There is one similarity and one difference between...

(a) Teaching people how to save on airfare by wearing wings and flapping until they get to where they are going, and (b) teaching people how to perform manual CPR:

The similarity is that we're teaching something that most who need to cannot do. The difference is that a small number are able to perform guideline-compliant CPR.

It should be noted that the age distribution of the cohort approximated that of cardiac arrest victims.

For each of the four  groups, the upper-left point is what everybody in the group can do. The lower-right point is the best anybody in that group can do.

That's why my wife and I have a personal AED.

Bob

SLICC has proven that CPR is broken and has cast a plan to fix it.

Bystander  CPR as presently taught is something only one in six people can perform for ten minutes on a 40th percentile manikin! Four times as many people can compress a chest for ten minutes if they use the heel of the foot. (American Journal of Emergency Medicine, October 2015)

Further, the victim chest stiffness / rescuer weight mismatch prevents many from performing even one two-inch compression on the person with whom they live. For example, the average adult chest requires 130 pounds to be compressed two inches. Using manual compression, you need to weigh at least 156 pounds to be able to compress that average chest.

That's why I bought my wife a weight vest for Christmas.

Actually, I didn't - I bought an AED. We keep it handy and take it with us when we travel.

Things are bleak on the EMS side of the business, as well. The stiffness / weight mismatch also affects EMTs and Paramedics. If an ambulance crew is going to be able to provide two-inch compressions to 80% of adults, they both must weigh at least 216 pounds. Additionally, the 383 EMTs and Paramedics we tested tended to compress way to rapidly and tend to leave too much weight on the breast bone at the top of the supposedly full recoil stroke. This is all fixable, but it's going to take a concerted effort and mechanical chest compression devices on the ambulances.

Bob

The presentation slides I used at the ECCU - Emergency Cardiovascular Care Update - are available for download at http://www.slicc.org/ECCU_2015.pdf

The download volume has been steady and satisfying. The presentation Dr. Perez and I put together was titled "Fixing CPR: What's Wrong With CPR and What Do We Need To Do To Fix It?"

The comments and questions I've received from people at ECCU and from people who've accessed the slides online suggest there's a broad and growing interest in the topic and a greater understanding of what constitutes "Good CPR."

The rate has to be right, the depth has to be right, the recoil has to be right, the interruptions have to be limited, and the ventilations (if you are doing ventilations) can't be too fast or too slow.

And messing up on any one of those factors is enough to make sure that the victim stays dead or eventually gets discharged from the hospital in a state where the victim requires assistance to perform the activities of daily living.

I encourage any of you with an interest in the topic to download the slides, and don't hesitate to send your questions to bobt@slicc.org - that's me.

Let's focus on the details...

Whom should we be trying to train in recognizing a cardiac arrest and whom should we train in CPR?

The first one is easy - everybody needs to know when they encounter a person who is non-responsive and not breathing normally, and they need to know it well enough that they reflexively call 911 when they see someone who has arrested.

The second question's answer is not so obvious. From the standpoint of getting the job done, we should first train those most likely to witness an arrest.

With about 85 percent of arrests occurring in a private residence, it makes sense to train a population whose age distribution matches that of the victims. Here are the implications of that strategy:

From the CARES database we know that the age distribution of out-of-hospital SCA victims is skewed. We've all known that for quite a while, but the actual numbers are interesting:

Age    SCA's
 0-17   1.9% 
18-34   3.7%
35-49  13.1%
50-64  30.2%
65-79  28.8%
Older  22.3%

We could train more than 80% of the bystanders who are most likely to witness an arrest by only training those who have reached 50!

This also raises the question of what's more important? Training the kids in school or training the faculty with a CPR method they can use from the time a child arrests until the ambulance crew is "hands-on"? (Hint: only one in five can perform what's taught to bystanders for ten minutes.)

