By MIKE MAGEE
The leaders of America’s scientific community seem genuinely surprised by the actions of the past three weeks. They expected to be spared the wrath of Trump because they believed that “Americans of all political persuasions have respect for science and celebrate its breakthroughs.”
Maybe so. But that is an inadequate defense against a multi-pronged attack which includes purposefully selecting unqualified hostiles to key management positions; restricting scientists travel and communications; censuring scientific discourse; and clawing back promised funding for research projects already underway. This “knee-capping” has extended beyond our geographic boundaries with Trump’s vengeful withdrawal from the WHO and the Musk inspired elimination of USAID.
“This too will pass,” whisper Republicans behind closed doors. But even so, the nature of scientific discovery and implementation is a complex rebuild. This is because the path from innovation to invention to implementation is interdisciplinary and requires collaborative interfaces and multi-year problem solving. Not the least of the challenges is gaining access, trust, and cooperation from the general public which requires funding, public education, and community planning.
Take for example a life saving device that is increasingly ubiquitous–found everywhere these days from rural high school cafeterias to the International Space Station and everywhere in between-– the Automated External Defibrillator or AED.
It is estimated that AED’s have the potential to save 1,700 American lives a year. Experts estimate that over 18,000 Americans have a life threatening cardiac arrest outside of a hospital with a shockable rhythm disturbance each year. But 90% don’t survive because access to an AED is delayed or not available. Without a correction in about ten minutes, you are likely to die. This means that the 6 pound AED has be where the patient is, the bystander has to know what to do with it, and there can be no delay.
Creating the modern day AED was a century long affair according to the “Institute of Electrical and Electronics Engineers” or IEEE .
That organization traces its own roots back to 1884 when electricity first sparked the imagination of our nation’s inventors. As they state, the IEEE has “long been composed of engineers, scientists, and allied professionals. These include computer scientists, software developers, information technology professionals, physicists, medical doctors, and many others.”
Mark Kroll, is an electrical engineer and member of IEEE. He enjoys sharing his role and those of physicians and a range of science specialists in the AED creation story. His starting point is to remind listeners that in order for the AED to reach its potential, it had to be “idiot-proofed.”
Without hesitation he labels the AED as “one of the greatest engineering success stories of the last few decades.” His reasoning is threefold:
- “Efficacy of the waveform that delivers the electric shock.”
- “The innovative way that the unit’s energy is stored and delivered.”
- “The AED’s overall ease of use.”
In the early 1900’s, Thomas Edison’s company, General Electric, was more than aware of the lethality of electric shock (electrocution). The switch from direct-current to alternating current transmission was accompanied by a disturbing increase in accidental electrocution deaths of their linemen. They turned to university experts (at institutions like Johns Hopkins) to get to the bottom of it. While experimenting with dogs, they noticed that a second shock sometimes brought the electrocuted dogs back to life.
In 1921, a Hopkins medical student, Claude Beck, took notice. Beck went on to train in surgery at Yale and Harvard under Harvey Cushing, and in 1926 accepted a position as the first Research Fellow in Surgery at Case Western Reserve University in Cleveland, Ohio. Beck would eventually transition from General Surgery to Neurosurgery and then to Cardiac Surgery, but always wandered back to the lab to support his primary interest, applied research. In the 1930’s he began to pick up where the Hopkins researchers had laid off, doing a series of animal experiments, applying AC current directly to laboratory animals’ exposed hearts and measuring the effects.
He created the first rudimentary defibrillator in the process consisting of “a transformer to isolate the animal from the 110-volt ac wall supply, a variable resistor to limit the current to a heart-safe value, and two metal tablespoons with wooden handles to deliver the jolt to the exposed heart.” A decade later, while operating on a 14-year-old’s heart, the child’s heart began to beat wildly and stopped. In an act of desperation, he rushed his machine from his lab to the OR and shocked the boy’s heart. When the first shock didn’t work, he repeated it and successfully brought him back to life.
By 1965, local Heart Associations had begun training citizens in closed chest massage for heart attack victims, and the first “portable” defibrillators were utilized with limited success. Much of the reason why was their lack of portability (they weighed 70 kg or 154 pounds) and required two operators – one to apply the clothes iron size paddles, and the other to conduct and interpret an electrocardiogram to assure the victim actually had an arrhythmia, and hadn’t simply fainted or suffered a seizure.
Still, a few were saved, enough to encourage the physicists and engineers to innovate refinements that would make the invention capable of mass introduction. These included;
- In 1980, biomedical engineers replaced the bulky paddles with flexible adhesive patches lined with a metal chloride gel.
- The patches reduced skin contact resistance from 150 ohms to 75 ohms, which allowed for a lower voltage shock. This meant that the defibrillators could be built with higher-density electrolytic capacitors and miniaturized semiconductor switches lowering the weight to 20mg or 44 pounds.
- The patches also simultaneously delivered an ECG allowing the machine to be operated by just one individual.
Over the next two decades, further advances in understanding the generation of a functional modern biphasic wave form, creation of software to automatically detect the target arrhythmia and time the delivery of the shock to the exact 100 millisecond moment when it would be most effective, and the creation of algorithms to get around a range of complicators (for example, what if the victim has a pacemaker) occurred.
Nowadays the AED is portable, increasingly accessible and affordable. The HeartStart model by Philips is available on Amazon Prime for $1,723.63. It weighs only 6 pounds with dimensions about the size of a lunchbox (10.5 x 9.5 x 5.75 inches). So as not to confuse consumer operators under stress, there is only one button – and it delivers the shock. The on-off button was removed a few years ago. Now the machine turns itself on when the case is opened. The machine then guides with verbal commands. With patches attached, the machine automatically does a 3-second diagnosis, repeating the process 3 times. Only if 2 of the 3 tests positively identify an arrhythmia is the machine approved to shock.
And yet, for all the progress, the work in converting from invention to innovation to implementation still has a long road to travel. And the actions of Trump and Musk, in undermining the communication and funding between multi-disciplinary scientists and their institutions is not only destructive. It is potentially deadly.
What lines of AED investigation have been disrupted?
- Data gathering: Each time an AED device is used in the field, the data gathered is transferred to ongoing research databases to measure effectiveness and guide refinements. These efforts require federal funding.
- The expansions of these devices to schools, churches, airports, and the public square; and the training of citizens to confidently employ the devices without delay is a massive challenge, currently utilizing a combination of federal and state employees and non-profit organizations. Many of these individuals and organizations are on Musk’s chopping block.
- Advances in AED design have demonstrated that CPR chest compression, while awaiting AED arrival, not only moves blood out of the heart but also moves air through the lungs. But responders delivering CPR routinely tire and are lest effective after 60 seconds. Current research into next generation AED’s suggests that “complex, lower-voltage waveforms (100 to 200 V) that are delivered once or twice per second and cause strong chest constrictions” could eventually replace human administered CPR, and convert arrhythmias as well.
Will Mark Kroll and his medical science collaborators carry the day? He remains optimistic. He says:
“Indeed, we may now be on the cusp of a wave of medical automation that allows ordinary individuals to intervene constructively when other people’s lives are at stake. The AED, we think, serves as an important case study for how to fit sophisticated life-saving medical electronics into health care and rehabilitation outside of hospitals. Advances in portable and easy-to-use equipment, home-based therapy, remote health monitoring, and telemedicine may one day allow patients to avoid long, expensive, and emotionally draining hospital visits.”
Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)
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