It takes practice. Over the ensuing months two things became apparent. First, success required that everyone, every day, opened their hearts to those they were caring for. One person with a bad attitude could undo the heartfelt efforts of a dozen colleagues. Not surprisingly, front line employees and their managers started to become less tolerant of colleagues with crappy attitudes.
In the end, more than a few of the curmudgeons were asked to leave. Before long, Lakeland was reverberating with stories about heartfelt connections. So how to thank all of those who were bringing their hearts to work? Here, too, the CEO had a plan. Whenever a patient or a colleague reported a small act of heartfelt service, a senior leader would show up within minutes to personally thank the warm-hearted associate. Surrounded by their nearby co-workers, the leader would retell the story, thank the individual, and pin a heart on their badge. Over the course of a few months, more than 6, stories were celebrated across Lakeland, and more than 6, hearts were affixed to employee IDs.
There was a wicked commotion in the hall, and two security officers suddenly found themselves facing a husband in complete emotional melt down. He had come in with his wife who was desperately ill. The news struck like a thunderbolt, and he simply lost it. Having been called to the scene, the security guards were ready to phone the police when an associate nurse comes around the corner. Finally calm, he returned to support his wife and the nurse went on with her duties.
She was an LPN, who had never been through any course on conflict management, or de-escalation, but she had heard lots of stories about how to connect with another human being. The newborn had arrived healthy and happy, but as the mother recounted her birthing experience, her eyes filled with tears.
Upon arriving at the hospital, the first person she encountered in the OB unit had failed to look up and greet her with a welcoming smile. He went on. We are in the business of saving lives, of enhancing heath, of restoring hope.
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When we touch the hearts of our patients we create a healing relationship that generates a relaxation response, lowers the blood pressure, improves the happy neurotransmitters, reduces pain, and improves outcomes — for both the patient and the caregiver. For me, the point of his story was simple but profound: empathy is the engine of innovation. Listen to the speech of a typical CEO, or scroll through an employee-oriented website, and notice the words that keep cropping up—words like execution, solution, advantage, focus, differentiation and superiority.
Writing in the early years of the 20th-century, Max Weber, the famous German sociologist, said this about the modern age:. The fate of our times is characterized by rationalization and intellectualization and, above all, the disenchantment of the world. The ultimate and most sublime values have retreated from public life. A century later, Weber still seems on the mark.
It does not have to be this way. These are exactly the sorts of soul-destroying experiences that energize innovators. When Bakken accepted Lillehei's assignment, it seemed to him just like any other special order for a piece of equipment. This was not to be! Initial attempts at building a more reliable and portable pacemaker involved adding an automobile battery with an inverter to convert 6 volts direct current into volts alternating current and then power the conventional alternating current pacemaker on its wheeled stand.
These plans were soon abandoned, as they were obviously highly inefficient! A 10 volt direct current pulse was sufficient to stimulate the heart and transistors were becoming widely available. Bakken dug out the April back issue of Popular Electronics in which he recalled seeing a circuit for an electronic, transistorised metronome. The circuit transmitted clicks through a loudspeaker: the rate of the clicks could be adjusted to fit the music. He simply modified the two-transistor circuit Fig. The circuit was powered by a powerful miniature 9. There was an on-off switch and control knobs for stimulus rate and amplitude Fig.
I drove the device over to the University's animal lab where it could be tested on a dog. Of course it worked. I must have done a double take when I glanced through the door. The little girl was wearing the prototype I had delivered only the day before! I was stunned. I quickly tracked down Lillehei and asked him what was going on. After only 4 weeks of experimentation and work, the first battery-powered, transistorised pacemaker was already in clinical use!
A feat that is unlikely ever to be repeated given the regulatory labyrinth that all devices have to go through from inception to clinical use. The first production run of ten or so units were more refined versions of the original prototype and went into clinical use soon after at the University Fig. The dials had been recessed so that children would be less likely to adjust them and a little neon light blinked red with each stimulus. In addition, two metal handles borrowed from an old ECG machine were been added such that a strap could secure the pacemaker to the body. The pacemaker was not only portable but wearable!
This pacemaker became known as the because it was made in The product literature Fig. The Pacemaker is designed for internal applications with at least one wire attached directly to the myocardium for temporary stimulation or with a bipolar patch for prolonged stimulation. Its self-contained miniature power source will operate the instrument for approximately hours. The blocking oscillator repetition rate was variable from 60 to pulses per minute. In the entire history of medicine before , there had never been a partly or completely implantable electrical device. It was however apparent that for long-term pacing a totally implanted device would have to be designed as ascending infection via the pacing electrodes occurred frequently.
