If it’s a good idea to audio-record cardiac arrest resuscitation scenes, shouldn’t it be an even better idea to video-record them?
The answer to that question isn’t so simple.
Audio-recording arrest scenes can have clear benefits. For docs and others who review the recordings later, it can bring a resuscitation effort to proverbial life, letting them scrutinize the sequence and timing of events and identify the causes of delays. In his 2009 book Resuscitate! How Your Community Can Improve Survival from Sudden Cardiac Arrest, prominent emergency physician Mickey Eisenberg touted the idea:
Voice and ECG recordings provide the crucial data allowing for the event to be accurately reviewed. When shared with EMTs and paramedics it provides beneficial QI and teaching material. And it makes everyone want to do better the next time.1
Eisenberg recounts reviewing an arrest where the paramedic asked the EMT to stop CPR so he could intubate. The ensuing pause lasted 65 seconds before the medic asked the EMT to resume compressions. When the medic heard the tape, he was shocked at how long the pause actually was. Eisenberg predicted that would have a big impact on the provider’s future care.
‘What Happens in the Real World’
If that’s the case, couldn’t you tell just as much, maybe more, from actually seeing what went down on such a scene? For a brief period in 2013, the Anchorage Fire Department tried to find out.
“Basically we’re always trying to find ways to improve our approach to cardiac arrest,” says the department’s medical director, Michael Levy, MD. “So much of this talk about pit crews and stuff comes from a training environment, but you don’t really have much to go on with regard to what happens in the real world.”
The approach was simple: EMS supervisors, dispatched to cardiac arrest calls along with engine and medic companies, took small GoPro cameras that were Velcro-mounted on crews’ Lifepaks, which were always positioned at the patient’s head. That produced a top-down view of activities that showed only the crew, not the patient’s face.
In fact, the process took great pains to protect patient privacy. After each call, the SD card with the video was removed by the supervisor and put in a sealed envelope for delivery to Levy, who was the only person to review it. He then destroyed it. “It was a pilot to look at whether using this as a quality improvement tool had any validity; I want to really stress that,” he says. “There was nothing that anybody else in our system even saw.”
The privacy emphasis was important for a few reasons. One, it ensured the department stayed within HIPAA boundaries. As well, it protected families and bystanders. For them video-recording is more visible and may feel more intrusive than audio-recording. No family during the trial period specifically objected, but in a life-and-death situation, you wouldn’t want anyone feeling exploited or that any other consideration distracted from rescue efforts.
Had the program moved forward, the department would have worked to find ways to share findings with front-line personnel. But in the end the trial produced just eight recordings, and they didn’t shed much additional light.
“What we found was, the way we deployed it, we were already at a point where the scene had been established, compressions were going on, and we were kind of in that second phase of cardiac arrest scenes, where you get past that initial flurry and are into more of the work mode versus the setup mode,” Levy says. “So there wasn’t much to see after that. Given the issues surrounding it versus the information we gleaned, I didn’t find it to be of high value.”
Next Best Thing?
Perhaps video recordings might be of greater value if they captured those first few moments of scene organization, but that’s difficult for crews to accomplish. When a collapse happens in public, though, sometimes there’s security footage that captures the full sequence of events. Obtaining and reviewing that, where possible, is a certain best practice.
“From that you can clearly see what happens, and that’s really of high benefit for reviewing later with crews,” Levy says. “As the fly on the wall, you have the unusual ability to see the person basically in cardiac arrest before they’re discovered as being in cardiac arrest, and then you can see the latency that occurs until the first responders notice a cardiac arrest is going on, to the point where the first compressions are done.
“It’s also interesting just to watch how crews assemble: Is the focus on the patient, or is it on the tools of resuscitation? I think a lot of times when you look at these tapes, you see the focus is more on the tools of resuscitation than on the resuscitation itself.”
There’s also the back of the ambulance, depending on how much resuscitation activity a department conducts there. But for the most part, video-recording cardiac calls will require starting early in people’s homes. If there’s benefit to be had there, it’s beyond some serious hurdles.
“If you enter a home with a device, that’s different from the other settings where we might videotape, like a trauma bay. It doesn’t allow for a detailed discussion of informed consent,” says Levy. “I think there could be value to video recording; technically it’s very easy to achieve with all the mobile devices we have now. The problem is, it’s challenging to implement in a systemwide manner without encountering significant bioethical concerns.”
1. Eisenberg MS. Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest, 2nd ed. Seattle: University of Washington Press, 2013.