Restoring Breath: Questions, medical advancements and the importance of bystander participation

Tina Williams, PhD student on the Life of Breath project, writes a post prompted by the inaugural lecture of Jerry Nolan, Honorary Professor of Resuscitation Medicine in the School of Clinical Sciences, University of Bristol:

Loss.

We all lose something dear to us during our privileged status as breathing, questioning, self -reflective beings: often equating to pondering the differing elements of loss as part and parcel of human existence, particularly when studying chronic or life-threatening illnesses. Loss of uninhibited movement overtaken by chest pains or the onset of shallow breathing; loss of abilities to talk and walk at the same time; of being able to pick up our child or sing along to the radio. How can we intervene medically to improve and maintain these ‘taken for granted’ yet vital activities, quite apart from just trying to enjoy the life that we have left?

The tragic loss of others, too often strikes us earlier than our own confrontation with mortality and can lead us to such existentially-grounded considerations and reflections on loss and its many meanings when evaluating our lives and their worth. When somebody is chronically or life-threateningly sick, even routine habitual movements such as stretching, enjoying breakfast, talking, walking, running and going about our daily projects become insignificant compared to actually breathing. Reminders of our fragility, the temporally-limited nature of our existence as embodied, conscious beings thus surrounds us. Episodes of sudden cardiac arrest (if we are lucky to survive) can bring these realisations to the fore with frightening speed.

During cardiac arrest, the workings of the heart, breathing, oxygen levels and functions of the brain and major organs are catastrophically disrupted. Cardiac arrest is deadly, and survival rates are poor. Loss of brain cells through oxygen starvation and damage from adrenaline, damage to the entire body, and loss of life are huge risks, reflected in these poor survival rates. Only a small number of almost 30,000 cases of cardiac arrest in the UK between 2011-2014 survived to be discharged from hospital: 5,120 (17%) out of 29,945 in-hospital cardiac arrest incidences (Nolan et al., 2014). With cardiac arrest that occurs outside hospitals, many more people die without prompt medical assistance. Questions therefore arise regarding how we can improve early detection of cardiac arrest (which in turn improves survival rates). How do ideas about resuscitation, defibrillation, intubation methods and ventilation develop and inform medicine? What is the best method of imparting this knowledge to the public? How do we communicate the best evidence and how to perform CPR to maximise public engagement? How does mechanical ventilation work? How do clinicians, patients and loved ones decide when to withdraw treatment? How do clinicians cope with limitations? How do patients experience these life-altering experiences, artificial ventilation, and post-critical care? What does future technological advancement offer critical care and patient experiences?

Quite apart from our current comfortable, privileged status as healthy and medically-informed societies compared to historical periods, these questions and themes were all, to differing degrees present at the recent inaugural lecture of Professor Jerry Nolan ‘Back from the brink of death – cardiopulmonary resuscitation, past, present and future’.  Themes and facts that should shock us out of our complacency around our health, and our duty towards learning and teaching potentially basic life saving skills in our communities. Professor Nolan is a consultant in anaesthesia and intensive care medicine at the Royal United Hospital, Bath, and Honorary Professor of Resuscitation Medicine at Bristol University with research interests in airway management, resuscitation and post-cardiac arrest treatment. His expertise and breadth of knowledge and experience is impressive: as well as being the Editor-in-Chief of the journal Resuscitation, Vice-Chairman of the European Resuscitation Council, an elected member of Council of the Royal College of Anaesthetists and a past chairman of the Resuscitation Council, he also has training in shock trauma and critical care from the UK to across the Atlantic (Baltimore).

Professor Nolan’s exemplary talk (and decades of work) investigates, amongst many other things, the ‘chain of survival’, from early recognition of cardiac arrest, the process of CPR and defibrillation, through to post-resuscitation care. Of course each element is historically as well as medically informed via theory, knowledge of the human body and technological advancement. For instance, how ideas and shared knowledge about compression of the chest and mouth-to-mouth elements of CPR often envelops public opinion: the problem (squeamishness? Fear of germs? Too complicated to do?) of bystanders failing to administer mouth-to-mouth was tackled with the suggestion of chest compressions, as in the Vinnie Jones ‘staying alive’ public television campaigns. Obviously these arenas of study and expertise are relevant not only to our work on breath, breathlessness, and life and death: anybody interested in medicine, health and human existence can relate.

