Cardiac & Resuscitation, Exclusives, Heart of America

Reprogramming the Lay Rescuer Psychology to Cardiac Arrest

Every member of emergency services has heard the call too many times to remember: “3343 Main St … 29-year-old female passed out at her desk … is having a seizure. Breathing shallow and moaning.”

We all know this call often ends up as a sudden cardiac arrest (SCA). We also know it most likely will end with the victim dying where they collapsed, surrounded by grieving family members or co-workers. At these scenes do we often sit and wonder, why wasn’t anyone doing CPR? Were they too afraid? Was their card expired?

This scene played itself out on Feb 6, 2017, at a local law firm.

Ironically, what made this story remarkable enough to make three local network newscasts wasn’t that the 29-year-old victim died, but rather, that she lived!

The rescuer of this mother of a 10-year-old daughter was a retired city council member and had taken a crash course in CPR—a no frills, less than one-hour Lay Rescuer CPR course—along with the rest of the council, nearly three years ago.

The “saving” council member credited her instructor with giving her the willingness to acknowledge what she was seeing and more importantly, the courage to act immediately and without hesitation.

Take Heart America

Take Heart America is a SCA initiative developed to guide lay rescuers and professional medical personnel on how to better prepare for and treat just this kind of patient. We are a collaborative organization focused on developing and delivering cutting-edge technologies and strategic approaches to save more lives after cardiac arrest.

In this article on a series about the important efforts by Take Heart America to save lives, I focus on lay rescuer treatment objectives and strategies. I am a Coon Rapids police officer who helps direct our Take Heart America program in Anoka County, Minnesota.  

I also help direct HeartSafe Communities nationwide and have helped train more than 15,000 citizens, and am gratified that we’ve had 6 saves with the help of lay rescuers we trained in the past five years in Anoka County.  

All six of these cardiac arrest patients are back with their families and part of our community.

So what do we do and recommend to the lay public? We have a multipronged approach that includes starting with calling 9-1-1 for help, focusing on “just-in-time” instructions by dispatch-assisted CPR, public awareness campaigns, CPR and AED training in schools, and in small and large training events. Most of the time I help with small and large training events.

We keep our training simple and to the point.

As police officers, we don’t work alone. Although we race to a call, our dispatcher is giving instructions  They try to figure out—in seconds—if the caller is describing a cardiac arrest patient.

If yes, they provide just-in-time instructions on how to perform chest compressions.  Dispatch-assisted CPR is a key element, and it should be standard of care in every community. For it to work effectively, the dispatcher has to get to “No–No–Go” quickly.

·      “Is the victim awake?”—No.

·      “Is the victim breathing normally?”—No.

·      “We need to start chest compression now!—Go.

Many dispatchers still do not give CPR instructions. We are working to change that.

3343 Main Street

Let’s take off our EMS hats for a minute and look at this call for help on 3343 Main St. in Anytown, USA. Who was making it, what they were feeling? What was their mindset?  

Imagine you’ve never worked a witnessed cardiac arrest in the field. You’ve never heard or seen agonal respirations, or the seizure like activity of SCA victims.

Pretend you are at home or work and it was your co-worker, husband, wife, parent or child you saw go down. You don’t have your EMS vehicle or standard lifesaving gear.

You are an auto mechanic, a typist, import/export analyst, scientist. Does this change the dynamic of what you’re seeing, what you’re thinking and how you’re feeling? Is this an easy diagnosis, or is it a horrifying and traumatic scene where fear cripples you into inaction?

‘Mind Set’ vs. ‘Skill Set’

We start with and emphasize the concept that survival begins with the lay rescuer, and we keep it simple. Without their immediate recognition and treatment of an SCA, we will continue to respond to death scenes.

Our Take Heart America program is focused on reprograming the lay rescuer mindset from a “wait for help” mindset to the “be the help.”

There’s a time and place for more formal CPR training, and Take Heart America strongly supports these efforts. But when a mother of three watches her 12-year-old son suddenly collapse, we need to help provide her with tools to her overcome the fear and panic of not knowing what to do and inspire her to take action.

Nine Tips for Lay Rescuer CPR Training

1) Make it personal.

The bystander needs to understand that if they’re confronted with SCA, it will likely be someone they know.

By pointing out that 70% of cardiac arrests occur in the home, and that it’s the number one killer in the workplace, you’re immediately changing the lay rescuer student’s perspective on why this is important to them.

