Frank Pantridge, physician and cardiologist, will be remembered for having initiated with John Geddes the world’s first prehospital cardiac care unit at the Royal Victoria Hospital, Belfast, in 1966, and subsequently for developing the first readily portable cardiac defibrillator. These achievements, which resulted in a ‘revolution in emergency medicine’, cannot however eclipse his award of the Military Cross in 1942 for outstanding gallantry in Malaya.
Frank was born near Hillsborough, Northern Ireland, the son of Robert James Pantridge, a farmer, and Elizabeth née McCandless, and was educated locally. Judging from his autobiography, An unquiet life: memories of a physician and cardiologist (Antrim, Greystone Books, 1989), he was a somewhat wilful youth, but he gained a place at Queen’s University, Belfast, to study medicine, qualifying with honours in 1939. In an incident during the final examination, foreshadowing many in his future career, he disputed the physical signs with his examiner and then proved himself right by arriving hot-foot at the examiner’s house carrying a specimen of (supposedly non-existent) freshly aspirated pleural fluid.
At the outbreak of the Second World War, Pantridge immediately joined the Royal Army Medical Corps. He was sent to the Far East and seconded to the Second Battalion the Gordon Highlanders, north of Singapore. After the Japanese invasion of the Malayan peninsula, during the southward retreat of the battalion, he received an immediate award of the Military Cross: the citation read “This officer worked unceasingly under the most adverse conditions of continuous bombing and shelling and was an inspiring example to all with whom he came in contact. He was absolutely cool under the heaviest fire”. The circumstances surrounding the inevitability of the retreat made him forever mistrustful of politicians and administrators. After the fall of Singapore, he was imprisoned along with thousands of others and was subjected to humiliating and brutal treatment. Later he was among those transported to work on building the Siam-Burma railway. Infection and malnutrition were rampant, and he developed cardiac beriberi. Unable to perform his duties, he was transferred to the infamous ‘death camp’ at Tanbaya and later, lucky to be alive, back to Singapore. The medical officer who found him after the Japanese surrender described, in addition to gross emaciation, “(his) blue eyes that blazed with defiance”.
Returning to Belfast, Pantridge lectured in the university and used the available laboratory facilities to study beriberi in pigs. This employment provided a springboard for him to acquire the (then highly elusive) MRCP (London) in 1947, and in 1948 to obtain a fellowship to the United States, where he worked in Ann Arbor with Frank N Wilson, the renowned expert in electrocardiography, and later with George Burch in New Orleans, who had similar interests. He became well versed in both electrocardiographic interpretation and electronics, knowledge which was to stand him in good stead later with the advent of coronary care. Of more immediate relevance, he witnessed a demonstration of mitral valvotomy by Charles Bailey in Philadelphia.
Pantridge was appointed consultant physician at the Royal Victoria Hospital in 1951 and soon, with surgical help, he initiated a highly successful cardiac programme, an average of 100 mitral valvotomies being performed annually. With the development of effective cardiopulmonary resuscitation and cardiac defibrillation, a possible solution to the formidable problem of fatal ventricular fibrillation complicating the acute coronary attack came in sight. Pantridge opened a four-bed coronary care unit in late 1963. Successful resuscitations within the hospital began in the following year and rapidly became commonplace. When data indicating that mortality was heavily concentrated into the early hours after onset of the coronary attack, whereas hospital admission usually occurred late, were discussed with him in 1965, his immediate response was, “Well, we had better go out and pick them (the patients) up”. Following meticulous planning, devising a means to charge a defibrillator from batteries, securing the co-operation of existing staff, and adding a minimum of additional personnel with help from the British Heart Foundation, the family doctors were instructed in the logistics of utilising a hospital-based system and in cardiopulmonary resuscitation, and the first ‘mobile intensive care unit’ using a refurbished ambulance began operation on 1 January 1966. Transport of patients only after stabilisation, and direct coronary care unit admission, were decreed.
