CPR works, but not as well as most think

Doctors die with grace and dignity.  Actually, anyone who works with sick people for any length of time develops the skills necessary to die with grace and dignity. This is not always true of the general population, especially in a world where people are not exposed to death, and are exposed to the fantasy world of Hollywood where CPR works an amazing 64% of the time.

There are many examples of CPR being performed in a movie or TV show and the person living.  One such incidence that is fresh on my mind occurred in an episode of "Walker, Texas Ranger," which starred Chuck Norris from 1993-2001.  I described it n my post "No Vent, DNR, or Full Code: What's Your Choice?"

What might confuse people is what you see in the movies. There was one episode of "Walker, Texas Ranger," where Chuck Norris's character was having chest compressions performed on him, and his friend who broke his arm was watching on. Then Chuck woke up, the ambulance arrived, and the person who was taken away on the ambulance was not Chuck, but Chuck's friend with the broken arm.

A recent study performed at the University of Southern California Davis School of Gerontology showed that the survival rate for CPR was actually as high as 37%, although the survival rate of CPR performed on TV was a whopping 70%.  No wonder people get a warmed view of what modern medicine can do.

The study also revealed that:

The depictions show CPR mostly being performed on adults age 18 to 65, when in reality more than 60 percent of CPR recipients are older adults over 65... Also, trauma was behind nearly 40 percent of the CPR instances in the shows, even though traumatic injury cases only account for 2 percent of all CPR usage in real life.

When comparing these results to a similar study conducted in 1996, accuracy rates of television CPR depictions appear to not be improving. And though they seem like harmless entertainment, widespread inaccuracies in medical dramas could have real-life consequences.

Harmless indeed! Some experts speculate that the false perception of what medicine can do has lead many to falsely believe doctors can fix any problem, prolong life by "doing everything" including CPR, and that after "doing everything" quality of life will not be impeded.

This is not harmless.  It causes people to delay dealing with end of life care.  It causes people to avoid discussing with their loved ones, with their doctors, how they want to die.  And considering the difficulty of the discussion, doctors tend to avoid the subject altogether.

Just to provide an example, a 67 year old lady with end stage COPD was rushed to the emergency room by ambulance. The first question the doctor asked her was, "What do you want us to do if your heart stops."  She said, "I want everything done."

An hour later she was intubated and put on a ventilator.  Then her blood pressure dropped so low we couldn't feel a pulse.  Now we are forced to begin full blown CPR with chest compressions.  Yes, this did result in ribs cracking.

The chances of her surviving this are not good.  If she does survive, she's going to still have end stage COPD, meaning she is going to feel dyspneic. Only now she is also going to have some pretty bad chest pain due to the chest compressions.

Did we do the right thing.  Well, the emergency room doctor had no choice.  We had no choice but to follow the wishes of the patient, even though we all knew full well that this patient had set a path to a death that was not going to be very pretty.  She was not going to die with grace and dignity.

What can be learned from this.  Doctors must talk to their patients about end of life care.  They must be honest with their patients.  "Hey, you have end stage COPD.  If you should end up in an emergency room in respiratory failure, what do you want done? How far do you want us to take you with our medicine? Do you want CPR?"

Of course this discussion must progress to a definition of what CPR is.  It may progress to a discussion of what intubation is, and of what a ventilator is? It may progress to a discussion about the difficulty of getting a patient with end stage COPD off a ventilator? It may progress to a discussion of recent studies that show that ventilatory support has yet to be shown as useful in patients with chronic respiratory failure?

Options must be discussed. Hospice must be discussed. It must be explained to the patient that choosing to be a DNR, or choosing hospice, does not mean giving up: it means dying with grace and dignity.

Further reading:

• Wall Street Journal: Why Doctors Die Differently (or find full article at zocalopublicsquare.org)
• RT Magazine: CPR: It's Not Always A Lifesaver, But It Plays One On TV
• RT Cave: No Vent, DNR, or Full Code: What's Your Choice?
• RT Cave: How do people die?

