CPR is less effective than we think

I don’t know how many of you readers are old enough to remember the frequent use of open chest cardiac massage, first successfully performed in 1901. It began as a way to resuscitate suddenly dead people, assuming that their hearts had arrested or fibrillated.

The surgeon would open the chest between ribs 5 and 6 and rhythmically squeeze the heart to move the blood and re-establish life. Sometimes it worked; usually it did not.

Then, in a 1960 landmark article in JAMA, Kouwenhoven, Jude, and Knickerbocker at Hopkins described closed chest cardiac massage and everything changed. Suddenly, patients who were observed dying could be brought back to life without an open thoracotomy.

Great, or so it seemed.

Big organizations taught the procedure; new categories of emergency medical workers were created; ordinary people were educated to save lives dramatically; medical associations sponsored research and published papers, even entire theme issues in JAMA every several years.

A mass of television shows taught the public that codes were called and enacted with teams of beautiful male and female doctors breathing and beating the dead back to life. It became such a pervasive cultural phenomenon that any person who did not wish this effort to bring them back to life after they died the first time would have to file a predeath Do Not Resuscitate order and hope that it would be followed.

After the performance science was solid and positively enacted to create a culture of resuscitation, then came the hard data.

Judged on favorable outcomes (meaning a well functioning body and brain at 30 days) after the drama ended and the TV cameras went elsewhere, the whole schmear was found to hardly ever work to the patient’s or the family’s advantage.

But the culture was already ingrained.

Now we see a huge Japanese study of more than 400,000 people who experienced out-of-hospital cardiac arrest, published in the JAMA on March 21, 2012. Approximately 18% of those who were administered CPR and epinephrine did achieve spontaneous circulation but fewer than 5% survived 1 month and fewer than 2% survived 1 month with good or moderate cerebral performance.

So, if an average adult keels over in the street, is found unresponsive and pulseless by a bystander, and is administered CPR while a 911 call is made, the odds that such a person will emerge from the eventualities of the resuscitation effort healthy and with a normally functioning brain are about 2%.

The other outcomes are death — soon, or within 30 days — after lots of cost and much suffering for many, or being discharged from a hospital, alive but mentally impaired, presumably lifelong.

So, I don’t know about you, but if I drop dead on the street, observed or unobserved, I suppose the observer will feel obligated to call 911, but please do not administer closed chest cardiac massage to me.

I don’t want my rib caged collapsed and I don’t want to live with iatrogenic squash rot, only to have to die all over again sometime later.