May 16, 2016
By Audrey Fraizer
A show of hands at a NAVIGATOR 2014 session indicated at least a few dispatchers felt like they were simply going through the motions—in their case verbal—when providing PAIs for CPR.
“It was the same way with field responders,” said Dr. Douglas Kupas, Emergency Medicine Doctor, Geisinger Medical Center, Danville, Pa. “They were going through the motions. Many couldn’t remember someone they had saved.”
In time, attitudes changed. Responders were brought into the loop, linking the “every minute, every person counts” philosophy to the work they did in the field. Knowing their actions in the field were instrumental in the chain of patient survival led to a deeper commitment, Dr. Kupas said.
“We now have EMS providers who are very disappointed if they don’t get a survivor,” he said. “We have to take that same culture to dispatch. We know that dispatch-assisted CPR saves lives, and we have to get the success stories back to dispatchers so they know what’s going on. They know they are a linchpin in the patient’s survival.”
As facts continue to bear out, everybody in the chain of survival has a role to play. The survival rate for a person in sudden cardiac arrest (SCA) decreases 10 percent with each minute following collapse. Conversely, victims of SCA can survive if they receive immediate CPR and are treated quickly with defibrillators. To be effective, this treatment must be delivered quickly—ideally, within three to five minutes after collapse.1
That’s why bystander CPR is so important and why we’re targeting dispatcher CPR, Kupas said.
“I call it assertive dispatcher CPR,” he said. “Hopefully, we’ve all moved away from the era of saying to the caller, ‘I can help you with CPR. Do you want to try?’ We’re no longer taking ‘no’ for an answer. We no longer give the option.”
Dispatchers and CPR
Most people have heard the history of the Medical Priority Dispatch System (MPDS)—its development in Salt Lake City and subsequent spread nationally and then internationally. Bystander CPR was one of the first PAIs with a goal of saving more lives through recognition of SCA and keeping the patient alive until medical help arrived on scene.
The Academy pays close attention to the American Heart Association (AHA) recommendations for CPR in the event of SCA—updated and published in fiveyear cycles. In October 2010, the guidelines for CPR presented by the AHA and European Resuscitation Council continued its strong emphasis on the need for quality CPR with minimum interruption to improve patient outcomes.
The AHA, however, is not the only motivation for changes both in MPDS versions 12.2 and 13.0. The Academy conducts extensive research into its protocols and ProQA/MPDS users, large and small, contribute a stream of data through the application of the AQUA software.
On the MPDS user side, Richmond Ambulance Authority’s (RAA), Va., research into reducing the time it takes to get a 911 caller to initiate CPR was incorporated into the MPDS v12.2 upgrade.
RAA conducted the international research project with the University of Oslo, Norway, comparing the MPDS with a European equivalent, and a spinoff of that program resulted in the realization that the time from receipt of call to the bystander placing hands on the patient to deliver quality CPR could be shortened.2
Before submitting a formal Proposal for Change (PFC) to the Academy, the RAA authenticated its data against similar MPDS user organizations, including MedStar in Fort Worth, Texas; Medic EMS in Charlotte, N.C.; and the East of England Ambulance Service in the U.K.
Armed with the data, the RAA team submitted the results and its MPDS scripting recommendations to the Academy, which, after extensive review by the Academy’s Medical Council of Standards, were incorporated into MPDS v12.2.
The changes in protocol toward a higher number of compressions between ventilations follows from several studies finding that the rate of neurologically normal survival 24 hours after resuscitation in animals receiving continuous-chest-compression (CCC) CPR was significantly better than that in animals receiving the standard 30:2 (30 compressions every two breaths) CPR.
“The continuous compressions keep perfusion pressures consistent,” Kupas said. “Pressures drop when we stop compressions to ventilate and then take several compressions to rise again. Continuous compressions keep the blood flowing and improve survival.”
The MPDS gives the following instruction: “We’re going to do this (600 times or) until help can take over.” The parentheses were added in v13.0 since the text becomes situational with the addition of the “Compressions Only” (C Only) pathway.
MPDS users got a good look at what to expect in MPDS v13.0 with the release of MPDS v12.2 in September 2012.
The interim version introduced the Fast Track pathway to PAIs, bypassing the questions and instructions on Protocol 9: Cardiac or Respiratory Arrest/Death for patients with suspected medical arrest and directing the EMD to proceed with CPR immediately from Case Entry.
The interim version also modified the wording of the breathing detector to clarify its use for calltakers and added mandatory links to improve agonal breathing detection. Use of the breathing detector tool is mandatory for all unconscious patients triaged on Protocol 31: Unconscious/Fainting (Near) who are not breathing completely normally.
AGONAL BREATHING Detector
Released in 2004, the AGONAL BREATHING Detector was created to assess a patient’s breathing and, ultimately, identify patterns consistent with SCA.
The Academy tries to stay on the top of science,” said Brett Patterson, Chair, Medical Council of Standards, International Academies of Emergency Dispatch (IAED). “The buzz [at the time the Academy developed the tool] was recognizing agonal breathing. This was a tool that could help the EMD from missing this.”
And, like the development of the MPDS as a whole, the AGONAL BREATHING Detector has gone through changes consistent with evolving clinical standards, scientific research, and member experience.
In some respects, the breathing detector was too successful, especially once EMDs discovered its significance in detecting breathing patterns indicative of SCA when the caller was unsure, Patterson said.
