Art Couldn't have said it better...

Bystander CPR: The biggest links in the chain of survival
Educating bystanders on basic life-support techniques presents a huge opportunity for improving survival rates

By Art Hsieh




The release of the American Heart Association 2010 Emergency Cardiac Care Guidelines marks the 50th anniversary of CPR. It is perhaps with some irony that some of the biggest changes in the resuscitation guidelines have occurred at the most basic level of care – public participation in managing sudden cardiac arrest (SCA). It may be that the greatest opportunity for EMS providers to improve patient survival from SCA is in the encouragement and support of the lay person to recognize cardiac arrest, activate the emergency response system, and perform effective chest compressions and defibrillation.

Scope of the problem
Approximately 350,000 people each year in the United States and Canada experience SCA and undergo resuscitation efforts1. Approximately half occur outside of the hospital. Despite 50 years of understanding the causes of sudden death and developing techniques to reverse it, out-of-hospital survival rates remain low, ranging from 3 to 16 percent in one multi-system study2. In another words, survival from out-of-hospital cardiac arrest has not improved significantly in decades.

Professional resuscitation comes of age
It has become apparent that the "professional" side of cardiac resuscitation has come of age. The number of medications that are routinely recommended for cardiac arrest management has been reduced, and advanced medical procedures such as endotracheal intubation has not been shown to reliably improve survival outcome.

This evolution is reflected in the 2010 Advanced Cardiac Life Support Guidelines; there have been relatively few changes in the recommended care provided by the advanced healthcare provider. The AHA has clearly organized its resuscitation guidelines around the delivery of high quality chest compressions to increase perfusion through the coronary arteries and the need to defibrillate early in cases of ventricular fibrillation. This makes sense – there is no reason to believe that the ALS "house" would stand if the BLS "foundation" is weak.

The effect of bystander participation
If the above statement is to be believed, then the greatest opportunity to improve survival is to turn to the first three links in the chain of survival: early recognition and activation, early CPR, and early defibrillation. In its executive summary of the 2010 Guidelines, the AHA states that, for the management of cardiac arrest "no initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act."3 Recent studies show that the sooner the CPR begins during cardiac arrest, the better the outcome.4,5

Where EMS plays a role
Prehospital care providers own the fourth link in the chain of survival in the out-of-hospital cardiac arrest. We are portrayed as heroes in television shows, movies, and newspaper reports when someone survives after a cardiac arrest. It is critical that the profession plays its part in getting the public to participate in the saving of a life.

While providing certification courses in CPR, AED and First Aid is helpful, there are additional ways to increase public knowledge of CPR. The AHA has endorsed the concept of "hands only" CPR, where recognition of cardiac arrest, activation of the emergency response system, and high quality chest compressions are the key knowledge points.

A casebook example of public participation would be the San Francisco Paramedic Association sponsorship of "sidewalk CPR," which began two years ago. During National CPR & AED Awareness week, volunteer instructors coaxed and cajoled people passing by the SFPA’s building during rush hour, and encouraged them to spend less than 5 minutes practicing hands only CPR on manikins that were laid out on the sidewalk.

Music such as the Bee Gee’s "Staying Alive," "Quit Playing Games with my Heart" by the Back Street Boys, and "Rock It" by Master P provided a soundtrack that allowed participants to practice a rate of about 100 beats per minute. Over the course of two hours, more than 50 individuals stopped and practiced CPR. The cost was low, and the fun factor was high. Last year the event expanded to San Francisco City Hall, where more than one hundred individuals trained during a short period.

Conclusion
EMS providers play a pivotal role in educating and encouraging their community in the management of cardiac arrest management. The level of respect and expectation from the public places us in a unique position to provide the leadership necessary to improve survival from cardiac arrest.

References:

1. Lloyd-Jones D et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics–2010 update: a report from the American Heart Association. Circulation. 2010;121:e46–e215.

2. Nichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300:1423–1431.

3. Field, et al. Part 1: Executive Summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122;S640-S656.

4. Yoneomoto N. The Effect of Time to Bystander Cardiopulmonary Resuscitation on Survival From Out-of-hospital Cardiac Arrest From All-Japan Utstein Registry Data: A Validation of 3-Phase Sensitive Model. Circulation 2010;122:A260.

