If Ewy’s results had been accepted at that time, I probably would have learned a very different sort of CPR when I was in
medical school, but there were admittedly a couple of hurdles still to cross. The first problem was, the research subjects
were swine, and no one was paying much attention to doctors trying to revive a bunch of pigs. Another problem was that other
researchers tried similar experiments and got different results. Their pigs died.
12
When we asked Ewy about that, he was ready with an answer. He says these other studies failed because researchers paralyzed
the pigs’ chest muscles, so they couldn’t gasp in at least a small amount of oxygen during cardiac arrest, as would happen
during a “real-world” arrest.
Some doctors still argued that the studies were misleading. One argument that caught my eye was that a pig’s trachea, or windpipe,
is shaped differently than a human’s. But Ewy says critics were setting the bar impossibly high. “When you’re talking about
cardiac arrest, you just cannot do randomized, controlled trials in people,” he told me. Research on swine, he argues, is
a good substitute. “In our animal model, we’ve come up with a lot of different ways of doing CPR that improve survival in
man.”
Ewy wanted the American Heart Association to stop telling people to give mouth-to-mouth resuscitation, but for a long time,
the AHA didn’t see things his way. When it comes to writing guidelines, the AHA lists six criteria that it will consider:
Number one, the gold standard, is a randomized, controlled study involving people. Number six is animal studies. To start
changing minds, Ewy and his colleagues needed a real-life experiment. But how? Who would possibly be willing to buck the guidance
of the national medical organizations? What they needed was someone outside the establishment, someone willing to take a leap
of faith.
And then in November 2002, opportunity knocked, more or less out of nowhere. A week after announcing their desire to break
with AHA guidelines, Ewy and Kern were at the American Heart Association meeting in Chicago. As always, the meeting was a
big one, a virtual small city at the glass-enclosed McCormick Place convention center. Neither of the Arizona physicians had
ever seen the burly, bespectacled doctor who strode up out of the crowd.
He introduced himself as Mike Kellum, an ER doctor from southern Wisconsin, just a two-hour drive from the meeting. For almost
a decade, he had been the emergency services director for Mercy Health System, a group of clinics and small hospitals serving
Rock and Walworth counties. Kellum didn’t work in academia, but he liked to read medical journals in his spare time. He had
the energy of a young man, but he was nearly sixty, and his keen interest in resuscitation research dated back to the 1980s,
when he’d read an article about dogs who were successfully revived after flatlining on a heart monitor for several minutes.
13
Kellum was well aware that most times when his paramedics were called to the scene of a cardiac arrest, they couldn’t offer
much help. To me, he described a sense of impotence as EMS director, going through case report after case report: “Looking
at these cardiac arrests, reviewing these, you’re seeing ‘they’re dead,’ ‘they’re dead,’ one after another. ‘Dead, dead, dead,
dead.’ After all this time, why are we spending time trying to bring
no one
back to life?”
The reports out of Arizona gave Kellum a sense that he might have a way to change the game. In the hallway outside the AHA
meeting, he told Ewy that he wanted to see if the new protocol could work among the flat, sprawling dairy farms of southern
Wisconsin. Soon after, he flew to Tucson, accompanied by three other EMS directors from Wisconsin. This small group of unknown
physicians was launching a major challenge to the field of emergency medicine.
While not a prestigious academic center, Mercy Health System is the dominant medical provider in Rock and Walworth counties,
about an hour south of Madison. Its sixty-three facilities handle more than 85,000 patients a year.
14
Kellum’s ambulance squads have a lot of ground to cover. Even with sirens blaring full tilt, it takes an ambulance twenty
minutes to get from Mercy’s main hospital in Janesville to the far western edge of Rock County.
15
In the three years prior to Kellum’s experiment, emergency teams had responded to ninety-two cases of witnessed cardiac arrest.
Of those patients, only nineteen survived—and only fourteen without serious brain damage. It was, as Kellum’s team wrote in
a subsequent paper, an awful record—but no worse, probably better in fact, than the results from the rest of the country.
Put bluntly, under the accepted standard of care, the vast majority of patients died.
