During my years working as a doctor in England’s NHS (National Health Service), one routine ritual we had to go through every year or so was an updating of our cardio-pulmonary resuscitation (CPR) skills. These were the emergency procedures that every member of the clinical staff, doctors, nurses and paramedics would have to perform upon someone who had collapsed, to manually preserve intact brain function until further measures could be initiated to restore spontaneous circulation and breathing. One needed to have a recent CPR certificate in order to stay in practice in the medical profession. It usually meant a day off from work, a study day during which a CPR team from the hospital Trust one was working in would revise with us the principles underlying CPR, and we would then have ‘hands-on’ sessions with life-size mannequins on the actual procedures involved.

It was on one of those sessions that I was first introduced to ‘Nellie the elephant’. According to the International Liaison Committee on Resuscitation guidelines, CPR “involves chest compressions at least 5 cm (2 inches) deep and at a rate of at least 100 a minute” in an effort to create artificial circulation by manually pumping blood through the heart and thus the body. Our trainer actually sang us a full stanza from the “Nellie the elephant” song. Many of my British colleagues already knew it, from their kindergarten and early childhood. Apparently, delivering the chest compressions in time to the song matched the ideal rate of 100/minute needed for CPR. And the first verse (15 compressions) was just right to give one pause to ventilate the patient. The ideal compression to ventilation ratio is 30:2.

Nellie the Elephant

I reproduce the lyrics here, with the fifteen beats capitalized, to emphasise where the chest compressions would be delivered: “NEL-lie the EL-ephant PACKed her TRUNK, and SAID good-BYE to the CIR-CUS; OFF she WENT with a TRUMPety-TRUMP, TRUMP, TRUMP, TRUMP.” Pause to ventilate the patient, and start all over again until further help arrives or the patient responds.

This was new to me. I had been taught CPR before, in India and in my early years in England, but this was the first time someone was actually asking me to insert a tune into my head, and ‘play’ it there, and all in the line of duty!

I began to view CPR and my anaesthesiology, internal medicine and A&E (Accidents and Emergencies) colleagues (as they most often were in the frontline for emergencies that required CPR) on the hospital staff, in a new light. From then on, whenever I saw CPR being administered, I could in my mind’s eye visualise a thought bubble hovering above the person delivering the chest compressions, and ‘Nellie the elephant’ prancing around within, with a ‘trumpety- trump, trump trump’. It seemed too incongruous for words: a nursery song being marshalled to pull people back from the brink of death, the ‘other end’ of their lives.

Another almost poetic irony came to my mind: many patients who experience a massive heart attack report feeling tightness or a massive weight on their chest, akin to “an elephant sitting on my chest.” And if they went into cardiac arrest, here was medicine resuscitating such victims and others, using the imagery of another elephant, to thump-thump-thump their heart back into action! How many elephants could one possibly fit into an emergency room? It seemed like the start of a jokey riddle, but Nellie had packed her trunk, so it looked like she had come to stay.

A little more about Nellie the elephant: she was ‘born’ in 1956, through the eponymous song written by Ralph Butler and Peter Hart (Heart! Will the ironies please stop?). It rapidly rose to become a children’s favourite.

And just in case you were wondering: Nellie’s an Asian elephant, from India, no less. The prelude of the song tells us: “To Bom-bay, a travelling circus came; They brought an intelligent elephant and Nellie was her name; One dark night, she slipped her eye and chain; And off she ran to Hindoostan and was never seen again.”

So does it end well for Nellie in the song? Despite being “never seen again”, the lyrics tell us at the end that she meets with a friendly wild herd “one night in the silver light, on the road to Mandalay.” The song-writer certainly believed that animals should be living free, even if not always born free.

So how and why did a song about a travelling circus elephant become such a life-saver? In addition to the two reasons already discussed (an optimum ‘tempo’ of 100 beats/minute and just the right number of beats for a compression-ventilation ratio of 30:2), to my mind the tripletty rhythm (Nel-lie-the el-eph-ant) in the verse allows enough recovery time; so one delivers the compression on the downbeat ‘1’, and the breastbone and rib cage are allowed to spring back at the ‘2-3’, ready for the next compression to be administered.

In the last few years, Nellie the elephant has come under a cloud, though. A ‘large’ (although at just 130 participants, one could question this claim) prospective randomised crossover trial published in the BMJ (British Medical Journal) in 2009 concluded that while “listening to Nellie the elephant significantly increased the proportion of lay people delivering compression rates at close to 100 per minute, unfortunately it also increased the proportion of compressions delivered at an inadequate depth. As current resuscitation guidelines give equal emphasis to correct rate and depth, listening to Nellie the Elephant as a learning aid during CPR training should be discontinued.” Many have questioned the conclusion, and old Nellie fans are likely to continue ‘thumping’ with her in an emergency.

But what are the alternatives to Nellie the elephant, then? One could go with 30 chest compressions to the tempo of “That’s the Way (I like it)” by KC and the Sunshine Band. The others seem like tongue-in-cheek practical jokes, but they’re for real: “Another One Bites the Dust” by Queen. For the patient’s sake, we certainly hope not (bite the dust, that is).

I’ve saved the best (literally, in terms of popularity and effectiveness, after Nellie, as well as for witty titles) for last. Wait for it: “Don’t Break my Heart (My Achy Breaky Heart)” by Billy Ray Cyrus. Even better: “Staying’ Alive”, the BeeGees disco anthem. Now that’s more like it (and the way I like it).

(An edited version of this article was published on 26 July 2015 in my weekend column ‘On the Upbeat’ in the Panorama section of the Navhind Times Goa India)