Another common - but mistaken - belief is that all it takes to get the chest compressed by two inches is strength. This would be true if you could put one hand on the back and the other on the front of the chest, but few are that strong. Your ability to get to two inches depends upon your weight, your weight distribution, the stiffness of the chest you are trying to compress, and the compression method (hands or heel of foot) you are using.

The one exception is that, if you were taught to "crunch your abs" while performing compression, that boosts the depth of your compression a little bit, but I've never seen anyone be able to do that for more than a few minutes.

Another non-obvious implication is that males and females usually have different weight distributions. Weight below your hips doesn't count at all if you are performing manual compression. Weight at your shoulders really contributes to the force you can apply. Weight half way between your hips and shoulders contributes 50%. If you are performing compression with the heel of your foot, you can get more weight on the victim's chest.

Make sure the people around you watch the videos at www.slicc.org - click on "Class Video" in the left column. You'll be safer if they do.

Some things most bystanders don’t know about CPR…and why you need an AED in your home.

A heart attack is not the same thing as a cardiac arrest.  Heart attack victims normally are able to talk and many are in pain. Cardiac arrest victims are non-responsive, clinically dead, and are either not breathing normally – or they might be gasping.

CPR is not used on heart attack victims. CPR is only used on cardiac arrest victims

CPR does not usually re-start hearts – It tries to keep the heart muscle and brain alive, and it delays the transition from a shockable rhythm to a non-shockable one. This transition drops your chance of survival seven-fold. It usually takes an AED and drugs to re-start the heart, and sooner is a lot better!

Eighty-five percent of all cardiac arrests occur in a private residence. The witness, if there is one, is usually about the same age as the victim. Heel Compression quadruples the number of people who can perform guideline-compliant chest compression ("GC3’s") for ten minutes.

If there is nobody in your home that weighs enough to perform 2" deep chest compression until the ambulance crew is "hands-on" you really ought to consider purchasing a personal AED for home and travel use. My wife and I have one. (SLICC will be running another AED Group Purchase this fall. Let bobt@slicc.org if you want to learn the details when the program is beginning. SLICC does not profit from this program.)

Your ability to perform GC3’s for ten minutes does not depend upon your strength, it depends upon the stiffness of the victim’s chest, your weight and weight distribution, and the method of chest compression you use.

The three largest flaws in how Bystander CPR is performed are:

1. Leaning i.e.,  leaving too much force on the breastbone at top of the “full recoil" stroke. Leaning keeps dead people dead. 
2. Very rapid chest compression - 120-150 compressions per minute was common in the nearly 400 EMS workers measured.  Compressions  in excess of 120 per minute reduce the probability of victims’ survival. 
3. Compressions that are too shallow reduce the probability of victims’ survival.

Please watch the video at http://www.slicc.org/ClassVideo

Thank you.

What are the most serious problems with CPR?

FROM 10,000 feet:

1. We're not focusing on training the people who most need to be trained. The people most likely to need to perform CPR are about the same age as - and live alone with - the victim.
2. The technique most commonly taught is something that the vast majority cannot perform for ten minutes.
3. Many of the people who will be called upon to perform CPR weigh too little to perform 2" chest compression on a chest of average stiffness.
4. Even with free instruction, many people who need to know won't take the time to learn.

THE DETAILS:

1. We're not focusing the training on the people most likely to be presented with an opportunity to perform CPR on their spouse. More than 80% of the arrests involve people over 50. Given the ratio of male vs female arrests (2/3 are males) we should be training twice as many females as males, and we should be focusing on persuading both genders over 50 to get trained.Eighty-five percent of all USA Cardiac Arrests occur in a private residence - most are in someone's home, the rest in a nursing home - and the bystander that has to call 911 and start CPR is most likely the victim's spouse.  It's not always the case, but in general the spouse is about the same age as the victim. The CPR in the Schools program that we ran and that the SCA Foundation runs are valuable because it starts to sensitize young people at an early age and should eventually reduce the #4 problem.
2. The CPR method being taught in the vast majority of cases - manual chest compression - is something that fewer than one in six can perform for ten minutes on an adult with an average stiffness chest. We have proven that the use of Heel Compression quadruples the number of people who can perform compression for ten minutes. The study was published in the American Journal of Emergency Medicine in October.
3. Many potential rescuers don't weigh enough to perform guideline compliant chest compressions on their spouse. One's ability to perform guideline-compliant chest compressions is dependent upon the rescuer's weight, the rescuer's weight distribution, the stiffness of the victim's chest, and the method of performing compressions. An adult chest of average stiffness requires that the rescuer using manual compression weigh somewhere between 160 and 175 pounds, depending upon their weight distribution.  If the rescuer were using Heel Compression, the rescuer weight needs to be between 132 and 150 pounds. It's not always the case, but the female in the relationship is generally lighter than the male.
4. Even if the training is available without charge (it is), not everybody who needs to learn will attend. We have trained more than 10,000 in Chatham  County, GA. Given that we know the age distribution of the victims, it would be reasonable to provide free, teacher-less videos (www.slicc.org/ClassVideo) and focus the Bystander Course instructor resource on the people most likely to need to know CPR: the folks over 50.

It worked

The Short Version
An elderly male suffered a cardiac arrest at a meeting. Another elderly male began to perform manual CPR but quickly tired and was unable to continue. The other person present - who had recently read an interview with one of the authors of an article in the American Journal of Emergency Medicine regarding Heel Compression CPR began to perform Heel CPR. The victim's heart was restarted before the arrival of EMS.

That's the whole point of Heel CPR - when you cannot get down on the ground or you have a problem pressing hard enough on the chest to get adequate compression depth, consider an alternative: Heel CPR. Go to www.slicc.org/ClassVideo and click on the Adult CPR video.

Background
Dr. Perez and I wrote a paper about the advantages of Heel Compression CPR. It was promptly published in the American Journal of Emergency Medicine. We wrote the article describing our research so that organizations such as the American Heart Association and the American Red Cross would have a peer-reviewed basis for considering the adoption of the technique in their Bystander course curricula.

Because 85% of cardiac arrests occur in the home - and about half are witnessed - the witness is generally about the same age as the victim. Because of the age distribution of the victims, the witness / rescuer is likely to be unable to perform CPR in the same manner as a medical student or Intern - the typical cohort in a CPR study. Many cannot get down on the floor. Many have arthritis or other afflictions of the hands or arms that reduce their ability to perform Guideline-Compliant Chest Compressions ("GC3's"). It was for this reason that we developed Heel Compression CPR.

Heel Compression CPR enables four times as many people to perform GC3's. Here's the abstract from the AJEM publication:

Heel compressions quadruple the number of people who can perform chest

compressions for ten minutes.

Abstract:

Objective: To evaluate whether chest compressions using the heel provide a more

effective method than manual compressions for bystanders.

Methods: This is a cross-sectional observational comparison study where each subject

acted as his or her own control. A 49-person cohort whose age distribution approximated

that of sudden cardiac arrest (“SCA”) victims, were asked to perform ten minutes of five

cm manual compressions on a CPR manikin at 100 compressions per minute. The

compression rate and the endurance of each subject were recorded. The same subject was

then asked to perform ten minutes of heel compressions at the same depth and rate.

Results: Sixteen percent of the cohort performed compliant manual compressions for ten

minutes versus sixty-five percent using heel compressions. Twenty-four percent of the

subjects were not heavy enough to get compliant depth with manual vs. two percent with

heel compressions, and six percent could not get down on the floor to attempt manual

compressions.

Discussion: Most cardiac arrests occur in private residences. If there is a witness, his or

her age usually approximates that of the victim. Heel compressions are useful in

situations where a lone rescuer cannot get down on the floor, cannot compress the chest

to guideline depth because of an infirmity or lack of weight, or becomes too tired to

continue manual compressions. Heel compressions significantly increase the bystander

population’s ability to provide effective, uninterrupted compressions until EMS arrival.

Heel compressions quadruple the number of people who can perform chest

compressions for ten minutes.