Shocked

by David Casarett

  “We need to get CPR started,” Halvorson says.

  “Yeah, we can’t do CPR,” Colleen replies.

  As you can imagine, there is a momentary pause as Halvorson processes this new information. You can almost hear the wheels turning as she’s trying to determine whether she’s heard correctly. This is, after all, someone who has called 911. Halvorson’s working assumption seems to be that most people who call 911 are interested in saving a life. So Halvorson is understandably nonplussed to hear that saving a life is not currently on the menu.

  It doesn’t take her long, though, to realize that she has heard correctly. Halvorson is incredulous at first, but then she begins to try to persuade Colleen that, in this situation, CPR might actually be a very good idea. For instance, Halvorson points out that anyone can do CPR. Then she suggests handing the phone to someone else who is more open to considering the benefits of CPR. Then she says that Bayless is going to die without CPR.

  Halvorson: Okay. I don’t understand why you’re not willing to help this patient.

  Colleen: I am, but I’m just saying that—

  Halvorson: Okay, I’ll walk you through it all. We, EMS, take the liability for this, Colleen. I’m happy to help you. This is EMS protocol.

  There’s a break as Colleen asks someone to get a supervisor. We only hear her half of the conversation: “Can you get [unintelligible] . . . right away? I don’t know where he is. But she’s yelling at me and . . . I’m feeling stressed and I’m not going to do that, make that call.”

  Then Halvorson asks, again, whether anyone else is willing to perform CPR, and Colleen says, “We can’t do that.”

  Halvorson’s desperation is palpable now, and she runs through an increasingly frantic list of others who might be willing to perform CPR. She begins by asking, “Is there anybody that’s willing to help this lady and not let her die?”

  When Colleen says, “Not at this time,” Halvorson asks about guests who might be nearby. Colleen declines.

  Then Halvorson suggests calling a gardener. This is when it becomes clear that things are not going well. I mean, when you have to pull a guy away from his weed whacker to perform CPR, it sure sounds like you’re nearing the bottom of the list, option-wise. Halvorson seems to have reached the same conclusion when, in a last attempt at persuasion, she asks if Colleen might pull someone off the street: “Can we flag someone down in the street and get them to help this lady? Can we flag a stranger down? I bet a stranger would help her. I’m pretty good at talking them into it. If you can flag a stranger down, I will help, I will tell them how to help her.”

  Listening to this exchange is frustrating, heartbreaking, and generally depressing. Halvorson is trying every trick in the book to get Colleen to help. She’s failing, though, and she knows it.

  If you listen more closely, though, you can also hear Colleen’s distress. In fact, the quotes above don’t do justice to the discomfort that she seems to be feeling. On the recording, it’s obvious that she’s confused and uncertain. It sounds as though she really believes that she can’t do this. Or that she shouldn’t.

  It’s shortly after this point in the conversation that paramedics arrive on the scene. A few seconds later, the call concludes and the recording ends. Bayless is transported to a nearby hospital, where she is pronounced dead. But the uproar is just beginning.

  First, there was widespread condemnation of Colleen and Glenwood Gardens. The headlines tell most of that story. “Staff at Senior Living Home Refuses to Perform CPR on Dying Woman,” a local news station proclaimed.

  Expert opinion was hardly more forgiving. One physician described the lack of CPR as “horrifying.” She went on to say: “I think anyone with any clinical training is morally obligated to try to help in a situation like this.”

  Other experts took their censure one step further. It wasn’t just that a nurse has an obligation to perform CPR, they opined. Anyone does. “All of us,” an ethicist is quoted as saying, “have a duty to respond to people in life-threatening situations. This is a general ethical commitment we have to each other as part of living in society.”

  If you read the transcript and listen to the howling of the media and their pundits, Bayless’s story sounds like an open-and-shut case of bad nursing home care. In short, it sounds like the case of a nursing home that callously let its resident die. That’s the simple, easy answer.

  But it probably isn’t the truth.

