Someone Please Rescue 911: Teach Them to do CPR Correctly

I’ve been teaching CPR for almost thirty years. Can you believe that? I hardly can.

I’m pretty passionate about CPR because time after time studies have shown that this is the patient’s best path for survival— high quality CPR given as soon as the patient needs it. It’s not rocket science and it’s pretty easy to research. Here’s a Google link to a bunch of images that show the algorithm for CPR.

What you want to be sure of is that you’re using the most recent guidelines. For the American Heart Association (AHA), their most recent set came out in 2015. The AHA reevaluates their CPR guidelines based on research every five years. Next update will probably happen next year, but the educational materials likely wouldn’t be released until 2020.

In episode nine of this season’s 911, Hen and Howie rescue a boy from a submerged vehicle. He is unresponsive and pulseless once he reaches the shore. They begin CPR (just compressions) and after every set of compressions they do a pulse check. After about a minute, they revive the patient.

Did you know that even healthcare providers are not that great at determining whether or not there is a pulse? It’s true. On top of that, imagine trying to do a pulse check with cold hands, in the dark, in the rain. Not easy to be sure.

The reason the pulse shouldn’t be checked that much is that it ultimately delays compressions and we don’t want to do that. Every time compressions are stopped, the blood perfusion to the heart also stops and it takes several compressions to reperfuse the heart. Some fire departments have gone to doing two hundred uninterrupted compressions for this very reason.

In lieu of this issue, I did like this episode quite a bit. It’s Hen’s origin story and I do think it highlighted some of the issues minorities face in the fire service.

911— let’s just stop messing up the little things.

Dear Medical Thriller Author: Please, Ask a Nurse

I just got done reading a recently released medical thriller by a well known author. The novel, overall, was really enjoyable. Truly a captivating story line. However, there is one medical scene that continues to bug me because of the medical inaccuracies that could easily be solved by having a nurse with expertise in the area read over the scene.

In the last three medical thrillers I’ve read, the author always notes the doctors that helped with the novel, but I honestly don’t think I’ve ever heard a nurse mentioned. Trust me, they needed a nurse. Our expertise is in delivering the medical care as ordered by the physician so we know what makes sense and what doesn’t.

In the scene, the patient is suspected of ingesting the poisonous mushroom Amanita Phalloides also known as the Death Cap. The patient has potential political fallout so our hero, a family practice physician, is designated as team leader for this code over two ER physicians. I’ll discuss some of the things I find problematic with the scene.

The hero admits he’s not an expert on mushroom toxicity, but doesn’t phone a friend. One of the first things that should be done in addition to providing for the patient’s medical needs is consulting a toxicology expert (a poison control center is a great place to start). In toxic ingestions of any kind, the medical team needs to know how to counteract the poison. This targeted therapy may be the only thing that will save the patients life. Even if the patient is provided stellar medical interventions, if they’re not given the antidote, it will all be in vain and the patient can proceed to death. That being said, not every poison has an antidote, which then means supportive care.

Let’s discuss these two statements from the novel:

“BP is sixty over palp,” said a nurse, taking the measurement by palpating with her fingertips.
“Pulse one forty-eight by monitor. I can’t even feel a carotid pulse.”

First of all, taking a palpated blood pressure is not usual in the hospital setting. This is typically done by EMS as a quick and dirty measure for obtaining a BP because it is really hard to hear through a stethoscope with sirens blaring above you. Next thing is, one of these two people are wrong. A carotid pulse is considered a central pulse so if it can’t be palpated then the patient is pulseless, has no BP (because you need a palpable pulse to have a BP), and therefore requires CPR no matter what is seen on the monitor. This rhythm is called pulseless electrical activity (PEA) and is treated medically like the patient is asystolic or flatlined. Treatment is high-quality CPR and IV epinephrine, but our hero calls for a central line.

Then there’s this statement:

“Right now, D-five normal saline at two hundred an hour. Wide open.”

D-five normal saline is an IV solution. This is typically not given in a code situation which I won’t highlight here. In reading about this mushroom’s toxicity, I get why the author chose this IV solution, but the reader doesn’t know and so it should be spelled out what the doctor is worried about clinically for this ingestion and how he’s going to treat it.

However, what’s really wrong with this statement is that it is a contradiction in terms for the nurse. Either the rate is 200 ml/hr or the rate is wide open which means the IV bag is let to run into the vein via gravity as fast as it will go. In an adult patient, the IV bag could be delivered in as little as five minutes depending on the size of the IV catheter that’s been placed.

Lastly, this gem:

“Compressions at ten per minute.”

There is a lot wrong with this medical scene (too much to blog about here), but this is by far the most egregious. I read this to my accountant husband and even he knew this was not medically correct. In fact, I googled, “How fast should you do CPR?” and it gives the correct answer without having to click into a web site which is 100-120/minute. This can’t even be a typo because one hundred and ten— can you really mistype that?  Flat out, this is an easily researched aspect and there is prolific information out there on doing CPR.

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What’s Wrong with this Medical Scene? Click to Tweet

Just as I ask doctors about the medical accuracy of my scenes, so should nurses be asked. Particularly those who are actively practicing in the area.