To borrow from the Grinch I hate, hate, hate… hate, hate… double hate… Loathe entirely how we teach CPR to the general public as well as to many medical professionals in a class known as BLS. BLS stands for basic life support. Basic life support are the most basic components of CPR which would enable a bystander or medical professional to sustain a life long enough for medical professionals to arrive to save the life which is in peril. These basics include chest compressions and rescue breaths. However, a harsh degree of irony exists with this premise because I believe it is the very thing we are teaching people that is hurting our ability to save those in need. Much like in the live action movie of How the Grinch stole Christmas the Grinch is not alone in having a problem with Christmas. Cindy Lou Who also has a problem with Christmas. It is the fact that every single person in Whoville goes absolutely insane in preparation for Christmas that has them both out of sorts. Because the Whos are seemingly going crazy not for the true meaning of Christmas. They seem to have gotten lost in the commercialism of Christmas. The Whos seem to have forgotten the true meaning of what Christmas is all about. So in a similar ironic fashion it’s the very thing that is being pushed so hard that is creating a problem. While it may sound like blasphemy for me to say CPR and Christmas are a problem I believe if you look at them at least from a certain context they can be.

I started teaching CPR to the general public for the America Red Cross in 2006. It was not my first exposure to CPR as I took a class in high school that was not only a driver’s education class, every student also learned CPR. I took this class back in 1993. In 2006 I was excited to teach basic CPR and later first aid. Even later still CPR for the professional rescuer classes. I really enjoyed teaching the various classes because I saw it as a way of me fulfilling a desire that I had to help others. At the time I was not working as a medical professional I was coaching and was running my own football league. I also was working as a supervisor for a fairly small, but successful company. I had already experienced a short stint in emergency medical services but decided to leave for the improved financial security of my family. Hands only CPR was a component of the CPR class I was teaching back in 2006, but it was more of a side note rather than a main feature. The ratio at the time was still 30:2. This means 30 chest compressions to two breaths for adults, children, and infants as one rescuer but 15:2 for children & infants for two or more rescuers. We provided face shields to the students and the students were asked to place their mouths on the manikin’s mouth with a face shield in place. We sold pocket masks and at least one or two people per class would purchase at least one of them. After several months of teaching I started identifying a pattern. During the class I would ask the students how many of them would put their mouth on a stranger’s mouth if needed. No hands were ever raised for the most part in response to this question. If at any point someone were to raise their hand it was extremely rare and the person would do so with obvious hesitation. Now the opposite would occur when I would ask if the students were willing to place their mouths on the mouths of family and friends. It was normally a rare thing to find someone not raising their hands for that question. After returning back to EMS and later teaching CPR classes again I also began asking that question to all of the students I taught yet again. The answer’s I heard did not change for more than a decade of teaching CPR. During the peak of the COVID-19 pandemic an interesting shift occurred. When I posed the question not a single student raised their hands when asked if they would perform mouth to mouth on a perfect stranger. There does not appear to be a second thought. The student’s arms remain by their sides without a semblance of a notion that they are considering raising their hands. In addition, a dramatic shift occurred when I asked about family or friends. About 99% of the students kept their hands to their sides. The few that raised their hands for family and friends every so often do so hesitantly. I even had a question asked in return multiple times as soon as the question about family and friends was asked. The question was: what family member and what friend’s? At first this response seemed a little harsh but then I realized that I could relate to that answer. Overall, upon reflection on this unofficial survey I have conducted for all of these years I cannot say I blame the people when answering in the negative. In fact, I feel exactly the same. As a paramedic, if I happened upon a perfect stranger on duty or otherwise I would not put my mouth on their mouth I would only do continuous chest compressions. If God forbid I am ever to be placed in the position to do chest compressions on a family member or friend I would only perform chest compressions until equipment arrived that would allow me to do more. I would still perform continuous chest compressions with now asynchronous ventilations just the same we do it in the prehospital arena during 911 calls and in the hospital environment. We do CPR this way because it allows for continuous oxygenated blood to flow from the heart to the brain and back again. This allows for a 100% chest compression fraction otherwise known as hands on chest percentage. This just means the percentage of time that someone has their hands on a patient’s chest doing compressions. For reference, you can say that a person that is alive has a 100% chest compression fraction since their heart continuously beats. In comparison the AHA (American Heart Association) openly admits that a 30:2 compression to breaths ration allows for a 60%-80% chest compression fraction. The reason for this is simple. Every time chest compressions stops you no longer have blood flowing from the heart to the brain. Also it takes time to build the pressure you previously obtained while performing chest compressions. As further evidence of the concern associated with stopping or interrupting CPR. It is said that if you follow 3 minutes of high quality chest compressions with even 1 minute of interrupted chest compressions you never build the same pressures you had previously again. Ultimately, after all these years of teaching CPR in classes titled BLS, Heartsaver CPR, and CPR for the professional rescuer I believe I have identified a significant problem with how we teach the components of CPR. That problem is that people flat out admit they are not willing to participate with a life-saving/life-sustaining concept that they are being taught and certified for. Not only do I observe their answers firsthand during classes I clearly experience the impact of bystanders and family members/friends in real world application when arriving for cardiac arrest calls. The lack of action is the true living embodiment of the answers I get during class. When contemplating this significant concern I cannot help but to think of the Whos in Whoville who are seemingly ruining Christmas the very holiday that they love by worrying more about buying gifts then rather celebrating the true meaning of the holiday and why it exists to begin with.