  As the wave of criticism was breaking, it emerged that Colleen was hired not as a nurse but as a resident services director. So she truly was a bystander. And Bayless wasn’t in a nursing home, she was in an independent living facility—essentially an apartment complex.

  Now consider the fact that, by most accounts, Bayless’s family was satisfied with the care that she received. Bayless, they said in a statement, wanted to die of natural causes. Although neither Colleen nor the other bystanders knew that, they nevertheless did what Bayless would have wanted, which is to say, nothing.

  Then Bayless’s death certificate was posted. She died not of a cardiac arrhythmia or myocardial infarction, but of a stroke. That’s significant, because in a patient who collapses as a result of a stroke, CPR is unlikely to save a life. This isn’t a criticism of Tracey Halvorson’s advice, of course. She made all the right recommendations. But in this case, it’s unlikely that CPR would have helped. And in fact local law enforcement declined to pursue an investigation of Colleen or Glenwood Gardens.

  If you look at this story dispassionately, the whole episode begins to seem surreal. Lorraine Bayless was an eighty-seven-year-old woman who had led a full life and who wanted to die a natural death. Even if CPR had been attempted, it would have been highly unlikely that she would have survived. After a serious stroke, even if she did survive to leave the hospital, a substantial degree of neurologic impairment would be likely.

  So why the drama about what should have been done? And how is it that we’ve arrived at the point at which saving a life—or trying to—is mandatory? How did it happen that all of us have “a moral obligation” and “a duty to respond”?

  Not too long ago, the sorts of resuscitation techniques that could have been applied to Lorraine Bayless were still largely theoretical. Even fifty years ago, if she had collapsed, that would have been the end. But advances in the science of resuscitation have so thoroughly permeated our culture that no matter where you are, the crowd has an obligation to intervene.

  And the crowd does intervene. All the time. Although it’s difficult to get accurate estimates, it’s possible that somewhere between 250,000 and 350,000 people suffer cardiac arrests every year in the United States. Add to that the cardiac arrests that happen in hospitals—at least 200,000 per year in the United States alone—and that’s a lot of opportunities for bystanders and professionals to do CPR. (However, as we’ll see, not everyone steps up to the plate when the opportunity arises.)

  In a sense, the past fifty years have been a gradual revolution in democratizing resuscitation. No longer the province of medical professionals, now anyone with two arms and a sense of rhythm can resuscitate someone. It’s a revolution that we’re all part of, whether we know it or not.

  THE MOST KISSED FACE OF ALL TIME

  The notion of crowdsourcing resuscitation is an idea that’s as old as resuscitation itself. The Amsterdam Society was basically a group of concerned individuals who got together spontaneously to try to keep their fellow Dutch citizens from dying. In a word: crowdsourcing.

  The problem they faced, of course, was that it was difficult to generate much of a crowd if you can’t offer them tools that are more effective than barrels and trotting horses. Moreover, it’s difficult indeed to instill a sense of obligation and duty if what you’re doing is nothing more than performance art. So if crowdsourcing resuscitation was going to catch on, someone needed to ramp up the science of CPR, bringing CPR on the street into the same
league as resuscitation in hospitals.

  Alas, that took a little longer than our Dutch friends might have hoped. Despite the advances of the Society, and the later discoveries of the receiving house in Hyde Park, the nineteenth century was not a particularly productive one for the science of resuscitation. In fact, the first part of the twentieth century wasn’t much better. If you were a cardiac arrest victim who was “apparently dead” in 1951, your chances of survival probably weren’t much better than they would have been a hundred years earlier.

  Fortunately, this dismal track record finally began to improve, thanks in large part to an anesthesiologist named James Elam. Elam was a contemporary and collaborator of Peter Safar, the CPR pioneer whose Safar Center for Resuscitation Research at the University of Pittsburgh would later cause a misplaced media frenzy over “zombie dogs.” In a lecture Safar gave in the last years of his life, he credited Elam with inciting his own pursuit of resuscitation: “He sparked me into a lifelong pursuit of animatology,” Safar said. No pun intended.

