Doctor! The heart’s stopped!

Cardiac arrest is a popular narrative device in TV and film. However, on screen, it is shown to have much better odds of survival than in real life. During fictional hospital resuscitations, the dramatic significance of eye contact between team members generally exceeds that of any individual medical technique. Despite this, the frequent depiction of external – or closed-chest – cardiac massage on screen means it is now a familiar concept to all.

Emergency resuscitation by the accident and emergency team. The hospital staff are performing CPR, including chest compressions to restart the heart. Photography, 2000. Image credit Leicester Royal Infirmary and Wellcome Images.

Two 1958 digitised films about cardiac arrest provides some striking historical context. The first, The Treatment of Cardiac Arrest, was directed by C E Engel, then Director of Medical Photography at Guy’s Hospital. Medical advice came from two eminent Guy’s thoracic surgeons, Sir Russell Brock and Mr Donald Ross.

According to a contemporary review, this prize-winning film could “be considered a standard work on the procedure”, instructing doctors how to prevent brain damage in patients due to lack of oxygen. “If irreversible [brain] changes are to be avoided”, the film’s narrator tells us, “cardiac massage must be started within one minute”.

As the film demonstrates, the patient’s chest is opened “with any sharp instrument to hand” and the heart directly squeezed with ungloved hands. This internal – or open-chest – cardiac massage is also advocated, rather more drily, in the second film, Causes of Cardiac Arrest. This film was made by Dr John Beard, an anaesthetist at the Postgraduate Medical School, London. Both films reflect 1950s acting techniques as well as the medical techniques of the day.

Internal or open-chest cardiac massage. Diagram by Sylvia Treadgold from the film The Treatment of Cardiac Arrest (1958).

Internal cardiac massage for cardiac arrest during surgery first appeared in the medical journals many years earlier. By 1906, a Lancet review was already citing 40 reports. The 1958 films were apparently intended to encourage more widespread adoption of the technique, both in terms of who was doing it and where. Beard’s film for example depicts a dramatised arrest in an outpatient department.

It is Donald Ross, though, who appears to have been the true evangelist. He describes internal massage again in a standard surgical textbook of the day, edited by two other Guy’s Hospital surgeons.

The consequences of his enthusiasm at Guy’s were, perhaps, predictable. One eye witness, who worked on a Guy’s psychiatric ward in 1957, describes internal cardiac massage performed by a consultant anaesthetist with a scalpel found on a nearby windowsill. The incident was not unique. The minutes of a 1960 meeting of the Guy’s Hospital Medical Committee report that: ” …The Superintendent had written drawing attention of the fact that on three occasions in recent weeks House Officers had performed thoracotomy and cardiac massages for acute cardiac arrest due to coronary thrombosis, in various places in and around the hospital.”

A change of heart

Major change, however, was imminent. In the same year, closed-chest cardiac massage for cardiac arrest was described for the first time in the Journal of the American Medical Association. Less than six months later, the Lancet published the first ever UK report of the same technique from Guy’s Hospital.

It was a familiar joke that it was not possible to faint in the precincts of a teaching hospital for fear of some zealot opening one’s chest.

In July 1961, Donald Ross conceded, in the Guy’s Hospital Gazette, that closed-chest massage for cardiac arrest represented “an alternative initial line of treatment”. The Gazette’s editor commented: “Closed chest cardiac massage has come to the rescue of the house officer … It was a familiar joke that it was not possible to faint in the precincts of a teaching hospital for fear of some zealot opening one’s chest.”

External, or closed-chest, cardiac massage for cardiac arrest. Image from the film Emergency Resuscitation: part 3, 1963.

The rapid subsequent switch to closed chest massage at Guy’s was enhanced by the arrival of another new treatment for cardiac arrest: external defibrillation. In this method, the therapeutic electric shock is administered via electrodes on the chest wall, rather than on the surface of the heart itself as before. By 1963, equipment necessary for the new techniques had been widely distributed. Training programmes had been established for junior anaesthetists and were already being proposed for nursing staff.

Time to resuscitate the old technique?

The widespread abandonment of open-chest cardiac massage probably owed more to cultural distaste than to scientific reasoning. The new methods back then then offered no proven improvement in efficacy or safety. Since 1960, however, a modest amount of comparative evidence has accumulated. From its objective analysis, a remarkable conclusion emerges.

Contemporary cardio-pulmonary resuscitation using an automated external defibrillator (depicting external electrode placement). Credit: Leicester Royal Infirmary and Wellcome Images.

The International Liaison Committee on Resuscitation recently reviewed trials comparing cardiac arrest outcomes after open- and closed-chest massage. Of the 32 animal or human studies that they identified in the medical journals, 31 favour open massage. There have been calls in the literature for some years, as yet unheeded, for a randomised controlled trial comparing the two techniques.

The complication rates of the open method are high, but so are the potential rewards. In Causes of Cardiac Arrest, John Beard declares: “In suitable cases, resolute men have restarted the heart in most difficult situations. They were prepared for such an emergency and they were familiar with the techniques of opening the chest and cardiac massage”

Who knows? Given current poor survival rates from cardiac arrest, we may yet see the reappearance on the wards of resolute men and women with scalpels in their pockets.

Author: Dr Andrew Morley is Consultant Anaesthetist at Guy’s and St.Thomas’ NHS Foundation Trust in London.