Despite early demonstration that out-of-hospital resuscitation was a practical proposition and the subsequent adoption of the principle of mobile care in many countries, there was difficulty in achieving recognition in large areas of the United Kingdom. Pantridge took on the skeptics with characteristic vigour, citing the very limited relevance of coronary care if confined to the hospital: further, he and his team demonstrated the high incidence of autonomic disturbances during the acute phase of infarction and adduced evidence that their treatment might limit infarct size and prevent shock. He developed a light and readily portable self-contained defibrillator, which replaced previous unwieldy equipment. He disproved a proposition that defibrillatory shock strengths of more than 400 J might be required for heavier patients (which if correct would have rendered his concept of widely available light and portable machines - with ‘a defibrillator beside every fire extinguisher’ - impracticable), and emphasised the advantages of low energy shocks. As early as 1976 he conceived the principle of the automatic external defibrillator, which would provide selectivity and additional safety. Although he had been awarded a personal chair in cardiology by the university, and received the honour of a CBE in 1978, it was not until the second half of the next decade that the Department of Health and Social Security began to approve the policy of providing prehospital coronary care according to the ‘Pantridge plan’.
Frank had a somewhat intimidating reputation among the junior staff, but those working with him quickly learned that his criticism was always directed toward the individual concerned and was never expressed behind his or her back. Indeed his sense of humour was seldom far below the surface and he was intensely loyal when his staff or colleagues were criticised from outside his unit, on one occasion stating publically that the critics were ‘flat earthers’. He could take a very tough line with administrators and medical committees over issues such as bed allocation, equipment and staffing, the yardstick being his ability to give his patients ‘the treatment they had a right to expect’. When it came to critical bargaining over an issue, he had an uncanny sense of the optimal time to compromise and accept that his ‘minimal requirements’ had been met.
Pantridge recognised the genuine anxieties of his patients and understood that their priorities were to know whether they would survive and when they would go home, rather than to understand the pathophysiology of their diseases. Many a face lit up when he said, “Right, we’ll be sending you back home very quickly indeed”. His ward rounds sparkled with repartee and good humour as he harangued the junior staff with questions about physical signs, investigation or diagnosis. There was particular difficulty with early diastolic murmurs, which he could hear easily despite having suffered auditory damage from the roar of artillery while in Singapore. Some with less auscultatory success suspected that he kept the murmurs bottled up in his stethoscope! He had the knack of being able to put his finger on the one important investigation which had been omitted: frequently a registrar, reciting a catalogue of complicated investigation results, would be floored by a simple but completely unexpected question. Ward rounds seldom ended without him drawing a diagram illustrating some clinical or electrocardiographic finding (usually on the back of a patient’s chart and annotated with his unique ‘hieroglyphic’ labelling).
He authored numerous papers and in 1975 he and three colleagues published a book, The acute coronary attack (Tunbridge Wells, Pitman Medical), detailing their experience of the previously uncharted period immediately following the onset of symptoms and confirming the effectiveness of low energy defibrillation. Much of his research focused strictly on the particular question at issue, resulting in definitive answers emerging without undue delay. He had an excellent command of English and during preparation of manuscripts he would meet frequently with his co-authors, ensuring that the text consisted of relatively short sentences, each with an unmistakable meaning. The entire paper was retyped many times, sometimes daily, to ensure accuracy and clarity before the final version appeared.
Frank was argumentative and he never suffered fools gladly, nor people he considered to have let him down. Although he could be highly aggressive and quarrelsome when provoked, he was generally on cordial terms with his staff and he spared no effort in supporting them in their careers. In his later years, despite some persistent disagreements, his morale remained intact and he was proud to be invited to give the opening address at the Second South American Congress on Prehospital Care in Montevideo in 1999, and to receive enthusiastic recognition at the congress as the father of prehospital cardiac care, recognition which led to his meeting the president of Uruguay.
He did not marry and much of his social life centred around meeting his friends and acquaintances over a drink after work. This ‘lubrication of his synapses’ often seemed dramatically to unleash his academic ingenuity. Frank was certainly a genius, but he could haggle over details almost endlessly. To settle a lengthy negotiation over clinical space he was once heard to say that he would accept half, provided that he got the bigger half! He freely admitted that he could never have been a successful diplomat, but equally it seems highly unlikely that he could have succeeded in initiating prehospital cardiac care, or indeed have exhibited such extreme gallantry in Malaya, had his genius been accompanied by a less forceful nature.
John Geddes
[‘Frank Pantridge and mobile coronary care’ in Baskett PJF & TF eds, Resuscitation greats (Bristol, Clinical Press, c.2007); The Daily Telegraph 29 Dec 2004; The Guardian 6 January 2005; The Independent 24 January 2005; Brit.med.J., 2005,330,793]