Putting the Pit Crew Approach Into Practice

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.

In our area we have access to many physicians who are willing to present to EMS. One system neurologist is a big supporter of our program and an advocate for improving neurological outcomes from sudden cardiac events. He also consulted as we created our protocol and procedure for inducing TH. He was the perfect presenter to explain the science behind post-cardiac arrest syndrome and how proper care can salvage brain ganglia and neurons both during an arrest and following ROSC.

The neurologist explained the theory of slowing metabolism in a suboptimal environment of high lactic acid, and discussed the potential damage fevers and seizures can bring to the brain in this chilled state and during the rewarming process. This lecture was important because it explained what happens in the intensive care unit after EMS hands off the patient.

Improving cardiac arrest survival takes coordination with at least one tertiary cardiac care center. To address the continuum of care inside the hospital, we recruited the manager of our STEMI and stroke system. Her lecture covered operation of the Arctic Sun temperature management system from the emergency room into the catheterization lab. Since roughly 25% of cardiac arrests are STEMI in origin, this was a good time to emphasize the importance of early recognition in the ROSC patient. She also reviewed how the Arctic Sun stays in place even during the catheterization process. This supported the importance of EMS beginning hypothermia in the field.

In the spirit of being a part of a grander mission in North Carolina, we invited the state RACE CARS manager to present. RACE CARS stands for Regional Approach to Cardiovascular Emergencies-Cardiac Arrest Regional System. RACE is an effort to organize better systems of STEMI care, and it has produced dramatic results. This speaker shared cardiac arrest data from across the state. A key take-away was that the more EMS systems that reported their data, the greater the evidence base to support best practices, and the more they could be embraced to improve outcomes. The data we compiled from our charting clearly had meaning. And, by entering it into the CARES (Cardiac Arrest Registry to Enhance Survival) platform, we could be part of the same thing on a national scale. This topic showed our providers how important our documentation and review of cardiac arrest is and that better patient outcomes could come from evidence-based practice.

Breakout Sessions

The afternoon consisted of four breakout sessions designed to apply the morning’s information: Operational Questions, Inducing Therapeutic Hypothermia, The Pit Crew Process and Dealing With the Living.

The operational session, led by a senior battalion chief, was designed to address questions surrounding logistical demands of the new approach and the issues of conducting resuscitations in public. He discussed the increase in manpower the pit crew model required and how a busy system could have six medical personnel on a cardiac arrest scene for up to 30 minutes.

The American Heart Association now classifies induction of mild hypothermia as a Class IIa intervention, and our session on inducing it was led by two FTOs who explained the clinical management of patients following ROSC. EMS begins the process based on a set protocol that prevents delays in definitive care. Because TH may be harmful if patients are allowed to rewarm prematurely, coordination with our tertiary care hospital is essential. After reviewing different options for initiating TH, our system chose to use a 4ºC saline fluid bolus (30mL/kg, max 2 liters) and application of cold packs to the groin and armpits.

Questions about the new protocol focused on when to initiate the saline and other care required following ROSC, including the rapid acquisition of a 12-lead ECG and aggressive airway management.

For the session on the pit crew process, we introduced and broke down each position. Our process assigns roles to arriving providers as follows:

Arriving first would be ideally three EMTs on an engine. Position 1 is on the patient’s right side; this provider checks pulse and responsiveness, then begins compressions. Position 2 is on the patient’s left side and prepares the AED, including placement of pads around the compressor. Position 3 manages the airway, preparing a King LT (see sidebar) and inserting it without disturbing compressions. Positions change at two-minute intervals to keep the compressor fresh and check the AED rhythm.

Arriving second should be a dual-staffed paramedic unit with a paramedic-staffed quick-response vehicle as backup. Arrival of the third paramedic should allow for the role of position 4, the team leader. This position is responsible for explaining everything to the family or, if necessary, bystanders, who may wonder why we don’t move the patient to the ambulance. This provider also works with the team to get equipment and other needed items. This position need not be a paramedic-level person, but that’s helpful for medical interpretations for the family and public.