16
Once home Kellum and the other EMS directors made a radical decision to change the way they responded to cardiac emergencies.
They would try the resuscitation method that had formally been tested, at that point, only on pigs. They would teach it to
their paramedics, firefighters and police officers—everyone who was part of the counties’ 911 emergency response system. The
single focus would be ensuring circulation to the brain. Every effort would focus on chest compressions, and interruptions
would be kept to a minimum. When they first came to a patient who had stopped breathing, they would immediately begin by giving
not fifteen, not thirty, but two hundred hard and fast compressions to the chest. Emergency responders would follow that with
a single shock from a defibrillator rather than the multiple shocks that were considered standard medical procedure.
Defibrillation is a powerful lifesaving tool, but Kellum knew that each shock takes precious time. So after each single shock,
emergency responders would give another two hundred chest compressions. Rescue breaths were eliminated entirely. A small device
would be inserted into the mouth to pump in additional oxygen, but no breathing tube would be inserted until the patient had
a pulse or until he or she had received three rounds of shocks and compressions—six hundred chest compressions in all.
All through 2004, Kellum called down to Tucson with updates. Everything was going great; it was obvious the new technique
was working. Paramedics were getting saves they had never gotten before. Ewy was thrilled, but it wasn’t enough. He needed
other people to know about the results, so every time he got Kellum on the phone, he would harangue him to submit them to
an academic journal. Bouncing in his seat across from me, Ewy reenacted the phone calls. “I’d say, ‘Mike, you gotta get some
data!’ After he’d called me up several times, I’d be screaming at him, ‘You gotta get some data!’ He’d say, ‘I’m just an ER
doc; I can’t do that.’ But eventually I just wore him down,” said Ewy.
In the fall of 2006, when Kellum finally published his article (Ewy was a coauthor) in the
American Journal of Medicine
, the results were astounding. In the previous three years, of ninety-two people in Rock and Walworth counties who suffered
out-of-hospital cardiac arrest, only 15 percent had survived with intact brain function. After the new protocol was implemented,
that rate more than tripled. In thirty-three cases of sudden cardiac arrest, nineteen people survived and sixteen of them—48
percent—walked out of the hospital, more or less as good as new. Ewy recalls, “We had a dickens of a time getting it published.
People thought this was just too good to believe.” But a longer follow-up study found nearly identical results,
17
and in the meantime, Ewy had found a bigger stage to test the theory.
He had also found an important ally, Dr. Bentley Bobrow. Bobrow is a serious, small, almost dainty man in his mid-thirties.
As director of emergency services for the state of Arizona, he oversees the training of paramedics, and by 2005, he was familiar
with Ewy’s research, not to mention the real-life experiments in Tucson and southern Wisconsin. Bobrow decided it was time
to try the experiment on a larger scale.
Unlike Gordon Ewy, Bobrow tends to worry out loud—especially about whether a reporter will paint him as a rebel. While Ewy
has been described as “a constant thorn in the side of the AHA,” Bobrow likes to emphasize what he shares with mainstream
thinking. “I don’t want to tell anyone else what to do,” he says. Still, despite the diplomatic language, the crew cut, the
neat white dress shirt and tie, an independent streak sticks out, and not just in medicine. Along with his wife and young
son, for example, Bobrow doesn’t own a television set.
18
And he doesn’t mince words.
“Some people felt it was negligent to not follow the existing guidelines, but if with the guidelines 97 percent of everyone
died, we felt it was incumbent on us to try something new” is how Bobrow explains the urgency. But “something new” was a hard
sell. In most Arizona cities, emergency response is handled by the fire department. As Bobrow drove from firehouse to firehouse,
he got an earful from medics and firefighters who had been doing things the same way for more than two decades. There were
paramedics on the job who had been part of Glendale’s first-ever CPR class back in the 1970s, when CPR was new and almost
miraculous in its promise. The paramedics thought of themselves as medical professionals, and now they weren’t supposed to
give breaths?
Anyone
could do this?
19
Patiently, stop after stop, again and again, Bobrow made the pitch. He kept coming back to the same point: What was there
to lose? When 97 percent of the patients died, how could they do worse?
