miller F. Ventricular fibrillation following a rapid fall in alveolar carbon dioxide concentration. Am J Phys 1952;169:56 – 60. [10] Elam JO, Brown ES, Ten Pas RH. Carbon dioxide homeostasis during anaesthesia. I. Instrumentation. Anesthesiology 1955;16:876 – 85. [11] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. II. Total sampling for determination of dead space, alveolar ventilation, and carbon dioxide output. Anesthesiology 1955;16:886 – 902. [12] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. III. Ventilation and carbon dioxide elimination. Anesthesiology 1956;17:116 –27. [13] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. IV. An evaluation of the partial rebreathing system. Anesthesiology 1956;17:128 –34. [14] Elam JO. Channeling and over packing in carbon dioxide absorbers. Anesthesiology 1958;19:403 –4. [15] Elam JO. The design of circle absorbers. Anesthesiology 1958;19:111 – 2. [16] Brown ES. Factors affecting the performance of absorbents. Anesthesiology 1959;20:198 –203. [17] Brown ES, Senniff AM, Elam JO. Carbon dioxide elimination in semiclosed systems. Anesthesiology 1964;25:31 – 6. [18] Elam JO, Brown ES, Janney CS. A fixed volume respirator for controlled ventilation during anaesthesia. Anesthesiology 1956;17:504 – 10. [19] Elam JO, Brown ES, Elder JD Jr. Artificial respiration by mouth-to-mask method. A study of the respiratory gas exchange of paralyzed patients ventilated by operator’s exhaled air. New Engl J Med 1954;250:749 – 54. [20] Elam JO, Greene DG, Brown ES, Clements JA. Oxygen and carbon dioxide exchange and energy costs of expired air resuscitation. J Am Med Assoc 1958;167:328 – 34. [21] Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. Airway obstruction during manual and mouth-to-mouth artificial respiration. J Am Med Assoc 1958;167:335 –41. [22] Gordon AS, Frye CW, Gittelson L, Sadove MS, Beattie EJ. Mouth-to-mouth versus manual artificial respiration for children and adults. J Am Med Assoc 1958;167:320 – 8. [23] Gordon AS, Sadove MS, Raymon F, Ivy AC. Critical survey of manual artificial respiration for children and adults. J Am Med Assoc 1951;147:1444 –53. [24] Comroe JH Jr, Dripps RB. Artificial respiration. J Am Med Assoc 1946;130:381 –3. [25] Nims RG, Conner EH, Botelho SY, Comroe JH Jr. Comparison of methods for performing manual artificial respiration on apneic patients. J Appl Physiol 1951;4:486 – 95. [26] Muir A, Clements JA. Studies in therapy of G-poisoning. Porton Technical Paper No. 273, 1953. [27] Clements JA, Elam JO, Johnson RP, Beaton RE. Respiratory effects of an anticholinesterase agent, DFP. Chemical Corps Medical Laboratories Special Report, 1954. [28] Elam JO, Clements JA, Brown ES, Elton NW. Artificial respiration for the G-agent casualty. Armed Forces Med J 1956;7:797 – 810. [29] Elam JO, Brown ES, Clements JA, Greene DG, Janney CD. Mask-to-mask studies in paralyzed human subjects. Chemical Warfare Laboratories Technical Report No. 2082, 1956, p. 43.
255
[30] Safar P, Elam J. Manual versus mouth-to-mouth methods of artificial respiration. Anesthesiology 1958;19:111 – 2. [31] Safar P, Escarraga LA, Elam JO. A comparison of the mouthto-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. New Engl J Med 1958;258:671 – 7. [32] Safar P. Failure of manual respiration. J Appl Physiol 1959;14:84 – 8. [33] Safar P, Aguto-Escarraga L, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959;14:760 – 4. [34] Morikawa S, Safar P, DeCarlo J. Influence of head – jaw position upon upper airway patency. Anesthesiology 1961;22:265 –70. [35] Safar P, Redding J. The ‘tight jaw’ in resuscitation. Anesthesiology 1959;20:701 – 2. [36] Ruben H. Combination resuscitator and aspirator. Anesthesiology 1958;19:408 – 9. [37] Elam JO, Ruben AM, Greene DG, Bittner TJ. Mouth-to-nose resuscitation during convulsive seizures. J Am Med Assoc 1961;176:565 – 9. [38] American Heart Association (AHA) and National Academy of Sciences-National Research Council (NAS-NRC). Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). J Am Med Assoc 1966;198:372 – 9 1974;277:S833 – 868. 1980;244:S453 – 478. 1986;255:S2841. [39] Safar P, Bircher NG. Cardiopulmonary-cerebral resuscitation. In: Laerdal A, Stavanger A, editors. An Introduction to Resuscitation Medicine. World Federation of Societies of Anaesthesiologists, 3rd ed. London: Saunders, 1988 1st ed. 1968; 2nd ed. 1981. [40] Elam JO, Greene DG, Schneider MA, Ruben HM, Gordon AS, Husted RF, Benson DW, Clements JA, Ruben AM. Head-tilt method of oral resuscitation. J Am Med Assoc 1960;172:812 –5. [41] Greene DC, Elam JO, Dobkin AL, Studley CL. Cinefluorographic study of hyperextension of the neck and upper airway patency. J Am Med Assoc 1961;176:570 – 3. [42] Ruben H, Elam JO, Ruben AM, Greene DG. Investigation of upper airway problems in resuscitation. Anesthesiology 1961;22:271 – 9. [43] Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc 1960;173:1064 – 7. [44] Safar P, Brown TC, Holtey WH, et al. Ventilation and circulation with closed chest cardiac massage in man. J Am Med Assoc 1961;176:574 – 6. [45] Safar P. Community-wide cardiopulmonary resuscitation, J Iowa Med Soc, 1964;629 – 635. [46] Safar P, Escarraga L, Elam JO, Greene D. Respiratory Resuscitation. Scientific exhibit produced by Army Institute of Pathology, AMA Convention, 1958. [47] Safar P, Elam JO, Jude JR, Wilder RJ, Zoll PM. Resuscitative principles for sudden cardiopulmonary collapse. Dis Chest 1963;43:34 – 49. [48] Elam JO, Greene DG. Mission accomplished: successful mouthto-mouth resuscitation. Anesth Analg 1961;40:440 – 2 also pp. 578 – 580; 672 – 676. [49] Cole WH, Birch LH, Elam JO, Gordon AS, Jude JR, Safar P, Scherlis L, Flynn RL, Vandam LD, Seeley SF. Ad hoc Committee on Cardiopulmonary Resuscitation: cardiopulmonary resuscitation. J Am Med Assoc 1966;198:372 – 9. [50] Tjomsland N. From Stavanger with care. In: Laerdals First 50 years. Stavanger, Norway: Laerdal Medical, 1991. [51] Smith A. American Society of Anesthesiologists Committee on Acute Medicine, Safar P (Chairman), Cheney FW Jr, Elam JO, Hamilton WK, Nagel L: Community-wide emergency medical services. J Am Med Assoc 1968;204:595 – 602. [52] Safar P, Elam J, editors. Advances in Cardiopulmonary Resuscitation. Proceedings of the Wolf Creek Conference of October 1975. New York: Springer-Verlag, 1977.
