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Dr. Peter Safar: A life devoted to cheating death

Peter Safar, nearly 78, pioneer of CPR, ICUs and modern ambulance service, now researches therapeutic body cooling

Sunday, March 31, 2002

By Anita Srikameswaran, Post-Gazette Staff Writer

few colleagues distilled Dr. Peter Safar's philosophy into catch phrases that, mixed liberally with Austrian inflection and Old World charm, could have come straight from the renowned anesthesiologist's smiling mouth.

Here's a sample of "Peter's Laws for the Navigation of Life," subtitled "The Creed of the Sociopathic Obsessive Compulsive":

No. 2: When given a choice -- take both!

No. 12: When faced without a challenge, make one.

No. 21: When on thin ice, dance.

A framed set of the laws was presented to Safar for his 70th birthday.

Dr. Peter Safar poses in front of an abstract painting of the girl whose death mask inspired the face of the Resusci-Anne doll. Designed by Safar and Asmund Laerdal, the doll is used worldwide in CPR training, which Safar co-invented. Norwegian artist Leila Wathne painted the picture, titled "The Girl From the River Seine." (Franka Bruns, Post-Gazette)

His colleagues know him to be the architect of intensive-care medicine and cardiopulmonary resuscitation, or CPR, and call him the driving force behind modern ambulance services. He has won lifetime achievement awards and, with a Russian resuscitation expert, has been nominated for the Nobel Prize.

Already a medical icon, the University of Pittsburgh researcher, who is about to celebrate his 78th birthday, remains hard at work identifying escape routes away from the brink of death.

Now, he's making a reality of what he calls suspended animation.

"I still have time left," Safar says. "Why waste the late years?"

His colleagues had good reason to dub them Peter's Laws.

No. 20. Death is not the enemy but occasionally needs help with timing

A visitor to his spacious Oakland office will likely find Safar hunched over his desk, deep in thought. Stacks of papers spill around his feet, and similar towers rise up from his desk.

When he realizes you have arrived, he springs up with a smile. He seats you on an old, soft sofa and sits in a chair opposite you. After a few pleasantries, he may offer you a glass of wine.

In fact, during some of the many meetings in the conference room of the Safar Center for Resuscitation Research, he circulates with a wine bottle and plastic cups. He also hands out sheaves of documents.

Safar talks about his latest project, the work of two decades built upon a foundation of another 20 years of research, with unbridled enthusiasm and perhaps a hint of challenge.

After all, suspended animation does raise eyebrows.

"You think of some kind of Disney scientist, quasi-scientific, body-freezing thing," says Dr. Pat Kochanek, current director of the resuscitation center.

Safar's mind is not slowing. As Kochanek notes, when editors of elite medical journals need an evaluation of therapeutic body cooling, they turn to Safar.

His version of suspended animation is "utterly scientific," Kochanek says. "This is hypothermia research at its highest point."

The project began almost 20 years ago, after Safar talked with a U.S. Army surgeon about how, medically speaking, soldiers were killed in action.

Combatants often had chest or abdomen wounds leading to massive internal bleeding that stopped the heart. CPR doesn't help these pulseless victims because blood just drains out of the vessels. And brain damage begins minutes after the heart stops pumping blood to it. How can time be bought so that the brain, and thus the patient, can be saved?

"A totally new approach had to be found," Safar explains concisely. "We have to find a way to pickle the whole organism with emphasis on brain and heart in the vulnerable period, within the first five minutes" of heart arrest.

His research team's painstaking experiments showed that if an injured animal is rapidly chilled -- with cold saline solution pumped through a portable bypass machine -- it can be resuscitated after two hours of death with no damage to the brain.

Car accident victims and other trauma patients could benefit just as much as combat casualties if profound cooling, down to 41 degrees, works in humans.

Safar's team is trying to devise a cooling method for the field. Perhaps icy fluid could be flushed into a large catheter placed in the aorta to drop body temperature.

 
 
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A Peter Safar timeline

   
 

"Then you relax. You have one to two hours to play with," he says. Surgeons can repair the injury and the patient can be brought back to life.

That's "suspended animation for delayed resuscitation," Safar clarifies. "It's not body freezing, which is charlatanism."

No. 9. If you can't win, change the rules

Safar has a knack for authoritative plain-speaking.

Take, for example, his reaction to recent human clinical trials that prove what he anticipated in the 1980s.

Australian and European studies show that cooling the human body to about 91.4 degrees after a person's heart stops -- even many minutes afterward -- improves the odds of the patient surviving without brain damage.

Dog experiments from the 1980s indicated to Safar that there was value in mild body cooling, or mild therapeutic hypothermia in doctor-speak.

