Last Thursday evening I had the privilege of addressing the Friends of Aberfoyle & Buchlyvie Medical Practice and I talked about some personal experiences of off-duty or “opportunistic” medicine. Three of these experiences involved bystander cardiopulmonary resuscitation or Basic CPR, which was serendipitous as this patient group is very involved in community “heart start” and “heart smart” initiatives. I wanted to express the idea that knowledge of CPR and skill in its delivery is a gateway to every other type of First Response. So with your indulgence, I reproduce here this segment of my talk.
Does bystander CPR work?
In 1988 I attended the 2nd International Conference on Emergency Medicine, held that year in Brisbane, Queensland, Australia. I know the fair city of Brisbane quite well because I worked there for a GP locum service in 1985. The 1988 conference was very good. It culminated with a lively debate entitled, “Does bystander CPR work?” This was before the days of community automatic external defibrillators like the one in the phone box at Arnprior, and many people believed that to invest in CPR training and to create the necessary infrastructure would not be cost-effective. I had some sympathy with that view because in 1985 while driving to a GP surgery in Brisbane’s northern suburbs I encountered a major road crash and attempted unsuccessfully to resuscitate a young woman. I can remember her quite clearly, and I still remember her name. I was upset. But if I was partly upset at my own inability I shouldn’t have been. This girl had suffered what is known as “blunt trauma arrest”, and the outlook for that condition remains dismal.
I don’t remember the conclusion reached by the 1988 Brisbane debate, but I do remember what happened after the conference had adjourned. I stepped out into the Queensland sunshine and went for a walk over the Brisbane River to the Cultural Arts Centre, via the Victoria Bridge. On the bridge, a man walking in front of me collapsed with a cardiac arrest. I commenced basic CPR with cardiac compressions and was immediately joined by a nurse from the conference who provided mouth-to-mouth respirations. An ambulance came – I don’t know how it was summoned because mobile phones then were a rarity and looked like bricks of the sort John Wayne used on Omaha Beach. But the paramedics arrived quickly, successfully defibrillated the patient, and transported him to hospital.
I don’t know what the final outcome was in that case, but I can tell you what it was the next time I carried out bystander CPR. Flash forward to Auckland New Zealand a few years later. In Auckland – actually about this time of year – they hold a huge road-run called “Round the Bays”. It starts on the wharf in downtown Auckland and proceeds east for about 9k round the Waitemata Harbour to end in the suburb of St Heliers. I took part many times. On the occasion in question the field was about 80,000 runners. After about 3k something in my left calf went “twang”. I debated whether to run through the pain, slow to a walk, or just stop. The decision was made for me when the runner in front of me collapsed. I stopped.
He was non-breathing, pulseless, and unconscious. I commenced CPR. I was joined again by a nurse who undertook mouth-to-mouth respirations. With 80,000 people on the road, the paramedics understandably took a long time to reach us. We continued basic CPR for some 30 – 45 minutes. During this time a large number of doctors and nurses running by asked, “Need any help, James?” to which I replied, “Not unless you’ve got a defibrillator.”
When the paramedics finally arrived the defibrillator duly shocked the gentleman back into normal heart rhythm. He woke up, but because of the hypoxic insult to his brain – lack of oxygen – he was what we call “combative”. I gave him a little intravenous sedation and accompanied him in the ambulance to the emergency department of Auckland Hospital. He was admitted to the Department of Critical Care Medicine and walked out of hospital a week later, as we say, “neurologically intact”. He was entirely well.
So if you are asking me, I think bystander CPR works.
Yet this issue doesn’t go away. In the British Journal of General Practice of January 2010 a GP wrote an article questioning the cost-effectiveness of CPR training. I wrote a letter in defence of CPR training which the journal published in February 2010. In the letter, I pointed out that the benefits of CPR training extend far beyond the particular scenario of a cardiac arrest. If you can respond effectively to a cardiac arrest, you carry with you the conceptual armamentarium to respond to any medical emergency. If you undertake a course of First Aid – an undertaking which I strongly recommend – you will, or you should, be taught basic CPR. Allow me to put on my pedagogic hat for a moment and share with you this one visual aid which I would suggest, if you have an interest in being a first responder, you memorise and hold in your head, heart, and gut.
Here it is:
Breathlessness, Shock, Coma
Patient safe? Am I safe? Extrication?
Airway, Breathing, Circulation, Disability, Exposure & Environment
Respiratory rate, Oxygen saturations, Pulse/Blood Pressure, GCS, Temperature
Professors of Medicine are wont to put up masses of data and say, “I apologise for this busy slide.” So I’ve kept it simple. This is all of emergency medicine on the back of a postcard. This is what an emergency physician does every single time he – or she – approaches a patient. The doctor works through this mantra. On first laying eyes on the patient, the doctor asks, “Is this patient fundamentally well, or fundamentally ill?” A very sick patient will have at least one of these, the triad of decompensation. Breathlessness, shock, coma. Breathlessness: some people call it respiratory embarrassment, but I’ve never seen a breathless person look embarrassed. Shock – shock isn’t what the daily papers think it is; shock is circulatory collapse, characterised by low blood pressure. Coma – unconsciousness.
So you see your patient is very ill and you rush to help. But don’t rush headlong. Have a care for the situation in which both you and the patient find yourselves. You may need to move the goal posts. People fall ill in awkward places. You may need to shift the furniture. You may need to move the patient. Is there a science of extrication? We will pass over this huge subject this evening.
Next comes your initial assessment of your patient, known as the Primary Survey. First Aid is as easy as ABC. Airway – breathing – circulation. Fix them in that order. Make sure the airway is open and make sure, if you can, that oxygen gets to the lungs, and that way the circulation has something to transport.
Disability stands for “neurological disability”. I always think it’s a bit of a lame mnemonic. “Diminished consciousness” would be better. You ask, how diminished? Well, we can quantify it, using the GCS or Glasgow Coma Scale. Yes, worldwide, Glasgow is home of the coma.
Notice also the way that the vital signs, pulse, blood pressure, temperature, respiratory rate and GCS marry up with the triad of decompensation and our response to it. To the vital signs we may add oxygen saturations if we have a pulse oximeter, an ingenious device the size of a memory stick which, when attached to a fingertip, or an ear lobe, will tell us the percentage of haemoglobin, the blood’s oxygen- carrying molecule, that is saturated with oxygen.
I say this slide encapsulates all of emergency medicine. In a sense it informs every medical consultation. I’m fond of stating that “all medicine is acute”. By that I mean that every time a doctor goes to the waiting room to summon the next patient he is looking at the patient as he steps forward and, albeit unconsciously, he is going through this mantra. We doctors sometimes, rather self-servingly, say we have a mysterious “sixth sense” for detecting a patient who is very sick. But there’s nothing mysterious about it. It’s a skill that can be taught and can be learned, and it is encapsulated in this mantra.