Perhaps inspired by an evening spent at just such a motel, two physicians, Jose Antonio Adams and Paul Kurlansky, have developed a table that does the same thing. That is, it oscillates back and forth and, they claim, it moves blood in the same way that CPR does. It may also move air through the lungs.
This technique, alas, has not really caught on. In part, this lack of enthusiasm is due to a lack of evidence that it works. In addition, during a cardiac arrest, just plopping a patient down on a wiggling bed or table doesn’t seem like much of an intervention. For doctors and nurses, though, an oscillating bed is no doubt a welcome sight. After an hour of laborious CPR, I can imagine code teams drawing straws to see who gets a Magic Fingers massage first.
“LIKE, JUST PUSH ON HIS CHEST”
So the mechanics of CPR are more complex than you might think. But while it might be true that one can push on the chest to get oxygen to the brain, it’s another thing entirely to get a person to do that pushing. Obviously, even the most sophisticated studies of how CPR works won’t do anyone any good if you can’t induce bystanders to “push hard and push fast.” Or to push at all.
Remember the story of Lorraine Bayless and Colleen? Colleen’s reluctance to intervene is hardly unique. Every day, witnesses to a cardiac arrest watch a person collapse, notice that the victim is no longer breathing, and . . . do nothing. As you’d expect, very few of the stories that illustrate this inertia have happy endings, but there is one that did.
When Tristin Saghin discovered his sister Brooke facedown in the family pool, he pulled her out of the water, laid her out on the concrete, and started CPR. Chest compressions, breathing . . . he did exactly what he was supposed to. His sister began to breathe again on her own, and soon she woke up. Eventually, she made a full recovery.
Nothing surprising there, right? That’s the way that CPR is supposed to work. And that’s what we’re all supposed to do when confronted with someone who is at risk of becoming dead.
The odd thing about this story, though, is that Tristin was only nine years old. His sister was two. Tristin had never taken a CPR course. Neither did he have any idea what he was doing.
He had, however, watched the film Black Hawk Down. And in one scene, as Tristin recalls it, “they were, like, pushing on [his] chest and giving him rescue breaths.” So that’s what Tristin did. He pushed on Brooke’s chest and gave her rescue breaths, and she survived. That success led to a media blitz and, like, a congratulatory e-mail from Black Hawk Down’s producer, Jerry Bruckheimer.
So life imitates art, and lives are saved. All is well, right?
Not entirely.
It’s true that Tristin saved the day, but it’s strange that he had to. For instance, Tristin’s mother and grandmother were right there. They could have started CPR, but they didn’t. So it fell to Brooke’s nine-year-old brother.
How could two adult bystanders stand there, doing nothing? Even if the mechanics of how CPR works are complex, the key steps in performing CPR are really quite simple. “Push hard and push fast” pretty much sums it up. And yet these two intelligent, caring adults didn’t do either.
This is hardly unique. For instance, one study found that bystander-initiated CPR occurred in fewer than one-third of cardiac arrests. That doesn’t mean that one in three bystanders stepped up to the plate. That wouldn’t be so bad. If you’re lying on your back next to a pool with no discernible signs of life, you don’t need an army. You just need one person, with two arms and a sense of rhythm.
No, what it means is that two-thirds of the time, no one stepped up to the plate. No one, sometimes, out of a crowd of ten or more. That’s a lot of spectators in the stands, and not nearly enough people out on the field where they can do some good. What was even more troubling was that this study found bystanders’ enthusiasm varied by neighborhood. Bystanders in lower-income neighborhoods, for example, were even less likely to help.
But why?
There are many reasons why bystanders like Colleen and Brooke’s mother and grandmother don’t help. People are uncertain about what a cardiac arrest is, for instance. They don’t know the procedure for CPR, and they’re afraid of doing CPR incorrectly and either hurting the victim or facing liability, or both. There is also the ick factor—and a deep-seated reluctance to use your mouth on someone else’s, particularly when that person is a perfect stranger. We also are likely to wait for others to act first.
All of those reasons help to explain why we tend to be reluctant rescuers. On the other hand, you have to wonder why we let ourselves be dissuaded by these reasons. Because if you look around, we’re surrounded by examples of successful CPR.
Indeed, it seems as though every day the headlines trumpet stories of heroic CPR efforts and lives saved. We hear about the man who has a cardiac arrest on a golf course and is resuscitated by a caddy. Or the woman who collapses while power-walking in her local mall and is revived by a clerk at Sears. These stories are everywhere, giving the impression that any one of us could be a hero.
And we get the same message from films and television. If Tristin Saghin’s story illustrates how life can imitate art, then art exaggerates life. I’m thinking in particular of the way that television portrays CPR. In a classic study, a group of researchers watched episodes from three television shows that were popular in the 1990s and recorded instances of cardiac arrest and CPR. What they found was that 75 percent of patients who underwent CPR were revived, and that about two-thirds appeared to survive long enough to leave the hospital.
Now, at this point it should be made clear that real-world cardiac arrests don’t always end so well. Those numbers are two or three times better, at least, than what nontelevised patients could expect in the 1990s. And many of the television “patients” experienced their cardiac arrest outside the controlled setting of a hospital and would have done much, much worse.
