Not long ago, while applying for hospital-based jobs, it occurred to me that I lacked a certification that I really ought to have, namely, Basic Life Support, or BLS. From the website of the American Red Cross:

Basic Life Support, or BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway. It requires knowledge and skills in cardiopulmonary resuscitation (CPR), using automated external defibrillators (AED) and relieving airway obstructions in patients of every age.

So I signed up for a class in my area, and decided to certify. It was relatively cheap, conveniently located, and scheduled to take all of four hours. A bargain.

I showed up at the appointed place on the appointed day and time. There were nine of us, eight students and an instructor. Six of the students were nurses or nursing students; one worked in physical therapy. I was the outlier, looking for work as an OR assistant. The instructor was a paramedic. Four of the students were male, as was the instructor; four, female. We were set up in a small room with eight chairs and desks, a video screen, six CPR mannequins (four adult, two infant), and a couple of AED devices. 

The class proceeded essentially as follows. The instructor introduced himself, and said a few words about the class. He then turned on an instructional video, which we watched for several 10-15 minute segments, as he went into another room nearby to check his phone or surf the web. Each segment of the video introduced a new technique within a new scenario. After each segment, the instructor came out of his room to drill us on the technique we had just learned in the video. Under his supervision, we took turns practicing on the mannequins until we mastered each technique to his satisfaction. We did this for maybe three hours, on maybe a dozen scenarios. We then sat for a very badly-designed multiple choice test. Acknowledging the defects in the test (and pointing out that he had neither designed it nor had control over its contents), the instructor gave us the answers to two of the more badly written questions, and hinted at the answers to some of the others. 

In taking the test, it probably occurred to everyone taking it–the thought certainly crossed my mind–that much of the class had been taught less with a view to preparing us to perform BLS under realistic conditions, than to passing the test. Predictably, everyone passed. I got a 96/100, getting one fundamentally nonsensical question “wrong.”* We then applied for our certification cards, which we all got a few days later by email. Mission accomplished. Business goal achieved. Performance metrics satisfied. 

It’s highly unlikely that the class rendered anyone capable of responding to an actual emergency in the field. Of the eight students, only one (not me) struck me as sufficiently competent at CPR to respond to a Code Blue or Rapid Response call in a hospital setting. This one competent student was clearly an experienced nurse trying to renew a pre-existing BLS certification. The rest of us could either be counted on to kill the patient or to watch them die for lack of competent care. In short, God help you if you suffer cardiac or respiratory arrest in our presence. I hate to put it this way, but there’s a fine line between a certification for basic life support and a license to kill.

Problematic as that may be, there’s something about the class that I haven’t mentioned so far that struck me as more problematic still. Go back and re-read the Red Cross’s description of the objective of BLS. This time I’ve italicized one salient word you may have missed on first reading:

Basic Life Support, or BLS, generally refers to the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway.

BLS equips you with the knowledge and skills to respond to “anyone” in the relevant sort of medical distress. I take it that “anyone” includes women. But in fact, the class was taught as though women either didn’t exist, were anatomically identical to men, or were collateral damage of the pedagogical incompetence of the BLS certification industry.

For anatomical reasons that I won’t belabor at great length, CPR on men differs somewhat from CPR on women. To be more specific, the details of how to do chest compressions, as well as how to apply AED paddles, differs in the two cases. For readers still wondering what the issue may be, it has to do with boobs. Women have them, and men generally do not. This, meaning the active presence of boobs, raises medico-logistical issues for the would-be first-responder called to a case of cardiac or respiratory distress. Suppose that the patient is a woman. What, to put the point delicately, is the first-responder to do with her boobs? And what not? 

Put it this way: if compressions or electric shocks were given to men in the region of the male pubis–in other words, in the immediate vicinity of the testicles–we would expect to receive a proviso or two from certificate-conferring instructors about how to compress or shock this region without, say, needlessly compressing or shocking someone’s balls in the process. As a man myself, with a certificate to prove it, I would certainly feel better if I knew that the person compressing or shocking my pubis knew enough to avoid putting undue pressure on or unnecessarily applying electric shocks to my balls. Frankly, I would be discomfited at the thought that certifications were wantonly being handed out to first-responders ignorant of or indifferent to the ramifications involved. And if they were, I would call loudly for reform. Some things are unacceptable.  

But I guess it’s different with women. Or so I gathered from my class. Four men and four women, along with their male instructor, practiced chest compressions on six male mannequins, four adults and two infants. Every scenario but one in every segment of the instructional video featured a male subject. The one exception was that of a woman in an advanced state of pregnancy; here we were told to exercise caution on behalf of the unborn child, pushing the mother’s belly to her left (our right, facing her) so as to increase blood flow to the fetus. Every reference but one to the gender of the patient on the written test made reference to a male patient. I think you can guess the exception. The exception involved a woman in an advanced state of pregnancy, and the question asked what we were to do with her belly, and why. Everyone got it right.