256
P. Safar / Resuscitation 50 (2001) 249–256
[53] Elam JO. Bag-valve mask O2 ventilation. Efficiency versus convenience; O2 versus valve lock. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:65 –71. [54] Elam JO. The intrapulmonary route for CPR drugs. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:132 –40. [55] Elam JO, Lim-Tan P, Shfieha M, Robert M. Airway management with oesophageal pharyngeal airway. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:132 –7. [56] Elam JO, ViaReque E, Rattenborg CC. Oesophageal electrocardiography and low energy ventricular defibrillation. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer –Verlag, 1977:167 –74 Chapter 26. [57] Weisman H, Weis TW, Elam JO, Bethune RM, Bauer RO. Use of double nasopharyngeal airways in anaesthesia. Anesth Analg 1969;48:356 – 61.
[58] Weisman H, Bauer RO, Huddy RA, Elam JO. An improved binasopharyngeal airway system for anaesthesia. Anesth Analg 1972;51:11 – 3. [59] Huffman JP, Elam JO. Prisms and fiber optics for laryngoscopy. Anesth Analg 1971;50:64 – 7. [60] Titel JH, Lowe HJ, Elam JO, Grasholz JR. Quantitative closedcircuit halothane anaesthesia. A clinical study on pressurized temperature-compensated vaporizer. Anesth Analg 1968;47:560 – 9. [61] Elam JO. Catheter subarachnoid block for labor and delivery: A differential segmental technique employing hyperbaric lidocaine. Anesth Analg 1970;49:1007 – 15. [62] Elam JO, Sterling R. Airway management I. M-A-S: a mouthmask-airway-sump system airway control. II. Elastomeric cuffs for long-dwelling endotracheal tubes. Crit Care Med 1981;9:425. [63] Elam JO. A volumetric system for monitoring minimal respiration in man. Anesth Analg 1975;54:232 – 7.
The Resuscitation Greats
James O. Elam MD, 1918–1995 Peter Safar * Safar Center for Resuscitation Research, Uni6ersity of Pittsburgh, 3434 Fifth A6enue, Pittsburgh, PA 15260, USA
James Otis Elam MD, was a pioneering anesthesiologist during the adolescence of this specialty in the 1950s [1 – 3]. He was a clinician and respiratory physiologist who made important original measurements on humans. Many colleagues remember him as an imaginative inventor and developer of devices that have helped those in anaesthesia. Health professionals and lay persons who are interested in first aid should remember Elam primarily for the fact that he was the first person to prove that exhaled air can be an adequate resuscitative gas [4]. I have a personal reason to thank him for having motivated me, through a chance encounter, not only to teach and practice, but also to research resuscitation, which became my lifelong pursuit [3,5]. I will remember him as a catalyst for research and development in resuscitation in the latter half of the 20th century, who influenced several colleagues. This laudatio of Elam as a ‘resuscitation great’ has input from Mark Lema, MD, Ph.D., present professor and chairman of Anesthesiology, University at Buffalo [2] and from Jim’s widow, Marjorie Elam, CRNA. Jim Elam was born on May 31, 1918 in Austin, TX. Sands and Bacon [1] remind us that he was born prematurely and needed external stimuli to start breathing. He had a creative and dynamic professional life and a family life that included five children with his first wife Elinor. In the 1990s, he suffered from a prolonged illness and died on July 10, 1995, in Valparaiso, Indiana, cared for by his wife Marjorie. Elam’s professional career took him from a bachelor of arts degree at the University of Texas in 1942, to an MD at the Johns Hopkins University School of Medicine in Baltimore in 1945, and via a rotating internship at the US Navy Hospital in Washington
* Tel: + 1-412-624-6735; fax: + 1-412-624-6736. E-mail address: [email protected] (P. Safar).
