Simulation and educationAn assessment of resuscitation quality in the television drama Emergency Room: Guideline non-compliance and low-quality cardiopulmonary resuscitation lead to a favorable outcome?
Introduction
Since Kouwenhovens’ original description of modern cardiopulmonary resuscitation (CPR),1 the techniques for CPR have been universally accepted, constantly improved, and internationally implemented as a standard of care for both out-of-hospital and in-hospital emergency medicine.2 Through an intensive process over many years, scientific and evidence-based data on CPR are regularly cited, critically analyzed, and discussed by representatives of the International Liaison Committee on Resuscitation (ILCOR) to improve both the survival and outcome of patients. These data are published in the Consensus of Science Statements with Treatment Recommendations (CoSTR) on an evidence-based level.3 The ILCOR member organizations (e.g., the American Heart Association, AHA) subsequently published specific resuscitation guidelines that are consistent with the science in this consensus document.3, 4
In the context of these consensus guidelines, CPR practice and CPR teaching should also be internationally uniform. Because only high-quality resuscitation, according to the guidelines’ algorithms, provides the best evidence-based care for patients in cardiac arrest, it increases both survival and optimal neurological outcome after cardiac arrest.
Traditional media, such as television (TV), are powerful tools for disseminating health information and serve as the primary source of health information for millions of people.5 In particular, lay persons and medical students gather medical knowledge presented on television.6, 7, 8 The most important fictional medical TV drama with the highest number of viewers is Emergency Room (ER), an American medical drama television series created by novelist and physician Michael Crichton.9 A few earlier studies have analyzed the portrayal of resuscitation outcome in television series.6, 7, 8, 10, 11 Concerning ER, previous studies have found that the outcome after resuscitation is not realistic, resulting in a discrepancy between TV and reality.6, 7 Thus far, no published studies have analyzed the quality of CPR shown on any television medical drama.
Therefore, the main goal of the present study was to analyze CPR scenes in the U.S. television medical drama ER according to the specific algorithms of the AHA guidelines for CPR. For detailed analysis, two hypotheses were tested. The first hypothesis was that CPR quality in the TV drama ER follows the guidelines of the AHA (200012 or 2005 guidelines13). The second hypothesis was that the quality of CPR found in the present study would explain outcome parameters after CPR.
Section snippets
Data basis
ER is an American medical drama series that is primarily located in the emergency department of the fictional County General Hospital in Chicago.6 The script was influenced by Michael Crichton's experiences in the emergency department as a young physician. The hospital scenes in ER occur on an exceptionally realistic set in which the medical team encounters emergency medicine cases ranging from drug overdoses and rape victims to motor vehicle crashes and gunshot wounds.14 Each episode lasts for
Results
A total of 136 (2001–2005 vs. 2005–2009, n = 82 vs. n = 54) on-screen cardiac arrests occurred in the 174 (n = 98 vs. n = 76) reviewed episodes of the TV medical drama ER. All of the patients were subjected to a CPR attempt and were therefore analyzed in detail (Table 1).
The median age of the resuscitated patients was 28 years (25 vs. 30 years), and 66% of patients were male (n = 90 of n = 136), and 34% were female (n = 46 of n = 136). Trauma was the leading cause of cardiac arrest (56.6%), followed by
Discussion
One of the most dramatic, fast-paced, and gripping storylines in medical television fiction involves in-hospital cardiopulmonary resuscitation.15 However, the quality of CPR in television dramas has not been previously assessed in this setting.16 In the present study, 136 CPR scenes from the series ER were analyzed for their compliance with AHA guidelines and resuscitation quality. Furthermore, this is the largest study to date (Table 2) and the first study to analyze the quality of CPR in a
Limitations
There are several limitations of this study. First, only two five-year periods of a single television medical drama (ER) were reviewed and compared with the corresponding AHA guidelines for CPR. Using a longer time frame would have resulted in more valid results. By contrast, writers may deviate from realistic scenarios on an episode-to-episode basis. Therefore, a longer period of analysis may not necessarily produce more consistent data. Second, some parameters were estimated (e.g., patient
Conclusions
Today, high-quality CPR is considered essential for a beneficial outcome after cardiac arrest. In the present study, CPR quality in the TV medical drama ER was assessed and found to be extremely low. In summary, only one scene was completely in agreement with the published guidelines and lacked any obvious, severe mistakes. However, low-quality CPR and non-compliant resuscitation efforts based on the AHA guidelines resulted in favorable outcomes after CPR.
Because laypersons may learn
Author contributions
Jochen Hinkelbein had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Hinkelbein, Marks, Wetsch.
Acquisition of data: Hinkelbein, Marks, Wetsch.
Analysis and interpretation of data: Böttiger, Hellmich, Hinkelbein, Spelten, Wetsch.
Drafting of the manuscript: Hinkelbein, Wetsch.
Critical revision of the manuscript for important intellectual content: Böttiger, Hellmich, Marks, Spelten.
Study
Funding/support
None of the authors received financial or other support from any of the companies mentioned in this manuscript. There was no funding for this study.
Conflicts of interest
BWB is Director Science and Research of the European Resuscitation Council (ERC) Board, and JH is chairman of subcommittee #13, ‘Resuscitation and Emergency Medicine,’ of the European Society of Anesthesiology (ESA).
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