How Hard Is It To Do CPR?

Some of the questions you get asked as an ER nurse are very interesting. Some I can talk about . . . and some I can't. One fairly consistent question is, "How hard is is to do CPR on someone?"

It's hard people . . . flat out hard. 

The goal of CPR is to do the work that your heart does from the outside of the body. Keep in mind all that protects your heart from getting injured: layers of skin, fat, muscle and bone. All that has to be overcome to squish the heart enough for it to generate blood flow. 

Research has proven two things. The first is that CPR done effectively is the best thing that can be done to save your life if you go into cardiac arrest. Every minute you go without CPR your percentage of survival decreases precipitously. The second is that the effectiveness of one person doing CPR also significantly decreases after about two minutes which is why the American Heart Association encourages changing out those people doing compressions every two minutes. 

This story of an EMT suffering a stroke after performing CPR for 30 minutes highlights how much exertion a body sustains from performing chest compressions. 

So, there is a definite balance between doing effective CPR with the amount of physical strength you have on hand. 

Studies are also showing that continuous CPR, without pausing for breathing, is also increasing a patient's likelihood of survival. Some EMS organizations have gone to doing two continuous minutes of CPR immediately upon arrival and then going into the appropriate advanced life support protocol. 

The newest approach is what is called Pit Crew CPR. Just as in car racing where everyone has a defined role and becomes an expert at that role-- the same is true for this style of CPR. The importance of this method is that there is little pause in compressions. The concern with stopping CPR is that it takes anywhere from 15-30 compressions to get pulsatile flow again which is never good for the patient in cardiac arrest. 

In Salina, KS where they've trialed this their rates of return of spontaneous circulation (getting back a heartbeat) increased from 44% from 32%. That may not seem significant but it is a tremendous leap in terms of resuscitation medicine. Each of those points is a person living. 

Basically, in Pit Crew CPR, two people alternate compressions at either side of the chest. The person at the head of the patient manages the airway but initially the patient is placed on oxygen but there is not an emphasis on providing breaths as in traditional CPR. One person at a leg manages the defibrillator and a provider at the other leg establishes IO access (drilling an IV into the leg). 

After a few minutes of this style of CPR if the patient doesn't have a return of their pulse, they are placed on an AutoPulse and transported to the hospital. 

New Medical Device: Zoll R Series Defribillator

It's difficult for new medical devices to impress me. This one did.

One of the challenges in medicine is doing effective CPR. Research studies have consistently shown that what generally saves a patient's life is early and effective CPR. That's when all the other bells and whistles that we have in our medical stockpile will work.

However, you might be surprised at how ineffectively we do CPR. For one thing, it's physically hard to compress the chest enough to generate a pulse. Second, it's tough to measure the effectiveness of compressions. The way this is traditionally accomplished now is through palpating a pulse during CPR (which is difficult to do accurately) or to measure what's called end tidal CO2 which is best accomplished when a patient has a breathing tube down their trachea.

Another difficulty in doing CPR is the amount of artifact it creates. Artifact is something you see on the monitor that isn't a true representation of the patient's condition. For instance, if a patient is connected to a monitor and you pick up their ECG leads and shake them-- you can make it look like they're in a lethal cardiac rhythm.

If you're doing effective compressions, you can't see the patients underlying rhythm but stopping CPR to check a patient's rhythm takes away from its effectiveness as well. It takes a while to establish pulsatile flow with CPR so every time you stop, the patient can suffer.

The Zoll R Series Defibrillator attempts to change some of these issues and if it is able to do what it says-- it could mean a big improvement for patient care.

It has a pad that is placed at the center of the patient's chest. This measures the effectiveness of compressions and makes sure they are at the right rate and depth. It also allows you to see the patients underlying rhythm while compressions are ongoing which can lead to better treatment at the bedside when a rhythm changes.

It will be interesting to see if a device like this will decrease the morbidity and mortality around code events.

I was not paid by the company to review this product.

Author Beware: Use of Electricity

Authors, television producers and scriptwriters are fascinated by the use of electricity. This is probably one of the most commonly abused medical scenarios in that it is rarely used correctly.

One of my most popular posts here at Redwood's was a post titled Shock Me To Death that highlights how electricity (or defibrillation) should be used.

I was reading a debut novel by a medical doctor and found many grievous errors around the use of electricity. Which distresses me because he also said he had a cardiologist review the manuscript. Seriously, I kind of want to know who that doctor is and what kind of training he had.

There was the usual error of shocking a flatlined patient or asystole. Remember, in order for electricity to work, there has to be some present. If a patient is flatlined, there is no disorganized cardiac rhythm to reset and so defibrillation is contraindicated in those patient scenarios.

Next error in this manuscript was cracking the sternum down the middle during compressions. For one, the sternum is extremely hard to fracture. It's designed to protect some very important organs. If the sternum is even slightly fractured, we know there have been extreme forces placed on that patient. So, to have mere hands fracture a sternum all the way down the middle is ludicrous. Remember, they saw this open for open heart surgery. Breaking ribs is very probably during CPR, but not the whole length of your sternum . . . sorry.

Last, and most creatively (as I'd never seen this error before), was the amount of electricity used in an ICD device (an implanted cardiac defibrillator.) ICD's are devices that are used to convert patients from lethal arrhythmias like v-fib and v-tach. They are not pacemakers-- which stimulate the heart to beat.

Whenever electrodes are placed near the heart, the amount of electricity used is very small. Think about it. When we shock you from the outside of your body, the electrical current has a lot of tissue to pass through to get to your heart. This is why we use more. When defebrillating someone-- it's in joules.

A pacemaker uses a lot less energy. Outside pacemaker use milliamps.

And here is the very interesting quote from a published novel:

"Cardiologists shock patients all the time under controlled conditions, remotely dumping up to 700V (volts) of juice directly in to the heart via the ICD."

Wow. That's just . . . overkill.

Just how lethal is 700 volts applied directly to the heart?

This site explains that 110V can kill you.

It's so egregious an error that I'm not quite sure what this author was thinking. It pains me more that he is an actual medical doctor. I even double checked the published manuscript (as I'd read a galley proof before) and the error was still present.

I think he needs a new cardiologist.

Up and Coming

I spend a lot of time on this blog critiquing things that are bad in books, movies and television. It does warm my heart when I see something done well.

It is true, that when we teach CPR, we tell people to do compressions to the beat of the Bee Gees song Stayin' Alive which is both funny and appropos. As you sing it in your head and do compressions to the beat this will be a proper rate to get in the correct amount of compressions per minute which should be at least 100 regardless of the age of the patient.

The Chattanooga Fire Dept took this to heart and did what I would call a PSA about the correct way to do CPR highlighting this song.

It's cheesy but it's funny and, most importantly, medically accurate. I'm pretty fond of the first line, "That only works in movies, mam." when a bystander tries to do a precordial thump. So, my hats of to Chattanooga Fire for your creative way of teaching CPR. A Redwood's GOLD star and "STRONG WORK." for you.

I am particularly fond of the disco balls on the ladder trucks. I don't quite get the throwing the baby mannequin but all in all--- a good show. 

For you this week:

I'm doing a discussion of the Jahi McMath case. If you aren't aware of the story it concerns a 13y/o California girl who suffered complications post tonsillectomy, arrested, and suffered brain death.

Tuesday: "Safe" surgeries. Is there anything as risk free surgery?

Thursday: The Jahi McMath case and futile care. Should withdrawing medical care ever be mandated by the state?