Sometimes, blog posts are very easy to write. I was tagged on this CPR video by a respiratory therapist friend of mine. It comes from a FB page called Enfermagen. Since I don’t speak the language, I’m not sure if they’re using this as a good or bad example of giving a patient CPR, but I’m here to confirm this is bad CPR and here’s why.
1. The patient has purposeful movement. As you can see, several times in the video the patient reaches up and attempts to move the mask from his face. Any time a patient crosses their midline, it’s purposeful movement. It definitely appears that he is sick, but he has enough of a perfusing blood pressure (and therefore pulse) for his brain to be getting blood flow in order to make these movements. Therefore, he does not need CPR.
2. The compression rate should be 30 compressions to 2 breaths. The compression depth is two inches. When the patient does not have a breathing tube in his throat (called intubation), the compressor should pause in order for the person to be able to deliver breaths. This compressor doesn’t really pause in order for the rescue breaths to be delivered. Luckily, for this gentleman, his compressor gives relatively shallow compressions and not the two inches they should be.
3. No one checks a pulse. What might help these rescuers is that when the patient starts moving, is to check his pulse. This might confirm for them that he has one and they can stop compressions.
4. Patients should not need to be restrained for CPR. CPR is for unconscious patients without a pulse. If you’re retraining the patient, they likely don’t need CPR.
I’m not sure the medical nature of this gentleman’s illness. Clearly, it looks like he does need some sort of medical assistance. It’s just not CPR.
Can you see anything else wrong with the way this team is delivering CPR?
Flatliners 2.0 released in October, 2017. If you haven’t seen the movie (or the original from 1990) then you may not want to read this post as there will be spoilers involved.
Flatliners centers around a group of medical students who become curious with the phenomenon of near death experiences (NDEs) to the point that they “flatline” one another so that they can purposefully have one.
This first post will deal with a medical scenario that happens in the first ten minutes of the film. We’ll look at two screenshots from the movie.
Here is the conversation among the medical students when their new patient arrives.
Paramedic: “Transfer from Holy Cross. Thirty-eight year old construction worker fell off a beam. Persistent coma. GCS 6.”
Marlo: “Standard procedure for a GCS 6 admit calls for 2 large bore IVs and diazepam on standby.”
Ray: “Seizure meds won’t do any good. Whatever is wrong is in his spinal column and not in his brain.”
Marlo: “And what medical protocol are you citing?”
Ray: “The protocol of actually living in the real world. Where guys with crappy HMO’s go undiagnosed with spinal injuries.”
Marlo: “Actually he’s on seizure meds which is a medical protocol of reading his chart.”
At this point an alarm sounds and the students begin to panic. This is the screen shot at the moment of panic. It shows the monitor. The patient’s heart rate is a nice steady 73. His oxygen level is 100%– can’t get any better than that. His respiratory rate is 19– the patient is on a ventilator. I don’t know– things looks pretty good to me for this patient.
An attending doctor arrives.
Attending: “What is it?”
Student: “Respiratory failure.” (Based on the screen shot, there is no basis for this. Also, nothing is quite hooked up correctly at the head of the bed for an ER.)
Attending: “He might be hemorrhaging. Page neurosurgery, call a code, and get CT on standby. Students, clear the room!”
They then show another monitor in the room which appears to show ventricular fibrillation (V-fib) which is a lethal, but shockable rhythm. Yet, no one starts CPR.
End Scene.
Issue #1: I’m not sure how a medical student within the first ten seconds of getting this patient can know if the problem is in the brain or the spinal cord. For me, the problem seems likely to BE in the brain considering his persistent vegetative state.
Issue #2: Because of the patient’s insurance, he didn’t receive an accurate diagnosis. Mmmm . . . I know this myth get’s perpetuated. You don’t necessarily need expensive tests ALL the time to get an accurate diagnosis. CT scans and MRI scans aren’t really seen as extreme measures anymore. Though they are expensive the cost has come down.
Issue #3: Nothing these medical people say makes any sense medically. What evidence is there that the patient is in respiratory failure? The photo of the first monitor doesn’t suggest that. What evidence is there that the patient is hemorrhaging into his brain? Fixed and dilated pupils? Unequal pupils? A worsening coma score? None of that is presented in the scene.
Issue #4: The one medical problem they seemingly show is the V-fib in the second screen shot. Good to call a code, but research has shown that early and effective CPR is the one thing that is best at bringing people back. The next is early defibrillation which no one seems to anxious to accomplish.
Is it that hard to find good medical consultants for movies?
This television episode caused more people to reach out to me over any other. This Is Ushas been building up to Jack’s death for eighteen months. It needed to be big. It needed to be dramatic. Can you tell I’ve been watching the show? It was really none of those and medically— well, just weird to be honest.
If you haven’t watched the episode then don’t read this post because it will reveal his cause of death . . . like right now.
Jack’s ultimate demise? A heart attack called the widow maker caused by the stress of the fire.
