Putting the Pit Crew Approach Into Practice

How do you teach a department a new way of doing things?


There was a better way to care for cardiac arrest, and it was sitting at our doorsteps. All we had to do was pick it up and put it to work.

We knew that what we wished to deliver—continuous quality CPR with clearly defined roles for all rescuers involved, plus delivery of therapeutic hypothermia (TH) to improve neurologic recovery after return of spontaneous circulation—could enhance cardiac arrest survival.

The science that drives our care at North Carolina’s New Hanover Regional EMS demonstrates that. But implementing it required instilling a new principle—staying put with cardiac arrest patients—among providers who had practiced “load and go” for decades, and ultimately retooling a system that had provided treatment in the same fashion for 20 years.

After observing the successes that came from making these changes to our EMS system, we hope they can be mirrored around the country.

Living, Breathing Proof

Racing is popular in North Carolina, so we labeled our new approach the “pit crew cardiac arrest process.” It took a year of creating protocols and policies before our team was ready to introduce these new concepts to our system. Buy-in was crucial for them to work, so effective communication was essential. To provide our clinicians the evidence they demanded for the medicine we’d ask them to apply, we developed a daylong “cardiac arrest academy.”

Step one was to form a committee, which met at least once a month until the big day. Specific topics for the academy were assigned to key field training officers. We settled on a morning of lectures followed by an afternoon of breakout sessions. Our local college provided a large auditorium and several classrooms for the 200 providers we expected to attend.

It was important that our lecture topics matched our mission of better cardiac arrest care. We began by sharing our vision and demonstrating a simulated cardiac arrest treated with the pit crew process.

The first lecture focused on the evolution of CPR. While CPR has only been around in its true form for about 50 years, attempts at resuscitation date as far back as 1768, when the Dutch Humane Society was formed in an effort to improve resuscitation in drowning victims. Their first formal attempt at CPR included instruction on clearing the airway via rolling the victim over a barrel and hanging them upside down for several minutes.

In 1960, Dr. Peter Safar brought his concepts of ventilation together with the chest-compression concepts of Drs. William Bennett Kouwenhoven and Guy Knickerbocker. Several years and many forgotten pioneers later, the organized technique of cardiopulmonary resuscitation was born.

In 2005 the American Heart Association provided one of the biggest updates in CPR since 1960 with a new emphasis on chest compressions being more important than airway management during the first several minutes of cardiac arrest care.

Sharing the history of CPR was an effective way to demonstrate that the practice of resuscitation medicine is constantly evolving. Our goal was to convince providers that their patients’ best chance at positive neurological outcome revolves on each provider’s ability to work a cardiac arrest where the patient is found, whether that’s in the mall with an audience or in a living room as a family looks on. After selling that the CPR process evolves, we needed to show the changes we proposed would work. For us that meant more than just numbers. We wanted living, breathing proof that these huge efforts would not be wasted. Bringing in a cardiac arrest survivor who’d been treated with extended on-scene care (and his grateful spouse) proved more powerful than any graphs and numbers we could show in a PowerPoint (see “Telling Dan’s Story”).

Further Topics

The day’s next lecture topic was neurology and the science behind cardiac arrest.

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