  In 1946, Elam had just arrived at the University of Minnesota Hospital in the middle of a polio outbreak that was ravaging Minneapolis. His tour of the polio ward was interrupted when a nurse and two orderlies hustled down the hall with a gurney, carrying a young boy. Elam saw that the boy wasn’t breathing and that he was rapidly turning blue. (Polio can cause such profound weakness that patients are unable to swallow their saliva or keep the back of the throat open to breathe.) So Elam sealed the boy’s mouth and breathed into his nose. “In four breaths,” Elam reports, “he was pink.”

  That maneuver wasn’t a new invention, and indeed many people had thought of mouth-to-nose resuscitation as well as the mouth-to-mouth variety, including crowds of concerned citizens in Europe. The problem, though, was that people hadn’t gotten it to work. Simply breathing into a person’s nose is unlikely to deliver air to the person’s lungs. It’s far more likely, instead, to go into the person’s stomach, where it will do no good whatsoever, or out through the mouth, which isn’t much better.

  But Elam was an anesthesiologist who knew something about anatomy. And unlike his predecessors, he knew that air wouldn’t reach a person’s lungs through the nose unless the head is tilted at just the right angle, the jaw is pushed forward, and the mouth is sealed. So by bending the boy’s neck back, and by nudging his jaw forward and sealing his mouth, Elam was able to open the boy’s trachea wide enough to ventilate his lungs effectively. The boy survived, and the science of CPR was born.

  Inspired by that success, Elam embarked on a series of ingenious experiments that might face some close scrutiny from an ethics review board if they were proposed today: As patients were just waking up from anesthesia—still groggy and paralyzed—they were disconnected from the ventilator. Then a physician would lean over and breathe into the endotracheal tube that went down to their lungs. Elam would monitor the oxygen in the patients’ blood and was pleased to learn that exhaled air was sufficient to keep people alive. Presumably those patients were even more pleased to wake up.

  Later experiments in conjunction with Peter Safar were even more ambitious. The two were convinced that mouth-to-mouth ventilation of another person’s lungs could be effective, but was it practical? Could you train someone to do what they, as anesthesiologists, were able to do?

  So they tried a new experiment in which twenty-five volunteers were sedated—heavily, one hopes—and paralyzed with a drug called curare, a natural version of many of the medications used today in surgery. A total of 167 people were then brought into the room and watched either Elam or Safar perform mouth-to-mouth ventilation on the volunteer. Finally, when the laypeople seemed to have the hang of the procedure, they were given a chance to try it for themselves.

  All concerns about personal hygiene aside, what Elam and Safar did was remarkable. In a sense, they took the real-world experimentation of the receiving house in Hyde Park to the next logical step. Not content simply to observe what happened, they brought the resuscitation process back to a laboratory where it could be monitored, measured, and controlled. And their experiments would prove to be hugely influential in shaping the course that resuscitation science was to take.

  Elam and Safar deserve a lot of the credit for getting resuscitation to where it is today. But not all of it. Because like everyone who had come before them—or almost everyone—they were still missing a key piece of the resuscitation puzzle. They needed to get the heart pumping too.

  That happened in 1958 when a group of researchers stumbled on this problem. Three researchers at Johns Hopkins—William Bennett Kouwenhoven, Guy Knickerbocker, and James Jude—were studying the effects of external shocks on dogs’ hearts. Somewhere in the middle of an experiment that was probably about as gruesome as it sounds, they realized that the act of placing the defibrillator paddles on a dog’s chest created a faint but noticeable pulse.

  Imagine their surprise. That sense of surprise was probably exceeded only by that of the dog when he discovered that the rules of the game had changed quite dramatically and that now three well-respected scientists had begun to pound on his chest. Even in the already-difficult life of a canine research subject, that probably would have qualified as a very bad day.

  Within a year, the trio was trying out their new technique on people. And one of the first was a thirty-five-year old woman who suffered a cardiac arrest just before undergoing gallbladder surgery. She lived.

