Shocked

by David Casarett

  Silence. Deer. Headlights. There is an intensely awkward moment as the girl looks very intently at her Converse-clad feet.

  But fortunately for us all, in that moment, a future doctor is born. On the other side of our little circle, a hand rises tentatively. The hand is attached to a boy who is looking excited and nervous.

  “You check for danger,” the boy says.

  Mr. Gym Teacher nods curtly. “Right. Then what?”

  The girl next to me decides that her feet are perhaps not as fascinating as she’d first thought. She looks up at me. Then at Mr. Gym Teacher.

  “Then you check for a response,” she says quietly.

  “Right,” Mr. Gym Teacher says. He smiles. Everyone relaxes, just a little.

  “Then?”

  No one’s talking, so I help out. Just a little. You send for help, I suggest, and Mr. Gym Teacher nods, pleased to be done with the preamble.

  Mr. Gym Teacher is about my age, which means it’s likely that he’s been teaching this stuff for a while. And, like me, he’s probably old enough to remember the good old days when the mnemonic we used was A (airway), B (breathing), C (circulation).

  But not anymore. Now it’s D (check for danger), R (check for a response), and S (send for help). In fairness, these letters seem to be proving themselves to be excellent guides. They’ve gotten this group of middle school students (plus one doctor) through D, R, and S. Not bad.

  Next, there are our old friends A, B, and C, albeit rearranged as “CAB,” which gives primacy to restoring circulation (C) through chest compressions. That, science is beginning to understand, is the most important part of the whole resuscitation thing. This is good news for many heart attack victims, but bad news for many trainees who are now stuck having to memorize the rather disgusting mnemonic “DRSCAB.”

  So now that we’re done with DRS comes the hard part: C.

  It’s safe to say that we’ve all been dreading C. That’s because we inherently dread another letter that is not part of the mnemonic—V—which stands for “volunteers.” As in: “I need a couple of volunteers to demonstrate CPR, in front of their peers, while being critiqued in front of said peers by an intimidating gym teacher.”

  But Mr. Gym Teacher doesn’t ask for volunteers, which is good. Instead, he points at the two kids who have volunteered answers so far, which isn’t. Perhaps he’s operating under the assumption that no good deed should go unpunished. He points at them, and then at Annie. Then, just in case it wasn’t clear, he points at each of them again.

  They both look very hard at the floor. The boy fidgets. The girl is starting to hyperventilate so forcefully I’m concerned that she, too, may join Annie on the floor.

  Thinking back to my own adolescence, it’s difficult to imagine a scenario that would be more embarrassing than performing CPR for the first time in front of a sniggering group of your peers. Unless, perhaps, it’s doing so with a person of the opposite sex.

  The boy—not so shrewd—takes a step forward. The girl, demonstrating a level of maturity far beyond her years, takes two steps back. She looks as though she’s seriously contemplating feigning a seizure. Out of sympathy, I raise my hand.

  Mr. Gym Teacher—who, for the record, amusingly enough, is named Jim and is actually a really nice guy—smiles at me and nods. So the boy and I approach Annie.

  Fortunately, I’ve read the official manual on “How to Pretend to Revive a Fake Dead Plastic Person.” (In case you, too, want some fun bedtime reading, this volume’s actual title is “Part 5: American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.”) For what it’s worth, I prefer my version.

  First, I remember, the rescuer should begin by “tapping the victim on the shoulder and shouting at the victim.” Tapping is easy. I tap. Annie doesn’t respond.

  The shout is more difficult. I settle for an innocuous but simple “Hey!”

  As expected, this outburst has no discernible effect on the armless torso in front of me. Oddly, though, the boy across from me is staring at Annie intently as if maybe he was thinking she might wake up. Alas, she does not.

  Next we need to start CPR. But the kid is now one step ahead of me. He remembers what, in the heat of the moment, I’ve forgotten. He turns, with a stage actor’s gravity, to one of the kids in the circle around us and tells him to call 911. The solemnity of the moment is marred somewhat when his voice cracks into a squeak, but no one seems to notice. Certainly not Annie.