(Bethesda, MD) in 1945/1946, physiology training at the University of Minnesota in 1946/1947, internship and fellowship in surgery at Barnes Hospital of Washington University in St. Louis, Missouri, in 1947 –1949, to an anesthesiology residency at the Massachusetts General Hospital in Boston and the University of Iowa in 1949 –1951. In 1951 –1953, he served as a research assistant professor at the Barnes Hospital. From there he went to Buffalo, NY, where he became chief anesthesiologist (‘Chief Cancer Research Clinician’) of the Roswell Park Memorial Institute, now called Roswell Park Cancer Institute (and hospital), from 1953 to 1964 [2]. During his 11 years at Roswell Park, he rose to the rank of major in the US Army while finishing his Army obligations in 1954 –1956 at the Army Chemical Corps Medical Laboratories (Research and Engineering Command) at Edgewood, MD (near Baltimore). His earlier military obligation had been interrupted by his residency training. The combination of US Army-funded research from 1951 to 1970 (: $30,000 per year, present value over ten times this amount) and the opportunity to study anaesthetized patients at Roswell Park, created the environment for his contributions to anesthesiology and resuscitation in general, and to exhaled-air ventilation in particular. That research took place before the advent of institutional review boards, which now have to give approval for patient research. Before the 1970s, Elam and I and other resuscitation researchers studied patients and human volunteers by assuming personal responsibility and seeking approval only from our local peers. The decade in Buffalo came to an end when Elam became increasingly disappointed that the lack of medical students and anaesthesia residents at the Cancer Institute would prevent his innovations being disseminated and continued. Therefore, in 1964, he left Buffalo to become professor and chairman of the Department of Anesthesiology at the University of Missouri at the
0300-9572/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 0 - 9 5 7 2 ( 0 1 ) 0 0 4 1 3 - 0
250
P. Safar / Resuscitation 50 (2001) 249–256
Kansas City General Hospital. He again experienced disappointments and, in 1966, went on to become a professor of anesthesiology at the University of Chicago, working mainly in obstetric anaesthesia, from 1966 until his retirement in the mid-1980s. Retirement gave him the freedom to innovate and further develop his devices privately. The frequent change in locations reflects the restlessness of a creative individual.
1. Respiratory physiology and anesthesiology Before his anesthesiology residency, while in Minnesota under the influence of physiologist Maurice Visscher, he used one of the first oximeters, an ear oximeter [6]. Designed by Glen Millikan, this device was then used by the US Air Force. He also used the ListonBecker (Model 16) infrared CO2 analyzer for research [7,8]. Elam was probably the first to use it in anaesthesia and resuscitation research. Excited by research in general, Elam continued some studies part-time during his residency in anesthesiology. Present-day anesthesiology board requirements preclude such a mixed experience of patient care, clinical research and laboratory research, although for workaholic, pioneering, young anesthesiology trainees like Elam, that experience was not uncommon in the 1940s– 1960s. Moreover, it was not unusual at that time to seek out colleagues of other specialties who had something new to offer. After his residency, when at Barnes Hospital, he was committed, under US Army funding, to study humans. The chairman of Surgery (anesthesiology was a division of the Department of Surgery) first accepted human studies, but later demanded that they be replaced by work on animals. Since this would be unrealistic and would have jeopardized his Army contract, Elam and collaborators Elwyn Brown, John Elder and Raymond Ten Pas, went to Roswell Park [2]. There, anesthesiology received departmental status. Elam’s team established a school for nurse anesthetists, which enabled him to continue focusing on his experiments in respiratory physiology. Physicians directed all of the anaesthesias administered by the nurses. His group then explored, for the Army, new valves designs, a flashlight laryngoscope and, most important, exhaled-air ventilation devices for nerve-gas-poisoned casualties (see later). They also acquired some patents. During his Army duty at Edgewood, he re-visited Roswell Park every week or two to study the data his associates had produced there. An effective synergy developed between Elam, who ‘dreamed and schemed’ and Brown, the practical engineer [2]. Elam himself was ahead of others in drawing attention to the elimination and monitoring of carbon dioxide [9]. Using the infrared CO2 analyzer, he described the ‘alveolar plateau’. Soon after his anesthesiology
training, based on closed-circle anaesthesia systems introduced by Sword, Waters, Adriani and others, Elam questioned the efficacy of the CO2 absorbers in use at the time. He designed a better system for CO2 absorption in anaesthesia circuits [10–17]. Elam and Brown greatly improved the CO2 absorber by making it larger, packing the granules better, using baffles, doubling the canisters and determining that the absorbers’ interstitial space should at least equal tidal volume [16]. His successors at Roswell Park wrote [2]: ‘‘Every anaesthesia machine over the last 30 years has used a carbon dioxide absorbence system essentially designed by these two physicians.’’ Elam and his collaborators also constructed a human respiration simulator, for various long-term ventilation experiments. That lung model was further developed into the Roswell Park ventilator, a bellows-in-box ventilator, powered by intermittent compression of the bellows by gas pressure in the box. This machine became the Air Shields Venti-meter Ventilator, which was in use throughout the 1950s, 1960s and 1970s [18]. They first used a windshield-wiper type power source obtained from the TRICO plant adjacent to the Cancer Institute. The ventilator could function by pressure or volume-cycling, with intermittent positive or positive– negative pressure patterns. The novel idea was that this bellows-in-box device was also useful for spontaneous breathing. The anesthetist, when squeezing the bag connected to the box, could monitor and control tidal volumes by watching excursions of the bellows connected to the anaesthesia circuit.
