Josh McFadden

Josh McFadden

Best Practices

By Josh McFadden

An EMD’s proper use of the Medical Protocol and a caller’s or bystander’s willingness and ability to follow the directions can be the difference between life and death in an Out-of-Hospital Cardiac Arrest (OHCA).

“Everyone has a role to play—dispatchers, bystanders, hospital and prehospital providers,” said Douglas F. Kupas, M.D., Commonwealth EMS Medical Director for the Pennsylvania Department of Health during the “When Time is the Enemy: Perfecting Dispatch-Assisted CPR” session at NAVIGATOR 2014.

Kupas collaborates with resuscitation leaders at the University of Pennsylvania and EMS providers in the Heart Rescue Project, a six-state effort to “increase survival outcomes of cardiac arrest by 50 percent in five years.”

As a medical doctor and a paramedic with 30 years’ experience, Kupas understands firsthand the sense of urgency involved in cardiac arrest situations. He also knows dispatchers have a critical responsibility when taking a cardiac arrest call and providing the step-by-step CPR instructions.

“Dispatcher CPR saves lives,” he said. “Many dispatchers feel like they’re going through the motions when giving people CPR instructions. We need dispatchers thinking every time they give CPR instructions that it’s an opportunity to get a survivor.”

And there’s no taking “no” for an answer, he said.

“The dispatcher must be assertive,” he said. “We’ve moved away from the era of ‘I can help you do CPR—do you want to try?’ Dispatchers must be fully engaged in the idea that if they are assertive in telling people ‘here’s what you’re going to do,’ and not taking ‘no’ for an answer, the rate of bystander CPR in their community will increase. It makes a big difference, and that’s a mindset in the person.”

Kupas is a staunch advocate of bystanders performing hands-only CPR, as opposed to the traditional CPR where the person administering aid gives breaths in between compressions. Often, a bystander is much more comfortable with and willing to use this method of continual compressions.

In fact, Kupas said hands-only CPR only increases the likelihood of the person surviving. He said using conventional CPR results in a much-less dramatic decline in the death rate from the 10 percent drop per minute if no CPR is done at all. But if you do compressions-only CPR, you reduce that even further, all the way to a 2-percent chance per minute that the person dies.

Hands-only CPR keeps a continuous circulation through the body.

“You have to do about 10 compressions to build up a pressure head,” he said. “Once you do that, you’ve got great compressions going. In the past, what happened was, it took a third of our compressions just to get the pressure up. Then we stopped to give our breaths, and the blood pressure went down, and then we just repeated that over and over. A lot of the minutes’ time, the person wasn’t getting blood flow to their brain or to their heart.”

Omitting the two breaths every 30 compressions will not result in negative results since, Kupas said, the patient has plenty of oxygen in the blood that early in cardiac arrest; continuous compressions keep it circulating.

“When you’re doing compressions-only CPR, you actually are also providing some ventilation,” he said. “The way blood moves in the chest with a chest compression, you increase the intra-thoracic pressure and decrease the intra-thoracic pressure, and those pressure changes are what keeps the blood moving. The same thing happens in the lungs, and as long as the airway is open, you get some ventilation.”

So what can dispatch centers do? Kupas has a few suggestions.

“Think big but start small—make little changes within your center,” he said. “Start to measure things. Use assertive and aggressive dispatcher-assisted CPR—do it in larger systems and with as much geography as you can cover. Celebrate successes and do a better job of getting feedback back to dispatchers.”

Editor’s Note: Brett Patterson, Chair of the Academy’s Medical Council of Standards, adds: “Version 13.0 of the MPDS will contain a ‘Compressions Only’ pathway for victims of OHCA. Local medical control will have a choice of choosing either the current Compressions 1st pathway or the new Compressions Only pathway. We suspect that agencies with extended response times may elect to stay with Compressions 1st since this pathway provides 600 continuous compressions and only adds ventilations past the 10-minute mark in an arrest, while agencies with shorter response times will likely move to the new Compressions Only pathway. Importantly, the recommendations for Compressions Only are for arrest with probable cardiac etiology, i.e., sudden, unexplained collapse. Patients with a known respiratory etiology, i.e., drowning, suffocation, etc., as well as children, should receive ventilations in conjunction with compressions, as is directed in the current Ventilations 1st and Neonate/Infant/Child pathways. In either case, quality improvement efforts need to focus on assertive CPR instructions, rapid hands-on-chest times, and quality CPR. A new Fast Track feature in v13.0 enables this objective by linking Case Entry directly to PAIs when presented with an obviously not breathing, suspected medical arrest. The ProQA software will provide real-time feedback to EMDs regarding their hands-on-chest times.”

Protocol 25
Best Practices

Protocol 25

EMDs should handle anxiety complaint by seeking specific symptoms and then selecting Chief Complaint