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Altering the Handling of CPR


You could say that Dale Becker, EMT-P, thinks a lot about light bulbs. The reason for this makes sense, when the captain of the Howard County (Md.) Department of Fire and Rescue Services puts it into context.

On Dec. 29, 1972, 101 people were killed when Eastern Air Lines Flight 401 crashed in the Florida Everglades. The flight crew was about to execute its routine night landing when they noticed the landing gear indicator light didn’t come on after they deployed the wheels. The crew became so preoccupied
with what they thought was a malfunction in the landing gear that they failed to recognize that autopilot had been inadvertently disengaged. The plane lost altitude and crashed. It turned out that the landing gear deployed just fine; the indicator light bulb had simply burned out. At the time, Flight 401 was the second deadliest single aircraft disaster in the U.S.

Becker thinks this tragic accident holds valuable lessons for EMS, particularly concerning patient care, CPR and cardiac arrest. So he has set out to make changes that will prevent EMTs from becoming distracted by their own burned out light bulbs.

Individual Assignments
It started in March 2010, when Becker was invited to Seattle’s Resuscitation
Academy to learn why the city has had such successful cardiac arrest survival rates. He saw how their EMTs, paramedics and firefighters worked together,  each executing a specific field assignment instead of arriving at a scene and being told what to do. “At the end of the week, we were asked what we were going to do to make a difference in our community,” says Becker. “I took on the responsibility of changing our culture and how we managed our cardiac arrests in the field.”

When he got home, Becker shared what he had learned with his EMS supervisor and captain. “I told him we could learn together. We’ll talk about it, and tweak it and we’ll put our fingerprints all over it,” Becker says. “We trained with a manikin, AEDs, monitors and stopwatches. We took notes. The medical director came out one day and saw what we were doing and gave us continued support and approval.”

Then they were ready for field-testing. When a firefighting crew arrives on scene, every member must know what to do; each has a specific assignment they are responsible for. “Everybody knows their role,” says Becker. “We’ve never done this before with EMS.”

The agency made riding assignments for EMTs responding to cardiac arrest calls so providers would know their responsibilities prior to reaching the scene. “I’ve been a paramedic for more than 20 years now,” Becker says. “You walk into a room and everyone looks at you. Then you have to move all the pieces of the puzzle around while you are intubating, doing drug calculations and monitoring EKG changes. It’s a lot, and you get distracted.” Having the crew assigned to pre-set responsibilities saved a lot of time and reduced confusion. Taking these steps allowed Becker and his crew to stop being fixated on the burned out light bulbs and hone in on the problem and solution. He notes that it was “shockingly simple.”

“It’s worked faster than I thought it would,” Becker says. “We still have a long  way to go in Howard County, but it’s catching on.” Under the new criteria, the EMTs were able to resuscitate the first five cardiac arrests they worked  on—every one of them. “The comments from the crew, veterans from three to more than 20 years, were that they have never had cardiac arrests that ran so smoothly,” Becker says. “They were calm, quiet, well organized, and things got done very quickly. It was amazing to them. They said we should have been doing this all along.”

Overcoming Concerns
Becker recognizes the controversy surrounding these new procedures, namely the argument that agencies need more paramedics. That is certainly true of  some woefully understaffed services, but Becker argues that many agencies already have the personnel they need, they just need to deploy people in a better, more effective manner. “We need existing paramedics to do what they should be doing and that’s taking care of critically ill patients,” he says. “We need to measure patient outcome. We measure how fast we can get out on the street, how fast we can get a unit to the street, and that’s well and good, but  what’s the outcome in the end?”

Becker wants EMTs to stay focused on administering CPR and doing effective chest compressions, not worrying about what role they should play when they first walk through the door or wondering who should execute what procedure.  “We are spending way too much time with our hands off the chest. Our goal now
is, 95% of the time, while the patient is in cardiac arrest, we expect you will do CPR,” he says. “If we get distracted by our burnt out light bulb, and effective chest compressions aren’t done, and done continuously, then patients aren’t going to survive.”

He adds, “We have marginalized the EMT’s role and their responsibility as part of the team. My goal in Howard County is to get back to a time when  paramedics used to work around the EMTs. But that culture has changed. Now EMTs often hesitate to act until paramedics give them directions.”

Becker now tells his EMTs to do what they have been trained to do and not to stop unless he tells them to. “That’s the approach we have taken with the cardiac arrests,” he says. “EMTs know under no circumstances do they stop chest compressions.” He admits they are still working on getting the bugs worked out and getting the culture changed, but he has seen the changes and is quite hopeful for the future.

Making Change
One of the most significant ways Becker was able to affect change in the culture was by actually measuring, with a stopwatch, the time EMTs were administering chest compressions on a manikin. EMTs were measured over 20 minute  intervals and then asked how long they thought they had done the actual chest compression. “Most of them thought 80–90%. The reality was everyone did compressions less than 50% of the time,” Becker says. “Those results were stunning."

“It’s about looking at ourselves in the mirror, seeing what we are doing and not being afraid of what we see,” Becker says. “If we don’t, we’re never going to make things better, and we’re never going to change anything. We’ll just keep doing it the same way.”

In the simplest terms, Becker and his agency are being highly intentional about focusing on cardiac arrests and giving the highest feasible quality of care in the shortest possible amount of time. “My crews know that I expect them to  resuscitate every patient we run with a cardiac arrest. Nothing else is  acceptable,” he says. “I also understand that it’s not going to be possible or happen all the time. But I want to put it in our minds that we are not going to be defeated before we run the call.”

In the two-and-a-half years since Becker has instituted these protocols, he says he has lost count of how many patients have survived cardiac arrest and walked out of the hospital. Before they were put in place, he could count only three survivals that he was involved in during his almost two decades as a paramedic. “If we don’t give the hospitals anything to work with, then they can’t make it any better,” he says. “It’s up to us to deliver the patient in the best possible condition.”

Saving Lives
Becker believes that EMTs, paramedics and the new protocols really can make a difference in people’s lives, but the thing that drives him is making their jobs easier, while saving as many people as possible. “Our patients are dying  because we are distracted by our burnt out light bulbs,” he says. “Everyone is paying attention to the paramedic intubating, or what the monitor says, or worrying about getting the drugs out, or moving the furniture. We’re not paying attention to doing CPR.” Focusing on that, Becker knows, will save lives.

So if you should see Dale Becker staring at a burned out light bulb, just know that he is probably contemplating new ways to give cardiac arrest patients a second chance at life.


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