American researchers could not do the tests then because of federal patient consent rules. Now, a stringently regulated waiver of consent permits researchers to recruit non-responsive patients into tests of potentially life-saving treatments.

But, Safar says, cooling trials for cardiac arrest no longer need to be conducted here.

The Australian and European studies were published -- along with Safar's commentary -- in last month's New England Journal of Medicine. Both found that mild cooling prevents brain damage after cardiac arrest.

Safar promptly recommended that the American Heart Association include the treatment in its resuscitation guidelines.

Australian investigator Dr. Stephen Bernard said mild cooling is now used routinely in Melbourne hospitals, and he credits Safar for inspiring the research. It's also being used at Vienna General Hospital, where European study leader Dr. Fritz Sterz works. He is an alumnus of the Pittsburgh critical care program, which Safar initiated 40 years ago.

Cooling may play a powerful treatment role for a host of other dangerous conditions.

Safar says, "We have 10 potential indications for the new therapeutic hypothermia," including stroke, spinal cord injury and heart attack.

No. 1. If anything can go wrong, fix it!

The heart beats almost 3 billion times in the average life span.

"There are phone calls and e-mails in enormous numbers," says Dr. Peter Safar, distinguished professor of resuscitation medicine, seen here in his Oakland office. "So many people want something. Sometimes I want something." (Franka Bruns, Post-Gazette)

Every year, about 300,000 Americans collapse and die because of a heart that abruptly falters and stops.

That's cardiac arrest. No blood circulates, so oxygen can't make its rounds. The most dire threat is to the brain, which is irreparably damaged in four to six minutes without CPR.

According to the Heart Association, 95 percent of cardiac arrest victims die before reaching the hospital. But, it adds, the use of CPR can dramatically improve survival rates.

Ask Safar about CPR and he might stretch out his legs, put his hands behind his head and relax into his chair, a grandfatherly figure filling in a neophyte about things now taken for granted.

He says the seeds were sown during a two-day car trip from Kansas City to Baltimore in October 1956. Eva Safar was at the wheel, wishing that her husband and his colleague, Dr. James Elam, would quit talking shop as they returned home from a medical conference.

Elam had just published the first scientific paper showing that enough oxygen could be delivered into a non-breathing patient's lungs from a rescuer's exhaled breath. Little attention was paid to his findings.

The ventilation method approved for first aid in that era involved pumping the patient's arms up and down with or without applying chest or back pressure.

When he got home, Safar rushed to test the effectiveness of a rescuer exhaling air directly into the mouth of a non-breathing person. Elam had used a tube, but Safar envisioned a gadget-free method that anyone could do.

The first human experiment took place in an operating room at Baltimore City Hospital, on a December Saturday in 1956.

Sedated volunteers were given curare, once a favorite of mystery writers, to paralyze the breathing muscles. The heart continues to beat. Safar took care of each participant during the hours they couldn't breathe on their own.

He sometimes shows black-and-white films in which a diminutive woman performs mouth-to-mouth resuscitation on a husky man hooked up to an oxygen monitor. When she gives him a breath, the line tracking his blood oxygen level climbs to normal. As she stands by, the line gradually drops.

Safar noted that the best results were achieved by tilting the head back and pulling the jaw forward, which keeps the airway straight and open. He had professionals perform the accepted arm-lift method and people untrained in medicine, including his wife, firefighters and Boy Scouts, do mouth-to-mouth ventilation.

That research was published in the Journal of the American Medical Association in 1958 and reprinted in September 2001 in Anesthesiology to launch a series called "Classic Papers Revisited."

Safar thanks Elam for sparking his research in life-supporting first aid. The experiments were quickly repeated in children by Dr. Archer Gordon, of the University of Southern California.

"The three of us convinced the world in one year to change artificial breathing methods," Safar says.

Those were just steps A and B -- for Airway and Breathing -- of modern CPR.

Step C, for Circulation, refers to pushing on the chest to force blood out of the stalled heart. The technique, which was occasionally used in the late 19th century, was rediscovered in 1958 at Johns Hopkins Hospital. It was already being tested behind the Iron Curtain by resuscitation expert Dr. Vladimir Negovsky who, with Safar, was thrice nominated for the Nobel Prize.

It is Safar who is credited with putting the steps together and winning worldwide acceptance of CPR.

"He did a lot of science to see what worked and why it worked," says Dr. Doris K. Cope, director of pain medicine at Pitt's medical center and the editor of the Bulletin of Anesthesia History. "He was instrumental, if not the prime mover, in resuscitation."

