No...They are not breathing. And they have no arms or legs.

-- The Office "Stress Relief"

When it comes to medical drama, there is nothing more exciting than the coding patient. That image of the flat line across the screen, the handsome doctor stubbornly refusing to stop compressions, the magic of faint beeping as the patient gasps and returns to the land of living.

While movie magic might make CPR seem like the last weapon against death, real life resuscitation doesn't quite live up its glamorous depictions. In fact, survival rates of CPR in fictional media are as high as 70% compared to the American Heart Association's statistic of 45% of patients even making it to the hospital. Moreover, approximately only 10.6% of patients end up leaving the hospital after cardiac arrest. And that number doesn't take into account the long-term treatment and therapies needed afterward!

In medicine, there is a concept of "heroic measures." It's the idea that there are treatments or courses of therapy that possess a high risk of causing further damage to a patient's health, but are undertaken as a last resort. CPR is one of these heroic measures--it's messy, it's brutal, but it can sometimes save a life.

Resuscitation and CPR is a huge topic: it could fill books and courses beyond what we'll discuss. But in this short look, let's try to dispel some of the big myths.

The Myth

Picture it. An older couple is arguing over dinner. The man suddenly clutches his chest, groans, and drops to the floor. The woman screams. Someone shouts to call 911.

A pair of hunky paramedics arrive on the scene a moment later. With barely a glance, they simultaneously tell each other that he's had a heart attack. One starts compressions, biceps rippling.

The other attached the patient to his very fancy monitor. Flatline.

"We have to shock him! Clear!"

His partner stops CPR, throwing his hands up as the jolt of electricity is delivered to the patient. The patient's body thrashes violently.

"Still flatline," one laments. "Don't die on me now!"

"Shock him again!"

Miraculously, that second current of live-saving electricity does its job. The patient sucks in a breath of air, blinking and groaning. The woman smiles through her tears. The paramedics fist bump. Another day saved.

The (Abridged) Real Deal

Let's use the same man and woman arguing at the restaurant. He has a history of angina--that is, chest pain brought on by stress or exertion. Normally he takes a medication called nitroglycerin to manage the painful episodes but he's taken a few doses and it isn't working like it normally does.

He feels a crushing pressure--as if an elephant is sitting on his chest--and starts to sweat. Anxiety and nausea start to creep in too. Although he's normally a pretty tough guy, he really feels that something is wrong. And his left arm just feels funny--kind of numb and prickly. (1)

This is when 911 should be called. He has the signs and symptoms of cardiac chest pain that is not responding to his medications. For the sake of drama, let's say he ignores the pain--he's a tough guy, after all.

Actually, he's been ignoring the pain all week. And now at dinner, his head slumps. He goes down. His wife shakes him but, beyond the horrible sound of agonal gasping, he is unresponsive (2). Someone calls 911 and a bystander starts compression-only CPR guided by the 911 dispatcher over the phone.

When EMS arrives, it's a team of paramedics, EMTs, and (sometimes) firefighters. An EMT takes over the compressions. The other EMT assembles a bag-valve-mask to deliver oxygenated breaths to the patient. Working around the compressions, a paramedic strips away the patient's shirt to attach the defibrillator pads.

Compressions stop momentarily at the machine's automated command. It's an Automated External Defibrillator--or AED--that can analyze the electrical activity in the heart and provide huge discharges of electricity. There are only a few types of scenarios where a shock can interrupt a dysrhythmia (an abnormal electrical pattern in the heart).

In a cool voice, the machine says, "Shock Advised." The machine guides each step in that same clear voice. In the heat of the moment, it's easy to panic: good thing it reminds the rescuers to place the pads on the patient's chest and plug them into the machine.

At the push of the button, the machine charges and everyone yells "Clear!" as they move from touching the patient. No one wants to inadvertently deliver a jolt to a colleague.

Once everyone is clear, another button push delivers the shock. The patient's body twitches slightly. The EMTs immediately re-begin CPR before the machine can finish giving the verbal command. They'll continue for another 2 minutes before the AED analyzes the electrical rhythm again. The paramedics will also work to get access to the patient's bloodstream with an intravenous catheter (IV) or intraosseous catheter (IO) so that they can give rapid-acting medications that can help the resuscitative efforts (3).

It falls on the paramedics and, sometimes, medical control to make a decision. Do they continue CPR on the scene or take the patient to the hospital? A lot of factors can affect this decision, but in most urban settings, it is better to get the patient to the hospital as soon as possible. For the most part, "stay and play" isn't the answer: especially when it comes to trauma, longer prehospital times are associated with a higher mortality rate.

The thought is this--if something caused cardiac arrest, are we really going to be able to fix it in the field? Heart attacks, pulmonary embolisms, electrolyte abnormalities, massive strokes...these things take a well-equipped hospital to treat. Resuscitation is a way to buy time--it does not fix the root cause.

In this case, let's say our paramedics decide to transport the patient to the nearest hospital with a cath lab (that is, a hospital that can perform the necessary treatment to help fix a heart attack). ACLS interventions will continue throughout the transport with the whole team piled in the back of the ambulance. CPR continues even as they push the gurney into the resuscitation bay of the hospital!

The Emergency team is waiting for them and jumps in to take over care. A team lead, usually the Emergency Department physician, calls out orders. Nurses jump in to draw blood, attach the patient to advanced monitors, and potentially start more IVs; and a line for compressions forms. Compressions, breaths, medications, and shocks will continue as needed through the cycle.

