August 21, 2019

Forget what you see on TV: Here's what CPR is really like

Daily Briefing
    Editor's note: This popular story from the Daily Briefing's archives was republished on May 12, 2021.

    On television, when providers rush to administer CPR to a patient, they're almost always successful, but the "reality of cardiac arrest" is much different, and despite providers' best efforts, it's often more deadly, Charlotte Huff writes for Mosaic Science.

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    Cardiac arrest: a life-threatening, but common event

    Millions of people around the world experience cardiac arrest each year. About one-third of cardiac arrests in the United States happen in hospitals, Huff writes.

    When a patient's heart suddenly stops beating "that individual automatically becomes the sickest person in the whole hospital," according to cardiologist Brahmajee Nallamothu.

    To save the patient, standard care calls for CPR. The continuous chest compressions mimic the pump of the heart and send oxygen-rich blood to the brain. But the compressions must be fast, roughly 110 a minute, and require great strength. The individual administering CPR must use straight arms to push repeatedly down 5 to 6 cm on the patient's breastbone.

    "[I]f the heart is considered shockable," the response team will administer an electrical jolt from a defibrillator, Huff writes.

    The reality of resuscitation

    But unlike what's depicted on television, resuscitation can be "a messy and, in some respects, undignified process, full of beeping machines, ventilators and other paraphernalia," Huff writes.

    The resuscitation process also is physically demanding. "The exertion can leave a clinician drenched in sweat, their triceps burning from the effort," Huff writes.

    When performing compression, Amy Dahart, an intensive care unit nurse at Mary Washington Hospital, always ensures that another clinician is nearby to step in.

    "If you're doing it correctly, you are going to beg for mercy after about a minute and a quarter," Dahart said.

    For patients and loved ones witnessing the event, the experience can be harrowing, as it's not uncommon for the force of the compressions to break the patients' ribs.

    Olga Rafidi recalled a situation when clinicians had to work for 90 minutes to restore her 48-year-old sister's heartbeat.

    Rafidi said the room looked like a "war zone" with medical trash, including paper and gloves, strewn around on the floor.

    Rafidi said her sister, Rima Rafidi-Kern, "looked like if you would take a piece of meat, like a steak, and beat it, and how it gets thin and big. … And she was gray, literally gray." After more than 90 minutes, the medical team restarted her sister's heart and rushed her to the ICU.

    How successful is CPR?

    However, television seldom depicts the real outcomes of CPR, Huff writes.

    A 1996 study that looked at 97 television drama episodes that involved 60 CPR attempts found that about 75% of the fictional patients survived after CPR.

    "That can influence our ideas about recovery rates," Huff writes.

    For instance, a newer study published in 2015 found that almost 75% of patient's family members and decision makers thought the patient's chance of surviving cardiac arrest was more than 75%.

    "The true post-arrest odds … are grimmer," Huff writes.

    One analysis of 24 studies of in-hospital cardiac arrests revealed that the chance of survival for patients was about 15%. And a study that looked at patients from 2000 to 2009 found that more than 25% of those who survive an in-hospital cardiac arrest will live with brain damage.  For every minute that a patient's heart isn't beating, even during the resuscitation process, the risk of damage to brain tissue, long-term disability, or death increase.

    What's more is that the odds of survival can vary significantly by hospital.

    One analysis sorted 468 hospitals from the American Heart Association's hospital registry into 10 groups based on the rate of patient survival. The study revealed that that only 12% of patients survived an arrest in the worst-performing group of hospitals, compared with 23% in the top group. "Even among similar types of hospitals, such as academic ones or rural ones, there were wide variations in survival rates," Huff writes.

    How hospitals achieve above-average survival rates

    While the disparities in survival rates between hospitals may seem "troubling," Nallamothu said they present an opportunity for hospitals with below-average survival rates to adopt strategies from hospitals with the best survival rates.

    Paul Chan, a leading cardiac arrest researcher at Saint Luke's Mid America Heart Institute, Nallamothu, and other researchers recently conducted onsite visits to hospitals with above-average survival rates, including the hospital where Dahart works. They observed that resuscitation can only be successful if all hospital team members "have been extensively trained, for example with surprise drills, and if they know their precise roles as soon as they arrive," Huff writes.

    "I use the analogy sometimes of an orchestra trying to play a beautiful song but they have never practiced together," said David Heegeman, an emergency physician at Marshfield Medical Center, a facility with above-average survival rates. "How could you pull that off?"

    Unlike heart attack treatment, which should occur within an hour, the crux of cardiac arrest treatment should be completed in two minutes, according to Chan.

    This is why "[h]ospitals with better survival results often have dedicated teams … who can drop whatever they are doing and race to a code," Huff writes.

    When cardiac arrest happens, Dahart said, "I just disappear." She added, "I don't even explain," (Huff, Mosaic Science, 8/13).

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