  Right. So now someone is sending for help. In the meantime, it’s on to CPR. This is when things get less fun, and I’m already wishing I hadn’t volunteered for this duty.

  The 2010 American Heart Association guidelines say that untrained bystanders can’t reliably determine whether a patient has a pulse. Checking for a pulse also takes time, which the victim generally doesn’t have much of. Thus the guidelines recommend avoiding this step entirely.

  If someone collapses and is not breathing (or is only gasping), the guidelines say, it’s safe to assume that they’ve suffered a cardiac arrest. Even trained health-care providers shouldn’t spend more than ten seconds checking for a pulse. Lay rescuers aren’t supposed to check for breathing, either, for the same reasons. It’s the compressions, and specifically the rate of compressions, that matter. The more compressions you do, the more likely a patient is to recover a heartbeat and a pulse.

  Unsure whether I’m a layperson or a trained health-care provider in this scenario, I skip the pulse check and the breathing check.

  As I kneel down next to Annie, my back creaks a subtle but unmistakable warning. It is telling me in no uncertain terms that regardless of whether I’m an untrained bystander or a trained health-care provider, I’m most certainly not a twelve-year-old boy.

  Nor am I as clever as this particular twelve-year old boy, who has slyly taken a position at Annie’s head, leaving the rest of her to me. What that means, in practical terms—and these terms are the only terms that my aging back cares about right now—is that while I’m doing thirty chest compressions, this kid is just going to sit there. Because that’s the ratio we’re expected to provide. Thirty compressions for every breath.

  What’s even more unfair is the fact that he’s not even essential to this CPR effort. There’s growing evidence that maybe chest compressions are the only part of CPR that matters. In one meta-analysis of adults with out-of-hospital cardiac arrests, compression-only CPR by the lay public had a higher success rate than standard CPR did. That is, cardiac arrest victims may actually do better if someone isn’t crouched over them trying to breathe for them. The reasons for this aren’t entirely clear, but it may be that it’s just too much to ask untrained bystanders to do chest compressions and breathing. It’s a little like talking on a cell phone while you’re driving. If rescue breathing distracts rescuers from doing (much more important) chest compressions, then the outcomes would be worse. Maybe much worse.

  Anyway, the guidelines—perhaps written by the same Madison Avenue firm that penned Nike’s “Just Do It” tagline—admonish rescuers to “Push hard and push fast.” So I do.

  Alas, apparently I’m not pushing fast enough. Jim asks me, in between compressions, how fast I’m supposed to be . . . compressing.

  It’s amazingly difficult to answer a question like that when you’re bouncing up and down like a demented bobble toy. Especially when your back is giving you the warning signs of a crescendo of twinges that indicate it’s not going to stand for this abuse much longer.

  The answer, I know, is one hundred compressions per minute. And each compression should depress the chest wall by two inches. And that’s what I’m doing. Or, at least, that’s what I think I’m doing.

  “Your depth is good . . .” Jim reports. Wow. My depth is good. I’m a star. I grin.

  And seriously, that’s something to be proud of. One large study of out-of-hospital
cardiac arrests found that rescuers don’t usually get the compression depth right. That’s important because the same study also found that patients who didn’t get the right compression depth had worse chances of survival.

  “But you’re not going fast enough.” There’s a moment of silence in which I try to think of a clever retort, without success.

  “Think about the beat of ‘Stayin’ Alive,’” Jim says. “You know, the Bee Gees.”

  In the few seconds it takes me to look up at Jim and nod, I register a wall of blank looks around me. I swear I can see wheels turning slowly in little adolescent heads. I also see a few of them mouth the words as if they’re trying out words in a foreign language.

  What are Bee . . . Gees? they ask themselves. What indeed?

  It’s true, that iconic song from 1977 provides the perfect beat for chest compressions. Unfortunately, this is probably not very useful information. In the year 2014, the only person at a typical cardiac arrest scene who is likely to appreciate this rule of thumb is the elderly person who is lying on the floor.

