“Code blue, code blue, code blue” over the hospital speakers immediately conveys a call to action. I remember being a resident in Internal Medicine, sitting at the nursing station in the CCU (Coronary Care Unit), signing out to another resident when that call came. A nurse set the alarm for a 74 year old cardiac patient who, while being turned suddenly stopped breathing.
Being the senior resident present I was responsible for leading “the code.” We administered cardiopulmonary resuscitation (CPR) when the nurse couldn’t find a pulse on the patient. We started chest compressions, after a backboard was placed under her so the compressions were more effective. I intubated, or put a breathing tube in her throat that allowed oxygen to flow into her lungs and protected her airway from any fluids that may come up from her stomach. We also administered appropriate medications, and her heart had to be shocked there times. After 40 minutes of aggressive CPR, with no response from a damaged heart, I “called the code,” meaning I stopped all the artificial heroic measures. No spontaneous breathing was noted. She did not have heart sounds. No pulses were felt. She was clinically dead. I looked up at the clock and noted the time of death. I then had the responsibility of informing her next of kin.
With all that modern technology and medications available and being already in the hospital, even in the CCU, the question needed to be asked. Why was the CPR not successful? This article will unpack interesting and disappointing statistics involving CPR.
My research showed that early CPR attempts with chest compressions that could circulate blood during cardiac arrest was first discovered and documented in 1878 with experiments on cats. It was not until 82 years after in 1960 that Johns Hopkins researchers published an article in JAMA, a major research publication. The July 9th article was entitled “Closed-Chest Cardiac Massage.”
You see, prior to this, when someone’s heart failed, the practice was to cut open the chest of the patient and directly manipulate the heart. The abstract ended by the statement, “Anyone, anywhere, can now initiate cardiac resuscitative procedures,” they wrote. “All that is needed is two hands.”
Now although CPR classes, including online classes, are available to anyone who desires the training as to how to save a life, many people learn what they know about CPR from, you guessed it, television. A research study published in 2015 “found that the rates of survival following CPR were far higher in popular TV shows than actual rates.” In fact researchers found that survival after CPR on TV was 70%. This seemed very good. However the true odds are much worse. In 2010 a review of 79 studies, involving almost 150,000 patients, found that the overall rate of survival from out-of-hospital cardiac arrest had barely changed in thirty years. It was 7.6%. Did you get that? Positive results from CPR in TV shows were 70%, but in real life it is 7.6%. (Circ Cardiovascular Qual Outcomes 2010 Jan:3(1):63-81)
That was out-of-hospital cardiac arrest statistics. Bystander-initiated CPR may increase those odds to 10% while survival after CPR for in-hospital cardiac arrest is about 17%. All of these low percentage statistics were a surprise for even physicians. Age will play a major factor in outcome also. A Swedish study published in 2015 in the journal Resuscitation found that survival after out-of-hospital CPR dropped from 6.7% for patients in their 70s to 2.4% for those over 90.
Do these statistics make me think twice about initiating resuscitation in a patient who stops breathing? Absolutely not. This is life or death no matter what the statistics say. I however do want the reader to understand that there are harmful consequences to CPR if it is done correctly.
Chest compressions can and do, especially in the elderly, cause sternum fractures and rib fractures. Lung hemorrhaging and liver lacerations can also happen. Brain injury may be a consequence depending on the time between cardiac arrest and initiation of CPR. Thirty percent of survivors of in-hospital cardiac arrest will have significant neurological disability according to The New England Journal of Medicine November 15, 2012 issue.
In conclusion, the decision as to whether you as a patient chooses to have or not to have CPR initiated, if your heart should stop, must be made, of course, before your heart stops. A conversation with you about this while you are actually having a heart attack is unethical. But remember, a patient with terminal cancer who is resuscitated will still have terminal cancer. In those cases, the most humane approach may be to ease the pain of the dying process. Do Not Resuscitate, or DNR orders would then need to be known by the medical staff so comfort measures can be initiated.
In my practice I have a conversation on a yearly basis with my patients about their health and desire for or against CPR. Maybe this should be a conversation for you to initiate with your health provider at your next visit. Just a thought.
