what would scooby do?
As some of you may know, last week I started ACLS training last week (I’ve been twittering about it quite a bit and even posted some pictures from class). For those of you who aren’t familiar with it, ACLS stands for “advanced cardiovascular life support” and I’m training so that I can participate in or even run codes in the hospital starting in July. Part of the training consists of basic life support (CPR and using a defibrillator) and part of it–the “advanced” part–consists of recognizing when and in what order to use certain drugs or shock patients in order to bring them back from the light. So when you’re watching Grey’s Anatomy and you see them yelling at each other, “EVERYBODY CLEAR”, “SHOCK”, “RESUME CHEST COMPRESSIONS”, “1 MG EPINEPHRINE IV”, and most importantly, “NOT ON MY WATCH–YOU’RE GONNA MAKE IT!!!” That’s gonna be me in about a month and a half.
So the training has been rewarding so far but I was minorly disturbed by something one of the course directors said to me in response to a question I had. As many of you know, a part of CPR is “rescue breathing”, which may have to be mouth-to-mouth resuscitation if you don’t have another way to push air into the patient’s lungs. Rescue breathing is the only source of oxygen for a patient that has coded. So in our class all of our mouth-to-mouth was done through a CPR mask that basically prevents direct mouth-to-mouth contact, for obvious “reasons”. I put reasons in quotation marks because while it seems really “yucky” to do mouth-to-mouth on a stranger, it has repeatedly been shown to be safe–i.e. the risk of acquiring any kind of blood-borne infection (e.g. HIV) is incredibly low–on the order of 1:1,000,000 or less. However, data also exist suggesting the rescue breathing may not be necessary in addition to chest compressions for a cardiac arrest. The physiologic basis for reducing the number of rescue breaths is that stopping chest compressions to give the rescue breaths greatly reduces the blood flow to the heart and brain. And a few studies suggest that chest compression-only CPR may be as effective as standard CPR for cardiac arrests. The impact of these studies is that people who choose not to give rescue breaths to the dude they watched keel over at the Old Country Buffet, are off the hook. The current recommendations by the American Heart Association are that rescue breaths be given at a ratio of 2:30 chest compressions, which is what you will see EMS/paramedics doing. But, EMS always carry their handy-dandy masks plus they use a bag to ventilate people so they don’t have to worry about catching herpes or HIV from the arrested patient.
So my question to one of our course instructors the other night was, how to do you feel about giving mouth-to-mouth given the strength of data suggesting that it’s pretty safe and probably worth the risk of saving somone’s life. The response I got was that this instructor would never give mouth-to-mouth and the example I got was, ”you see a dude pass out at a bar in [popular part of town for bars]–would you want to give that dude mouth-to-mouth? I don’t think so”. To me it’s not so clear-cut and reminds me of a bumper sticker I saw recently: “What would Scooby do?”
I’m not so sure how I feel about the thought of “yuck” coming into the decision making process of a healthcare professional performing life-saving measures. I’m not saying it’s not practical but I’m just not at that point yet. While some (and not rock-solid) data suggest no added benefit of rescue breaths for cardiac arrest, they don’t show any added harm either over the recommended guidelines. Moreover, there are situations where using rescue breaths in CPR is superior to no rescue breathing, such as when the patient has a respiratory obstruction or arrest. So while the two sides of the argument agree on little, I do think it can reliably be said that, for now at least, the data don’t show a harm from following the recommended 2:30 breaths:compression guidelines.
I don’t carry my CPR mask/microshield around everywhere with me (and I never will) but then again the preponderance of data that I’m aware of suggests that mouth-to-mouth is safe. So what to do? What would you do and what would you want if you were the 350 pound dude with the lobster bib at the local Red Lobster who keels over? If you’re giving different answers to those last two questions, you got a real dilemma on your hands, my friend.