This cycle will continue until ROSC--Return Of Spontaneous Circulation--occurs or a decision is made to stop. Five minutes or over an hour, that decision to stop CPR is up to the team lead.

In this case, let's say we get ROSC with our hypothetical patient. He's still unresponsive and not breathing, but he's got a pulse. A repeat EKG shows that he has myocardial ischemia in an area of his heart--looks like a massive heart attack. He's very quickly intubated (if he wasn't already). He'll get sent to the cath lab to try to fix the blockage.

So who actually needs CPR?

CPR stands for CardioPulmonary Resuscitation. The combination of compressions and breaths acts as a temporary measure to circulate oxygenated blood when the heart has stopped working.

The people who need CPR are mostly dead. They do not have a pulse. Their hearts have stopped working, thus the name, cardiac arrest. The hope is that their brain is still functioning and we can buy time until we figure out how to fix the heart.

The heart can stop working for a number of reasons (4). Heart attacks (also called myocardial infarctions), blood clots, lack of oxygen, toxins, drugs, trauma, electrolyte imbalances, structural abnormalities...It doesn't matter if you're old and sick, or if you're young with an underlying heart problem, anything that can affect the electrical system of the heart can lead to abnormal rhythms and cardiac arrest.

Notice that cardiac arrest isn't the same thing as a heart attack! Common misconception.

How does CPR work?

Once the heart stops circulating blood through the body, cells start to die. The most important of these cells are neurons, the cells that create brain tissue. These sensitive neurons only have 4-6 minutes before they start dying from lack of oxygen.

Good quality CPR pumps blood through the body, getting oxygen to the tissues. Good quality CPR, however, is a pretty brutal process. Pushing against the rib cage to squeeze the heart takes a lot of strength!

Compressions are the key to high-quality CPR. In bystander CPR, there is some evidence that compressions alone are enough to help keep someone's tissues perfused. So if you're squeamish about mouth to mouth, hard and fast compressions can always be performed in an emergency.

But what about the oxygen?!?! With compression-only CPR, the idea is that there is lingering oxygen bound to red blood cells that you can help circulate throughout the person's body.

In the atmosphere, approximately 21% of that air is oxygen. Oxygen is required in cellular metabolism--go without it for too long, and cells start to die. We exhale 16% oxygen. So mouth to mouth, while potentially better than nothing, isn't giving that much oxygen. When the ambulance arrives, the bag-valve-mask can deliver breaths of 100% oxygen. The high concentration helps force oxygen into the red blood cells.

Clear?! Clear!!

When it comes to cardiac arrest, only two electrical rhythms are shockable. Ventricular tachycardia and ventricular fibrillation (5). Don't shock a flatline.

But a flatline isn't the worst thing to see on a monitor. Now, if a person has clearly been dead for hours and they have a flatline--there's no coming back from that. BUT when we shock ventricular fibrillation or ventricular tachycardia, we're doing a hard reset of the heart's electrical generator. A flatline can sometimes show up during that reboot process.

*And this doesn't even start to get into Pulseless Electrical Activity and other unstable arrhythmias that require synchronized cardioversion*

So how do I put resuscitation into a story?

Whether it's literary or on the silver screen, resuscitation can make for dramatic moments. Do you want to give an emotional side to your hotshot doctor? Or does your narrative need a heartbreaking theme of inevitability? Maybe you want to show victory despite the odds.

Whatever it is, there is a lot of room for creative license.

Even if you're not interested in trying to write medically accurate narratives, I hope you learned something along the way.

Feel free to leave any questions about resuscitation or any topic requests for the next update. And if you read this hoping to learn how to perform CPR, I'd suggest that you check the local programs in your area. It's easy to learn!

Footnotes

(1) I've described a typical cardiac episode here for the sake of simplicity. However, it's worth mentioning that atypical chest pain can occur in women, the elderly, and people with diabetes. The symptoms in atypical cases are trickier! From nausea, abdominal pain, to just "feeling wrong," atypical chest pain takes a suspicious mind to catch.

(2) Agonal gasping is a last-ditch effort from the brainstem -- even if a person is gasping, if they don't have a pulse, start CPR!

(3) These medications change from time to time, but normally epinephrine is the go-to in an arrest. Depending on a person's underlying risk factors for cardiac arrest, other medications can be given. Feel free to ask for specifics.

(4) If you're curious about other reversible causes of cardiac arrests, the Advanced Cardiac Life Support (ACLS) algorithms suggest using H's and T's to remember the reversible causes of cardiac arrest.

(5) Electrical cardioversion is a different beast that won't be discussed in his brief chapter

References

Gonzalez, R. P., Cummings, G. R., Phelan, H. A., Mulekar, M. S., & Rodning, C. B. (2009). Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis. The American journal of surgery, 197(1), 30-34.

Monahan, K., Ducach, G., & Olympia, R. P. (2019). Cardiopulmonary resuscitation survival rates depicted in emergency department-associated medical television shows. Resuscitation, 135, 236-237.

Ouellette, L., Puro, A., Weatherhead, J., Shaheen, M., Chassee, T., Whalen, D., & Jones, J. (2018). Public knowledge and perceptions about cardiopulmonary resuscitation (CPR): Results of a multicenter survey. The American journal of emergency medicine, 36(10), 1900-1901.

Portanova, J., Irvine, K., Yi, J. Y., & Enguidanos, S. (2015). It isn't like this on TV: Revisiting CPR survival rates depicted on popular TV shows. Resuscitation, 96, 148-150.

Releases, A. H. A. (2015). Heart and Stroke Statistics, The Sudden Cardiac Arrest Foundation-You Can Save a Life Anywhere.