Friday, October 8, 2010

Change of Heart

In my daytime alter ego of “faceless bureaucratic cog”, I attend many professional training classes. Most of these are devoted to navigating some new online database that has replaced the previous online database etc. But recently my employers really came through and sent me, along with the rest of the staff, to become CPR certified. Now, before you declare, “I’m already CPR certified… this is of no value to me!” let me tease you with the news that CPR is different now than it used to be, perhaps even different than it was when you learned it (depending on how expired your CPR certification card is). In fact, more research and more change in guidelines for how CPR should be performed by laypeople* has occurred in the past decade than during the rest of the 50 years since the method was introduced. You are living in an exciting time! But first, the stuff you already know, or will probably claim you knew even though you never actually bothered to think about it.

CPR stands for Cardiopulmonary Resuscitation. That means the heart and lungs are the organs of focus. The target audience for CPR is anyone experiencing cardiac arrest outside of a hospital setting. In cardiac arrest the heart stops circulating blood (and thus oxygen), causing the victim’s breathing to be impaired. This is the problem that performing CPR is aiming to fix. CPR does not address realigning dislocated shoulders, sucking venom out snake bites, escaping a burning building and countless other first-aid and wilderness-survival emergencies. You’ll need to go elsewhere to acquire those skills. However, CPR is potentially life saving to those for whom regular heartbeat and breathing have suddenly ceased.

CPR training got an overhaul in 2005. In the late 1990’s The American Heart Association (AHA) commissioned a reevaluation of existing guidelines for providing CPR, and the new guidelines were based on these findings. The biggest changes were made to how laypeople are taught to do CPR. In the past, we would have been given instructions similar to those designed for healthcare providers. However, things have been significantly dumbed down for our frail civilian brains. The reasons for this can be distilled to the observation that laypeople often forgot the intricacies of their training soon after obtaining it and then, when faced with an emergency, worried about screwing up. They lost valuable time fretting over making things worse when almost anything would have been better than nothing. With this in mind, the 2005 AHA guidelines dropped distinctions in the chest compression-to-ventilation ratio for different ages (sizes) of people. Every man, woman, child and infant now receives cycles of 30 chest compression and 2 breaths. You’re just told not to press as hard on the smaller humans (2 hands for an adult, 1 hand for a child, 2 fingers for a baby).

Another innovation by omission is that laypeople are no longer instructed to take the pulse of the suspected victim of cardiac arrest. We are only to check for breathing. No breathing = CPR. Why? Apparently we were being really slow about it. Locating a pulse is harder than it looks, and this was found to delay the initiation of CPR. With CPR, sooner is better than later.

And something is better than nothing. The rescue breathing is optional. If for whatever reason you do not feel comfortable blowing into a stranger’s mouth, the AHA says to just go ahead and do the chest compressions. There’s been much talk lately that switching to a “hands-only” protocol in general might be beneficial. The logic behind this echoes the above-mentioned concerns about bystanders being more likely to rapidly initiate CPR if it is made as uncomplicated as possible. Just press on the person’s chest in a rhythm similar to a normal heartbeat. Also noted was that the ick-factor of the breathing might deter more germ-phobic would-be-rescuers.

A number of studies have examined this, 2 of which were recently published in the New England Journal of Medicine. Both studies were conducted by having emergency dispatchers deliver randomized different sets of instructions to callers reporting cardiac arrest emergencies: some were instructed to provide chest compression and breaths, the others chest compression only. What the authors found was the while recipients of the hands-only CPR did not fare significantly better than those who received the traditional sets of compressions and breaths, they certainly didn’t fare worse. Additionally, in one of the studies, those whose cardiac arrests had cardiac causes (as opposed to non-cardiac causes such as drug overdose) tended toward better outcomes when given just chest compressions and no breaths. It can be argued that, since at the time of a sudden cardiac arrest the body still has a decent volume of oxygen available (roughly 10 minutes worth), rescue breathing is not as important in the first few minutes and it is best to minimize interrupting chest compressions, other than to reassess breathing.

There has yet to be a consensus as to which version of CPR is best. Our class taught the chest compressions and rescue breathing version, although at least 2 members of our small class (myself and the lady who posed the question) were already aware of the debate.

I had a number of other questions for our instructor. What if the unconscious person might have choked on something (as small children are prone to do)? Answer: still perform CPR, it won’t make anything worse and might help. Can I get sued for doing this? Answer: in America, anyone can get sued for anything, but such cases are generally dismissed.

Had I consulted with others prior to attending the class, I would also have inquired if, once I got my CPR certification card, I could get sued for not performing CPR. One friend claimed to have been told something to that effect during his CPR certification, but I have yet to find any confirmation of this. Either way, I will gladly administer chest compressions to any of you who have heart attacks in my presence. Although I can’t make any promises about doing the rescue breathing.

* For our purposes here, a layperson is anyone who is not a healthcare provider, regardless of how brilliantly you did on your college biology exams.

The EMS guy who taught our CPR class informed us that the song “Stayin’ Alive” has a suitably paced beat to it, so you can always hum the Bee Gees to yourself if you’re unsure of what a normal heart rate feels like.

If you’re thinking that it sounds like people were participating in these studies without consenting, you’re absolutely correct. However, the authors assure us that ethics committees and “appropriate review boards” signed off on their methods. If it makes you feel any better, surviving participants of one of the studies were eventually informed of their contribution to science. And now you’re probably thinking, “What about the friends and families of the non-survivors?” and I just don’t have an answer for you. I’m guessing no?

Who told you this?

2005. “Overview of CPR.” Circulation 112: IV-12-IV-18.

Sayre, M.R. et al. 2008. “Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest.” Circulation 117: 2162-2167.

Weisfeldt, M.L. 2010. “In CPR, Less May Be Better.” New England Journal of Medicine 363: 481-483.

Rea, T.D. et al. 2010. “CPR with Chest Compression Alone or with Rescue Breathing.” New England Journal of Medicine 363: 423-433.

Svensson, L. et al. 2010. “Compression-Only or Standard CPR in Out-of-Hospital Cardiac Arrest.” New England Journal of Medicine 363: 434-442.

Helpful and patient CPR instructor whose name I forgot.

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