Jack is in intense smoke and heat for several minutes. He emerges and is first checked by EMS. He is being given oxygen and a dressing to his arm for “2nd degree burns”. The EMS person says she can’t treat the burn and he is seemingly refusing transport, but she does encourage him to be seen. Also, giving oxygen is correct, but it is not the right type of mask. A note on burns. Burns will evolve over the next several days so you don’t really know how severe a burn will be for a while.
Jack does eventually go to the hospital to get his burns checked. The doctor is initially giving him instructions on burn care. The doctor says, “I’d like your heart rate to come down.” and glances at the monitor— which doesn’t have any readings on it. No waveforms. No numbers. He then says, “There’s soot in your airway so we’ll have to run some tests. The swelling is minor.”
That’s about it. The doctor tells Jack he basically dodged a bullet and seems none too concerned about his potential airway damage.
Just as I mentioned above, airway burns from smoke inhalation are similar to skin burns in that they evolve over time. Smoke inhalation and the potential for upper airway swelling is taken very seriously. There is a nice overview here. At the very least, there should be discussion of admitting Jack to the hospital. As quoted from the article, “Studies have shown that initial evaluation is not a good predictor of the airway obstruction that may ensue later secondary to rapidly progressing edema.” If there is concern about significant injury to the airway then the patient is electively intubated until the airway injury heals. It’s VERY difficult to intubate someone with a lot of airway swelling.
Shortly after this consultation, Rebecca decides to make a phone call and get a candy bar from the vending machine. In that, perhaps under two-three minutes passage of time, Jack codes and dies. Even though she is just outside the ER nurses station, she never hears a code being called. Doesn’t see the commotion.
The doctor approaches her and says, “One of complications of smoke inhalation is that it puts a terrible stress on the lungs and therefore the heart. Your husband went into cardiac arrest. It was catastrophic and I’m afraid we lost him . . . Mrs. Pearson, your husband has died.”
After a few exchanges she goes to Jack’s room where there is a spotlight shining on his chest with a cursory ambu bag at the head of his bead . . . but no other equipment. I’m telling you in two minutes, a code has barely just begun and is never called so hastily . . . like ever. Later, explaining the event to Miguel, Rebecca says he had a widow maker’s heart attack.
There would be no realistic way the doctors would know it was specifically this kind of heart attack as shown in the episode without an autopsy. Presumably, Jack went into one of the lethal heart rhythms, v-tach or v-fib, at the time of his code. In the time frame given on the show, the medical team would have barely started CPR and given the first line treatment which is electricity. A 12-lead ECG can be a strong diagnostic tool for this type of heart attack, but they never did one. Had they done that early on, they probably would have seen the changes.
Also, he would likely have some signs and symptoms. Chest pain. Nausea. Left arm pain. Sweating. Demonstrating these might make the scenario seem more believable. Having Rebecca witness the code would have been more dramatic.
Also, it would make more sense that he would suffer this cardiac event while he is actually under duress— such as during the rescue of the children and the dog.
The only way to truly know that this is the type of heart attack Jack suffered as presented in the show would be to conduct an autopsy.
This Is Us— thanks for killing off a beloved character in a totally lame way— at least from a medical standpoint.
It’s difficult for new medical devices to impress me. This one did.
One of the challenges in medicine is doing effective CPR. Research studies have consistently shown that what generally saves a patient’s life is early and effective CPR. That’s when all the other bells and whistles that we have in our medical stockpile will work.
However, you might be surprised at how ineffectively we do CPR. For one thing, it’s physically hard to compress the chest enough to generate a pulse. Second, it’s tough to measure the effectiveness of compressions. The way this is traditionally accomplished now is through palpating a pulse during CPR (which is difficult to do accurately) or to measure what’s called end tidal CO2 which is best accomplished when a patient has a breathing tube down their trachea.
Another difficulty in doing CPR is the amount of artifact it creates. Artifact is something you see on the monitor that isn’t a true representation of the patient’s condition. For instance, if a patient is connected to a monitor and you pick up their ECG leads and shake them– you can make it look like they’re in a lethal cardiac rhythm.
If you’re doing effective compressions, you can’t see the patients underlying rhythm but stopping CPR to check a patient’s rhythm takes away from its effectiveness as well. It takes a while to establish pulsatile flow with CPR so every time you stop, the patient can suffer.
The Zoll R Series Defibrillator attempts to change some of these issues and if it is able to do what it says– it could mean a big improvement for patient care.
It has a pad that is placed at the center of the patient’s chest. This measures the effectiveness of compressions and makes sure they are at the right rate and depth. It also allows you to see the patients underlying rhythm while compressions are ongoing which can lead to better treatment at the bedside when a rhythm changes.
It will be interesting to see if a device like this will decrease the morbidity and mortality around code events.
I was not paid by the company to review this product.
Flatliners centers around a group of medical students who become curious with the phenomenon of near death experiences (NDEs) to the point that they “flatline” one another so that they can purposefully have one.
Ray: “The protocol of actually living in the real world. Where guys with crappy HMO’s go undiagnosed with spinal injuries.”
Attending: “What is it?”
The widow maker is a real term for a heart attack. 
Redwood's Medical Edge 