PHILADELPHIA -- Every few seconds, the sonorous male voice issues a command:
Compress a little deeper. Increase duration of each compression. Release pressure between compressions.
Ernest Kwiatkowski obediently adjusts the force of his hands on the breastbone of Resuscitation Anne, a vinyl dummy long used to teach cardiopulmonary resuscitation.
As an emergency department nurse at the Hospital of the University of Pennsylvania, Kwiatkowski already knows CPR. But this is the first time he can tell exactly how well he is doing it, because Anne is connected to a new CPR monitoring device.
Within a minute, the voice falls silent, satisfied with Kwiatkowski's technique.
"That is the best teacher you could ever have," he enthuses.
That "teacher," introduced to him last week, is part of a wave of technology and research aimed at breathing new life into CPR, the emergency treatment for cardiac arrest.
Developed almost half a century ago, the procedure allows someone to work a victim's heart and lungs manually. A rescuer pushes -- twice per second -- on the victim's chest, and that rescuer or a helper also gives intermittent mouth-to-mouth breaths. The two maneuvers temporarily force enough oxygenated blood through the victim to protect vital organs.
Studies show that high-quality CPR can double or triple the chance of survival, and that each minute without CPR cuts that chance by about 10 percent. Yet only about 15 percent of the estimated 215,000 Americans who suffer heart attacks outside hospitals each year get CPR right away.
"Sometimes, even if bystanders have taken a CPR course, they're paralyzed," says Vinay Nadkarni, a physician and resuscitation expert at Children's Hospital of Philadelphia. "They don't want to do it wrong."
Few people do it right, studies show. Even in hospitals, the quality of CPR is surprisingly poor, partly because there have been no quality-control instruments, according to research led by Penn emergency physician Benjamin Abella.
"We've been treating CPR as if we're still in the 1950s," Abella says. "We need to bring it into the modern era."
Three years ago, the American Heart Association reviewed the latest studies and updated CPR guidelines, putting more emphasis on chest compressions and less on the breaths -- which many rescuers find disgusting, not to mention germy.
Last month, a heart association committee led by Abella called for "creative new approaches" to increase and improve CPR performed by bystanders.
One approach, pioneered in Seattle in 1981 and now standard throughout the country, involves training 911 dispatchers to talk callers through CPR until an ambulance arrives. Variations of dispatcher-assisted CPR would be a cost-effective way to reach more untrained witnesses to heart attacks, the committee said in a paper published in the journal Circulation.
Another example of outside-the-box thinking is CPR Anytime, a $30 boxed kit containing a training video and "Mini Anne" -- an inflatable head and chest. The chest has a metal pin that clicks when compressions are deep enough.
In the three years since the heart association partnered with Laerdal Medical Corp. to launch CPR Anytime, more than 400,000 kits have been distributed to schools, companies, municipalities, and hospitals in the United States -- including Penn and Children's Hospital. The program has also taken off in other countries.
Studies suggest that people learn CPR just as well (and maybe remember it better) with the 22 minutes of self-instruction than with the standard four-hour, information-overload CPR certification course.
"We wanted to take the time commitment and intimidation factor out of learning CPR," said Kathryn DiPuppo, the heart association's community strategies manager. "Anybody can learn adult or child CPR within half an hour."
Another innovation capitalizes on the automatic defibrillators that are now available everywhere from federal buildings (where they're mandated) to shopping malls, airports and office buildings. Defibrillators check for abnormal heart rhythm and then, if necessary, deliver a corrective electric shock.
Not all heart attack patients need defibrillation -- but they all need CPR to keep blood circulating. So Abella and other experts thought: Let's modify the heart-jolting device -- which already has user-friendly voice commands -- to monitor and coach CPR.
One result is the "MRx Defibrillator with Q-CPR" that Kwiatkowski and his colleague Suzanne Coste used last week. Made by Philips Medical Systems, the technology includes a sensor the size of a computer mouse that is placed on the breastbone of the patient (or training dummy). The rescuer performs chest compressions on top of the sensor, which transmits vital information to a computer screen on the briefcase-size defibrillator.
"The machine gives you real-time feedback," says nurse Joanne Phillips, a resuscitation expert at Penn. The data can also be reviewed after an emergency to critique the team's response.
Next door, at Children's Hospital, similar technology is helping intensive-care nurses keep their CPR skills sharp. The defibrillator-CPR monitor and child-size mannequin are wheeled on a cart right to the nurses.
"When it's crazy busy, they can't get away from the floor," explains Dana Niles, the clinical research coordinator who oversees the "Rolling Refresher" program. "Just 30 seconds of chest compressions are enough to reinforce the technique."
A defib/CPR system for lay rescuers is not yet on the market, but Abella has been working on a version with Cardiac Science Corp.
In the future, advocates hope, CPR training will become a rite of passage, as routine as driver's education. Indeed, one idea is to link driver's licensing to voluntary CPR training, like the motor-voter initiative that has increased voter registration.
"I envision a world," Abella says, "in which everyone has the chance to do the best CPR possible."
A Brief History of Cardiopulmonary Resuscitation
Ancient times: References to the apparent use of mouth-to-mouth resuscitation are found in the Bible.
1740: The Paris Academy of Sciences recommends such a technique for drowning victims.
1891: Dr. Friedrich Maass performs first documented chest compression in humans.
1956: Drs. Peter Safar and James Elam invent modern mouth-to-mouth resuscitation.
1957: U.S. military adopts the method to revive victims.
1960: Chest compressions are combined with mouth-to-mouth as cardiopulmonary resuscitation -- a new method of lifesaving intended for physicians.
1966: National Research Council convenes a conference to establish standardized training and performance standards for CPR.
1972: Dr. Leonard Cobb holds a mass citizen training in CPR in Seattle. He goes on to help train 100,000 people in two years.
2005: The American Heart Association updates CPR guidelines to recommend 30 chest compressions (instead of 15) for every two breaths.
SOURCE: American Heart Association
A photo slide show of dummy CPR, and where to find training by real people near you is at http://go.philly.com/health.Contact staff writer Marie McCullough at 215-854-2720 or firstname.lastname@example.org.