If you do CPR the way you see it on TV, you’ll never save a life…

When FBI Agent Renee Walker attempted to revive a car accident victim on the popular television show 24 last season, the victim had no chance.  Agent Walker only pushed weakly a few times on the victim’s chest before giving up.  Her compressions were shallow, her timing too slow, and her demeanor glamorous—but distracted.  It’s no wonder the patient died.

24 CPR from Meredith Sorensen on Vimeo.

In real life, effective cardiopulmonary resuscitation (CPR) looks brutal—and it should.  In order to keep blood moving and provide oxygen in patients whose hearts stop unexpectedly, chest compressions have to be forceful and fast.  Rescuers must assume a stiff-armed, dominating posture above the victim, who must be lying flat on a hard surface.  Rescuers must push on the patient’s chest hard enough to actually compress the heart, meaning the entire chest wall should be depressed by 2 inches—about the width of an 800-page paperback.  That’s a big distance for bones to move, and ribs often snap.  The compressions must be given at an exhausting pace—ideally 100 per minute—and continued until medical help arrives.  It may sound violent, but, as Agent Walker showed, gentle CPR does not save lives.

In fact, the CPR technique used by actors in television shows and movies rarely would be good enough to save a real patient.  That’s a problem because the entertainment industry reaches far more people than the American Heart Association or local emergency services, the organizations that offer formal training in CPR.  Indeed, 70-92% of the general public reports that they receive most of their information about CPR from television.  If they see it wrong, they will do it wrong.

Unlike most medical interventions that are based on the skill of specially-trained medical professionals, successful CPR depends on knowledgeable members of the public.  After a person’s heart stops, CPR must be started within 4 minutes—preferably sooner—in order to prevent serious damage to the brain, heart, and other vital organs.  Even the fastest emergency medical services rarely arrive that quickly.  So, the burden of initiating timely and effective resuscitation efforts falls to lay people—the same people who admit to learning about CPR primarily from television.

Although doing chest compressions is a kinetic experience, effective CPR also looks different from ineffective CPR.  Proper technique starts with positioning, which is easily observable.  Rescuers should kneel or stand over the victim, place the heel of one hand in the middle of the victim’s chest between the nipples, and overlap the other hand over the first for reinforcement.  With straight arms and locked elbows, rescuers push forcefully on the breastbone using the weight of their entire upper body to depress the chest by two inches—a distance big enough to see.  Any shallower and the compression won’t generate enough pressure in the heart to squeeze blood out to the rest of the body.  After every compression, the chest must be allowed to recoil, or bounce all the way back to its normal position.  This allows the heart to refill.  Uninterrupted compressions given at the rate of 100 per minute promote blood flowing forward.

It would be easy to show these essential components of CPR on film, and yet producers rarely do.  Actors often give weak chest compressions with bent elbows.  On an episode of Baywatch, David Hasselhoff teaches ten other lifeguards to give CPR.  Their arms are tanned and muscular, but none of them are appropriately straight.  In other episodes of Baywatch as well as in episodes of Lost, the actors correctly lock their elbows, but do not push nearly hard enough.  Their shoulders merely twitch or their heads bob rhythmically, but they do not actually use their upper body strength to compress the victims’ chests.  Close-up shots of the patients show no depression or recoil of the chest.  Timing of compressions on television also varies too widely.  In general, they are too slow.  Nowhere is this more pronounced than in Friday the 13^th: Jason Lives, in which the actress playing Megan gives Tommy one weak chest compression every four seconds.  Miraculously, Tommy recovers to sit up and embrace his savior.

On television, CPR often serves as an entrée to sensual scenes.  Rescue breathing frequently morphs into making out when the attractive victims simultaneously regain consciousness and lust for their rescuers.  Interestingly, mouth-to-mouth resuscitation, which figures so prominently in fictional CPR scenes, actually matters much less than chest compressions in terms of physiology.  The official American Heart Association algorithm still teaches rescuers to give two breaths after every 30 chest compressions, but recent studies suggest that survival rates are similar when bystanders give compressions only.  If Hollywood portrayed CPR as mere rib crunching, they may have fewer excuses for unlikely pairings of characters to lock lips, but the survival of these characters would be far more believable.

CPR on television has come under fire before.   TV shows and movies depict survival rates that far exceed even the most optimistic rates in real life. At least 75% of fictional film characters survive CPR, whereas only about 40% of real patients do—and many of them suffer from serious complications.  A 1996 New England Journal of Medicine article criticized television shows for that very reason, claiming that inaccurate depiction of survival after CPR on TV leads to unrealistic expectations by patients and families.  While this may be true, the outcome of CPR on screen matters far less than how well the actors do it.  Perhaps if their technique were perfect, a 75% survival rate would not be quite so far-fetched.

Some producers and directors might think that depicting CPR correctly cramps creativity, but this is simply not the case.  In a scene from Season 5 of The Office, Michael Scott organizes a CPR class for his employees after one of them suffers a heart attack at work.  The roughly four-minute scene delivers plenty of laughs and pokes gentle fun at the American Red Cross and the stereotypically uptight instructor.  However, it also packs in several accurate and memorable facts—such as the initial assessment of unconscious patients (Airway, Breathing, and Circulation) and timing compressions to the tune of the Bee Gees’ song Stayin’ Alive (a recommendation published in a real study from the University of Illinois).  Not to mention, the actors’ techniques are reasonably good.

The Office CPR from Meredith Sorensen on Vimeo.

Despite this model example, there is no real incentive for the entertainment industry to change.  They include CPR in order to heighten drama, not to educate the lay public.  Hollywood has been criticized for other portrayals of behaviors that negatively affect public health, most notably for glamorizing smoking.  Proving the strength of this subliminal message, however, is impossible.  Similarly, proving that modeling effective CPR on film actually saves real lives cannot be done.  Consequently, Hollywood would have to modify their depiction of it based upon an altruistic assumption.

Granted, fictional television shows and movies are not training videos, but a few simple changes would drastically improve the accuracy of CPR on screen.  If actors consistently straightened their arms, locked their elbows, pushed harder, and pushed faster, it would provide a positive model for the public.  Then, in the event of a real emergency, people would be more likely to save lives by doing CPR “as seen on TV.”