Safar points out to those who call him the Father of CPR that there were many contributors. He routinely peppers his remembrances with the names of people who, in his view, played significant roles. After the 2000 publication of his professional memoirs, he wrote a letter of apology to those who were left out.

No. 3: Multiple projects lead to multiple successes

Safar calls the six years he spent at Baltimore City Hospital exciting and the happiest of his professional life.

As he said in his memoirs, "Modern resuscitation and intensive care were born then, and much of it there."

Thanks in large part to Safar. Even the spinoffs from his CPR work had global impact.

A Norwegian colleague told him to approach toymaker Asmund Laerdal to develop a realistic mannequin for CPR training. A few months after Safar and Laerdal talked, a prototype of the life-size Resusci-Anne doll was ready. Its face was inspired by a death mask, owned by Laerdal, of a girl who drowned herself in the Seine River.

Since then, many a student of basic CPR has been taught to check if a patient is unconscious by gently shaking the doll and calling, "Annie, Annie, are you OK?"

Another Safar project led to modern emergency medical services. One of the volunteers in the mouth-to-mouth experiments was Martin McMahon, chief of the Baltimore Fire Department ambulance service. He opened Safar's eyes to the reality of pre-hospital care. Across the nation, ill people were taken to hospital via station wagons or even hearses, with no treatment given en route.

Safar and McMahon designed a modern ambulance, with a large compartment for a patient bed and seating for an attendant. It had an oxygen source and equipment to insert an airway tube to support breathing.

McMahon's staff learned to put in those breathing tubes, a technique called intubation, along with basic CPR. So the first ambulance was staffed by the first emergency medical technicians.

And while the resuscitation work went on, another "first" evolved.

Scandinavian anesthesiologists had started constant-care units for patients who needed long-term breathing assistance because of drug overdoses or polio. Safar took that idea and expanded it, because unstable patients, surgical or medical, were often left alone at night in the Baltimore hospital.

He established in 1958 what is considered the first intensive care unit in the United States, physician-staffed 24/7 for the prolonged care of patients with any life-threatening organ failure.

On its heels, ICUs sprung up in Toronto, Boston, Auckland, New Zealand, and elsewhere.

No. 10. If you can't change the rules, then ignore them

Eva Safar has less fond feelings about those days.

"To me, Baltimore was very difficult," she says.

Right after their 1950 wedding, her groom went to work in a Viennese clinic. Their arrival in Philadelphia, for his anesthesiology training, was a more rude awakening.

"He took off [for work], leaving me 10 cents and saying: Find yourself a job," Eva says. "Peter was always hardworking, diligent, ambitious. But he was gone."

She found work as a housekeeper to contribute to their once-meager income. Since then, she has been a blood bank technician and a docent at the Carnegie Museum of Art.

Eva, now 71, manages their household, which her husband calls her territory, and is a gracious hostess for his colleagues and students, freeing him to revel in his work.

Peter Safar greets his wife, Eva, before attending the University of Pittsburgh's Honors Convocation last month at the Carnegie Music Hall. Safar has received numerous awards during his long career in medicine, including the Republic of Austria Cross of Honor, that nation's highest honor. In January, he received the Lifetime Achievement Award from the Society of Critical Care Medicine. (Franka Bruns, Post-Gazette)

"The nitty-gritty of daily life passed him right by," she says. "That was [true] throughout our life."

In Baltimore, and later in Pittsburgh, the couple nurtured their love of classical music, often holding musicales in their home. She sang soprano while her husband accompanied her on the piano. He still regularly plays his family's 1919 Boesendorfer baby grand, which his parents shipped to them from Vienna almost 50 years ago.

Eva Safar's bittersweet memories of life in Baltimore center on daughter Elizabeth, who was born prematurely in August 1954.

"My husband was away and everything went wrong," she says. "That was hard."

Soon after her birth, Peter Safar diagnosed his daughter's severe asthma. The steroid inhalers that might have eased Elizabeth's breathing problems wouldn't exist for 20 more years. The young parents kept oxygen at home and helped her clear the thick mucus that regularly clogged her lungs.

"My wife or I would take care of her at night because her asthma was so much torture for her," Peter Safar said. "She needed some support every night for 11 years."

Personal tragedy adds a note of poignancy to his quest to evolve CPR into CPCR, for Cardiopulmonary Cerebral Resuscitation.

He and his wife were at a conference in Chicago in June 1966 when the imagined scenario, the one that stole pleasure from out-of-town trips, finally became real. Their daughter, at home in Pittsburgh, suffered a deadly asthma attack.

When he got to Children's Hospital, Elizabeth's doctor father was able to revive her heart and lungs. But her brain could not be saved. After a few days of coma, the 11-year-old died.

