In my comments on The Abyss back in September, 2007, I suggested that misconceptions people have of medical interventions for serious medical problems are often reinforced by the misrepresentation of these in movies and television.
Viewers believe what they see. Therefore, they believe things like patients in asystole (the proverbial cardiac flatline) can have their hearts "jump started" with defibrillation; that many patients spontaneously revive with just a few seconds of CPR; that long large needles pre-filled with epinephrine are often stabbed right into a patient's heart when it stops, etc.
In cases of sudden collapse with suspected cardiac arrest, one misrepresentation seems ubiquitous in movies and on TV (and occurs in a recent movie with Morgan Freeman and Greg Kinnear, entitled Feast of Love): the fist strike to the patient's chest, often accompanied by medical personnel jumping onto gurneys and straddling the patient, etc.
Otherwise known in medical circles as a precordial thump, this practice was a component of early Cardiopulmonary Resuscitation (CPR). The theory was that striking the sternum could produce a mechanical shock to the heart that would instigate a spontaneous rhythm. The practice has since been discontinued because it was found to be highly ineffective and more likely to injure a patient who was mistakenly thought to be having a heart attack.
In the movie mentioned above, a young male character collapses during a friendly football match. When he does not arouse, several people run to his aid including a female character who we know to be an emergency physician. In my willing suspension of disbelief concerning Hollywood portraying resuscitation attempts accurately, I actually thought the doctor might follow the ABCs for resuscitation. But what did she do? THUMP! THUMP! What happened? The patient regained a pulse!
Well, I won't spoil the movie and tell you what happens thereafter, but I'll point you in this direction:
http://www.nytimes.com/2008/04/01/health/research/01heart.html?nl=8hlth&emc=hltha1
If you witness someone collapse, don't be a movie star. Don't thump the patient. Just follow the ABCs. Call 911. Then...
Does the patient respond? Yes? STOP No?
Check the patient's Airway. Obstructed? Open the airway. Unobstructed?
Is the patient Breathing? Yes? STOP and wait for EMS. No?
Does the patient have Circulation (a pulse)? Yes? Reassess A and B. No? Press hard and fast on the lower portion of the patient's sternum until EMS arrives.
No Hollywood, No Heroics. Just the common sense of ABC.
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3 comments:
When I took ACLS a year and a half ago the precordial thump was still part of the algorithm . . . so unless things have changed . . .
The official guidelines of the American Heart Association's Emergency Cardiovascular Care for Healthcare Providers (Advanced Cardiac Life Support) even as long ago as 2005 do not include theprecordial thump in any of the cardiac care algorithms, not even the algorithm that might have been applicable in the fictitious case I described (the Pulseless Arrest Algorithm).
The 1st step of the algorithm for pulseless arrest references the BLS algorithm (i.e., ABCs) and subsequent steps include oxygen delivery (if possible), the application of a cardiac monitor, and the delivery of defibrillatory shocks for rhythms that are considerable shockable (e.g., ventricular fibrillation/tachycardia).
For asystole or pulseless electrical activity (PEA), the algorithm specifies continuing assisted breathing and chest compressions until intravenous or intubation access is available for the delivery of medications. Precordial thump is never advised.
In the ACLS course you took, perhaps informal or unofficial information was presented about precordial thump, but if your instructors presented it as part of an algorithm, I'd question their understanding or their credentials.
Of course, there is the fact that dead is dead, and you can't hurt a dead person. However, you CAN hurt a person who isn't dead and who might otherwise benefit much more from a patent airway, assisted breathing, and chest compressions. But don't get your hopes up...must of these patients end up dead, too (a little known and infrequently discussed fact about CPR and one that is often never represented in movies and TV).
I thought I remembered it as a parenthetical sort of "here is where it goes if you want to do it" box . . . maybe I am wrong.
It took the class at your hospital, if that helps you to evaluate the instructors' credentials. ;)
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