2. Exhaled-air ventilation Before Elam became an anesthesiologist, his interest in respiratory resuscitation was aroused by having been given responsibility for the care of paralyzed polio patients in 1946 in Minneapolis [4]. While assigned to the polio floor, when he temporarily ran out of tank respirators (the Iron Lung), Elam instinctively performed mouth-to-mouth or mouth-to-nose ventilation, sometimes for hours, he said. During his residency in Iowa City, under the direction of Stuart Cullen, when moving patients from induction areas to operating rooms, he again instinctively used mouth-to-tracheal tube ventilation, as I and other anesthesiologists had done quite routinely. Around 1952, when Elam was assistant professor of anesthesiology at Barnes Hospital, he found in the literature descriptions of over 100 manual (push–pull) methods of artificial respiration, but only brief mention of the mouth-to-mouth method for use in the newborn. He noted that no one had investigated the physiology of exhaled-air ventilation [4]. He and Brown embarked on studies of patients experiencing residual muscle
P. Safar / Resuscitation 50 (2001) 249–256
paralysis in the post-anaesthesia recovery room, under renewed succinylcholine paralysis. Elam demonstrated that mouth-to-mask or mouth-to-tracheal tube ventilation could maintain normal arterial blood-gas values, as recorded by the CO2 analyzer and tedious blood-gas analyses by the VanSlyke system. These first data on exhaled-air ventilation were published as a landmark paper in the ‘New England Journal of Medicine’ soon after his arrival in Buffalo [19] (Fig. 1). Elam documented that it requires ‘‘doubling the tidal volumes, because you are breathing for two’’. After Elam and I had met (in 1956), he published these blood-gas data in greater detail, in the ‘JAMA’ of 1958 [20], simultaneously with my data on airway control and the controlled comparison of direct mouth-tomouth with manual methods [21] and the data by Gordon on mouth-to-mouth versus manual methods in children [22]. Between 1953 and 1956, Elam’s breakthrough data [19] seemed to have been dormant, with no one in anesthesiology or first-aid circles paying much attention to them. Gordon [23] had earlier found in curarized adult human volunteers, that the prone back-pressure
Fig. 1. James Elam in the 1960s.
251
arm-lift (Holger–Nielsen) method moved more air than the then widely taught prone back-pressure-only method (Schafer)— both techniques were studied with a tracheal tube. The views of my mentors of 1950, Comroe and Dripps [24] and similar data obtained using tracheal tubes by Nims et al. [25] in Dripps’ department, also questioned the efficacy of the Schafer method. Only the US Army took Elam’s work seriously. When Elam worked for the Army Chemical Corps, he found the chest- or back-pressure methods too weak to ventilate nerve-gas-poisoned animals. These animals developed bronchoconstriction, massive bronchial secretions, bradycardia and paralysis. At Edgewood, Elam worked side-by-side with John Clements, a brilliant civilian researcher at the Army Chemical Center (who pioneered pulmonary surfactant). Elam and Clements developed prototypes of valved mask-to-mask devices for intended resuscitation of nerve-gas-poisoned humans [27–29]. A gas filter could be put on the air intake for the rescuer. Clements recently recalled: ‘‘Adam Muir and I [26] found that the Holger– Nielsen method did not move any air in rhesus monkeys (with nerve-gas poisoning), and I designed a flow-valved, non-rebreathing mask-to-mask device that was effective enough to overcome severe bronchoconstriction and led to long-term survival [26].’’ The research and development of modern emergency resuscitation exploded after Elam and I met, by coincidence, in 1956. I described this event roughly as follows [3,5]: The spark that started my lifelong commitment to resuscitation research, including interest in pre-hospital first aid, was a chance contact with James Elam. It happened at the American Society of Anesthesiologists (ASA) meeting in October 1956 in Kansas City. For the previous 100 years, various chest-pressure arm-lift methods had been used; since the early 1950s, the back-pressure arm-lift method was favored, because of data obtained by Archer Gordon (then in Chicago) who used intubated curarized human volunteers [23]. Until that ASA meeting of 1956, I had not been aware of the 1954 publication by Elam [19] that documented normal blood-gas values in apnoeic patients during IPPV with mouth-to-mask or mouth-to-tracheal tube ventilation. On October 12, 1956, Eva (Safar) and I had supper with James Elam. This was the first time I talked with him. Elam asked to hitch a ride back to Baltimore with us. During that ride on October 13 and 14, 1956 from Kansas City via Chicago to Baltimore, I was inspired by his first published proof that exhaled air is an adequate resuscitative gas [19], and by his imaginative personality. Elam revealed to me that his results were not widely known. He gave me the impression during that trip that neither he nor others had challenged the current doctrine, and that first-aid agencies continued to adhere to teaching the back-pressure arm-lift method.
