Hands Only Cardiopulmonary Resucitation (CPR)

L’Inconnue de la SeineThere was an interesting story on MSNBC.COM about hands-only CPR.

As a physician, every two years I get re-certified in Basic Life Support (BLS), which is essentially what most folks know as CPR,  as well as Advanced Cardiac Life Support (ACLS), which is essentially what they try to portray in shows like “E.R.” when everyone is dramatically yelling  stuff like “Give him an amp of epi, stat!”.

Since finishing residency, I no longer practice any obstetrics (for reasons discussed in my medical liability and malpractice reform blog post), so I no longer get re-certified in Advanced Life Support in Obstetrics (ALSO).

I have never gotten certified in Advanced Trauma Life Support (ATLS), which is something that the surgeons and ER docs all get certified in. I don’t do ER medicine, so I haven’t really been able to justify the extra expense and time involved with getting this certification. I keep thinking perhaps I will get it someday though, as moonlighting in the local ER may be something I’d like to pursue in the future.  For now though, I’ll leave the chest tubes and tracheotomies and such to others.

Anyway, all of these various certifications require re-certification every two years. One of the reasons for this is to ensure that stuff is vaguely fresh in the mind should the need for this training actually come up. When somebody has a sudden cardiac arrest, time is of the essence. Actions need to occur without a lot of thinking and pondering. There isn’t time to run down to the library or hit google to look up what to do.

The other reason for these re-certifications is because the guidelines are constantly changing.

I remember seeing a short film once where they showed the various forms that CPR has taken over the years. (Of course, it wasn’t always called CPR.)

Back in the days of Benjamin Franklin, the recommended procedure included draping the victim face down over the back of a horse and then trotting the horse around on a lead so that the jarring action would stimulate breathing and heart beats. I’m not too sure how well that equine strategy worked out.

When I was in fifth grade, we were taught “Artificial Respiration”. It basically involved laying the victim on their belly on the ground and pushing on their back with both hands, to cause air exchange in the lungs.

Eventually, in junior high, we learned CPR from our Phys. Ed coach. We all snickered at the plastic nipples on the ubiquitous Resusci-Anne, who no doubt suffered severe liver damage from the multitude of alcohol swabs to which her mouth was subjected over the years.

In veterinary school, I learned the equivalent of ATLS and ACLS on dogs and cats, and even had the occasion to perform unsuccessful CPR on a white-tail deer once during my large animal clinical rotation, when it arrested under injectable anesthesia in the field.

By the time I was in medical school, it was called BLS. 

In medical school, we were required to each purchase a pocket resuscitation mask, so that we could perform rescue breathing on the mannequin without having to actually do “mouth-to-mouth.” Instead we could do mouth-to-mask-to-mouth.  (As an aside, I suppose age does make some difference in maturity, because fewer of my classmates were snickering at Resusci-Anne’s plastic nipples now.)

We were instructed by our well-meaning teacher to carry that mask with us at all times, so that we would always be ready to do BLS out in the “real world” and not have to expose ourselves to potential infections.

Of course, that mask and it’s plastic carrying case are about the size of a Hardee’s Thickburger (which by the way, if you eat very many of, you will likely learn more than you want to know about CPR or BLS or whatever they want to call it), so it didn’t get carried around for too long.

Anyway, I really think the whole point of the mask, while ostensibly to protect us from infection, was largely about the whole “gross-out” factor.

Let’s face it folks, even if you are a trained medical professional, the idea of swapping spit (and usually vomit) with a total stranger is pretty disquieting. Particularly if that total stranger is a morbidly obese, toothless, elderly three-pack a day smoker with pants full of feces and urine (as is apt to happen with cardiac arrest).

I’ve known fellow physicians, nurses etc., who have openly said “There’s no way I’m doing mouth-to-mouth on a stranger. It’s nasty and I have no desire to catch HIV”

If trained medical professionals, who have dedicated their careers to saving lives are resistant to doing mouth-to-mouth, what can we expect from the general lay public?

Personally, I think these new guidelines are a good thing. If you read the details, they don’t eliminate rescue breathing in all cases, but they do eliminate it in the majority of instances when bystander CPR would likely be used, which would be sudden cardiac arrest in an adult.

To me, this makes good sense.

The majority of arrests in adults are due to ventricular fibrillation (V-fib). In V-fib, the heart has basically turned into a quivering mass of muscle with no organized contractions. It basically stops pumping blood. Without blood flow, organs, particularly the brain, rapidly die. Restoring blood flow as soon as possible is vital. These people need to be shocked with a defibrillator to hopefully restore a normal heart rhythm. Until that can happen, they need rapid powerful chest compressions to get some blood flowing.

The lungs are not the source of their problem. The reason they’ve stopped breathing is because the part of their brain that tells the lungs to breath has shut down due to not receiving any blood flow. Theoretically at least, if you could start effective chest compressions immediately upon the patient going into V-fib, they might not even stop breathing (although I imagine breathing would be at least somewhat difficult with somebody pushing on your chest with enough force to break ribs). They might even regain consciousness and maintain it as long as you could keep their blood flowing.

Reality is not theory though. Outside of film or television, I’ve never personally witnessed a person regain consciousness during CPR. What I have witnessed however is the sort of agonal sporadic breathing that the article mentions. It also makes sense that even if no actual respirations occur, there is probably still some fresh air moving in and out of the lungs due to the chest compressions, similar to what I was taught in my “artificial respiration” class in 5th grade.

Anyway, I’m glad to see these new guidelines. It is my hope that they will encourage more folks to learn CPR and be willing to put it into action should the need arise.

If you, the reader, have not taken a CPR course and become certified, I encourage you to do so.  It might give you the tools to save the life of someone you love someday.  It might also give you the tools to save a total stranger…like me, for instance.

Do it.



p.s. Oh, and by the way, I know some folks reading are wondering, so I’ll go ahead and satisfy your morbid curiosity. 

I’ll apologize in advance to anyone I’m about to gross out.

The answer is yes.

I did do mouth-to-mouth on the white-tail deer all those years ago in veterinary school.

I did get some partially digested plant material in my mouth.

It was pretty nasty.

As far as I know, I managed to avoid acquiring any weird infections from the experience.

Looking back, I probably wouldn’t do that again and don’t recommend it to others.

Again, sorry for the gross out.

p.p.s.  I’d also like to take a brief moment to give a shout out of thanks to Kevin Pho for mentioning my blog on medical liability reform on his blog, Kevin, M.D., last week.  It caused a small spike in my traffic that was much appreciated.

I subscribe to several different blogs using the google reader service and his is one of the most valuable.  His main content consists of ferreting out the latest and best medical stuff  on the internet and providing links to it.  I think of him as being sort of like the air traffic controller of the medical blogosphere.

Thanks, Kevin!

1 Response to “Hands Only Cardiopulmonary Resucitation (CPR)”

  • Thank you very much this is a very nice information!. . .

    Learning basic or advanced level life support will be much more enjoyable when students understanding is congruent with the level of training. We should win Online acls and pals certification card and really not have mastered the objectives. Although it is the objective of the course to teach these life saving skills, it is not expected that all who attend leave with the same confidence. In contrast, it is very possible to leave an advanced level course.

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