The alarm sounds and dispatch keys up the radio: "60-year-old male, jogger, witnessed collapse, bystander CPR in progress." Radio in hand, my partner calls us "en route" and navigates the afternoon traffic as our cadet and I run through our code check list: AED, airway/O2 kit, suction. The police are already on scene, pads and AED attached, chest compressions in progress.
The patient looks younger than 60. His grey sweatpants tore at one knee when he fell, his navy T-shirt already a victim of trauma shears, sunglasses cracked and broken on the pavement, iPod blaring from his pocket.
With ALS and BLS on scene, my cadet takes over compressions, vocalizing landmarks and counting out loud, as much for herself as for everyone else. My partner takes the airway and I attach the monitor. A small crowd is forming and a bystander's voice cracks as he bears witness to what may be the last minutes of this man's life: "He was just jogging, and then he grabbed his chest and fell."
Someone is waiting for him to come home.CPR AND RESUSCITATION CARE
Since its development in the 1950s, CPR has been the mainstay of cardiac arrest treatment and has consistently demonstrated improvement of outcomes when delivered promptly and correctly to arrest victims. The importance of CPR is emphasized in our introductory field training in basic and advanced cardiac life support, and the American Heart Association (AHA) provides on-going CPR guideline updates as new and innovative research becomes available. The most recent update in 2005 introduced a significant change in ventilation-to-compression ratio for adults from 2:15 to 2:30 in order to increase circulation time to oxygen-starved tissues.
While the AHA updates its guidelines every five years, a question remains for EMS professionals: What can I do now to improve my care and survival rates from cardiac arrest without waiting for the next guidelines update?
The key to survival improvement in the short term truly brings us back to basics. Recent investigations have shown that both in- and out-of-hospital CPR quality during actual cardiac arrest care is highly variable.1-3 In these studies, CPR providers were monitored and their actual performance was compared to guidelines recommendations. These guidelines included rate and depth of compressions, rate of ventilations and "no flow" time, or periods of time without chest compressions and therefore without circulation of oxygen to tissues.
The results of these evaluations were surprising. Marked deficiencies were found: Continuous chest compressions were performed for less than 50% of the duration of cardiac arrest, compressions were too shallow, ventilations were too fast, and "no flow" time was significantly greater than the time built in for pulse/rhythm checks.
These findings are especially important in the context of recent work showing how delivering more and better CPR can make a big difference in real outcomes. Arizona emergency physician Bentley Bobrow et al performed a pioneering study in which EMS crews delivered what they termed "minimally interrupted cardiac resuscitation" (MICR) and demonstrated an increase in survival rates of witnessed cardiac arrest victims with shockable rhythms from 4.7% with standard CPR to 17.6% with MICR.4 Similarly, another variant of CPR that emphasizes compressions over ventilations, termed "cardiocerebral resuscitation" (CCR), strongly advocates for strict attention to the amount of time spent "off the chest," with the goal of neurologically intact survival—giving patients their best chance at returning to their normal lives after cardiac arrest. Additionally, it is important to realize that EMS providers tend to arrive between 4–10 minutes after collapse, when chest compressions appear to provide the best chance at survival when followed by defibrillation. This fact lends even more support to the theory of MICR, as high-quality compressions before defibrillation improve the chance of shock success.