252
P. Safar / Resuscitation 50 (2001) 249–256
Elam recalled later [4] that he did try to persuade Army physiologist Bruce Dill (research director at Edgewood), Army generals, and the Red Cross ‘‘to recognize the method of Elisha. I even told them that Elam was a biblical name and that I (Elam) might be a prophet disguised as a major.’’ I do not know whether this happened before or after we met. Dill, who recognized that the Schafer method would be ineffective for nerve-gas casualties, created the US Army contract for Elam on artificial respiration. Dill promoted the first Army conferences of investigators for artificial respiration and originated the first National Academy of Sciences (NAS) conferences on this subject. Dill, Elam and Dripps probably recommended funding of my first research proposal to the Army in 1956. I further recalled [3] that when Elam, in October 1956, told me about his results [19], it occurred to me that anesthesiologists’ know-how in handling upper-airway obstruction had not penetrated beyond the operating room. On that fateful car trip, I proposed that we conduct the following needed studies and documentations: (1) A study of upper-airway soft-tissue obstruction on curarized adults. (Elam had used a mask, a pharyngeal tube and a tracheal tube in his landmark study [19], but had not explored backward tilt of the head, which I considered crucial.) (2) A controlled study in which ventilation volumes and oxygenation produced by the ‘push –pull methods’ would be compared with those produced by direct mouth-to-mouth inflations, using both methods on the same apnoeic adult curarized volunteers and on patients, without the use of a tracheal tube, pharyngeal tube, or mask, with each subject serving as his own control and mouth-tomouth ventilation performed by lay persons. Elam agreed that this should be done. I suggested that we do it together at the Baltimore City Hospital where I was chief anesthesiologist. He attended the first two or three experiments in December 1956 [30,31] and then moved to Buffalo and continued on his own. Elam and I maintained some communication thereafter until his death. When Elam left the Army to return to Roswell Park, Brown took his research position in the Army. I thank Jim also for having brought me in touch with John Clements, who gave valuable advice for our human volunteer experiments [31]; John the pianist and his wife Margot, a superb professional singer, made classical music with the Safars and other medical amateur musicians in Baltimore. Our preliminary [30] and definitive data [31] from the human volunteer experiments in 1957 and my first documentation of the failure of manual methods of artificial ventilation [32]; the mechanisms of upper-airway soft-tissue obstruction in coma and need for backward tilt of the head, jaw thrust, and open mouth [21,33 –35]; and the efficacy and techniques of exhaledair ventilation without adjuncts [20– 22], were received as a bombshell in the US and Europe.
On March 8, 1957, the NAS held a meeting in Washington DC, chaired by Julius Comroe, concerning artificial respiration for children. Elam and I presented the data of our first experiments on adult volunteers. Mouth-to-mouth ventilation was recommended for children but not yet for adults. At that meeting, Archer Gordon learned about our preliminary results on adults [30] and gathered similar data on anaesthetized children and adults [22]. On May 10, 1957, Dill gathered Army researchers in Denver; Elam’s and my data were hot topics. On November 3, 1958, after our definitive data had been published [20–22], the NAS held its second meeting on artificial respiration, chaired by visionary surgeon Sam Seeley. Backward tilt of the head with direct mouth-to-mouth ventilation was decided upon as the preferred method of artificial respiration. The recommendation applied to adults as well as children. Within 1 year, medical associations, the Armed Forces and the American and International Red Cross organizations changed from the manual methods to the exhaled-air methods of artificial ventilation. In 1960, Elam was honored by the US Army Chemical Center with an Award of Achievement and by the New York Medical Society with its highest honor, the Albion O. Bernstein Award of Distinction for Contributions to Medicine. He was honored by the American Heart Association as one of the pioneers of CPR. As was to be expected, there were controversies. Elam had recommended mouth-to-mask ventilation and had produced a green plastic pocket mask. To my knowledge, this never came to market. I introduced blowing through an S-shaped Guedel-type oro-pharyngeal tube. We agreed that use of devices should be restricted to health care professionals. After Elam had returned from Baltimore to Buffalo, he enticed Henning Ruben of Denmark into collaborating with him. Ruben had earlier introduced the self-refilling bagvalve-mask unit, a breakthrough in resuscitation devices [36]. Gordon and I recommended to try blowing into the mouth first [21,22] because of frequent nasal obstruction [33– 35], while Elam and Ruben recommended to blow into the nose first [37]. ‘Mouth first and nose second’ became the national [38] and international guidelines [39]. Elam popularized exhaled-air ventilation in the state of New York and beyond by writing manuals and making teaching films. After the first volunteer experiments at Baltimore City Hospital, Elam produced a film that included a medical student paralyzed with succinylcholine on whom he demonstrated the various ventilation methods, accompanied by ear oximetry. Elam was also sought after in the early years as a lecturer because of his message and impressive speaking style. Airway control became step A of CPR. Ruben and Elam [40–42] confirmed my head-tilt data [21,33–35]. Elam tried to minimize gastric insufflation and regurgi-
P. Safar / Resuscitation 50 (2001) 249–256
tation by blowing into the narrower nasal passage, which reduced pharyngeal pressure [37]. I found gastric distension to be self-limiting [21] and documented expiratory nasal obstruction as a greater obstacle [33–35]. Exhaled-air ventilation [20– 22] became step B of CPR. I combined steps A and B with step C, external cardiac massage, re-discovered by Kouwenhoven et al. [43], into basic life support (BLS) [44,45] and added advanced and prolonged life support for the cardiopulmonary-cerebral resuscitation (CPCR) system [39,45]. Elam continued to promote exhaled-air ventilation together with me [46,47] and reported on actual cases of successful resuscitation [48]. He became co-initiator (with Gordon, Jude and Safar) of the first American Heart Association CPR-Emergency Cardiac Care Committee [49]. Elam joined me in advising Laerdal in the creation of the Resusci-Anne manikin [50]. He also advised the Ambu Company of Denmark concerning resuscitation devices. Elam served on the first American Society of Anesthesiologists acute medicine committee that I had initiated [51]. Later, Elam co-initiated, with Jude and me, the first Wolf Creek Conference of CPR Researchers [52]. At that conference in 1975, Elam contributed imaginative ideas on bag-valve-mask O2 ventilation [53], intrapulmonary administration of CPR drugs [54], the esophageal– pharyngeal airway [55], esophageal electrocardiography [56] and esophageal defibrillation [56].