  So there you have it: the building blocks of CPR. More than fifty years ago, we’d figured out how to breathe for a dead person, and how to pound on his chest. In short, we knew how to keep someone alive, at least for a little while.

  But while it’s one thing to revive a dog in a lab, the real challenge was resuscitating people in the real world, far outside the familiar confines of an operating room. Safar and Elam and others realized that they needed to teach the skills that they were perfecting to bystanders so that if anyone—anywhere—attempted to become late, there would be someone right there who could help. It’s one thing to train a handful of volunteers in an operating room but another thing entirely to train a CPR army.

  Although no one realized it at the time, the solution was born back in the late 1880s, when the body of a young woman was pulled from the Seine in Paris, at the Quai du Louvre. There was no sign of violence, so suicide was the suspected cause of death. That, by itself, was hardly noteworthy. By some estimates more than a hundred women ended their lives this same way every year. That river running through the heart of Paris was, unfortunately, an all-too-obvious means of suicide.

  What was noteworthy, though, was that a pathologist at the Paris morgue was so enchanted by her face—even in death, and after what was probably days in the water—that he had a molder make a plaster death mask for him. That mask, or others like it, became wildly popular in the Bohemian salons of the late nineteenth century. The mask inspired comments from Albert Camus, for instance, and a poem by Vladimir Nabokov (“L’Inconnue de la Seine,” originally written in Russian), among others. Copies of the original were common, and imitations were numerous.

  Almost a century later, in Stavanger, Norway, one mask fell into the hands of Asmund Laerdal, then the owner of a toy manufacturing company. Coincidentally, Peter Safar had given a lecture about his research in September 1958 at the meeting of the Scandinavian Society of Anesthesiology and Intensive Care Medicine. A Norwegian anesthesiologist named Bjørn Lind was in the audience, and, inspired by the possibilities for public education, approached Laerdal about making a model on which members of the lay public could be taught how to perform resuscitation. After contemplating the mask he’d discovered, Laerdal used that anonymous woman’s face to begin manufacturing a life-size mannequin who has since become ubiquitous in medical schools and classrooms.

  You probably know her as Rescue Annie. Or Resusci Anne. And if you’ve met Annie, then you’ve kissed the same face that was pulled from the Seine more than
a hundred years ago.

  Annie and I first met years ago, in a medical school classroom.

  But it’s been a while, and I’m thinking this might be a good time to get reacquainted.

  PUSH HARDER. PUSH FASTER. REPEAT.

  Just as she was the last time we met, again Annie is lying on the floor. As usual, she is dead.

  Admittedly, it’s difficult to tell whether a mannequin like Annie is dead. For instance, mannequins don’t scratch their chins or sneeze or wink at you. They don’t do much of anything that can reliably distinguish the quick from the dead. This makes it difficult to determine with certainty that they are, in fact, dead.

  This ambiguity, in turn, makes mannequins not particularly well suited to a CPR training class, which is where I am right now. I’m in the basement multipurpose room of a suburban middle school, standing in an uneasy circle of a dozen fidgety adolescents with the attention spans of fruit flies. None of them seems particularly concerned about Annie’s future health and well-being.

  Nevertheless, we know that she’s dead because there is a large, slightly intimidating man standing over her, who has announced this fact. His artfully mussed sandy hair, crisp chinos, and polo shirt make him look like a gym teacher, which is exactly what he is. The cause of death, Mr. Gym Teacher tells us with a macabre enthusiasm, is a heart attack.

  “What do you do now?” Mr. Gym Teacher asks the group.

  Mr. Gym Teacher turns to the person next to me, a girl of maybe thirteen. He looks at her intently and enfolds his barrel chest in bulging forearms, which, he confided to me when I arrived a few minutes early, came from his evening work as the drummer for a Journey tribute band. Now he attempts a comforting smile that, in this context, comes off as just plain scary.

  “What. Do. You. Do?”