So we’re exposed to these stories of spectacular successes all the time. We see reports of stunning rescues portrayed in headlines, on television, and in movie theaters. The message—clear and unmistakable—is that CPR saves lives. We should all learn CPR. And we should always, always perform CPR when we have a chance, because any one of us could save a life. And yet most of us don’t.
But hope isn’t lost. Maybe we’ll never truly crowdsource CPR, but that’s OK. Maybe we don’t need to.
MS. HOT SAVES A LIFE
There is a man lying on the floor. There is a certain family resemblance to Rescue Annie and, like her, this man is very clearly made of plastic and metal. So no one in the room is particularly distressed by his deadness. There is one person, though, who is doing a passable imitation of someone expressing concern.
Leaning over the dead mannequin is a young woman of perhaps twenty-five. In a gesture that is borrowed from either television medical shows or the adult film industry, she rips the mannequin’s shirt open, exposing his plastic chest. And then, in a gesture that is not taken from any medical television show that I’ve ever seen, she brushes long blond hair back with both hands, and sticks out a chest that is emblazoned in silver glitter with the word “hot.”
Ms. Hot and I are in a newish, linoleum-tiled windowless room buried deep within the bowels of a suburban shopping center that has recently embarked on an effort to train its employees in the use of eight new automatic external defibrillators (AEDs). These are devices that let bystanders with no medical training shock a heart back to life. The harsh overhead fluorescent lights illuminate a group of ten people, all of whom are shopping center employees. And we’re all here for a crash AED course.
Now Ms. Hot has dispensed with her theatrical Vogue pose and has turned her attention to the AED that is next to her. It’s basically a stripped-down version of Adam, the self-important defibrillator we met in chapter 3. But while Adam was designed for use by medical professionals who could choose whether to follow his advice, this version—let’s call her Eve—is not goi
ng to permit any improvisation. She’s hardwired for safety and can’t be overridden, modified, or cajoled into giving a shock when she shouldn’t.
Ms. Hot removes two patches from Eve’s front pocket and places them on the mannequin’s recently exposed chest, at roughly nine o’clock and three o’clock. Ideally, the patches should be a little more north-south, and Ms. Hot’s placement is optimally suited if her goal is to defibrillate his spleen. Oh, well.
Ms. Hot presses a button on Eve’s face. Then she waits as Eve reads the patient’s heart rhythm.
“The rhythm is ventricular tachycardia,” Eve says in a tone that indicates she’s seen it all before.
“Stand clear,” she warns.
Ms. Hot, perhaps fearing that the room will be engulfed by an electrical storm, jumps to her feet, and takes half a dozen steps back. Suddenly I’m actually closer to Eve and the patient than anyone else, and all of the women in the room are looking at me worriedly. I’m pretty sure there’s no immediate danger of electrocution from six feet away, but I take a step back too. They look relieved, and turn their attention back to the mannequin.
Eve winds up and delivers a shock. Ms. Hot seems somewhat confused. It’s as if she were expecting sparks and singed flesh.
“The rhythm is sinus,” Eve reports. Then she checks out.
The instructor thanks Ms. Hot for a job well done, and everyone applauds. Ms. Hot takes a bow. Just another day of life and death in suburbia.
I’ve just met the most exciting development in crowdsourcing CPR to come around in the past twenty years and its star is . . . you. Or me. It’s all of us.
Just as CPR revolutionized the science of resuscitation, taking an OR procedure to the streets, AEDs take the lessons of defibrillation to malls, stadiums, and even airplanes. Now any one of us can slap a couple of patches on a chest, yell “Clear!” and perhaps even save a life.
To be fair, at least some of the technology is relatively simple. Remember Charles Kite? The DIY paramedic who is credited with shocking a girl back to life after a fall in 1788? He accomplished that feat—the story goes—with a homemade battery. Basically he used a charge of electricity in a jar. So the science of shocking someone is not terribly complex or new.
What is complex and what delayed this latest advance in crowdsourcing by more than two hundred years, is figuring out when to shock. Some rhythms respond to a shock, and others don’t. As we’ve seen, shocking asystole (a flat line) won’t work, no matter what fictional rescues you may have observed on the television screen or in movie theaters.
The real risk of a mistake, though, arises if you shock a normal or almost-normal rhythm. A sinus tachycardia, for instance, is a normal rhythm, propagated in the usual way, but is just faster than normal. Apply a shock to that rhythm, and you could cause ventricular fibrillation, which would be bad. Or asystole, which would be worse. (Ms. Hot’s anxiety notwithstanding, the risk to a bystander is negligible.)
Now, maybe I’m being unfair, but if that were me, flat on my back without a pulse, I’m not sure I could count on someone like Ms. Hot for an accurate diagnosis. So any DIY resuscitation device needs some way to figure out whether a rhythm will respond to a shock. And it needs to be able to restrain itself from delivering a shock that would be ineffective, or even harmful.