Position 5 obtains IO access and is the ACLS drug handler. We emphasize how important IO access is outside of the “triangle of CPR” formed by the first three positions. Position 6 is declared the code commander and directs ACLS measures based on the ECG rhythm checks occurring at two-minute intervals. Here we also instructed on the technique of precharging the defibrillator before the end of the two-minute cycle of CPR. This helps reduce cerebral perfusion loss, which we risk every time we cease compressions for more than 10 seconds.

We explained to our people why each position exists and how each role is designed to highlight the most important feature of patient care: continuous chest compressions. We presented the science behind the pit crew idea, including its variations in places like Seattle, Austin and Collier County, FL, as well as Wake County in our state. This station was led by FTOs who were well-versed in the process. Hands-on practice followed, allowing everyone to participate in each role at least once during a simulated cardiac arrest.

We explained that the role of team leader may become difficult due to the stress of informing the family in the home that efforts have been terminated. This will either prepare family members for the beginning stages of death or explain what happens once a pulse returns. We believe a member of the team with experience in death and dying situations may be best suited for this role.

The last breakout session covered the topic of death and dying and was led by our EMS chaplain and one of our battalion chiefs who has a background as an ordained minister. The AHA recommends explaining resuscitative efforts during the event to help survivors cope with the stages of death and dying. To be good at this, we needed to prepare our providers with support for the psychological and spiritual challenges they may encounter through these traumatic events. The presenters covered spiritual and psychological aspects drawn both from scientific literature and riding several shifts with us. We provided access to the chaplain outside the session as well, in case anyone didn’t feel comfortable asking a question in front of their peers.


The combination of traditional lecture and breakout sessions resulted in a renewed passion for the treatment of cardiac arrest. We rolled out our new hypothermia protocol and pit crew process with 700 providers ready to perform. It was an amazing demonstration of how a good training initiative can work. The academy helped catapult our system into a new age of cardiac arrest care. Since our changes, our overall cardiac arrest survival rate has doubled.

Our system’s next goal is education of the public on hands-only CPR and we currently are in the beginning stages of training 200,000 citizens, free of charge. No cardiac arrest system of care will work in the long run without that first link of the chain of survival.

Telling Dan’s Story

I spent a lot of time with our guest speaker, Dan, and his wife. They told me an amazing story of an EMS system that would not give up. The local fire department members who’d responded to their farm were old friends who knew Dan personally. As we walked around his home, he pointed out the bedroom floor where he’d laid during 50 minutes of resuscitation. That battle for Dan’s life included advanced cardiac life support from advanced providers layered onto BLS efforts that included the core of effective circulation, CPR. After his rescuers achieved a return of spontaneous circulation, they transported Dan. En route they began the hypothermia process with cold fluids in his arm. At the hospital Dan’s wife waited nervously in the emergency department, thinking her husband was dead. Sue would later help guide his recovery over the coming weeks, staying by his side day and night.

Typically, cardiac arrest survivors are not professional presenters, so we created some slides to help tell Dan’s story. I took pictures of his street, his house and the room where he collapsed, and to fill in the gaps I interviewed everyone involved. Using the backdrop of their own home not only helped Dan and Sue present, but helped their audience understand what they would have done had this been their call. (Keep in mind that a cardiac arrest survivor cannot tell an audience much about their actual event, as they were, quite literally, dead.) We discovered it’s essential to include a close family member as an event historian.

Why We Chose the King LT

We have our first-responding EMTs insert the King LT rather than waiting for paramedics to intubate. Studies have shown the two airways are equally effective in cardiac arrest management, and the King LT can be inserted more rapidly and with a higher success rate.

An endotracheal tube is not the ideal initial airway for a cardiac arrest patient. The data shows CPR will be affected more often when trying to intubate. The King LT removes that from the equation and introduces ventilation with measurable CO2, which is crucial for cardiac arrest management. After providers achieve ROSC, we prefer they change out the blind-insertion device with an ET tube for better airway management.

David Glendenning, EMT-P, is education coordinator for New Hanover Regional EMS in Wilmington, NC. He has been in EMS for over 18 years and is currently leading an effort to train 200,000 individuals in hands-only CPR. Contact him at david.glendenning@nhrmc.org.