The best and worse parts of being an RT

Your Question:  What is the best and worse parts of being a respiratory therapist

My Answer:  Politics is the worse part of any job, although let's take politics right out of the equation.  That said, the best and worse part of this job is taking care of infants and kids who are not breathing on their own.  No one looks forward to doing CPR on an child.  However, on the bright side, it's nice having the skills that might help them.  It's nice to work together as a team to provide a service that can save a life.

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Myth Buster: Mouth to Mouth breathing does not oxygenate patients

It has been a belief of mine that one of the reasons mouth to mouth breathing should no longer be performed was because exhaled air only contains 16 percent oxygen compared with inhaled oxygen containing 21 percent oxygen.  As it turns out, it was this myth that was one of the obstacles that was disproved just prior to its worldwide acceptance.

I'm going to give you a brief history of mouth to mouth breathing before I disprove the myth.  The most common cause of sudden death prior to the 1950s was drowning.  In the first century Galen believed a person inhales a vital spirit, and this vital spirit is absorbed and moves through the body to sustain life.  This theory was still believed in the 18th century.\

It also should be noted here that when a person died, the "vital spirit" left the body immediately.  It was probably for this reason that there were very few efforts to revive a presumably dead person.

In the ancient world, and into the 18th century, it was viewed as sacrosanct to touch a dead body except in preparing it for burial.  For this reason people were forbidden from toughing, let along performing autopsies, on dead bodies.

During the course of the 16th century men like Andreas Vesalius started inspecting the body, and therefore began doubting the words of Galen.  So it was in the 16th century that the science of anatomy was begun, whereby people started learning about the various structures of the human body.

During the course of the 18th century people started realizing that diseases were caused by changes within the body.  This began the science of pathology.  Realizing that changes within the body caused disease, some people started speculating that there was a reason a person suddenly dropped dead, and perhaps by rescue efforts a person could be brought back from the dead.

This was not a knew idea, although prior to this century it was not talked about much.  There were various efforts as far back as the primitive world where descriptions of artificial respiration were described, such as in Isaiah in the First book of kings, and Elisha in the Second book of Kings. Elijah pressed his body over a child three times to revive him (perhaps an early version of chest compressions) and Elisha performed mouth to mouth breathing to revive a child. Likewise, there were various stories of midwives providing mouth to mouth breathing to newborn babies, and the method working.

Yet in the 18th century, as people were learning about pathology, various efforts were made to save the lives of drowning victims.  And, lo and behold, some of the time these efforts worked.  Even though successes were rare, it was enough to inspire repeating of these efforts.

Noting success stories, in 1774 a British Physician named John Fothergill became impressed with accounts of successful efforts of mouth to mouth breathing, that he wrote about it as a safe and easy procedure that anyone could perform to reanimate a person in suspended animation.

Back then the term artificial resuscitation was not used, and instead it was referred to as resuscitation.  A person was suscitated at birth, meaning that he was given life.  Given the stories of some people being brought back to life, the period from when a person died and was reanimated was called "suspended animation."

Likewise, given these success stories, it was now believed that the vital spirit stayed in the body for a period of time after a person died.  However, it was not known how long before it left the body.  It was for this reason that you will read stories of reanimation attempts lasting for two hours or longer.  There was also no timetable for efforts to be started.

There were a variety of methods, that included mouth to mouth breathing, rolling a person over a barrel, hanging the person by his heals from a tree, performing chest compressions or abdominal thrusts, tickling his nose with a feather, covering his body with spirits, or breathing for him with bellows.

Mouth to mouth breathing was effective at times, although due to disease pandemics, it quickly went out of vogue.  It was replaced by using fireside bellows, which were readily available in most fireplaces.  Back then there were fireplaces in every house and place of work.