The idea behind AEDs has been around for a while, mostly as a science-fiction dream, reminiscent of those Star Trek gadgets that would diagnose injuries, treat them, and give you a deep tissue massage, all at the same time. But the progression of their development has been gradual. Early defibrillators provided shocks only, and later became integrated defibrillator-monitors. At first, those integrated AEDs offered cues and suggestions to health-care providers, and from there it was a relatively short step to offering more simple recommendations to bystanders.
That’s what Eve did for Ms. Hot. Eve was a semiautomated device. Eve read the rhythm and then asked Ms. Hot to push a button to administer the shock. I suppose it’s the machine world’s way of making us humans feel as if we’re still in control. It’s a nice gesture, but in general, in my experience, when an AED as authoritative as Eve tells you to push the button, people generally do exactly that.
These AEDs are undeniably cool. They can make a paramedic out of almost anyone, including middle school students. But do they work?
Indeed they do. In one large descriptive study of out-of-hospital arrests, patients who received bystander CPR had a 9 percent chance of survival, whereas those who had an AED applied had a 24 percent chance of survival. What was most impressive, though, was that the AED group’s survival increased to 38 percent if the AED found a rhythm that it could shock. And 38 percent for an out-of-hospital arrest is about as good as these numbers get. So yes, even in the hands of someone like Ms. Hot, AEDs save lives.
So should we deploy AEDs everywhere? Well, maybe not. Remember that AEDs work best if they can find an abnormal rhythm to shock. And it turns out that, for some reason, these “shockable” rhythms are more common in public places. When a bystander applied an AED in a home, 36 percent of patients had a shockable rhythm, compared to 79 percent when a bystander applied an AED in a public setting.
Why that’s the case isn’t clear, but it’s possible that cardiac arrests at home are caused by different events (such as a massive blood clot in a pulmonary blood vessel) that are more likely to go straight to asystole, bypassing treatable rhythms. Not surprisingly, in the same study, survival rates in public settings were almost three times greater (34 percent versus 12 percent). The bottom line, therefore, is that although it probably makes sense to put an AED in a mall, it’s probably not worth investing in one for your living room.
So in order for AEDs to save lives, they need to be common in public places. Common enough so that there’s always one within shouting distance. Think about how ubiquitous ATMs are, and that would give you an idea of how many AEDs we need out there. The problem, though, is that we have a long way to go.
“LOCATION, LOCATION, LOCATION”
In matters of life and death, as in real estate, location matters. To see just how much it matters, I’m taking a walk. Two walks, actually, about ten miles apart.
First, I check out an outdoor shopping center in a nice suburban neighborhood. I pass a long list of nice stores selling clothes, shoes, and very expensive espresso machines.
After perhaps fifty yards, I see it. There, next to the restrooms, is an AED station. I keep walking. I turn and go into a large department store and wander through to the back. And there, right next to the customer services desk, is another AED station. Out the back door and past the Apple store. Then through a long arcade and out the other side, next to a small food court. And there, just where I was expecting it, is—you guessed it—another AED station. I’ll spare you the details, but I spent about two hours in that place and came across no fewer than six AEDs.
My second walk takes place in a different sort of neighborhood entirely. Now I’m walking down a slightly iffy street. It’s bordered by the University of Pennsylvania on one side, and on the other side by a neighborhood that gets dicey very quickly. To my left, each subsequent block contributes a progressively higher prevalence of boarded-up buildings, overgrown lawns, and other indicators of decline.
I’m keeping to what feels like the safer side of that dividing line, and again I’m on the hunt for AEDs. I wander by a gas station, and then another gas station. Nothing.
Then my hopes rise as I spy a convenience store. I wander in, picking up a package of M&M’s for company. Nope. No AED.
A block farther on, there’s a small strip mall of perhaps a dozen stores. Maybe this is the place? A hairdresser, a liquor store, a Radio Shack . . . I peer into windows and stop into a few stores just to be sure, but it’s as I suspected: no AEDs.
The problem with AEDs is that they’re not everywhere. My training session with Ms. Hot is living proof of that. That subu
rban mall had made a commitment to ensure that no one was going to die of a cardiac arrest on its watch. That’s admirable. Ditto the second shopping center I visited. And other establishments have made the same commitment. Hospitals, certainly. And airports. Even airplanes.
What’s interesting is not where these AEDs pop up, but where they don’t. Dr. Raina Merchant, a colleague of mine at Penn, has been studying the way that AEDs map to populations, and it was her research that prompted my two strolls today. In Philadelphia, for instance, she’s found that there are more AEDs per capita in areas of the city where the population is predominantly white, well-off, and highly educated. Conversely, if you’re in a poorer, largely African American neighborhood, you probably shouldn’t count on an AED coming to your rescue. If you’re thinking about having a cardiac arrest, a suburban mall is an excellent place to be. The corner of Forty-Ninth and Market Street in West Philadelphia, not so much.
Don’t like that uncertainty? Well, you know what they say: if you want something done right, you have to do it yourself. That’s perhaps more difficult when it comes to restarting a heart than it is, say, if you’re making a cup of coffee or changing a tire. But the same principle applies.
But how can someone restart their own heart? I’m about to meet someone who has pulled off this trick not just once, but several times. Although, truth be told, he’s had a little help.
Shocked Page 22