3. Chicago and semi-retirement With rescue breathing as the climax of his professional career, one can consider Jim Elam’s years at the University of Chicago (from 1966 to 1980), a professorship at the University of Texas Southwestern Medical School in Dallas (in 1981– 1983) and his semi-retirement in Valparaiso, Indiana (from the mid-1980s to the 1990s) as a continuum (Fig. 2). Starting in the 1970s, he had turned his attention to new airway-control devices. His conception, design and promotion of devices spanned many years. Most of the recently invented devices have so far not become commercially available. One reason was the bureaucratic demands and delays posed by institutional review boards against human trials, which since the 1980s have been essential to bring devices to fruition. Another reason for some of his inventions having remained dormant may have been a lack of publications. Since the 1960s he had tried the use of soft rubber nasopharyngeal tubes in both nasal passages as an alternative to tracheal intubation [57,58]. Reportedly, more than 1000 patients at the Lying-In Hospital in Chicago received this airway in operating rooms between 1966 and 1970. Connecting one nasopharyngeal tube directly to an anaesthesia or resuscitation system
253
Fig. 2. James Elam in the 1980s.
was not new. Reducing airway resistance by doubling the tube was new. The nasopharyngeal tube connected directly to the anaesthesia circuit did not become a widely accepted method for prolonged general anesthesias, since anesthesiologists and nurse anesthetists felt that patients were safer with a cuffed endotracheal tube. When in Chicago, Elam also made contributions to anaesthesia method [59–61]. He promoted sound principles when he sought new approaches and devices: (1) As alternative to tracheal intubation, he developed a pharyngeal airway with a pharynx-occluding balloon [62], which actually became a forerunner for the laryngeal mask airway (LMA) designed and published by Brain. (2) He designed a double-barreled plastic tube to be inserted into the mouth without a laryngoscope, with one barrel as a conduit for a tracheal tube and the other for a nasogastric tube. The idea was that people without medical knowledge could safely intubate blindly and decompress the stomach at the same time. This was a forerunner of the ‘Combitube’. (3) He wanted to develop a non-distensible manual bellows ventilator for use in nerve-gas-poisoned stiff lungs, as he initiated it in the 1950s with the Army. (4) His further work with the Air-Shields ventilator focused on an assist/control mechanism that would allow patients to regulate their own spontaneous breathing volume and rate [63].
254
P. Safar / Resuscitation 50 (2001) 249–256
Elam’s US patents and developments between 1952 and 1983 included CO2 absorbers, ventilators, valves, masks, airways, sensors, a tracheal tube double-cuff, and a cuff monitor. Between 1947 and 1984, he published about 120 works, including peer-reviewed papers, reports, books and abstracts. During Elam’s retirement, we honored him as visiting professor at the opening of the International Resuscitation Research Center facility at the University of Pittsburgh in 1980. After that, we met occasionally at resuscitation conferences sponsored by the American Heart Association. In January 1994, I invited Jim to the May 1994 International Conference of Resuscitation Researchers in Pittsburgh. Elam had to decline because of health reasons: ‘‘too many diagnoses including cardiac myopathy and diabetes … When you asked me why I was still working on gadgets, the answer is that in retirement, with no access to patients, developing better equipment was about all I could do. For example, regurgitation during resuscitation … we should be concerned about it … if I could attend your symposium, I would report on my recent project which utilizes (combines) a conventional endotracheal tube, an Ewald (esophago-gastric) tube, and the method of rapidly establishing (inserting) both before aspiration occurs. I have arranged for clinical testing of the method by others. I shall send you the results when the project is done.’’ Sadly there was no follow-up because, according to his wife Marjorie, he became increasingly ill. At Roswell Park, he had a godfather for his research and development in surgeon and Institute Director George Moore [2]. Thereafter, he lacked such support. In the early 1990s, feeling that time was running out, Jim re-visited Roswell Park in attempts to obtain patients for trials of his novel devices. I believe that airway and ventilation methods and devices would have been further improved had Elam succeeded during the 1970s and 1980s in translating his ideas into prototypes, testing in patients, publishing results and bringing some of the devices to the open market. Helping inventors like Elam should be among the important roles of academic medical centers. Industry and academia may have (incorrectly) perceived him more as a gadgeteer than as a visionary, which I believe he was. Jim’s wife, Marjorie Elam of Valparaiso, Indiana, wrote to me after his death: ‘‘Jim died around 10:00 pm on July 10 (1995). He had suffered what seemed to be a small stroke, in addition to kidney failure, chest pain, and diabetes. … He died very peacefully. Life had become a struggle. His son Michael lives in Los Angeles, son Peter in Minnesota, son David in San Francisco, daughter Joann in Chicago, and daughter Susan in Boston.’’
4. Conclusion James Elam started as a patient-focused respiratory physiologist and became a visionary inventor of devices that improved the safety of general anaesthesia and contributed to more effective resuscitation methods. He has been called charismatic, determined, innovative and ingenious [2]. His most important contribution was to the noble endeavour of emergency respiratory resuscitation: the documentation that exhaled air can be adequate for artificial ventilation. This sparked the development by others of modern external CPR and beyond. Elam’s influence on me and on others, and our subsequent influences on resuscitation researchers who followed, with cross-fertilization between them, which will continue for decades to come, reminds us that each one of us represents one or more links in the chains of human evolution. Elam was a strong link from which modern CPR, cerebral resuscitation (CPCR), trauma resuscitation, emergency medical services and critical care medicine developed during the latter half of the 20th century. Jim Elam helped put the Roswell Cancer Institute in Buffalo on the map [2]. His legacy has been summarized in several documents on the history of modern resuscitation. I would like to conclude this laudatio by quoting Sands and Bacon [1]: ‘‘James Elam, from his early work on CO2 homeostasis, leading to the first human capnograhic tracing, leading to the modifications of the soda lime canister, to his recent work on an airway that laymen can use to intubate victims of cardiac arrest outside the hospital, Elam has always strived to improve the quality of life of his fellow humans. Battling through hardships of his own … including debilitating osteoarthritis necessitating multiple hip replacements and ultimately confinement to a wheelchair, Elam persevered.’’ References [1] Sands RP, Bacon DR. An inventive mind. The career of James O. Elam, M.D. (1918 – 1995). Anesthesiology 1998;88:1107 –12. [2] Peppriell JE, Bacon DR, Lema MJ, Ament R, Yearley CK. The development of academic anesthesiology at the Roswell Park Memorial Institute: James O. Elam, MD, and Elwyn S. Brown, MD. Anesth Analg 1991;72:538 – 45. [3] Safar P. From Vienna to Pittsburgh for anesthesiology and acute medicine. Careers in Anesthesiology. Autobiographical Memoirs. Vol. V, American Society of Anesthesiologists, Wood Library-Museum, 2000. (Wood Library Museum, 515 Busse Highway, Park Ridge, IL 60068). [4] Elam JO. Rediscovery of expired air methods for emergency ventilation. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:263 – 5 Chapter 39. [5] Safar P. From back-pressure arm-lift to mouth-to-mouth, control of airway and beyond. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:266 – 75 Chapter 40.
