CPR, and First Aid Preparedness for the Real World

Lay rescuers must possess not only the technical skills, but also the ability to overcome fear
and concerns that often accompany emergency situations.
by Ralph M. Shenefelt (Dec 01, 2006)

THE typical response to sudden cardiac arrest is not the stuff of Hollywood movies or
TV medical dramas. Rarely is the most-trained, clearest-thinking person on the scene
first, taking charge and saving a life against long odds. Rarer still are bystanders who
instantly become part of the solution instead of a distraction or impediment. Panic,
confusion, fear, people getting in one another's way--now, that's often the real world.

Consider the all-too-typical workplace emergency response when an employee suffers

sudden cardiac arrest (SCA): Perhaps only one person in the area has had
cardiopulmonary resuscitation training, and that may have been at least a couple of
years ago. While precious seconds tick away, human nature takes over and there is a
debate about what should be done, who should do it, and a variety of legal and personal
concerns.

Finally, someone begins CPR and puts his hands on the victim's chest and pushes
hard. Something cracks. He pushes again. Something cracks again--it's the ribs. The
sound stuns the rescuer and bystanders. On the third push, lines of thick clear fluid
stream down both sides of the victim?s purple-gray face. Concerned about doing more
harm than good, the rescuer keeps pushing but not as hard. The rescuer knows he
should give mouth-to-mouth resuscitation, but he just cannot bring himself to do it.

Once security arrives, there is a shuffle of equipment, and the guards start CPR. Then
an ambulance and fire truck arrive and the professionals take over. They have an
automated external defibrillator and place the pads on the victim's chest. After a shock,
the pulse returns. The victim arrives at the hospital alive but dies later in the day.

Immediate Action Is Essential

Despite heroic efforts by lay rescuers and professional emergency responders, the
scenario above is quite typical. In fact, more than 325,000 Americans die each year
from SCA--more than from cancer and automobile accidents combined. And when
cardiac arrest occurs outside a hospital setting, fewer than 5 percent of victims survive,
primarily because CPR and defibrillation are not performed soon enough.

The brain begins dying within four to six minutes of SCA onset. However, if no more
than 3 minutes elapse between collapse and defibrillation, survival rates of 74 percent
have been achieved.
So in the real world, what can you do to give an SCA victim the best hope for a second
chance at life? Technical training for would-be rescuers remains the most critical
component. To be able to make a difference, people from across the workforce and
work shifts should be trained in first aid, CPR, and AED use--with all three areas being
important. In the workplace, providing first aid training to all employees, rather than
limiting it to a small number of designated responders, may help to reduce both the
frequency and severity of occupational injury and illness. Training has been shown to
improve participants' motivation to avoid injuries.

Lay-rescuer AED programs are becoming common in America's workplaces, but they
should not overshadow the more traditional first aid and CPR programs. All three areas
are prominent components of a total solution. AEDs on their own are seldom enough to
save lives; victims of cardiac arrest need immediate CPR. CPR provides a small but
vital amount of blood flow to the heart and brain, and it increases the chances that an
AED shock will allow the heart to start working effectively. Eighty percent of SCAs are
caused by ventricular fibrillation, a heart rhythm variance for which defibrillation and
CPR are the only effective treatments.

Refresher training is also essential, and it is more important than ever now because
new first aid, CPR, and AED guidelines have been published. For example, the new
CPR guidelines for adults recommend 30 chest compressions for every two rescue
breaths (compared with the previous 15-to-2 ratio). The new guidelines also
recommend beginning chest compressions immediately after the two rescue breaths--
not waiting to check for a pulse or other signs of life, which is often difficult for lay
rescuers to do and delays delivering potentially lifesaving chest compressions.

In addition, the recommendations for combining CPR and defibrillation have changed.
The new recommendation is for a single shock from a defibrillator followed by
immediate CPR for two minutes, beginning with chest compressions. The 2000
guidelines recommended up to three AED shocks before returning to chest
compressions for one minute. There is an important new focus on "effective" chest
compressions to maximize the quality of CPR. "Effective" means that the rescuer needs
to push hard, push fast, allow complete chest "recoil," and minimize interruptions in
CPR. Rescue breathing without chest compressions is no longer taught in programs
that follow the new guidelines.
To help people learn and perform CPR and AED better, all nationally recognized training
programs are now encouraging instructors to talk less and help students practice much
more. Training is moving away from large-group, instructor-focused, lecture-based
programs to small-group, student-focused, scenario-based, interactive programs. But
even that is not enough for giving your program the best chance of success in the real
world. Employers should consider integrating their first aid, CPR, and AED training
programs into their emergency response drills so that would-be rescuers have an
opportunity to "rescue" their manikins in a workplace setting, not just under calm, ideal
classroom conditions. These special drills also can be helpful in uncovering any rescue
equipment problems and supplies shortage that might have been missed by the
ongoing maintenance and recordkeeping program.