5. Bobrow B et al. Chest Compression–Only CPR by Lay Rescuers and Survival From Out-of-Hospital Cardiac Arrest. JAMA 2010;304(13):1447-1454.


About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P is the Chief Executive Officer of the San Francisco Paramedic Association. In the profession since 1982, Art has worked as a line medic and chief officer in both third service and fire-based EMS. He has directed both primary and EMS continuing education programs. A Past President of the National Association of EMS Educators, and a scholarship recipient of the American Society of Association Executives, Art is a published textbook author, has presented at conferences nationwide, and continues to provide patient care at a rural hospital-based ALS system. Contact Art at Art.Hsieh@ems1.com.

Now, THAT's a Program!

June 01, 2011 13:00 ET

Canadian Youth Learning CPR in the Tens of Thousands-and Saving Lives!

School's out for the summer and over 250,000 more youth have been trained in CPR this year!

OTTAWA, ONTARIO--(Marketwire - June 1, 2011) -

Editors Note: There is a photo and a video associated with this press release.

Students across Canada are celebrating the end of the school year. Also cause to celebrate is the fact that 250,000 more high school students have been trained in CPR this year. They will bring lifesaving skills to their communities this summer. The Advanced Coronary Treatment (ACT) Foundation is the organization that is setting up in-house CPR programs for high schools right across Canada.

Many lives are being saved and youth are confidently putting their skills to use in the face of emergencies.

Ninteen-year-old York University student Samantha Hunt is just one example. While relaxing at home after a week of demanding class work, she heard a loud crashing sound in the next room and heard her roommate Taylor yelling, "Call 911, Dylan collapsed!"

Trying to remain calm, Samantha ran to the next room and found Dylan, her roommate's boyfriend, unconscious on the floor. Samantha called 911 and a few seconds later Dylan's breathing stopped, leading to cardiac arrest. The 911 operator asked Samantha if she knew CPR. She did and quickly began performing CPR on Dylan's lifeless body.

"It was an automatic thing; I knew I had to do it (CPR). I didn't really think," remembers Samantha.

Samantha had learnt the lifesaving skill from her physical education teacher through the ACT High School CPR Program when she was in Grade 9 at East Elgin Secondary School in London, Ontario.

Dylan survived his cardiac arrest. "I really can't put it into words," Dylan says, as he talks about Samantha's actions that day. "She saved my life. If it wasn't for Samantha knowing CPR, I could have been dead."

Samantha urges everyone to learn CPR. "You hope you will never have to use it but if you do, you're going to be so happy that you know what to do. Things like this don't just happen to young people, but to older people as well," she says.

Call to action:

- Ask your teen if they learned CPR in school this year. If not, find out how you can bring the program to your school.

- Check ACT's list of schools to see if your school has a CPR program.

- Learn CPR!

To learn more visit www.actfoundation.ca and "like" us on Facebook.

ABOUT THE ACT FOUNDATION

The ACT Foundation is a national charitable organization dedicated to establishing CPR as a mandatory program in every Canadian high school. ACT's health partners who are committed to bringing the program to all high schools across Canada include AstraZeneca Canada, Bristol-Myers Squibb Canada, Pfizer Canada and sanofi-aventis. The Foundation has already established the CPR program in more than 1,500 high schools and more than 1.8 million youth across Canada have been trained to date.

To view the photo associated with this press release, please visit the following link: http://www.marketwire.com/library/20110601-ACT_Foundation_800.jpg

To view the video associated with this press release, please visit the following link: http://youtu.be/VrvRlyu2cPY

PLEASE!

1. Go to heart.org/cpr and watch the one minute video. That will make the people around you safer.
2. Get 10 of your family members and friends and acquaintances - the people you spend most of your time with - to watch the video. That will make YOU safer.
3. Go to www.slicc.org/ClassVideo/ Download SLICC's 35 minute class video and watch it. That will round out and re-enforce your CPR skills. That will really make the people around you safer if they have a cardiac arrest, a choking emergency, or a stroke.
4. [I'll bet you could see this coming...] Forward the SLICC class video link to 10 family / friend / acquaintance type people and get them to watch it. That will make YOU a lot safer.