Recurrent heart block in patients who had recovered from their post-operative heart block caused several deaths. It was apparent that these patients needed indefinite and not temporary pacing for them to survive. The myocardial wire developed exit block as scar tissue grew around the site of stimulation increasing electrical resistance and requiring a progressive increase in pacing stimulus voltage to maintain capture. The thoracic muscles began to twitch at these increased voltages. A totally implantable system with better designed elctrodes neede to be designed! Meanwhile elsewhere, on the 16 th July a transvenous catheter electrode was introduced fluoroscopically, via the basilic vein into the right ventricular outflow tract, in a patient with fixed complete heart block who required colon resection because of a malignancy.
Pacing was continued for two hours, during the operative procedure, and ended with slowing of the stimulation rate until an unpaced idioventricular rhythm developed. The catheter was removed without complication and the patient resumed the idiventricular bradycardia. On October 8 th , the first pacemaker implantation was performed in Sweden. The system had been developed by the surgeon Ake Senning and the physician inventor Rune Elmqvist and implanted on a year old engineer called Arne Larsson.
This first experience with a fully implantable pacemaker system was reported at the Second International Conference on Medical electronics in and published as an abstract in Fig. The patient suffered from Stokes-Adams attacks that required resuscitation many times daily and whose situation was considered hopeless. The implantation was a more or less desperate rescue measure.
The risks taken with this completely unknown therapy were immense. Ake Senning Fig. He had observed Lillehei's work with temporary external pacing. Rune Elmqvist Fig. He had designed a portable ECG machine in and then the widely used ink jet recorder, the Mingograf, in These two men began to collaborate closely in and developed fibrillators and defibrillators for open heart surgery.
They realised that the main problem with external pacemakers was the open route for ascending infection along the lead and decided to design a fully implantable system. Arne Larsson Fig. He had been hospitalised with complete heart block and frequent Stokes-Adams attacks for 6 months. He was having 20 to 30 attacks daily and his prognosis was poor. Treatment was maximised with ephedrine, pentymal, atropine, isoprenaline, caffeine, digoxin and whisky. Else Marie was the patient's wife who pleaded with Elmqvist and Senning to help her hopelessly ill husband.
She had read press reports about ongoing experiments with electrical stimulation of the heart and hounded down the two scientists for a solution that did not yet exist: an implantable pacemaker. Senning recounts his encounter with this lady: "An energetic, beautiful woman entered my lab on the 6 th October and told me that I had to implant a pacemaker into her husband.
I told her we had not completed our experimental series and we did not have a pacemaker for human clinical implantation. That day she drove several times from Elmquist's electronic lab and back and finally convinced us. To avoid publicity, the implantation was done in the evening when the operating rooms were empty. Via a left-sided thoracotomy two suture electrodes were implanted into the myocardium and tunnelled to the pacemaker box placed in the abdominal wall. The first pacemaker implanted functioned only a few hours but the second one implanted in the same patient had better longevity.
Presumably, I had damaged the output transistor or capacitance with the catheter and I did not have the other one which was in the lab. The patient and relatives were happy if the patient survived. The second pacemaker functioned well for about 1 week before suddenly showing a decrease in the ECG pacing stimulus size: suggesting probable lead fracture rather than pulse generator malfunction.
The pulse generator delivered impulses at an amplitude of 2 volts and a pulse width of 1. The pulse rate was fixed at a constant rate of 70 to 80 beats per minute. The energy utilised was minimised since Elmqvist managed to obtain a few of the first silicon transistors imported into Sweden.
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These were more efficient than the older germanium transistors. With them Elmqvist designed a stable and efficient blocking oscillator with a small power consumption Fig. The first transistor forms a repetitive blocking oscillator whose pulses are fed to the base of the second transistor.
Several types of primary battery cells could have been used. The Ruben-Mallory cells with zinc as the anode and mercuric-oxide as the depolarizer were a possible choice Fig. They had been invented during World War II for army field telephones.
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Although the cell potential remained constant, these cells had a short lifetime and released hydrogen gas at the zinc anode. The effect of this gas in a cell encapsulated in plastic was not known. For these reasons, nickel-cadmium rechargeable cells were then chosen. Two cells of 60 mAh each were sealed, encapsulated and connected in series.
Recharging was accomplished inductively. A coil antenna with a diameter of about 50 mm was connected to the cells via a silicon diode. This was inductively coupled across the patient's skin to a large external flexible coil 25 cm in diameter attached to the patient's abdomen with adhesive tape. Recharging was accomplished by a kHz radio frequency current generated by an external mains-powered vacuum tube device connected to the external coil.
