Feature: Staying Alive

FRIDAY, 27 APRIL 2012

Staring into the camera, ex-footballer and celebrity Vinnie Jones growls, “You only kiss your missus on the lips”. This scene—appearing on a TV or 4oD screen near you—is not from EastEnders or a reality show. It is part of an advertising campaign by the British Heart Foundation, promoting a new ‘hard and fast’ technique: hands-only CPR (cardiopulmonary resuscitation). Survival rates after cardiac arrest are woeful; just 10% of those who suffer a heart attack in public recover and leave hospital. The days of the ‘kiss of life’ being recommended for the general population are gone. Now, the only instruction for performing this lifesaving technique is to lock your hands over the chest and push hard and fast, to the tune of the Bee Gees’ classic Stayin’ Alive.

This is not the first time that the official CPR advice has been revised, though most changes do not come with a catchphrase. The history of resuscitation is enormously long and varied. Although adjustments in recent decades tend to be minor changes in positioning the victim or the ratio of breaths to compressions, this was not always the case. Historically, CPR was based on best-guesses and whatever tools were available at the time. Most of these methods would definitely not come under doctor’s orders today, but the central question of how to keep a non-breathing patient alive is no less crucial now than it was centuries ago.

Early attempts at resuscitation, before the anatomy of the circulatory system was fully understood, ranged from the ineffective to the downright bizarre. Resuscitation in the Middle Ages was based on the correlation of life with body heat, and involved warming the patient with blankets, hot water, or even heated excrement placed directly onto the skin. Survival was predictably poor. In the 1530s the ‘bellows method’ was devised as a way of introducing air into a non-breathing casualty, but poor understanding of anatomy meant that the tongue often blocked the airway and little air was able to enter the lungs. Despite the problems presented by this method—and the fact that few people had a set of fireplace bellows to hand when out and about—variations of this technique persisted for the next two hundred years. Emphasis continued to be placed on maintaining the victim’s body heat, as warmth was considered to be one of the most important signs of life in an unconscious person.
The first serious advocacy group for resuscitation was the Society for the Recovery of Drowned Persons. This formed in Amsterdam in 1767 to address the leading cause of death in the city at that time. Their recommendations included the traditional warming of the body and the bellows method, as well as some innovations. Inversion of the victim to help the fluid drain from their lungs was common, as was ‘fumigation’: blowing tobacco smoke into the mouth and rectum. Although some of their treatments were still aimed at stimulating life-like signs in the casualty, other methods such as ventilation of the lungs, using a bellows or mouth-to-mouth, and applying manual pressure to the chest, are strikingly similar to resuscitation methods used today. The society’s ideas are evidence of a significant shift towards modern CPR methods, guided by a better understanding of anatomy and circulation.

The principal method of forcing air into and out of the lungs, by any means necessary, continued into the next century. Life-saving aids in the 1800s included barrels, which the victim was rolled over to compress the chest, and even horses, with many American lifeguarding stations having their own horse to take drowning victims for a quick trot down the beach. The movement of the horse did sometimes succeed in forcing air into the chest cavity and squashing it out again, but the technique was abandoned after complaints from the ‘Citizens for Clean Beaches’ group. As a result, this technique was replaced by the more subdued ‘roll method’ in 1859, where the victim was rolled repeatedly back and forth to alter the volume of the chest.

After several centuries of trial-and-error methods of resuscitation, the two major techniques currently recognised as effective, mouth-to-mouth ventilation and chest compressions, were developed in the mid-twentieth century. Mouth-to-mouth came first in the 1950s, with the initial scientific articles describing its use and efficacy appearing in 1954. While the importance of getting air into a non-breathing casualty was self-evident, cardiac massage—now considered to be possibly the most important feature of effective resuscitation—was not formally described until 1960. It was previously thought that this was only effective if the heart itself was massaged, but new research showed that even external compressions on the chest were enough to stimulate blood flow. The primary advocates of these new techniques, anaesthesiologists James Elam and Peter Safar, are widely credited with pioneering the modern ‘ABC’ method. This combines all of the components necessary for successful resuscitation: an open airway and the two elements of CPR, breathing and compressions. This formed the first demonstrably successful resuscitation method, which is still broadly in use today.

The rescue breaths are proven to be an important feature of CPR, which makes the sudden, well-publicised shift towards compression-only CPR a little odd. However, there is another feature of CPR that had not been previously considered: the person performing it. If the casualty has had a heart attack in public, there is a high chance that the person performing CPR on them will be a stranger. Recent guidelines, outlined by the British Heart Foundation, state that many bystanders are put off from performing CPR by the thought of doing mouth-to-mouth. However, the damage caused by not giving breaths is offset by the chances of no-one performing CPR at all. The focus has shifted from everyone knowing the technique of CPR to simply making sure that everyone feels able to do it.

This is not the first time that first aid advice has been altered due to the public’s attitude, though in a far less life-threatening situation—St John Ambulance had to change their guidelines for dealing with strains and sprains, given by the acronym RICE: Rest, Ice, Compression, Elevation. Overzealous bystanders took ‘Compression’ to mean ‘wrap as tightly as possible’, which restricts blood flow to the limb and can cause nerve damage. ‘Compression’ is now instead described as ‘comfortable support’. It is hoped that a similar change to a simpler, more direct set of instructions for CPR will mean more people will feel confident enough to administer the first aid which could be life-saving.

The move towards hands-only CPR has been widely supported. Organisations such as St John Ambulance, London Ambulance Service and American Heart Association have all endorsed the change, and studies suggest that the new guidelines will increase the number of cardiac arrest patients reaching hospital alive. However, most of these groups have also stated that they will continue training first-aiders in full CPR, and those who have up-to-date training in performing rescue breaths should continue to do so. It is not yet certain that considering the psychology of the first-aider will improve the poor survival rate of cardiac arrest patients in public, but compression-only CPR marks yet another change in our understanding and treatment of emergency incidents.

Beth Richardson is a 1st year undergraduate studying Natural Sciences