  Life is not fair to the aged. Not only am I being forced to do thirty laborious chest compressions for each little breath that the kid delivers, but I’m also doing it at the exhausting rate of a hundred beats per minute. I’m thinking this would be an excellent time to remind everyone around me that rescuer fatigue sets in very fast—after the first minute of CPR. Studies show fatigue results in a measurable decline in CPR effectiveness after the first minute of compressions, even though rescuers may not feel tired.

  For the record, though, I feel tired.

  Meanwhile, the kid is clowning and making a show of his exhausting one breath given every thirty compressions. The crowd begins to giggle. I keep sweating.

  I give Jim a warning look. He relents. “Switch,” he says.

  I smile and try to straighten my back, which I think is permanently locked into a C-curve. The kid looks uneasy. I smile sweetly and body-check him out of my way, pointing at Annie’s torso.

  Now I have to do B for breathing. At a rate of about three breaths per minute. Each breath gets about one second. And each breath should have a tidal volume of 500 to 600 cc. This is about the volume of air that’s in an empty Venti iced latte cup, once you drink its contents. Something I’d really like to do right now.

  Instead, I tilt Annie’s head back, pinch her nose with my left hand, and move her jaw forward with my right. I’ve done this perhaps half a dozen times with a real person, but with Annie, there’s much more resistance and it’s more manhandling than there would be under normal circumstances. Annie doesn’t seem to mind.

  One breath, and Annie’s chest rises and falls. Easy. Then I sit back and watch happily as the kid proceeds to get everything wrong.

  His compressions are not deep enough, which one of his classmates is quick to point out. Then he gets flustered, and his compressions slow down. He is not anywhere close to “Stayin’ Alive” speed.

  I mention this.

  The kid is momentarily distracted by my helpful advice and he pauses, which everyone knows you’re never, ever supposed to do.

  “Push harder!” someone yells.

  “Push faster!” another chimes in.

  Soon they have a singsong pep rally chant going.

  “Push harder!”

  “Push faster!”

  “Push harder!”

  “Push faster!”

  Converse Girl and the girl next to her are slapping their thighs to keep the rhythm going. This, I’m thinking, is much better than disco. Take that, 1970s.

  Alas, Jim assumes an expression that suggests he is about to put an end to this rally before it turns into a rave and Annie gets trampled. The chanting subsides gradually. Then our little rescue comes to a close.

  Jim announces that we have—against all odds—saved Annie. She’s alive. Except for the fact that she’s still missing two arms, two legs, and pretty much everything else.

  Nevertheless, the kid and I are heroes. Jim invites everyone to clap for us, and, much to my surprise, they do. What’s more, I feel good. I really do. I saved Annie!

  The kid, back in clown mode, takes a bow. I contemplate joining him, but my back suggests that any sudden movements would not be welcome right now. Instead I hobble out of the circle to safety.

  Finally, after it’s all over, there’s a reward. Each of us gets an I LEARNED HOW TO SAVE A LIFE TODAY! button. I’m thinking this might be worth a free drink at my local bar. And since I’m the only one here who is old enough to take advantage of this potential perk, I seriously consider asking a couple of these kids to hand theirs over. Converse Girl, at least, owes me.

  “MAGIC FINGERS” CPR

  Several weeks later, my back is starting to feel more normal. But the memory of my encounter with Annie is still fresh in my mind, and I still get a reminder of that afternoon whenever I lean over to put a leash on my dog. CPR may be effective, but it’s not easy.

  But at least the theory is simple, right? You push on the chest of a dog—or a person—and that pressure squeezes blood through the heart. What could be more straightforward?

  Actually, the mechanics of CPR aren’t nearly as simple as they sound. Josh Lampe, the engineer who was testing various ways to cool Petunia the pig while her heart was stopped, explains to me that although CPR looks like something even a chimpanzee—or an eighth-grader—could do, it turns out that it’s actually far more complicated than you’d think.

  We’re talking about the C part of CPR, and Josh is holding up a piece of paper in one hand. This, he’s telling me, is the argument for the complexity of C. Sprawled across the page is a graph that looks to me like a stream of squiggly lines layered on top of one another.

  “This,” Josh says dramatically, “is a pig.”