If you have bad hips / knees / arthritis and can't get down on the floor skip step 1. The SLICC class video has a solution regarding how to perform CPR, even if you are 'blessed' with bad knees, hips, hands, etc.

Thank you.

Bob

Dr. Dustin Ballard: A hands-on approach to saving a life

[NB: Dr. Ballard is using "Heart Attack" to mean "Cardiac Arrest". It's not accurate, but it's likely intentional in order to better communicate with the public.]

By Dr. Dustin Ballard
correspondent

Posted: 05/30/2011 05:33:00 AM PDT

WHEN RENE ISMAEL Martinez collapsed while playing soccer on Nov. 7, his friend and teammate, Luis San Ramon, could think of just one thing: Rene's young children and what they would do without their dad.

The thought was grimly real; 44-year-old Rene had just suffered a sudden cardiac arrest. This notion would be enough to paralyze most people — freezing them like a driver at a red light. But not Luis, he managed to block out the background noise so he and another teammate could attempt to resuscitate Rene.

The other man was Alejandro Higareda, the assistant director of operations at Marin Academy High School; he's trained in CPR and basic life support as a prerequisite for his job. Alejandro knew to perform chest compressions fast and deep, sternum to backbone while keeping count in his head and giving direction to Luis (who was providing rescue breathing) and others.

This powerful CPR, the force of which at first worried some onlookers, proved to be life-saving. Later described by one of the responding paramedics from Novato Fire as "simply awesome," Alejandro's forceful chest compressions kept blood circulating through Rene's body for the five or so minutes it took help to arrive. Alejandro was just doing what he'd been trained to do — with the help and support of bystanders who urged him on — and he had no idea how profoundly important his actions were for Rene.

On May 19, atthe first Marin EMS survivors' celebration, Rene Martinez walked onstage with Luis, Alejandro, and a crowd of paramedics, firefighters, doctors, nurses and medical communications specialists (dispatchers and interpreters). It had been a little more than six months since that day on the soccer field, and if we hadn't just heard the story, no one in the audience would have guessed that Rene had so recently suffered a cardiac arrest. Through an interpreter, Rene tearfully thanked everyone onstage for saving his life.

Rene is one of the lucky ones. Nationwide, more than 200,000 people a year suffer a cardiac arrest and of these only 2 percent to 2 percent to 8 percent survive long enough to be discharged from the hospital. Some of these never fully recover brain function.

But Rene regained mental faculties by the time he reached the hospital. I know, because I was there that day and asked his doctor, Bob Stein, how it could be that his patient, who had just suffered a prolonged cardiac arrest, was now awake and talking to the staff. I don't recall exactly what Stein replied, but I now know the explanation.

Without a doubt, Rene's remarkable recovery was because of the simply awesome CPR he received from Alejandro. This CPR kept his brain oxygenated while his heart was stalled. Thus, after the Novato Fire paramedics used an electronic defibrillator to restart his heart, Rene's brain was able to quickly recover.

Rene was one of 17 Marin residents who survived an out-of-hospital cardiac arrest last year. This number represents a 15 percent survival rate — much better (albeit with a small sample size) than national averages. But could it be better? What would it take to do better? A new hospital? Defibrillators in every home? No, nothing that drastic.

All it would take is every citizen knowing how to do CPR. And now, it's easier than ever to learn CPR, as new evidence and guidelines suggest that hands-only CPR is at least, if not more, effective in adult patients with cardiac arrest than traditional CPR with mouth-to-mouth breaths.

I asked our new County Public Health Officer, Dr. Jason Eberhart-Phillips, about the importance of bystander training for CPR.

"Heart attacks," he wrote, "remain one of the leading causes of out-of-hospital death in Marin County. When heart attacks happen, bystanders who phone 911 and begin CPR can greatly increase the chances of survival. Effective chest compressions can move oxygen-rich blood to the heart and brain, keeping a victim alive until emergency responders arrive on the scene."