Professor Nolan began the talk defining cardiac rest, the sudden disruption and cessation of the functioning of the heart. Cardiac arrest must be distinguished from a heart attack: it is attributed to a wide range of causes (two-thirds are heart-related issues arising from coronary heart disease and linked to smoking, obesity, and so forth) that essentially cause the heart to stop pumping. A heart attack, on the other hand, is caused by a blockage that causes damage to part of the heart muscle through oxygen deprivation. Cardiac arrest, for whatever cause, has a short frame of successful rates of survival. Once blood has failed to pump oxygen around the body to the brain and vital organs for three minutes brain injury occurs. So these minutes, seconds even, are vital. What can we do to improve these rates?

Firstly, bystander intervention administering CPR saves lives, despite actual bystander administered CPR intervention rates being quite low. Secondly, utilising technology – even if it is motivated by monetary gain – consistently shows that prompt first responder rates help survival rates. Automatic external defibrillators (AEDS), when used properly, enable this. For example, in Japan, a country very familiar on vending machines, the general public know where and how to access and utilise these machines effectively to improve the chances of survival in patients. Given these two elements of improving survival, we may ask why such findings are not already in widespread use or implementation across other nations. Perhaps we can point to the idea that medicine, technological developments and government policy have sometimes been uneasy bedfellows: there have been wondrous advancements (e.g. abatement of infectious diseases; reduction in mortality rates; artificial limbs, and so on). Yet, monitoring and translating these potential life-saving technologies are often not even considered, as government policy and funding appears not to have time or the designated funding to recognise and implement the lifesaving results in public training and education.

Bystander CPR has been shown to increase survival to hospital at a rate of two to three times, and yet only 55 per cent of those undergoing cardiac arrest have CPR administered by bystanders. Why? Again, there are many reasons, of which we will just give two. Firstly, due to lack of widespread education of what cardiac arrest actually can look like – jerking movements and gasping for air as opposed to notions (in part) spread by film and media as dropping down perfectly still means that recognising that not everyone recognises someone as undergoing cardiac arrest. Secondly, many people are not trained in CPR. Given that bystander CPR is vital in improving chances of survival, what can we do? Studies in the Nordic countries where children are taught CPR from a young age show much better outcomes (Wissenberg, 2013). Indeed, these results have been so impressive that CPR was made mandatory  in elementary schools in Demark in January 2005, and for anyone obtaining a driving licence (2006).

Artificial ventilation has a long history. From the ‘Bellows Method’ (Paracelsus, 1530, in which bellows were literally placed into a person’s mouth and air forced in), to blowing smoke into the rectum, to mouth-to-mouth (Tossach, 1732) and right through to resistance of mouth-to-mouth, Professor Nolan gaves a tour of changes to resuscitation methods over time. Essentially, mouth-to-mouth was considered a method that was both difficult to study and to teach. It also has been viewing pejoratively, as the mouth is often considered an intimate area and/or source of germs. He also described methods that focus on compressions to the chest or back, and of course now CPR is delivered in terms of 30 compressions to the centre of the chest before administering two breaths. Defibrillation was also examined, and studies show that training paramedics (and others) in the use of AEDs significantly improves survival rates. With the use of AEDs, a trial in Las Vegas in 1997 showed that individuals (casino security guards) without any medical training saved approximately 60% of individuals experiencing cardiac arrest. How can we ignore these rates?

In post-resuscitation care, reducing bodily damage and restoring quality of life is vitally important, the chain of survival comes full circle – from recognition of cardiac arrest through to continued care. However, knowledge gaps exist on cooling the body. Many studies show that such methods help survival rates and may reduce neurological damage, but much work needs to be done. Professor Nolan discussed these findings and explores the research ideas and proposals of future advancements, such as AED drones and medicine drawing on technology, such as aiming to reach first responder volunteers by mobile ‘phones. These would send automated texts to volunteers who, in conjunction with more available AEDs. The programmes already mentioned can all contribute to improving survival rates. I would recommend listening to his entire talk for further enlightenment into his work and depth of knowledge on these life-altering experiences and resultant medical interventions and their relationship to technological discoveries.