Rethinking CPR training: when the "man" in manikin affects performance, a randomized crossover simulation study

Women are less likely to receive bystander or in-hospital cardiopulmonary resuscitation (CPR) than men and have lower survival rates following cardiac arrest. Current CPR training relies heavily on manikins that represent white, lean, male-presenting bodies. This study investigates whether manikin sex influences CPR performance using simulated cardiac arrest scenarios.

We conducted a randomized crossover simulation trial of 52 internal medicine residents who completed two ventricular fibrillation arrest scenarios using male-bodied and female-bodied manikins in alternating order (1:1 allocation to female-first vs male-first) separated by a 4‑h washout period. The primary outcome was time from ventricular fibrillation onset to defibrillation and secondary outcomes included time to compressions, time to pad placement, time to recognition of ventricular fibrillation, and CPR quality metrics (depth, rate, and compression fraction). Data were analyzed using linear mixed-effects models controlling for participant sex and experience.

Participants in the female-first condition demonstrated delayed time to defibrillation (28.05, p < 0.006), delayed time to compressions (12.08 s, p = 0.007), delayed pad placement (14.58 s, p < 0.001), delayed recognition of ventricular fibrillation (17.79 s, p = 0.004) on the female manikin compared to male-first. The proportion of time spent within the target compression depth was lower in the female manikin-first group (11.02%, p = 0.027).

CPR performance was inferior when the female manikin was encountered first, with an asymmetric improvement pattern suggesting presentation order alone does not fully explain the gap. Early and routine female manikin representation in CPR education may improve cognitive readiness and attenuate sex-based disparities in resuscitation performance.