Mouth to mouth breathing made a brief appearance in 1909 when Dr. Robert H. Woods wrote about it, but people were so in love with other methods of resuscitation at the time, they ignored Wood's suggestion.  The preferred methods of breathing at this time were rolling a patient form side to side, providing abdominal or chest compressions, or applying pressure on the patient's back.

But during the 1950s Dr. James Elam and Dr. Peter Safar proved that mouth to mouth breathing was superior to any other method.  They proved that it was so simple that even a child could do it on an adult.  They even proved that it provided better tidal volumes.  The only obstacle that remained were critics who claimed that the 16 percent oxygen exhaled by the rescuer would be too little to oxygenate the victim.

This obstacle was hurdled by experiments by Elam and Safar.  I will allow Mickey S. Eisenburg, in his 1997 book "Life in the Balance, to explain the rest:

To prove the value of mouth to nose breathing (or mouth to mouth breathing), Elam first had to show scientifically that exhaled air was adequate to oxygenate a nonbreathing person.  It was widely believed that exhaled air, with 16 percent oxygen, was too low compared to air, which contained 21 percent... Elam needed irrefutable data collected in a rigorous fashion.  The year was 1952 and Elam was an assistant professor in the Division of Anesthesiology at Barnes Hospital in St. Louis.  he obtained permission from his chief of surgery, Dr. Evarts Graham, to do studies on post-op surgical patients before they recovered from ether anesthesia.  The endotracheal tube was left in place and succinylcholine (used ot keep the patient paralyzed) was continued as a drip.  By blowing into the tracheal tube with his expired air, Elam found that total arterial oxygen saturation could be maintained at 100 percent.  Nine patients were studies and the results were unequivocal: expired air was able to maintain adequate oxygenation.  In his scientific writings Elam called his technique expired-ari resuscitation, but he always thought of it as the "method of Elisha." 

 Surely this was a small sample, but this study was enough to convince the medical society that mouth to mouth breathing, when done effectively, was enough to provide adequate oxygenation. For those grossed out by the procedure, or worried about catching a disease, he invented what he called the Safar S-Tube.

The Safar S-Tube that was inserted through the oral opening into the pharynx.  On the opposite end (the end sticking out of the mouth) was a mouthpiece, whereby the rescuer would provide breaths.  The S-Tube, thereby, acted as both an oral airway and as a means of providing ventilation.

Now there were no obstacles preventing the method from being accepted.  By 1958 Elam and Safar had succeeded in convincing the experts of that era that expired-air resuscitation was far superior to other methods used, and it was accepted worldwide.

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End of Life Lexicon

Here's a few definitions regarding end of life:

1. Autonomy:  Independence freedom, as of the will or one's actions:  the autonomy of the individual (From dictionary.com)

2.  Patient Autonomy:  The patient is allowed the freedom to make the best medical decision based on the best available information about all possible options.  The desire of caregivers to treat the patient as an individual person

3.  Real Patient Autonomy:  The patient is lead down a certain path, given one or two options, and lead to believe he made the best decision on his own.  Most people are naive about medical options and trust their physician to make the right choice for them.

4.  Do Not Resuscitate (DNR):  I want to live, but I understand the futility of my medical condition, and I don't want you to make rescue efforts to save me if I stop breathing or if my heart stops.  This means no chest compressions, no intubation, no rescue medicine if your heart stops, but other than that the doctor has many options available to keep you alive.

5.  Do Not Intubate (DNI):  Load me up with medicine, do chest compressions on me, but, by God, do not you dare put a tube in my throat so I can breathe.  The doctor can do everything possible to keep you alive except the one thing that will keep you alive  We have to pump $10,000 of medicine into you to keep you alive, but we can't keep you alive.  This is the option taken by patients improperly informed by their physician.

6.  Comfort Care Only:  Keep me pain free, help me breathe comfortably, but don't make rescue efforts to save me because I have a terminal medical condition.  Attempts to save me will just be prolonging my suffering, and I understand that. I prefer to pass on with grace and dignity.