“There was a time when EMDs told us, ‘Your protocol does too much,’ and now it’s the exact opposite,” Patterson said. “EMDs want the protocol to tell them exactly what to do. That’s what happened with the breathing detector, and, in many cases, it was being used inappropriately.”
For example, EMDs were applying the breathing detector to verify use of compressions or when the caller was unsure whether the patient was breathing (in answer to MPDS Key Question 6 in Case Entry: Is s/he breathing?) or if the pattern of breathing didn’t indicate to the caller that the patient is at risk of SCA.
“EMDs should use the detector when they are unsure, not when the caller is unsure,” Patterson said. “If a patient is gasping, we need to be doing CPR, not going back to testing them, which is where we got.”
If the EMD is unsure, the EMD tells the caller to “Say ‘now’ every single time s/he takes a breath in” and applies the detector to time the intervals during a maximum of four breaths (three intervals tested).
The Determining AGONAL BREATHING section was again modified in MPDS v13.0 to encourage decreased time to handson-chest.
More than three lines—about one-third of the language—in the Determining AGONAL BREATHING section were modified, without changing the intent of the information. Also, as cited earlier, the interval between breaths was decreased from “10 seconds or more” to “eight seconds or more.”
The section revision appears in Case Entry, Protocols 9, 31, and 12: Convulsions/ Seizures:
“Use when the patient is unconscious and breathing reported by the caller is questionable, or when mandated by the protocol. A time between breaths of 8 seconds or more is considered INEFFECTIVE BREATHING. Check a maximum of four breaths (three intervals tested).”
In the cardset, the red “Mandatory AGONAL BREATHING Detector use” symbol has also been added following the first sentence.
The last portion of the revised Determining AGONAL BREATHING text also appears in the corresponding PAI Panels on Protocols N, A, B, C, Ya, Yb, and Yc.
Protocols C and Yc also contain a new “Compressions Only (C Only)” pathway director in Panels 4, 6, 9, 11, and 12. The pathway director gives Local Medical Control the choice between the Compressions 1st pathway and the new Compressions Only pathway, owing to the debate regarding when ventilations are absolutely necessary and whether the benefit of ventilations outweighs the risk of stopping compressions to provide them.
In addition, instructions regarding an AED were revised to a more direct approach— if there is one available “go get it”—and the caller is instructed to let the EMD know when the AED is there to use on the patient.
What’s so important about AGONAL BREATHING?
Agonal respirations are an abnormal pattern of breathing characterized by shallow, slow, irregular inhalation followed by irregular pauses. Agonal respirations are commonly seen in patients immediately prior to and during cardiac arrest, and, according to Kupas, agonal respirations indicate a more favorable prognosis than in cases of cardiac arrest without agonal respirations.
While clinical definitions vary, simply put, in an agonal state, “The breathing doesn’t look normal,” said Dr. Jeff Clawson, co-founder of the IAED. “At the minute point [following cardiac arrest], normal respiration changes into irregular, gasping respirations. It’s diaphragmatic breathing. The chest is not moving. The diaphragm is moving up and down, and the patient’s mouth is open.”
The problem, especially in the dispatch environment, is recognizing agonal respirations. Callers to 911 might report the patient is breathing, without realizing that one or two irregular breaths does not equate to normal breathing.
“A call is made to 911, the dispatcher asks if the patient is breathing, and if the caller reports ‘yes,’ the dispatcher thinks the patient’s not in cardiac arrest,” Patterson said. “We know there are a lot of cardiac arrests dispatch might be missing because the caller mistakes gasping for breathing.”
The duration of the agonal respiration phase varies.
According to the Sudden Cardiac Arrest Foundation:
When SCA occurs, the heart stops beating in an effective, organized manner. As a result, blood is no longer pumped throughout the body. The person suddenly passes out and appears lifeless, except for abnormal “gasping,” which may last for several minutes. Occasionally, SCA victims experience 10–20 seconds of seizure activity (shaking of the arms and legs) at the onset of the event, as the brain stops receiving blood and oxygen from the heart.3
This is vastly different from a person breathing effectively.
“If breathing effectively, the patient will be struggling, and gasping isn’t a sign of life,” Patterson said. “It’s the struggling, and if that stops, it’s a sign to start CPR. It’s about getting hands-on-chest.”
Rather than the EMD relying on whether the patient is gasping, Patterson suggested that the EMD ask the caller for signs of life.
Kupas said paying attention to the research available, making small changes in methodology, and tracking the results do lead to more efficient CPR and potentially higher survival rates.
MPDS incorporates the most current standards, including the increased number of compressions to ventilations ratio, the Fast Track to hands-on-chest, and instructions for hand positioning and method: “Pump the chest hard and fast, at least twice per second and 2 inches (5 cm) deep.” Centers can track dispatcher time to hands-on-chest through the ProQA Paramount software.
“Measuring matters,” Kupas said. “You have to know the numbers of patients receiving dispatcher-assisted CPR and the outcomes. If you don’t know, there’s no possible way to suggest that you’re doing the best for your patients by providing dispatch CPR to everybody that you can when they need it.”
1 Newman M. “Sudden Cardiac Arrest: A Healthcare Crisis.” Sudden Cardiac Arrest Foundation. http://www.scaaware.org/about-sca (accessed Dec. 1, 2015).
2 “Va. Agency’s Research Incorporated into Medical Priority Dispatch System Upgrade.” EMS World/Patient Care. 2012; Sept. 28. http://www.emsworld.com/news/10796262/ cardiac-care-and-cpr (accessed Dec. 1, 2015).
3 See note 1.