In the opening scenes in the last episode of Body of Proof, a television series starring Dana Delany as medical examiner Dr. Megan Hunt, a patient was given CPR after being shot in the back.
While the writers of Body of Proof, no doubt, will claim dramatic license in the depiction of the scene to further the episode’s story line, the technique and protocol used by Dr. Hunt does not fit with the standard diagnosis and treatment steps as described in the 2010 guidelines for cardiopulmonary resuscitation and practiced in real-life resuscitations by trauma surgeons, intensive care physicians, emergency medicine physicians, and prehospital educators.
In the scene, Dr. Hunt examines a shooting victim and realizes through undescribed clinical clues that the patient is still alive. She then turns the patient over onto his back, calls for 5 ml of epineprhine, does 2-3 chest compressions with her hands positioned over his left mid-rib cage, gives 2-3 breaths via mouth-to-mouth resuscitation, and then injects in a perpendicular direction 5 ml of epinephrine via a large syringe and needle into the anterior left chest cavity.
Following ACLS protocol and the standard CPR field protocol taught to and practiced by prehospital personnel, some highlights of Â real-life practice and how this differs from the television scene are described below:
When a patient is found unresponsive, the ABC protocol is started after a single bystander has called for help. In this scene, Dr. Hunt was attended by a paramedic crew who had access to the standard CPR drugs (see below) so there was no need for the character to call for help.
In the real world, a prehospital team would begin inserting intravenous lines, setting up a bag mask, and starting oxygen during the initiation of the CPR protocol.
After the provider calls for help, the ABCs are then started. A quick check of the airway to insure it is patent is done by opening the jaw and inspecting the mouth for obstructing fluids or objects. This was omitted in the scene.
Breathing is next assessed by checking for respiratory muscle movement or using the ear close to the mouth and nose to detect respirations. This was also omitted from the scene.
Circulation is assessed to detect if there is a pulse. If there is a detectable pulse, even in a patient that is unresponsive, chest compressions are never administered. Dr. Hunt in the scene does not appear to do any pulse check before starting compressions.
In an adult male, a detectable pulse at the carotid artery in the neck implies a systolic blood pressure of about 50 mmHg. In this scene, in a gunshot victim, the likely mechanism for unresponsiveness would be stage 4 hemorrhagic shock.
The treatment would be intravenous fluids (blood products if available), not chest compressions and intracardiac epinephrine.
In this scene, possibly because of the constraints of the story line, no monitor was placed.
However, it is important to note that in real-life cardiopulmonary resuscitation, a monitor is always placed by the paramedic team in unresponsive patients. The detection and diagnosis of a pulseless rhythm is key in determining if the ventricular tachycardia/ventricular fibrillation or asystole/pulseless electrical activity treatment arms are to be initiated.
The treatment drugs and whether the patient is given electrical shocks are determined by this diagnosis. There is no way to determine the rhythm without placing the patient on the monitor.
To continue the scene’s analysis, Dr. Hunt then proceeded to give chest compressions using heel-on-palm over the left rib cage in the mid-clavicular line. The correct positioning of the hands is on the mid-sternum (breast bone), not the mid-clavicular line.
Because of the mechanics of the rib cage and the lack of articulation of the ribs in the area over the cardiac silhouette, adequate compression of the heart muscle can not be effected by compressing directly over the heart outline in the mid-clavicular plane.
In addition, the use of an injection of epinephrine using a long needle through an intact anterior chest wall into the cardiac muscle is never done in resuscitation of gunshot victims or patients with exsanguinating hemorrhage in the field or the trauma bay.
While the liberal use of epinephrine is in the treatment protocol of cardiac arrest of any type, it is given in the field via intravenous administration, intraosseus administration (directly into the bone marrow of Â a bone such as the tibia or shin bone), or via an endotracheal tube (breathing tube).
Lastly, it is possible to access the heart and surrounding sac (pericardium) with a long needle through an intact anterior torso.
This is typically done to temporarily relieve cardiac tamponade (fluid build up around the heart). However, experienced cardiologists and intensive care physicians always use a 45 degree sub-xiphoid approach to approach the pericardium in the area of the left ventricle.
A perpendicular approach directly over the cardiac and through the lung parenchyna is not used. Passing a needle the size that was handed to Dr. Hunt in the episode would most likely cause a pneumothorax or puncture of the lung, a condition that can be life-threatening in a injured patient in the field.