In fact, Bobrow and Ewy were confident they would do much better. They’d both heard too many stories to be convinced otherwise.
Ewy’s favorite one dates back to the mid-1990s when an emergency physician from Seattle played a tape recording for him. It
was of a phone call from a woman who called 911 after her husband collapsed and stopped breathing. While an ambulance raced
toward the house, the 911 dispatcher tried to guide the woman through basic CPR. The advice would sound familiar to anyone
who has taken a CPR class in the past thirty years: Feel for a pulse. Tilt the head back. Check the airway. Listen for breathing.
Pinch the nose. Breath into the mouth twice. Fifteen chest compressions. Repeat.
Frightening as the scene must have been, Ewy can’t stop grinning when he tells the story. The frantic woman would ask how
far away the ambulance was, and the dispatcher would send her back to continue CPR. “After a while,” says Ewy, “she came back
to the phone and said, ‘Why is it, every time I press on his chest, he opens his eyes, and every time I stop and breathe for
him, he goes back to sleep?’ ” He paused and gave a rueful laugh. “This woman in ten minutes learned more about cerebral perfusion
[getting blood flow to the brain] than we had in fifteen or twenty years of CPR research.” All that research, Ewy says, points
to one thing: “You don’t stop pressing on the chest for anything.”
By March 2007, Bobrow’s firefighters were ready to pull up the curtain on their experiment. The results were better than anyone,
except perhaps Ewy, had dreamed. Among all victims of out-of-hospital cardiac arrest, the survival rate more than tripled.
Among those whose heart stopped in front of a witness who called 911, it nearly quadrupled. Bobrow set the bar high: he didn’t
count people as survivors unless they walked out of the hospital without significant brain damage. And yet, among victims
of an illness that typically kills more than 95 percent of those it strikes, one in four was walking around almost as if nothing
had happened.
20
As we came to learn, this phenomenon wasn’t isolated to small towns in Wisconsin and Arizona. In 2007, researchers in Japan
unveiled the results of a massive study on bystander interventions. They examined cases where a person collapsed of sudden
cardiac arrest outside of a hospital but in view of a bystander: of those receiving no help before an ambulance arrived, only
3 percent survived; of those who got traditional mouth-to-mouth resuscitation along with chest compressions, the survival
rate jumped to 11 percent; but of those who got chest compressions only, it was even better—19 percent.
21
Kellum says that when he first started telling people about his results, he was met with stark disbelief. At one point, he
flew to Kansas City to give a presentation about CCR to a medical group. Afterward, Kellum says, “The top three people went
out to dinner and said, ‘That guy is certifiably insane.’ And then they began to look at the data, and you just can’t argue
with it.”
By tripling the survival rate from cardiac arrest in Arizona, Bobrow estimates his paramedics saved several hundred lives
during the three-year study period alone. A medicine that did the same would be a best seller. “It’s a phenomenal thing,”
Bobrow told me. “Here you have a situation where not one nickel has been spent teaching this, and it turns out to be just
as good—or in my view, better—than something on which millions of dollars and man-hours have been spent.”
In the world of medicine, paradoxically, it can be much harder to convince people to try a simple and inexpensive solution
than one that is complex and unproven. Here’s my own theory: There are thousands of medical journals churning out new articles
every week. Sorting the useful from the useless is a herculean task. Meanwhile, there are approximately 800,000 physicians
in the United States, most of whom aren’t leafing through medical journals in their spare time. In that sea of information,
a new idea or therapy, even one that’s a proven success, has to struggle to capture attention. A company with a new wonder
drug is often willing to spend millions or even billions of dollars to tell physicians about its benefits. On the other hand,
something as basic as a new kind of CPR—well, who’s got a stake in that?
22
O
N A FEBRUARY
day in 2008, in the mellow afternoon glow of the Arizona winter, Mike Mertz grinned from ear to ear as he walked into Glendale
Fire Station 154. He wanted to shake hands with Ruben Florez and the rest of the crew that saved his life. Bentley Bobrow
was there, too, shaking his head: “He truly was dead, and here he is, fine.”