Cardiopulmonary resuscitation performed by lay people is finding itself in an unfamiliar and uncomfortable position--questioned by researchers who say it may not improve survival after heart attacks and can sometimes even increase brain damage when the heart has stopped.
And though the number of critics is small so far, some of them contend that much of the money spent to train citizen CPR rescuers would be better used to increase the quick availability of electric heart-jolting machines called defibrillators and to expand paramedic and emergency medical technician programs.
The critics concede citizen CPR occasionally saves some lives, but they argue other victims may be harmed and that CPR's benefits have been greatly exaggerated. (In contrast, favorable studies have found that heart attack victims' chances of survival are up to five times greater with CPR.)
Still other critics say significantly improved response times by professional rescuers could also be turned to advantage by rushing patients to hospitals to undergo open-chest CPR, in which surgeons cut through the ribs and massage the heart itself. Used extensively before development of external CPR, open-chest heart massage has recently been undergoing a resurgence in interest. Even proponents of bystander CPR concede the open-chest procedure is the best technique and agree that quicker response times by paramedics could lead to greater use and more lives saved.
"Would I have it (bystander CPR) done to me if I dropped over? Yes. There's no alternative at the moment," said Dr. Bruce Thompson, formerly of Milwaukee and now on the staff of Henry Ford Hospital in Detroit and one of the researchers who has questioned citizen CPR programs. "I would do it to my wife and to my child, but I would also realize full well that unless the definitive care (defibrillation) to convert to a (viable) rhythm was immediately available, the chances of neurologic survival are virtually nil.
"If you are taking public money (to train people in citizen CPR), you would probably better spend that money on improving access to the system."
It is a controversy in which citizen CPR as a grass-roots, do-it-yourself system touted as capable of saving tens of thousands of lives a year has found itself on profoundly strange turf--in question and even under attack for the first time since a national commission recommended, in 1966, that millions of Americans undergo CPR training.
Since then, the citizen CPR movement has attained a nearly religious fervor, with an estimated 50 million people trained in the belief that the simple steps of CPR can help to bring heart attack, drowning and some accident victims literally back from the dead.
Four million to 5 million people undergo CPR training each year--either for the first time or in refresher courses--according to the American Heart Assn., which shares national responsibility for citizen rescuer training with the American Red Cross. Newly revised guidelines for CPR training--published just last week--say the program's goal is to save 100,000 lives a year nationwide.
The new guidelines pointedly call for major increases in defibrillation availability. This could lead to stationing defibrillators on fire engines, in police cars, in public buildings and many other places where they can be quickly brought into play in an emergency--without waiting for paramedics to arrive.
Since 1984, however, CPR itself has been the subject of a quiet but growing controversy among both emergency medicine specialists and basic science researchers. The battle has been joined and fought almost exclusively within the pages of medical journals and the confines of physician conferences.
A Critical Definition
It is a dispute nowhere near resolution, with CPR's critics contending that in the largest and most thorough study of patient outcomes yet completed, there was no significant difference in survival rates between heart attack victims who had citizen CPR and those who didn't. The definition of "survival" has become crucial, with most experts on both sides of the issue agreeing that the fairest measure now is whether a patient lives to be discharged from the hospital--not just long enough to reach the emergency room while technically not dead.
However, no reliable research design has been developed to collectively measure the degree to which large numbers of heart attack victims whose hearts stopped beating have suffered severe, permanent brain damage--a factor most specialists agree is of growing concern.
CPR's defenders have counterattacked with studies of their own--more numerous than those of the critics--whose data indicate CPR is a major lifesaver. Some of the defenders have branded some of the critics as "irresponsible" for suggesting that the national dedication of resources, manpower and training to CPR may have accomplished little.