7.  Cardiopulmonary Resuscitation (CPR):  If your heart stops we will make every effort to attempt to get you breathing, get your heart beating, and save your life.  This means we will do chest compressions, intubate you, and put you on a ventilator.  Despite contrary Hollywood myths, CPR has less than a 1% success rate.  You will not walk away from a CPR session smiling.  Medical professionals must do this unless we have a DNR order.

8.  Chest compressions:  One part of CPR where medical professionals will thump on your chest in order to circulate blood through your body.  This is now believed to be the most important part of CPR (for adults anyway).  Outside the hospital this is the only part of CPR that is recommended.  Chest compressions are now believed to both circulate blood and cause negative pressure to simulate breathing, making mouth to mouth breathing unnecessary. Plus people are more likely to do CPR when they don't have to do mouth to mouth. 

9.  Mouth to mouth breathing:  This is where you put your mouth over another person's mouth to breathe for that person.  You can use a barrier to keep your mouth clean.  And despite myths, rarely do people catch diseases this way.  While there is 21% oxygen in the air, the oxygen you exhale is more like 14%.  So such efforts are now deemed to be useless.  Likewise, studies show most people are hesitant to do  mouth to mouth breathing, and are more likely to do CPR if they just do chest compressions.  Yet old doctors who sit on the Basic Life Support boards are reluctant to change anything regardless of the facts. 

10.  False Heroism:  Saving a life when you know that person will be dead within a month no matter what.

Sometime CPR really does work

So what is it?  One percent?  Actually, I think I saw a study recently that showed that as many as three percent of people who had CPR performed on them lived?  I think it's this percent that lived and had a somewhat normal quality of life afterwords.

Today I had a lady come into the emergency room.  She was in the passenger seat.  Her husband was driving.  She was on the phone talking to her brother.  She dropped the phone.  Her husband saw that something was wrong.  He pulled over.  He had a bystander call 911.  He started CPR.

Within 5 minutes the EMTs arrived.  The patient was in v-tach.  Shocked three times.  Gave four doses of epinephrine.  By the time I received the patient she was intubated and, of course, chest compression and breaths with 100% oxygen were being given.  She had no pulse.  No rhythm.

Ah, and just as the good doctor was about to call it, the patient took in a deep breath, started breathing on her own, and had a good rhythm of the heart.  No, she did not miraculously wake up like they do in the movies.  That, my good friends, never happens in real life.  So all those people who have "CPR but no vent" on their advanced directives are living in a pipe dream.

Anyway, we shipped her to another location and that's all I know of her.  Due to HIPPA I will never get an update.  That's unfortunate, because her follow up would be a good learning experience.

However, we did have a lady a few years ago in the same situation, and two weeks later she came in complaining of dizziness.  It was neat to see that she came out of it just fine.  I will never see this lady again, because she resides in another state and was just in town on vacation with her husband.

And yes, for you dunderheads who want to get me into trouble for writing about a patient, I did alter enough details so even the most anal person will have no clue which patient I'm referring to here.

Mouth to mouth not indicated for adult CPR

Way back in 1995 I learned that chest compressions during Basic Life Support (BLS) were all that was needed to get CO2 to exit the lungs and the 21% Fraction of Inspired oxygen that's in the air we breath to enter the lungs.

The constant banging on the chest causes the CO2 to sort of vibrate out of the body, and air to vibrate into the body. It works similar to high frequency ventilation. During normal living this wouldn't be comfortable, but in emergency situations it works.

Way back then we learned that chest compressions were all that was needed during CPR, and breaths were not indicated and even harmful.

Since then more and more evidence has come out confirming the idea that chest compressions alone are more beneficial to a patient who is in cardiopulmonary arrest than wasting your time putting your less than 21% Fraction of Inspired Oxygen (FiO2) that's in expired breaths into a person. 15% FiO2 is simply not that beneficial to the patient.

