Stayin’ Alive and Playing It Forward: A Revision for ‘Resusci Annie’

Someone presses the arrest button. I start CPR, my muscle memory working faster than my brain. 1, 2, 3, 4, 5 . . . 30. I count while mentally singing “Ah, ah, ah, ah stayin’ alive, stayin’ alive,” so that I can keep up a rate of 100-120 compressions per minute. 1, 2, 3, 4, 5 . . . 30. There are a lot of people in the room, but I just focus on my count. A defibrillator arrives. No shockable rhythm. 1, 2, 3, 4, 5 . . . 30. I keep going until someone takes over compressions.

My accidental introduction to real-world CPR happened on the day of the high-stakes “cardiology masterclass” at the hospital where I was training: I was one in a group of prospective medical trainees competing to dazzle senior cardiologists with our clinical skills. It is a Sherlock Holmes-esque event, deciphering the smallest of clues—clubbed fingernails, rumbling heart murmurs, and distended, writhing neck veins, all in the hope of producing a correct diagnosis within 7 minutes.

My “cardiology masterclass” fell, as these inevitably things do, during my rostered week of night shifts. Just as the bell went off to start the next station, I heard a terrible noise coming from behind the curtain of the exam station next to mine. The volunteer, a gentleman with a history of valve surgery who had forgone golf that morning to volunteer as a patient, had arrested. The red buzzer was pressed, but as we were not in the hospital proper, it would take some time for the cavalry to arrive. My colleague was maintaining the airway, and I was performing CPR. Our examiner, who happened to be our consultant cardiologist, was running the arrest.

Seven minutes feels long when you are being observed by your future boss. Seven minutes is much longer when you are doing CPR to save someone’s life. 1, 2, 3, 4, 5 . . . 30. Not every patient is lucky enough to have a cardiac arrest in a room full of expert cardiologists and budding physician trainees. Timely provision of CPR in an out-of-hospital cardiac arrest affords the opportunity of life. The “chain of survival” math has been well established: early and effective CPR plus timely defibrillation equals better survival. As a heart failure cardiologist on the receiving end of patients who suffer both in-hospital and out-of-hospital arrests, time to CPR and defibrillation means the difference between a functioning heart and brain or, more simply, between returning the patient to their family or not.

Recent studies show, however, that almost half of individuals who suffer a cardiac arrest do not receive bystander CPR. In addition, worldwide from the United States to the Netherlands, women are statistically less likely to receive CPR than men, while bystander CPR is even less likely in people of color. CPR is a skill that is perfected by practice. As a society, do we need to reconsider and adapt the way we are “practicing”?

The story of the simulated CPR’s origins goes like this. In 1955, a toymaker drags his own son from a river and performs CPR to bring him back to life. This pivotal moment inspires him create his most well-known “toy” in the form of “Resusci Annie,” the CPR training manikin now used worldwide. The design of Resusci Annie is based on L'Inconnue or the “Unknown Woman of the Seine,” a beautiful woman who met a different fate than the toymaker’s son when she was dragged lifeless from the river in Paris.

It's unsurprising that a toymaker whose own son skirted death would envisage a doll that would save so many lives. Playtime is a vital aspect of brain development for children. It allows them to mimic everyday activities that will become muscle memory as adults. Dolls serve a function, first as friends, then as confidants. Tea sets and miniature cooking equipment help children learn about preparation and consumption of food, babies simulate their caregivers’ facial expressions to form their own. The list goes on.  

In the medical community, play is integral to our procedural learning, although we tend to use the more technical term “simulation.” In this context, it is far from child’s play. Modelled on lessons hard-earned from aviation failures, we aim to simulate every aspect of a scenario that might improve real-life outcomes. Across high-risk fields, studies have shown that the closer a simulation is to real life, the better performance is in an actual emergency event.

Medical procedures are made safer by practicing on manikins before moving to patients. In a specialty like cardiology, simulation reduces risks whether practicing efficacy, speed, and calm in an arrest situation or proctoring a new structural heart intervention. Simulation provides the muscle memory that ensures, in a high-stress situation, we will default to our training.

In Gabrielle Zevin’s recent bestseller, Tomorrow, and Tomorrow, and Tomorrow, the main character announces: "There is no more intimate act than play.” He is referring to video games, whereby if one was to die, multiple new lives arise. With each new opportunity at life, one improves their skills and advances to the next level. The same can be said of simulation.

There is no question that L'Inconnue, whose own life was lost, has saved countless lives as Resusci Annie. A 2010 study of doctors found that practice on lifelike manikins improved outcomes to greater degree than clinical experience alone. But resuscitation training for the public is voluntary in most countries, with uptake rates as low as 50%—would bystander CPR rates be higher if the public had more chance to practice simulation?

Rates of CPR in women are even lower. That’s thought to be linked to a fear of inappropriately touching the chest area and the lack of awareness about cardiac disease in women that continues despite multiple campaigns. But in fact, the original Resusci Annie was deliberately designed as a woman, the justification being that it would reduce hesitation to perform mouth-to-mouth for fear of repercussion. Today, Resusci Annie has a whole family of training manikins surrounding her, with more sophisticated features. Baby manikins allow for the practice of CPR on children under the age of two, conveniently popularized to the “Baby Shark” theme song instead of the slower Bee Gees “Stayin’ Alive” for adults. Resusci Annie’s airways now simulate the rise and fall of the chest, and there are disposable masks to make the experience as lifelike as possible.

But there is more to be done. Resusci Annie was designed as flat chested, and bra-less, which does not simulate real life. Recent attempts to combat this include designs such as the “Womanikin,” with manikins dressed in bras, though such changes have not been widely implemented. Other researchers have noted that Resusci Annie has more systemic diversity problem. If we want CPR to happen without hesitation for ourselves and our patients, we need to more completely reenvision today’s Resusci Annie.

Whether you call practice “play” or “simulation,” it is, in essence, the opportunity to learn. When the time comes, your innate response will be to simply let your training push you into action.

1, 2, 3, 4, 5 . . . 30. Return of spontaneous circulation. Along with the patient, we all breathe a sigh of relief.

Off Script is a first-person blog written by leading voices in the field of cardiology. It does not reflect the editorial position of TCTMD.