I would like to make it clear that I do not dislike all components of the BLS or heart saver class by the way. I have no problem with explaining how to use an automated external defibrillator or as it is readily known as simply an AED. It is a true life-saving device especially when applied within the first few minutes. In fact the only problem I have with an AED is that they are not more readily accessible. One could argue that they should actually be in every American home and every American business. That may seem like overkill to some but they are a life-saving device that you would rather have and not need rather than need and not have. As a paramedic within the EMS system I can tell you that people survive cardiac arrest when their defibrillated within the first few minutes. The longer it takes for the victims of cardiac arrest to be defibrillated especially if no chest compressions are provided the less likely the patient will survive. AED’s have also become more affordable these days. One company even affords people the opportunity to rent an AED on a monthly basis. Over the course of two years of renting you would have paid for the device so paying outright is still the most advantageous way to acquire an AED. Many models are still pricey. However, no matter the price of the device if the use of one saved only one of your family members or yourself it will be well worth whatever price listed. The devices are truly priceless. The devices are also easy to use. They were originally designed to be made simple enough to allow an 8 year old to be able to use it. I also have no problem with teaching the choking maneuvers that we teach during the class. We still use the Heimlich maneuver. This maneuver has been studied and clinically proven to save lives. Dr. Henry Heimlich was a pathfinder with the life-saving techniques. Dr. Heimlich absolutely proved without a shadow of doubt that the Heimlich maneuver works. I have no problem with teaching this to the general public or medical professionals. The reader may also be surprised to learn that Dr. Henry Heimlich at the age of 94 saved a resident of the nursing home he lives in. The woman he saved using the same technique that carries his name is 86 years young. The woman was choking. Dr. Heimlich recognized the concern and he saved her. What an impressive feat for the now retired doctor. I also want it known that I have no problem with teaching the use of a bag valve mask or a pocket mask. These devices are clearly ideal. The devices create a barrier whereas you do not have to put your mouth on a stranger’s mouth and they do work. They are also relatively easy to use. However, the only problem with either of the devices especially the BVM is that they can be harmful if not used correctly. The concern is what is called hyperventilation. Essentially if you push too hard or too fast the patient receives more oxygen than they need. The negative outcome of this is decreased cardiac output. This means that the very device meant to help can actually hurt the patient. Well, if you are using the device for cardiac arrest they are already dead. What you would be doing is decreasing the possibility that they would be resuscitated. Moreover, it’s not really that practical to even teach the use of these devices because they are rarely ever available when a stranger or family member needs one for CPR purposes. Even the BLS rescuer may not have the equipment immediately available so once again they are faced with the choice of either putting their mouths on the patient’s or just doing hands only CPR. That is the epitome of the problem.