So, wondering how you can be prepared to be a hero among us like Luis and Alejandro? Or how you can feel confident that your fellow citizens would save you like they did Rene Martinez? It's simple, really. Rehearse. Learn something, practice it and when the time comes, memory will kick in. So, for those interested in learning proper CPR, here are some options:

• You can sign up for a basic life-support course or encourage your employer to offer one.

• You can pay attention to where Automated External Defibrillators (AEDs) are kept — you will notice them in gyms, at malls and in airports. And yes, there is an app for this, too.

• You can come June 4 to one of multiple sites in Marin and receive free (non-certified) training in hands-only CPR and AED use from local EMTs, paramedics, nurses and doctors. The training will take less than 10 minutes of your time and just might help you save someone's life.

As Alejandro Higareda will attest, this is both an opportunity and an honor, and one best informed by rehearsal.

Dr. Dustin W. Ballard is an emergency physician at Kaiser Permanente San Rafael and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column appears every other Monday; follow him on Twitter at http://twitter.com/dballard30.

Bicyclist credited with saving man in Bike the Drive

Cyclists head north near McCormick Place in a heavy fog during the 9th annual Bike the Drive today. The event closes down Lake Shore Drive from Bryn Mawr Avenue on the north to 57th Street on the south. (Nancy Stone, Chicago Tribune)

Staff report
5:15 p.m. CDT, May 29, 2011

A quick-thinking physician is being credited with saving a 72-year-old man who suffered cardiac arrest as he biked in the annual Bike the Drive event this morning, Chicago Fire Department officials said.

The incident happened at about 8:45 a.m. near the North Avenue exit when the bicyclist began to fall from his bike, said Chicago Fire Department Chief Joe Roccasalva said.

Luckily for the bicyclist, a doctor who was also participating in the event was riding behind the man when he saw him begin to fall, said Roccasalva.

The doctor jumped from his bike and began administering CPR as paramedics were called, Roccasalva said.

Paramedics from Engine 98 arrived and also began giving the man CPR and shocked him with a defibrillator, Roccasalva said. They were able to stabilize the man who was alert when he was taken to Northwestern Memorial Hospital in serious condition.

The Bike the Drive event kicked off at 5:30 a.m. at Columbus Drive and Jackson Drive and ended at 9:45 a.m., according to the event website.

About 20,000 people of all ages and experience levels turned out for the 30-mile, round-trip course, which had closed the drive from Bryn Mawr Avenue on the North Side to 57th Street on the South Side.

The weather was cool and gray for riders with a dense fog advisory and temperatures in the 60s near the lake, according to the National Weather Service. The agency has issued a dense fog advisory that took in most of the region.

What can happen when someone helps.

BEND, Ore. -- It happens quickly -- and half of the time, without warning. Sudden cardiac death is the leading cause of death for men and women in the U.S.

And it can happen to anyone, even active people like Jim Belfatto.

"If you see ESPN on TV, it's the same thing where these guys drop dead suddenly. Same thing. No one was there to help them," said Jim Belfatto.

But there was someone to help him.

A year ago, Belfatto went into cardiac arrest while working out at a local gym. But because of the quick action of bystanders trained in CPR and knowledgeable in using an AED, he was brought back to life.

Two days later, doctors at the Heart Center implanted an ICD -- an Implantable Cardiac Defibrillator.
"It's more of a governor, so if I get revved up over 190 (heartbeats per minute), it will shock me and kick in -- and that's what would save my life in the future," said Belfatto.

These devices have made strides in the past 25 years. For the past four years, patients in Central Oregon have been able to receive this treatment more readily with 2 full time electrophysiologists in town.

Doctors implant over 100 devices in patients locally each year, and many lives have been saved.

"its a machine that's kind of like a pacemaker," said Dr. James Laughlin, electrophysiologist at The Heart Center in Bend. "It also can slow heartbeats down, but the purpose of a defibrillator is to protect patients from dangerous fast heart rhythms."

Laughlin performed the ICD surgery on Belfatto. He says half the cases of cardiac arrest happen to patients with preexisting heart problems and heart disease. But Belfatto's case falls in the other half.

