EMS Hall of Fame: The Pioneers of Prehospital Care—Kouwenhoven, Knickerbocker, and Jude

John Erich

EMS Hall of Fame: The Pioneers of Prehospital Care—Kouwenhoven, Knickerbocker, and Jude

John Erich

March 2021

The short history of EMS has been driven by the wisdom, foresight, and innovation of countless individuals. As the field ages into its second half-century and its origins fade to the past, it’s worth commemorating the greatest pioneers of prehospital emergency medical services. This series honors these trailblazers.

William Kouwenhoven, Guy Knickerbocker, and James Jude

Developers of defibrillation, closed-chest massage

In the history of emergency resuscitation, EMS students well know the names of early pioneers like Pantridge and Safar. But their efforts were preceded by the even more foundational work of those who made the initial forays into electrical therapy and the chest manipulation techniques that helped lead to CPR. Coming together at Johns Hopkins in the mid-20th century, William Kouwenhoven, Guy Knickerbocker, and James Jude were among those key contributors.

Kouwenhoven started as a professor in the university’s school of engineering in 1914 with an interest in the effects of electricity on the human body and cardiac arrest. As electricity spread across the U.S., line workers had begun dying of ventricular fibrillation, and Kouwenhoven wanted to develop an instrument that could restore dysrhythmic hearts without invasive surgery. A ConEd grant in 1925 led to research showing that low-voltage shocks to the heart could induce v-fib and high-voltage shocks could stop the heart and lungs completely. In canine research in 1933, Kouwenhoven found delivering a second surge of electricity could restore sinus rhythm.

By the 1950s he was working toward a closed-chest defibrillator and by 1957 produced a 200-pound prototype for humans that saved the life of a patient at Johns Hopkins. By 1961 it was down to 45 pounds and fit in a small suitcase.

A student of Kouwenhoven’s, Knickerbocker was working in 1958 to better operationalize the professor’s cumbersome early device when a laboratory dog went into cardiac arrest. The defibrillator they needed was seven floors below, and Knickerbocker knew they couldn’t retrieve it in time. A few weeks earlier, though, he’d discovered that applying the copper electrodes even without current caused a rise in blood pressure when they were pressed down onto a dog’s chest. “We started to pump the dog’s chest because it seemed to be the right thing to do,” he told the BBC in 2015.¹

His colleagues compressed while Knickerbocker ran for the defibrillator. It took him 20 minutes to get back with it, at which time he shocked the dog twice—and resuscitated it. “We had found a way to slow down the dying process and give people time to receive defibrillation,” he told the BBC.

Jude was a cardiac surgeon who worked in the lab next door. When he learned of Knickerbocker’s discovery, he began investigating where to push, how often, and how hard. Ultimately research showed compressions could simulate up to 40% of normal cardiac activity and extend a dog’s life by more than an hour, but skepticism persisted about the approach’s efficacy on humans.

Then a year later, a 35-year-old woman at Johns Hopkins for gallbladder surgery had an unexpected cardiac arrest after anesthesia. Jude began chest compressions, and within two minutes her heart restarted. She then went on to a successful operation and full recovery.

With that save, Kouwenhoven, Jude, and Knickerbocker published their discovery in a landmark 1960 JAMA paper, “Closed-Chest Cardiac Massage.”²

“Anyone, anywhere, can now initiate cardiac resuscitative procedures,” they concluded. “All that is needed are two hands.”