The pacemaker required charging once a week for 12 hours. The entire unit was entirely hand-made Fig. These were encapsulated in a new epoxy resin Araldite produced by Ciba-Geigy, which had excellent biocompatibility. The approximate diameter and thickness became 55 mm and 16 mm respectively, according to the dimensions of the ever so popular shoe polish can from Kiwi Fig.
Elmquist in fact produced two such units using these cans as moulds! These first units had two electrode wires, each consisting of a twinned, stainless steel suture wire with polyethylene insulation. The distal ends of the wires were sewn into the myocardium to act as pacing electrodes. The proximal ends were hard-wired to the pulse generator circuit. It was estimated that the electrode had to withstand about 10 5 bends per day Fig. Rune Elmqvist soon ceased his involvement in pacing but remained active in other areas of medical technology. He died in , aged Ake Senning remained very active in the field of cardiac surgery.
He died in at the age of Arne Larsson survived both the engineer as well as the surgeon who had saved his life Fig. He required five lead systems and 22 pulse generators of 11 different models until his death on December 28 th aged 86 of a malignancy totally unrelated to his conduction tissue disease or his pacemaker system. Wilson Greatbatch was an electrical engineer teaching at the University of Buffalo where he was working on an oscillator to aid in the recording of tachycardias.
He accidentally discovered the way to make an implantable pacemaker Fig. William Chardack was chief of surgery at Buffalo's Veteran's Hospital at the time. In Dr. Chardack, Greatbatch had finally found a surgeon who believed in the viability of an implantable pacemaker. On May 7, , Greatbatch brought what would become the world's first implantable pacemaker to the animal lab at the hospital.
There, Chardack and another surgeon, Dr. Andrew Gage, exposed the heart of a dog to which they touched the two pacing wires. The heart proceeded to beat in synchrony with the device. The three looked at each other. Their feelings were best expressed by Dr. The three - Greatbatch and Drs. Chardack and Gage - became known as the bow tie team. I wear bow ties because long ties get in the way when I am soldering.
Over the first two years experiments were made with animals. In , Greatbatch patented the implantable pacemaker, and William Chardack reported the first success in a human with this unit in The procedure was completed in June on a year old man in complete heart block Fig. Chardack first implanted the lead and when threshold stabilised implanted the pulse generator. The patient survived uneventfully for 2 years before his death from natural causes. In , Chardack, Gage and Greatbatch reported a series of 15 patients who had pacemakers implanted.
Greatbatch later invented the long-life corrosion-free lithium-iodine battery to power the pacemaker Fig. The early pacing technology of the 's and 's was a spin-off from the research and development of World War II and Cold War eras. Faulty batteries, body fluids leaking into the encasement and broken leads caused numerous pacemaker failures that required emergency surgery. The main difficulty however was the lead.
It was soon obvious that the myocardial wire was unsuitable as a long-term electrode. Stimulation threshold increased after a few weeks until exit block developed and no more capture was possible. Moreover, the wire could not resist the enormous repetitive mechanical stresses of bending. These technical problems contributed to the delay in the widespread use of implanted pacemakers for several years.
Tight collaboration between engineers, physicians and patients was the fundamental driving force for the growth of a significant global industry. Well over 2 million pacemakers have been implanted worldwide since ! Earl Bakken co-founder of Medtronic Inc. Siemens then acquired Pacesetter Inc.
Jude Medical in Other investigators followed a different line of approach in designing self-contained implantable pacemakers: inductive coupling Fig. A pair of electrodes were sutured to the epicardium and connected to a coil antenna located subcutaneously. Minimal or no circuitry was implanted and no internal batteries were needed. This coil antenna was inductively coupled to an external coil taped to the patient's intact skin.
This external coil was connected in turn to a transistorised pulse generator powered by an external battery. The electronic components, relatively unreliable at this time, were therefore located entirely outside the body. Glenn, Mauro, Longo, Lavietes and Mackay's technique utilised a radio-frequency oscillator. Later versions of this system included triple-helix, silicone insulated endocardial leads and rate-control via an external knob which the patient himself could modify at will. Atrial pacing with this device was used in Inductively-coupled pacemakers proved to be very successful with several hundreds of implants and survival rates of over 10 years Fig.
These devices were extensively used in the Birmingham UK region for a number of years, being produced by the Lucas factory, more commonly known for its automotive electrical products until taken over by Bosch. One particular disadvantage of this device was that its removal for example, for bathing could result in bradycardia and syncope.
They continued to be used until well into the 's and several patients with later generation pacemakers still have the implanted coils from their original devices. Paul and Norman Roth Chief Engineer at Medtronic implanted a bipolar stainless steel electrode to pace a patient suffering from post-myocardial infarction complete heart block Fig. The lead consisted of a pair of stainless steel wires secured in a silicone rubber base Fig. This consisted of four thin bands of stainless steel wound around a core of polyester braid and insulated with soft polyethylene Fig. It was estimated to resist over million flex cycles, hence lasting for at least 6 years.