Safar's thoughts of his little girl are mixed with twinges of guilt.

"I wasn't here," he says simply. And, more wistfully, he wonders, "What could we have done better to show love, to help her with her handicap?"

The Safars have two healthy sons who are skilled at skiing and alpine hiking, like their parents. Philip, a lawyer, mountaineer and U.S. Army officer, and Paul, a musician and naturalist, live in the Pacific Northwest.

Elizabeth's death focused Safar's attention on finding ways to rescue the threatened brain, which is still the main thrust of his research.

No. 11. Perfection is not optional

Safar moved to Pittsburgh in 1961, eager to take on the challenge of establishing a new anesthesiology department at the University of Pittsburgh hospitals. He was responsible for the staff, who delivered anesthesia in up to 70,000 operations annually at five hospitals, including Magee-Womens and Children's.

Peter Safar spins his wife, Eva, around Carnegie Music Hall, waltzing at the Viennese Ball this month. The event was in support of the Austrian American Cultural Society of Pittsburgh. The Safars, who in 1950 left Austria to settle in the United States, have won several waltzing contests sponsored by the Pittsburgh Symphony Orchestra. In his memoirs, Peter joked, "Being Viennese with Strauss music in our systems, we felt later that it would be unfair to continue competing." (Franka Bruns, Post-Gazette)

He retired from the chairmanship of the department in 1979 and continued to treat patients for 10 more years, until he was 65. Also in '79, he founded the International Resuscitation Research Center.

In 1994, it became the Safar Center for Resuscitation Research, renamed in his honor when he stepped down from its directorship. He still works in those Oakland offices.

Safar has a reputation for being a gracious teacher and host.

"It's a real personal attention to making sure everything is right," says Kochanek, the current center director. "It's kindness, grace, charm, whatever, rolled up into one."

As pain medicine specialist Cope put it, "He sparkles all over -- he gets this grin. He's a very young person, despite his chronological age."

Dr. Samuel Tisherman, a center associate director, has frequently traveled with Safar.

"He's not the person to sit back and have a nap in the car," Tisherman says. "He wants to talk about something. Music, philosophy. And he makes sure he gets his point across."

Safar sends notes on birthdays, calls the physicians of ill co-workers and has parties at his home for staff and students.

"There's nothing halfway with my husband," says Eva Safar, noting his generosity.

She teases that his habit of bringing home flowers will soon drown her in roses.

No. 20. The faster you move, the slower time passes, the longer you live

Safar is the principal investigator of the suspended animation project. He is "co-P.I.," as researchers put it, on a study of hypothermia treatment for hemorrhagic shock patients who still have a pulse, which is led by Tisherman.

"He still has twice as much energy as I have," Tisherman said of the man who is more than three decades his senior.

The two once waited in a building lobby to take an elevator to the ninth floor.

"[Safar] turned to me and said, 'Do you want to walk?' and took off up the steps," Tisherman recalled.

Safar avoids rush hour by leaving early and staying late because "every minute counts" in his 12-hour workdays. A tiny, color-coded scrawl covers the pages of his appointment diary. He devotedly attends medical education sessions, designs and reviews experiments, writes scientific papers and is always ready to offer sage advice.

Recently, he was forced to rest a little after surgery to drain a neck abscess and a kidney operation. In what Kochanek labeled a "classic Safar," he dictated a letter of recommendation shortly before one procedure to ensure that his feelings were known should something go wrong.

Longtime secretary Fran Mistrick remembers an ill Safar working at his desk years ago while an intravenous line pumped fluids into him.

"He's very dedicated to what he's doing," she said. "I think he'd like to be able to save everybody."

Safar's other interests echo that. He is a committed member of Physicians for Social Responsibility, the International Physicians for the Prevention of Nuclear War and the local chapter of the World Federalist Association.

And he still hopes for systematic life-supporting first aid training of every man, woman and child in this country and around the world.

In the Safarian view, "you don't just want to collect stamps for your resume," Kochanek explains. You work in order to help people.

His co-workers, friends and family don't expect he'll ever retire. "He's working full-speed," his secretary says. "His relaxation is learning things, or teaching someone."

Safar doesn't deny it. He is already committed to writing a textbook covering resuscitation medicine in the 20th century, and he plans to write personal memoirs.

He is proud to say, "I made use of the opportunities that life offered to do some good."

The driving force behind CPR and critical care doesn't hesitate when asked if he'd want to be resuscitated if his heart stopped. "If I had a chance to come back with a good brain, absolutely," he says. "I will always have more things to do."

He acknowledged that there is some truth to Peter's Laws. In fact, he lives and works adhering to the final one:

No. 22: It's up to us to save the world

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