Programs like the American Red Cross and the American Heart Association have been shouting from the mountain tops for decades about CPR being done correctly with chest compressions and breaths. It is my strong opinion that people believe that they are not doing CPR correctly unless they do chest compressions and breaths for the downed victim. Therefore they often do nothing except call 911 because they are unwilling to place their mouths on the patient’s mouths and no equipment is available. As a paramedic arriving to a reported cardiac arrest I am more likely to arrive and find that people are standing outside of the residence or location waving their hands frantically so we know where to go then we are to arrive and find somebody doing chest compressions on the person in need. Every time I arrive on scene of a cardiac arrest I ask two questions to the bystanders or family present. Number one: what have you done so far? I am often times amazed with the response I receive. The people say what they have done so far is to call 911. This is a significant concern because the patient can only survive so long without oxygenated blood getting to their brain. The way this is completed is by performing high quality chest compressions on the patient. The second question I ask is: how long have they been down for (in cardiac arrest)? The answer more often than not is in essence they do not know. They can only estimate. Of course it is not always this straightforward. Getting the bystander or family to speak in clear concise sentences is not an easy thing to do at this point. The pure raw emotions present does not allow for clear articulation. The answer typically is they do not know how long the patient has not been breathing and has not had a heartbeat. This of course is a major concern because if the downtime is too long nothing a medical professional can do upon their arrival will change the outcome. Overall what I have come to realize to my dismay is an example of a complete ironic twist…the way that we are teaching CPR has led to no one doing CPR. In my 17 years in EMS the percentage is about 99% of the time that I arrive to a cardiac arrest call I find that no one is doing chest compressions. Even if a bystander is providing chest compressions they are hardly ever providing rescue breaths in conjunction with the compressions.

In the live action Grinch movie the Grinch steals Christmas as it is said. The Grinch nearly strips Whoville of almost everything that they have especially everything pertaining to Christmas. When the Grinch completes his monstrous undertaking of stealing Christmas he anticipates hearing shrieks and cries of agony in response. Instead he is shocked to learn that the Whos love of the commercial aspect of Christmas was actually superficial. In the face of a seemingly catastrophic end to their celebration the Whos come together and revert back to the true spirit of Christmas. They recall the very essence of love, family, fellowship, and thanksgiving of Christmas. None of these things come in a box. With no tangible gifts remaining the only gifts that was worth celebrating was love and togetherness. This overwhelming outpouring of love allowed the Grinch’s heart to grow three sizes that day. Now this is an actual medical condition called cardiomyopathy and would have caused the Grinch to immediately die but hey this was a fictional tale after all. 

I believe we need the Grinch yet again. The Grinch must act. The Grinch should steal the components of CPR from BLS and other lower level CPR classes. I believe if we strip CPR down to what matters most so that people are not confused by ratios they can never recall and are unwilling to provide anyway. If we simplify the life sustaining act to chest compression only so that potential rescuers are not overwhelmed with fear which often leaves them hesitant to act creating a scenario where they often do nothing for the patient that needs it most. If we just simply refer back to the most basic component needed to save a life perhaps more people would be willing to act. I am suggesting that until the day we can get AED‘s, pocket masks, and/or BVM‘s into everyone’s hands when CPR is needed we should just teach the very essence of what matters most which is chest compressions. The lesson is simple. We need to teach bystanders, family or friends to do deep, hard, fast continuous chest compressions at a rate of 100 to 120 times per minute with the sweet spot being identified as 110 times per minute. They should do this and nothing else until an advance provider can arrive and provide additional advance support. If we do so as a society perhaps then we will find a shift yet again. This time the shift will be instead of 98% to 99% doing nothing during a cardiac arrest we could find 98% to 99% perhaps even 100% of people actually providing chest compressions to the person who needs it. When they need it most. If so, perhaps we can have more happy endings just like in the movie How the Grinch stole Christmas.