The unipolar epicardial stimulation electrode was a platinium disc, 8mm in diameter and insulated at the back. The Elema Fig. The maket prospects were perceived to be poor! Pacemakers were considered as an expensive service to prominent customers with little commercial value. The external charging system was too complicated especially for elderly patients. Elmqvist constructed the Elema pacemaker in Fig. Ruben-Mallory zinc-mercury oxide cells were used as the power source thus eliminating the need for periodic recharging of the previously utilised nickel-cadmium cells.
Other models were implanted with similar success in by Zoll et al Fig.
The technique for inserting permanent transvenous bipolar pacing electrodes was developed in by Parsonnet et al. Pacemaker and lead technology continued to develop rapidly to make these devices reliable, automatic and flexible in the therapy they provide. The therapeutic end-point shifted from saving life to enhancing its quality and simplifying follow-up. Electrotherapy has become socially accepted and its indications are extending also to non-cardiac pathology: Parkinson's Disease, pain-control, drug delivery.
Transvenous leads replaced epicardial leads.
Pacemakers and their leads could be implanted without a thoracotomy and without general anaesthesia. The lithium-iodine battery was developed to replace the mercury oxide-zinc battery that had been used till then. This resulted in greatly increased pacemaker longevity Figs. In an American-made radioisotope pacemaker was implanted by Parsonnet et al. These nuclear pacemakers had an expected life of 20 years but went out of fashion mainly due to the need for extensive regulatory paperwork Fig. Titanium casing was developed to enclose the battery and circuitry.
This replaced the epoxy resin and silicone rubber that was previously utilised to encase the internal components of the pacemaker. Pacemakers were made non-invasively programmable in the mid's. Using a radio-frequency telemetry link, most pacing parameters could be adjusted to follow the changing clinical needs of the patient. By the end of the 70's dual-chamber pacemakers were developed to pace and sense in both atria and ventricles.
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Synchronised timing made it possible to preserve the atrial contrbution to ventricualar filling as well as to track the intrinsic atrial rate. In the early 's steroid-eluting leads were developed. These eluted steroid from their tip and hence decreased the inflammatory response evoked by the presence of the lead tip acting as a foreign body. Consequently, the early rise of capture threshold was blunted and safety was enhanced Fig.
In , Zoll patented and re-introduced a transcutaneous external pacemaker with a longer pulse width of 40 ms and a larger electrode surface area of 80 cm 2. This reduced the current necessary to capture the heart and thus improved patient comfort. This method of pacing could be applied very rapidly as a bridge to a the establishment of pacing via the transvenous route.
In the mid's rate-responsive pacemakers were designed. A tiny sensor within the pacemaker box detected body movement and used this as a surrugate measure of activity. Signals from the sensor were filtered and applied to an algorithm to alter the pacing rate up or down. Thus, pacing rate would change according to the patient's activity level.
Microprocessor-driven pacemakers appeared. These became very complex devices capable of detecting and storing events utilising several algorithms. They delivered therapy and modified their internal pacing parameters according to the changing needs of the patient in an automatic manner. The rate-response pattern also adjusted itself automatically to the patient's activity level Fig. Bi-ventricular pacing for heart failure was introduced. An additional specially-designed lead was introduced via the coronary sinus to the epicardial surface of the left ventricle.
The right ventricle via the standard lead and the left ventricle were paced simultaneously to attempt to resynchronise contraction of the left ventricular septum and left ventricular lateral walls. The improved contraction improved symptoms and survival fig. Automaticity progressively increased thus making follow-up visits easier and briefer. Pacemakers could also upload data telephonically to a central server via the internet Fig.
The history of pacing Fig. It is a unique mix of medicine, technology and marketing which has developed into a major industry and has brought electrotherapy out of the labs and into the clinics. Perhaps the single most important event that enabled the development of this form of therapy was the invention of the transistor in December Fig. Indeed one of the first applications of the newly invented device was in the nascent field of medical electronics, and particularly in pacemakers.
National Center for Biotechnology Information , U. Journal List Images Paediatr Cardiol v. Images Paediatr Cardiol. O Aquilina. O Aquilina Cardiology Department, St. Author information Copyright and License information Disclaimer. Cardiology Department, St.
A brief history of cardiac pacing
Luke's Hospital, Guardamangia, Malta. Luke's Hospital, Guardamangia, Malta tm. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract This article is the first of three articles that will deal with pacing.