A couple of questions occurred to me between chest compressions. For one thing, how exactly do you handle womens’ breasts when you do them? Are there any special protocols here, any special care that has to be taken to avoid injury? Or can breasts just be smushed at random without one’s having to worry overmuch about their fate? (Keep scrolling; text continues after the bra; photo credit: Victoria’s Secret catalogue.) 

The instructions for the use of an AED require that the paddles be applied to bare skin. It’s possible in theory to do this by leaving the bra on, and working around it. But is that how it’s actually supposed to be done? Or should the bra be taken off? Are there any ethical or legal problematics involving in taking off a stranger’s bra? There usually are. Granted, if the bra really has to come off in the interests of life support, cardiac arrest is a good time for it. But there is such a thing as medical error. What if the situation the first-responder faces isn’t cardiac arrest, but something else that doesn’t require the removal of a bra? What if it is cardiac arrest, but there’s no need to remove the bra? On the other hand, what if it’s cardiac arrest, and you’re supposed to remove the bra, but you’re too squeamish to do so? Without meaning to posture as some kind of expert on bras, I do happen to know that some bras contain metal wiring–“underwire” I believe they call it– that might prove problematic when using an AED. Is suspicion of underwire a reason for removing the bra, or is it simply a reason for summoning extra vigilance in applying a shock to the relevant part of the body?

These are not, I think, merely the frivolous, hand-wringing, wildly hypothetical questions of a former academic philosopher. They strike me as the kind of thing you’d want to know before you went out into the field with a BLS certification. Clinicians in the field are apt to encounter women there. Many of these women are likely to have breasts. And correspondingly many will be wearing bras. It seems eminently possible that women with breasts, wearing bras, might suffer cardiac or respiratory arrest in the presence of BLS-certified first-responders. And so, they might fall under the “anyone” to whom first-responders are expected to respond. If and when that happens, one might expect BLS-certified clinicians to know what to do, and be ready to apply that knowledge. 

But don’t count on it. I don’t mean to suggest that there are no answers to the questions that occurred to me during my brief BLS class. There are. My point is that you can get a BLS certification without asking, addressing, or answering any of them, and plenty of people do. I didn’t ask my questions, partly for fear of coming across as the proverbial “difficult student,” and partly for fear of coming across as the middle-aged male pervert of lore.  But then, neither did anyone else, and they didn’t have my excuses. Breasts didn’t come up in the video, weren’t raised by the instructor, weren’t practiced in the drills, and weren’t on the written test. Hear no breasts, speak no breasts, see no breasts, perform no chest compressions and apply no defib paddles near breasts. Come the day, I guess you just cross that breast when you get to it.

There’s an enormous irony here. We in the West supposedly live in a post-feminist age of sexual liberation and sexual explicitness. It’s a post-feminist age because, on one view anyway, women long ago achieved equality with men, feminism having completed the job it set out to do; arguably, some men say, feminism has gone too far, and the time has come to ratchet it back. And it’s an age of sexual liberation and explicitness because sex is now ubiquitous. Breasts, among many other things, are everywhere. Go on Instagram or TikTok, to say nothing of PornHub or YouPorn, and I have no doubt you’ll see a few. 

And yet. If women are equal, and breasts routine, you would expect breasts to make an appearance in a context where their appearance was a matter of life and death. Yet you don’t. It’s a disquieting question why this should be. Why would breasts, which make gratuitous appearances in contexts where far less is at stake, suddenly fail to materialize when their appearance would seem to be a matter of medical necessity? And if women are equal to men, why are women utterly absent from drills for basic life support? I don’t really know. This confession of ignorance involves a vague sense of guilt and complicity on my part. Or maybe not so vague. Here I am making criticisms after the fact, but there I was holding my tongue for fear of jeopardizing my BLS certification, and with it, my prospects for a job in the local hospital OR. 

If ever you wonder about the need for “woke culture,” think a bit about the strange lacuna I’ve described here. People who inhabit a pornography-saturated, supposedly post-feminist culture find themselves mute when it comes to asking crucial, relevant questions about female anatomy in a medical context. Could it be that for all the complaints about “wokeness,” we’re not woke enough?

“Wokeness” is, to be sure, an ambiguous term with many meanings. But surely one meaning is possessing the moral wherewithal to break through problematic silences, to ask awkward, otherwise unasked questions, and to demand answers, even at personal expense. That attitude is to be contrasted with the complacency that goes with moral slumber. A society that fails to wake up, break through its torpor, and ask the right questions is the victim of a kind of widespread moral failure. It is, morally speaking, sleeping at the wheel, and, as Socrates famously put it in the Apology, has to be stung awake. Doesn’t it? I’ll grant you that it’s an irritating metaphor, but then, maybe that’s what it was supposed to be.   

 *The question was: if you’re doing CPR in a two-person team, and the other person on your team, tasked with doing chest compressions, starts to lag in his pace, should you (a) tell him directly that he’s getting things wrong, or should you (b) try a more indirect approach? Given the gravity of the situation, I said (a), but the “correct” answer, more in keeping with the professional respect due to a colleague, is (b).