New evidence also supports that the negative recoil of the chest that you create during good chest compressions are enough to keep air flowing into the lungs, and CO2 out of the lungs. It's simply more evidence to support that mouth to mouth breathing is a waste of time.

Not only that , but mouth to mouth breathing is considered to be gross, and it's probably the #1 reason why some people don't do CPR. Plus trying to remember guidelines that recommend 2 breaths to 30 chest compressions for adults, and 1 breath to 15 compressions for two person CPR on children is way to confusing even for the well trained medical professional.

What is more important is that you keep the person's heart pumping. A person can stop breathing for minutes at a time, yet the heart never stops beating. So the best chance that person has is for you to keep the heart beating, preferably at 100 beats per minute.

The Red Cross has finally realized this by setting an initiative to teach people about hands only CPR by 2011 (article here). They now recommend hands only CPR outside the hospital setting.

I actually think this should say, "in the absence of advanced medical equipment." I say this because most hospitals don't have AMBU bags in every room, and there are times CPR must begin before one is available. In these cases, chest compressions should be given until such advanced medical equipment is available.

I don't think that just because we are "trained professionals" we should be expected to put our mouths over another person's mouth.

The American Heart Association (AHA) has updated its guidelines, although, in my opinion, they have yet to go far enough. As you can see by this post, the AHA has changed the sequence of doing CPR. While it previously recommended ABC (Airway-Breathing-Compressions) it now recommends CAB (Compressions-Airway-Breathing).

The new changes are recommended for all patients except for newborns. This is good, because for adults who suddenly become unresponsive, the heart is the cause, and this is why chest compressions are so important.

For babies who suddenly stop breathing the cause is more likely respiratory related, and in this instance breaths are important. So for newborn babies it's important to give breaths first, especially if the heart rate is less than 100. (In babies, the heart rate starts to go down when breathing is slowed down).

I like the Red Cross recommendation to do chest compressions only because it will get more people doing CPR, and makes the efforts more beneficial (although statistics of success are still minute). Yet the AHA still refuses to get rid of opening the Airway and giving Breaths. A true sign the old fogies making these guidelines are overly willing to hang on to old fallacies.

(Note: Breaths are still indicated if a respiratory problem is the cause of failure. A good example is near drownings).

So while our BLS instructor was spending loads of time making sure we were giving breaths correctly, I couldn't help but to think I was wasting my time. I even said so this time around. Yet she gave your typical, "I'm just teaching it as I was instructed." And I respect that: she is just doing as she's taught.

I have respect for that. Which is exactly the reason those old fogies at the AMH update their guidelines to get rid of un-oxygenated breaths during CPR in the absence of advanced medical equipment. It's simply pointless.

I was told during a recent Advanced Cardiac Life Support (ACLS) class a few years back taught by an AMH instructor that a board of 10 or so doctors sets and updates the guidelines every few years. And the last vote you had something like 8 of the 10 experts voting against giving breaths. Those two said something like, "Well, it only makes sense we should be giving breaths."

Sure it does. Yet the evidence shows these breaths are pointless and even detrimental. It's hard to keep your chest compression rhythm when you keep stopping to give breaths. Plus these recommendations that you give cycles of two breaths for each 30 compressions are too complicated. In real life it's impossible to do that. In real life we never do it like THEY recommended.

Way back in 2000 I had a patient whose heart stopped, and I did CPR with chest compressions only. My coworkers frowned at what I was doing, "Well, I'm not putting my mouth on that," I said, looking at the patient.

I simply pounded on the chest, and within a minute the CODE team had arrived with advanced medical equipment, an AMBU bag was used to give 100% oxygenated breaths, and the patient was shocked. Plus, believe it or not, the patient survived.

So it's time the AHA join the Red Cross by stopping the complicated recommendations in their guidelines that breaths should be given. It's time to go to chest compressions only when advanced medical equipment is not available.