P. Safar / Resuscitation 50 (2001) 249–256 [6] Sleator W Jr, Elam JO, Elam WN Jr, White HL. Oximetric determinations of cardiac output responses to light exercise. J Appl Physiol 1951;3:649 –64. [7] Luft K. Methode der Registrieren gas Analyse mit Hilfe der Absorption ultraroten Strahlen ohne spectrale Zerlegung. Z Tech Phys 1943;244:97. [8] White JU, Liston MD. Performance of double beam recording infrared spectrophotometer. J Soc Am 1950;40:93 –101. [9] Brown EB, Miller F. Ventricular fibrillation following a rapid fall in alveolar carbon dioxide concentration. Am J Phys 1952;169:56 – 60. [10] Elam JO, Brown ES, Ten Pas RH. Carbon dioxide homeostasis during anaesthesia. I. Instrumentation. Anesthesiology 1955;16:876 – 85. [11] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. II. Total sampling for determination of dead space, alveolar ventilation, and carbon dioxide output. Anesthesiology 1955;16:886 – 902. [12] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. III. Ventilation and carbon dioxide elimination. Anesthesiology 1956;17:116 –27. [13] Elam JO, Brown ES. Carbon dioxide homeostasis during anaesthesia. IV. An evaluation of the partial rebreathing system. Anesthesiology 1956;17:128 –34. [14] Elam JO. Channeling and over packing in carbon dioxide absorbers. Anesthesiology 1958;19:403 –4. [15] Elam JO. The design of circle absorbers. Anesthesiology 1958;19:111 – 2. [16] Brown ES. Factors affecting the performance of absorbents. Anesthesiology 1959;20:198 –203. [17] Brown ES, Senniff AM, Elam JO. Carbon dioxide elimination in semiclosed systems. Anesthesiology 1964;25:31 – 6. [18] Elam JO, Brown ES, Janney CS. A fixed volume respirator for controlled ventilation during anaesthesia. Anesthesiology 1956;17:504 – 10. [19] Elam JO, Brown ES, Elder JD Jr. Artificial respiration by mouth-to-mask method. A study of the respiratory gas exchange of paralyzed patients ventilated by operator’s exhaled air. New Engl J Med 1954;250:749 – 54. [20] Elam JO, Greene DG, Brown ES, Clements JA. Oxygen and carbon dioxide exchange and energy costs of expired air resuscitation. J Am Med Assoc 1958;167:328 – 34. [21] Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. Airway obstruction during manual and mouth-to-mouth artificial respiration. J Am Med Assoc 1958;167:335 –41. [22] Gordon AS, Frye CW, Gittelson L, Sadove MS, Beattie EJ. Mouth-to-mouth versus manual artificial respiration for children and adults. J Am Med Assoc 1958;167:320 – 8. [23] Gordon AS, Sadove MS, Raymon F, Ivy AC. Critical survey of manual artificial respiration for children and adults. J Am Med Assoc 1951;147:1444 –53. [24] Comroe JH Jr, Dripps RB. Artificial respiration. J Am Med Assoc 1946;130:381 –3. [25] Nims RG, Conner EH, Botelho SY, Comroe JH Jr. Comparison of methods for performing manual artificial respiration on apneic patients. J Appl Physiol 1951;4:486 – 95. [26] Muir A, Clements JA. Studies in therapy of G-poisoning. Porton Technical Paper No. 273, 1953. [27] Clements JA, Elam JO, Johnson RP, Beaton RE. Respiratory effects of an anticholinesterase agent, DFP. Chemical Corps Medical Laboratories Special Report, 1954. [28] Elam JO, Clements JA, Brown ES, Elton NW. Artificial respiration for the G-agent casualty. Armed Forces Med J 1956;7:797 – 810. [29] Elam JO, Brown ES, Clements JA, Greene DG, Janney CD. Mask-to-mask studies in paralyzed human subjects. Chemical Warfare Laboratories Technical Report No. 2082, 1956, p. 43.
