There isn’t much black and white in prehospital medicine, just many shades of gray. But you can take your protocol book and know one thing for sure: It contains protocols that are obsolete, outdated or need to be replaced. They may even make us scoff, “What were we thinking?” In 2005, the American Heart Association (AHA) introduced a new way of approaching the cardiac arrest patient and, for many of us, it was challenging to let go of the old way of managing a CPR call.
We tend to remember the first and last things we’re taught in a class and the experiences that made an emotional deposit into our memory bank. Instructors need to consider this as they face one of their biggest challenges—getting their team members to reduce “time off the chest” immediately prior to, and after, defibrillation.
It sounds simple, but it won’t be in many EMS systems, because we’ve done a masterful job of indirectly forcing everyone to unnecessarily delay defibrillations with the mandated speech, “I’m clear, you’re clear, everyone is clear,” that’s recited prior to defibrillating your patient. The problem is that this guarantees unacceptable delays in defibrillation and reduces your patient’s chance of survival.
The 2005 AHA guidelines stressed the need to improve chest compressions by staying on the chest as much as possible to minimize off-the-chest time throughout our code care and to ensure full chest recoil. Staying in contact with the skin, believe it or not, encourages the chest compressor to lean (just a little) on the chest, which interferes with full recoil.
So once again, educators will have to change the old paradigm of never letting the hand lose contact with the chest, to now ensure maximum chest recoil.
You can easily teach your crew and students these two paradigm shifts. However, you’ll have to focus your quality assessment audits on chest compressions, and continue to reinforce the need for change for a long time.
So how should we re-educate our crews to decrease compliance time? If we had access to the same technology that Will Smith and Tommy Lee Jones had in the hit movie Men in Black, it would be simple. We would just shine that bright light into the person’s eyes and “poof,” their memory would be erased. Unfortunately, that technology isn’t available to us, so we have to use traditional educational methods.
Your medical director needs to be involved from the very beginning, because some individuals may not initially understand how these small protocol changes will significantly impact your patients’ chances of survival. Anyone who’s been in the field for a few years has seen a multitude of protocol changes come and go and may not appreciate their impact on patient care.
Through the years, CPR has changed: We finally got away from “stack four breaths” and “hyperventilation is good,” to an evidence-based protocol that de-emphasizes the airway and focuses our attention primarily on compressions. Make sure you stress that these small changes may profoundly improve your patient’s chance of return of spontaneous circulation.
The foundation of good instruction is knowing the needs of your students. Your crews need to know the new way to perform (and continue) chest compressions. This may be one of those times when you need to provide an overview of the science that’s driving these changes. Also, today, adult learners want less talk and more hands-on skills practice. With practice and a firm understanding of the reasons behind the changes, you’ll be able to convince them that they’ll positively affect their patients’ outcomes. There are three critical steps you can take to re-educate your staff.
Step one: The first critical step is to adopt the philosophy that staying in contact with the chest during bi-phasic defibrillation is safe. This action sets up the rescuer to maximize their time on the chest. In San Diego, we haven’t taken that leap of faith … yet. Many hospital emergency departments currently double-glove the compression staff member and personnel practice this “stay in contact with the chest” method during defibrillation, and many EMS services are now following suit by incorporating this practice into their prehospital tool bag. They think that following this practice gives patients the best possible chance for survival.
Step two: Once your crews are comfortable with the concept of remaining in contact with the chest during defibrillation, it’s time to add the other critical paradigm change, full recoil. Crews need to practice deep, consistent chest compressions and maintain a rate of 100 per minute or more.
With every upstroke, the palm of their hands have to reach a point of “zero” pressure on the chest. It’s this last portion of the upstroke that maximizes the opportunity for blood to flow through the coronary arteries. This is easier said than done and will require relieving the person doing chest compressions every two minutes whenever possible.
Step three: Now that your crews are optimizing chest compressions, let’s not throw all that good work out of the window by losing forward blood flow into the coronary arteries, which happens when you stop compressions for more than four seconds to defibrillate. Limiting time off the chest to four seconds will dramatically improve your patient’s chance of survival.
Let your students know this and drive home the point by asking them to set the bar high and pretend the heart of a loved one is under their hands. Have them aim for no more than a two-second delay—it can be done.
The maximum two- or four-second “interruption” routine can be practiced rather easily. With the monitor in manual mode, continue to compress the chest while you push the charge button. This will take a little getting used to. The person in contact with the chest may remember hearing horror stories of someone being shocked by a rescuer while accidentally touching the patient. This is where training from step one will put their mind at ease.
While the defibrillator is charging, the compressions continue, and when the defibrillator is ready to deliver the shock, eye contact is made between the defibrillator operator and the person performing compressions. This subtle, unspoken communication will trigger the compressor to briefly lift their hands away from the chest wall. The defibrillator operator should immediately deliver the shock. Before the shock has stopped making the victim’s body twitch, the designated provider should restart compressions.
With practice, you can deliver a shock without interrupting chest compressions for more than four seconds. The four seconds is comprised of two seconds to clear your hands and deliver a shock, and two seconds to once again begin chest compressions.
Once your crews are comfortable with this sequence, it will be easy to master the gold standard of a two-second maximum off of the chest.
With these changes, it’s important to remember that you’re not teaching any new skills, and it doesn’t cost any money to bring an increased chance for survival to every cardiac arrest resuscitation. JEMS
Criss Brainard, EMT-P, is the president of San Diego Medical Services Enterprise and the EMS chief for San Diego Fire-Rescue Department. He has been with the fire department for 29 years and has been a paramedic for 31 years. Prior to becoming EMS chief, he served two years as a shift commander in operations managing major incidents and personnel on one of San Diego’s EMS/fire divisions. Brainard has extensive experience in emergency operations, has published numerous articles in fire and EMS journals. He’s also a member of the JEMS Editorial Board.
This article originally appeared in May 2010 JEMS as Redefining CPR: Prepare to re-educate your staff on the 2010 AHA guidelines.