"The other half like the patient in our story yesterday, had no warning that he was at risk. It just happened suddenly, and the reasons for that remain unclear," said Laughlin.

The best thing experts say to do, while keeping up a good diet and exercise plan and visiting a primary care physician, is to remain educated, in order to take care of yourself and take action when your help is needed.

Though doctors helped Jim Belfatto get back to normal, it was a bystander trained in CPR who initially gave him a fighting chance.
"I'm just grateful for the people working out with me and saved me," said Belfatto. "I survived 16 minutes of CPR, took an ambulance 16 minutes to get to me. Without them, I'm not here today."

Again, it doesn't take a doctor to help save someone going into cardiac death. Medical professionals stress the importance of learning CPR.

The man who gave life support to Belfatto, Todd Lushin, was a volunteer with the Mt. Bachelor National Ski Patrol and was just passing by when Belfatto collapsed. He was later awarded a Merit Star by the national organization for his quick, life-saving action.

School-Based CPR-AED Programs Save Lives

ACEP News
April 2011

BY BRUCE JANCIN

Elsevier Global Medical News

CHICAGO - Programs that assist schools in implementing comprehensive cardiopulmonary resuscitation and automated external defibrillator use are resulting in markedly higher survival rates for sudden cardiac arrests occurring on school grounds, according to a new report from Project ADAM.

In Georgia, where a 2008 statewide survey showed comprehensive CPR-AED programs were in place in 32% of schools, survival to hospital discharge occurred in 10 of 26 students and 12 of 23 adults with sudden cardiac arrest at participating schools. This 45% survival rate for out-of-hospital cardiac arrest is far superior to rates reported in the literature, which are typically 5% or less, Dr. Stuart Berger noted at the annual scientific sessions of the American Heart Association.

Eight of the 26 affected Georgia students were in elementary or junior high school, underscoring the point that sudden cardiac arrest in pediatric patients is not a problem confined to high school athletes, as is often assumed to be the case, added Dr. Berger, professor of pediatrics at the Medical College of Wisconsin, Milwaukee, and medical director of cardiology at Children's Hospital of Wisconsin, where Project ADAM is based.

The Georgia students who survived sudden cardiac arrest included individuals with long QT syndrome, Kawasaki disease, aortic stenosis, hypertrophic cardiomyopathy, Wolff-Parkinson-White syndrome, lightning strike, commotio cordis, and coronary artery from the opposite sinus of Valsalva.

Project ADAM's Georgia affiliate, Project S.A.V.E., based at Children's Healthcare of Atlanta since 2004, has provided information on comprehensive school CPR-AED programs to all 180 school districts in the state.

A quarter of all schools in Wisconsin and 90% of the state's high schools now have CPR-AED programs. So do all traditional schools in the Milwaukee public school system. A statewide survey found a 36% rate of survival to hospital discharge in schools where an AED was utilized during sudden cardiac arrest, Dr. Berger continued.

Project ADAM is a not-for-profit organization. ADAM stands for Automated Defibrillators in Adam's Memory, in tribute to a 17-year-old Wisconsin youth who collapsed and died while playing basketball. Project ADAM staff has developed a CPR-AED training manual with an instructional DVD and other no-cost materials for schools. The staff works with parents, administrators, school nurses, teachers, coaches, and athletic trainers to develop an emergency response plan and first-responder teams trained in CPR-AED. Project ADAM provides training grants to schools to support these efforts.

Dr. Berger said schools are a logical place to locate secondary prevention programs as part of a public access defibrillation strategy. Not only do many of the estimated 3,000 sudden cardiac deaths per year in children and adolescents happen during school or after-school activities, but 20% of U.S. adults spend time in schools each week for their jobs, to attend programs, or in visiting students.

"Increased student CPR education will also put a new cadre of first responders into the communities. As future collaboration is carried forward, endeavors such as Project ADAM and other educational public access defibrillation programs will continue to improve outcomes to a level that has not yet been realized," the pediatrician predicted.

Georgia and Wisconsin are among at least 17 states with laws requiring or supporting AED placement in schools.