255
[30] Safar P, Elam J. Manual versus mouth-to-mouth methods of artificial respiration. Anesthesiology 1958;19:111 – 2. [31] Safar P, Escarraga LA, Elam JO. A comparison of the mouthto-mouth and mouth-to-airway methods of artificial respiration with the chest-pressure arm-lift methods. New Engl J Med 1958;258:671 – 7. [32] Safar P. Failure of manual respiration. J Appl Physiol 1959;14:84 – 8. [33] Safar P, Aguto-Escarraga L, Chang F. Upper airway obstruction in the unconscious patient. J Appl Physiol 1959;14:760 – 4. [34] Morikawa S, Safar P, DeCarlo J. Influence of head – jaw position upon upper airway patency. Anesthesiology 1961;22:265 –70. [35] Safar P, Redding J. The ‘tight jaw’ in resuscitation. Anesthesiology 1959;20:701 – 2. [36] Ruben H. Combination resuscitator and aspirator. Anesthesiology 1958;19:408 – 9. [37] Elam JO, Ruben AM, Greene DG, Bittner TJ. Mouth-to-nose resuscitation during convulsive seizures. J Am Med Assoc 1961;176:565 – 9. [38] American Heart Association (AHA) and National Academy of Sciences-National Research Council (NAS-NRC). Standards for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC). J Am Med Assoc 1966;198:372 – 9 1974;277:S833 – 868. 1980;244:S453 – 478. 1986;255:S2841. [39] Safar P, Bircher NG. Cardiopulmonary-cerebral resuscitation. In: Laerdal A, Stavanger A, editors. An Introduction to Resuscitation Medicine. World Federation of Societies of Anaesthesiologists, 3rd ed. London: Saunders, 1988 1st ed. 1968; 2nd ed. 1981. [40] Elam JO, Greene DG, Schneider MA, Ruben HM, Gordon AS, Husted RF, Benson DW, Clements JA, Ruben AM. Head-tilt method of oral resuscitation. J Am Med Assoc 1960;172:812 –5. [41] Greene DC, Elam JO, Dobkin AL, Studley CL. Cinefluorographic study of hyperextension of the neck and upper airway patency. J Am Med Assoc 1961;176:570 – 3. [42] Ruben H, Elam JO, Ruben AM, Greene DG. Investigation of upper airway problems in resuscitation. Anesthesiology 1961;22:271 – 9. [43] Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. J Am Med Assoc 1960;173:1064 – 7. [44] Safar P, Brown TC, Holtey WH, et al. Ventilation and circulation with closed chest cardiac massage in man. J Am Med Assoc 1961;176:574 – 6. [45] Safar P. Community-wide cardiopulmonary resuscitation, J Iowa Med Soc, 1964;629 – 635. [46] Safar P, Escarraga L, Elam JO, Greene D. Respiratory Resuscitation. Scientific exhibit produced by Army Institute of Pathology, AMA Convention, 1958. [47] Safar P, Elam JO, Jude JR, Wilder RJ, Zoll PM. Resuscitative principles for sudden cardiopulmonary collapse. Dis Chest 1963;43:34 – 49. [48] Elam JO, Greene DG. Mission accomplished: successful mouthto-mouth resuscitation. Anesth Analg 1961;40:440 – 2 also pp. 578 – 580; 672 – 676. [49] Cole WH, Birch LH, Elam JO, Gordon AS, Jude JR, Safar P, Scherlis L, Flynn RL, Vandam LD, Seeley SF. Ad hoc Committee on Cardiopulmonary Resuscitation: cardiopulmonary resuscitation. J Am Med Assoc 1966;198:372 – 9. [50] Tjomsland N. From Stavanger with care. In: Laerdals First 50 years. Stavanger, Norway: Laerdal Medical, 1991. [51] Smith A. American Society of Anesthesiologists Committee on Acute Medicine, Safar P (Chairman), Cheney FW Jr, Elam JO, Hamilton WK, Nagel L: Community-wide emergency medical services. J Am Med Assoc 1968;204:595 – 602. [52] Safar P, Elam J, editors. Advances in Cardiopulmonary Resuscitation. Proceedings of the Wolf Creek Conference of October 1975. New York: Springer-Verlag, 1977.
256
P. Safar / Resuscitation 50 (2001) 249–256
[53] Elam JO. Bag-valve mask O2 ventilation. Efficiency versus convenience; O2 versus valve lock. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:65 –71. [54] Elam JO. The intrapulmonary route for CPR drugs. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:132 –40. [55] Elam JO, Lim-Tan P, Shfieha M, Robert M. Airway management with oesophageal pharyngeal airway. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer-Verlag, 1977:132 –7. [56] Elam JO, ViaReque E, Rattenborg CC. Oesophageal electrocardiography and low energy ventricular defibrillation. In: Safar P, Elam JO, editors. Advances in Cardiopulmonary Resuscitation. New York: Springer –Verlag, 1977:167 –74 Chapter 26. [57] Weisman H, Weis TW, Elam JO, Bethune RM, Bauer RO. Use of double nasopharyngeal airways in anaesthesia. Anesth Analg 1969;48:356 – 61.
[58] Weisman H, Bauer RO, Huddy RA, Elam JO. An improved binasopharyngeal airway system for anaesthesia. Anesth Analg 1972;51:11 – 3. [59] Huffman JP, Elam JO. Prisms and fiber optics for laryngoscopy. Anesth Analg 1971;50:64 – 7. [60] Titel JH, Lowe HJ, Elam JO, Grasholz JR. Quantitative closedcircuit halothane anaesthesia. A clinical study on pressurized temperature-compensated vaporizer. Anesth Analg 1968;47:560 – 9. [61] Elam JO. Catheter subarachnoid block for labor and delivery: A differential segmental technique employing hyperbaric lidocaine. Anesth Analg 1970;49:1007 – 15. [62] Elam JO, Sterling R. Airway management I. M-A-S: a mouthmask-airway-sump system airway control. II. Elastomeric cuffs for long-dwelling endotracheal tubes. Crit Care Med 1981;9:425. [63] Elam JO. A volumetric system for monitoring minimal respiration in man. Anesth Analg 1975;54:232 – 7.