What Are You So Afraid Of?

As discussed above, technical training, the right equipment, and timely maintenance are
critical for a successful workplace emergency care program. But there is also a softer,
more emotional side that can have just as much impact on a company's program. That
factor is overcoming people's fears, which can be seen at all levels of an organization.

At the management level, the safety and health professional has to be concerned about
the compliance obligations, including protection against bloodborne pathogens. The
CFO may be focused on costs and return on investment in these programs, while the
legal folks know that the American judicial system is fraught with complexities and time-
consuming, costly litigation. Any one of these issues could cause an organization to
drop or severely cut back its emergency care program, with potentially tragic
consequences. The best way to address these concerns is to involve the key
stakeholders in the creation, implementation, evaluation, and reauthorization of the
program.

At the individual level, several recent studies have shown that both trained and
untrained bystanders are reluctant to perform CPR and use an AED. For example, a six-
year study in Michigan, published in 2006, interviewed 684 bystanders in SCA cases.
Seventy percent of the bystanders were family members, and 54 percent of those family
members had been taught CPR. And yet, only 21 percent were actually willing to start
CPR. The rest said they were not willing to because they panicked, thought they would
not do it correctly, were afraid they would hurt the person, or were concerned about
contracting a disease or infection by performing mouth-to-mouth resuscitation.
A 2003 study of North Carolina high school students found that 86 percent of students
surveyed were trained in CPR and 21 percent were trained in AED use. However, only
32 percent of the students trained said they were actually willing to use an AED and
around 50 percent were willing to perform CPR. Again, they were held back by fear of
infection, legal consequences, and harming the victim.

Overcoming the Fear Factor

Legal issues and health concerns are among individuals' primary fears. Overcoming
these fears is paramount to reducing a leading cause of death for Americans. Quality
training materials cover these issues, and a good trainer will take the time to share the
knowledge and skills that can help students manage these fears.

Here is advice on how to tackle the most common fears:

Fear of infection: Much-publicized health risks, which include everything from AIDS and
hepatitis C to staph infections and bird flu, have had a chilling effect on people's
willingness to perform CPR. Scientifically speaking, however, the estimated risk for
acquiring infection during CPR is extremely low, about one in a million. Simple infection
control measures, including use of barrier devices, can significantly reduce the risk of
acquiring an infection disease during both CPR and CPR training. If no mask or shield is
immediately available, rescuers can still perform compression-only CPR by placing the
victim on his or her back and using two hands (one on top of the other) to push hard
and fast on the center of a victim's chest.

Fear of legal consequences: Good Samaritan laws protect people who "gratuitously and
in good faith" give CPR or use an AED. There has never been a successful lawsuit in
the United States against a person providing first aid/CPR in good faith. However, to
protect yourself, once you start CPR, do not stop until a person with equal or more
training takes over, you are exhausted, or the scene becomes too dangerous to
continue. For AEDs, there is an extremely low liability risk in establishing AED
programs; most lawsuits result from lack of an AED program.

Fear of harming the victim: Rib and breastbone fractures occur frequently during chest
compressions in adult CPR but are not major complications. Although CPR should be
"done right" and with high quality, remember that a person in cardiac arrest is dead
(without breathing or a pulse); it is hard to make them any worse. Mistakes in CPR may
reduce the chances for successfully resuscitating a victim, but they do not "kill" the
person. Their original condition is the cause.
Fear of failure: Lay people who participate in first aid, CPR, and AED training programs
provide a great service to their families, workplaces, and communities. They want to
make a difference, and there are many wonderful stories of lives saved. But there are
many more, unfortunately, where the victim cannot be saved. Perhaps nowhere else in
American society is a 5 percent success rate celebrated--and it should be; without the
fast response, there would be no survivals. However, employers and safety and health
trainers must manage would-be rescuers' expectations. They need to know that
situations where victims cannot be saved do not represent failure on their part. The root
of the word "resuscitate" is from the Latin revivere, which translates as "to live again."

The underlying lesson is that even the best equipment, even the best training, can take
you only so far in emergency response. At some point, you have to deal with the
emotional issues and overcome people's base fears. My best-practices
recommendation is to deal with these real-world preparedness issues now, long before
a would-be rescuer is thrust into service in a last-ditch attempt to save a co-worker,
family member, friend, or stranger.

This article appeared in the December 2006 issue of Occupational Health & Safety.