  What he means is that these lines are various measurements made in a pig who was undergoing CPR. These squiggly lines, he says, represent a composite picture of the way that blood flows through a pig—and presumably a person—while someone is pounding on its chest. These lines tell us how CPR works, and how those chest compressions move blood through the pig’s heart and out into its circulation.

  To me, these squiggles look like a generous slice of baklava in cross-section. To Josh, though, each line tells a story, and he can read the whole mess in much the same way that a surveyor reads a topographic map. What he sees is both confusing and really, really cool. And if you’re an engineer who makes a living studying the insides of pigs, those two adjectives amount to pretty much the same thing.

  The story told by these squiggles flies in the face of what I, at least, was taught in medical school. I’d always figured that when I performed CPR on a patient, the mechanical force of the chest compressions re-created some semblance of the heart’s normal function. Because the heart’s valves allow blood to move forward but not backward, a little squeeze, I thought, would produce something like natural circulation. Whenever I’ve been called to a cardiac arrest and ended up responsible for C, I’ve always thought of the mechanics of one of those small foot-operated pumps you use to inflate an air mattress. That is, I’ve thought of myself as a large foot.

  However, the squiggles in front of me suggest that the explanation is not that simple. As Josh points out, the blood flow illustrated on this graph is minimal. Blood isn’t really circulating at all.

  That’s eye-opening. It’s also a little depressing. Is he saying that all of those chest compressions I did as a medical student and resident didn’t really push blood out of the heart and into the circulation?

  Yes, it turns out that’s exactly what he’s saying. In this pig model, at least, the blood is just washing back and forth. This is known in technical circles as the sloshing theory. Maybe, the theory goes, chest compressions don’t really move blood from veins, through the lungs, and out through the aorta. Maybe they simply push blood out in both directi
ons—into the veins and into the aorta—and then suck it back in. This possibility is particularly interesting because it suggests that if CPR works, it doesn’t necessarily require the difficult task of making blood flow normally. Maybe it’s enough to simply slosh blood around.

  To see how that might work, remember that the chief goal of compression is to get oxygen to key organs like the brain. One way to do that is to load oxygen into the red blood cells as they pass through the lungs, and then push them out to waiting organs. But sloshing could do much the same thing. When you slosh blood around, you mix it. And when you mix any liquid, the stuff that it’s carrying diffuses, and concentration gradients eventually disappear.

  Put a few drops of blue food coloring into a bucket of water, and it forms a little blue cloud. But if you jostle the bucket repeatedly, that cloud starts to spread. Pretty soon you have a bucket full of blue water. That’s the appeal of the sloshing theory. Get a little oxygen into the blood via the lungs, and then slosh it up to the brain and everywhere else it’s needed.

  This seems farfetched, but Josh points out that there are other situations in which sloshing seems to work quite well. For instance, there is an odd type of ventilator that is occasionally used in ICUs called a jet ventilator. It’s used when the lungs are very stiff or severely damaged, and when normal (large) in-out breaths could damage lung tissue. Instead, the jet ventilator provides very small, very frequent puffs of air that diffuse oxygen at low pressure. Watching one of these in action, it’s difficult to believe it could deliver any oxygen at all, but it does.

  So is it possible that more effective sloshing could lead to more effective CPR? Maybe not. Blood is much more dense, and so you can’t slosh blood as quickly and effectively as you can slosh air. And with CPR, you’re talking about an entire body full of blood, not just a small bag of air. Nevertheless, there is an odd line of research that’s capitalizing on the sloshing theory.

  If you’ve ever spent any time traveling the back roads of the Midwest, and if you’ve ever stayed in an old motel—the kind that proudly advertises “Color TV” and “Air Conditioning” as if they’re newfangled inventions—you may have encountered an odd device that was popularized in the 1970s called a Magic Fingers bed. Drop a quarter into the metal control unit on the nightstand, and the mattress begins to vibrate, providing fifteen minutes of “tingling relaxation and ease.” Or so the sign promises. Having tried this device once in a motel outside the tiny town of Newberry in the Upper Peninsula of Michigan, all I can say is that it feels vaguely disorienting in a numbing sort of way. Like enduring a particularly long, mild earthquake.