Much like we do on our way to “hot calls,” we’re teaching the students to visualize that cardiac arrest scene involving their loved one before it happens. Pre-event planning is critical to success.

Get the student engaged, and “set the hook” for the rest of the class.  

2) Play to your environment.

Use the environment you’re in to your advantage. If you’re in a factory, ask the workers what they would do if you dropped where you stood. Where’s the AED from where they sit?

What would they do? How would they render aid? Let them discuss as a group how they would collectively treat you. Take note of how many different answers you get.

Watch the level of confusion and stress amongst the group as the “bystander effect” starts to take hold while merely discussing watching one of their coworkers go down.

My favorite example of setting the stage was giving a presentation to a room full of SCA experts. I started the presentation by asking a simple question: “How would this room full of experts treat me if I collapsed right here? By a show of hands, does this hotel have an AED and if so, where is it?”

One person raised their hand out of the entire group and gave the answer. “Well, Officer, it’s in the main lobby on the wall between the restrooms by the restaurant we’ve been eating at for the last two days.”

This story isn’t to disparage this group, but to make a point: This was a collection of the best and brightest minds in the world when it comes to SCA. Even they were caught off guard by the scenario presented to them.

When taken out of their environment, they didn’t have an easy answer because it was not in their professional comfort zone. How much attention does the average person pay to their environment?

SCA doesn’t have a comfort zone with the average person. Make them aware of their likely environment and try to create a comfort zone for the lay rescuer.

3) Know your audience.

Classes already know you’re a professional. They don’t need to be reminded with fancy words and war stories. Keep the language simple and in terms they understand: “Pushing down on the chest squishes the heart and pushes blood into the brain, letting the chest expand fully pulls the blood back out of the brain, like squeezing a sponge full of water and letting it expand”.

Use examples they can easily understand. This allows them to visualize the actual benefit they’re providing the patient and keeps their head in the game. Use examples of SCA that directly apply to the situations they’re most likely to encounter SCA. Get them thinking about SCA as it will apply to them, not you.

Limit your war stories.

4) Overcome fear.

You must be blunt. Minimize the shock the rescuer will feel by telling it exactly as they’ll see it. Explain that SCA is clinical death; it’s traumatic, horrifying and gross. If the patient isn’t breathing normally and has no pulse, they are dead! Their day couldn’t possibly get any worse.

Throw out the fear of doing harm. Would they rather a sore chest, possibly a few fractured ribs, or be dead? If the victim wakes up in the hospital complaining of a sore chest, tell them they’re welcome.

Throw out the fear of the victim “dying,” because they just did. However, this is the one opportunity in life where death may not be permanent. Tell them, “You have one shot to get this right and bring the dead back to life.”

5) Eliminate confusion.

Don’t overthink this. If the patient looks dead, treat them like they’re “nearly dead”. Call 9-1-1 and start CPR without hesitation. Explain in depth how common it is to see seizures and agonal respirations.

This is a critical part of the recognition process. Understand that movement does not necessarily equal life.

If the patient is unconscious and not breathing normally, they need CPR. Things have a tendency to quiver and groan as they go through the process of death.Use deer hunting or the chicken with its head cut off as examples.

In other words: if it looks like a duck, quacks like a duck, then dammit it’s a duck … until it barks at you.

If at any point the patient says, “ouch, stop or quit it,” go ahead and stop CPR.  

If they stop mumbling or talking and they become unconscious again, restart CPR.

If the patient isn’t complaining or trying to stop you, keep doing what you’re doing.

Believe what you’re looking at, your eyes aren’t lying! Do not waste your time ruling out SCA, spend a few seconds ruling it in and let the patient dictate the rest.

Throw the concept of look, listen feel out the window—stick with look, it’s the simple truth. If they focus on listen and feel, they’ll hear the gurgling and feel the seizures.

This will lead to second guessing and a “let’s wait and see” mentality. You can always apologize later if the patient didn’t need CPR, but you’ll  never get the opportunity to apologize for not doing CPR.

6) Keep it simple and eliminate objections.

We’re only asking the lay rescuer to manage the first, most critical, 5 to 10 minutes of SCA. We want the lay rescuer to call for help and restart circulation right away. They need to start chest compressions.

Most times, rescue breathing presents an insurmountable obstacle for the lay rescuer to take action. Who will put their mouth on those herpes or chunks of foamy vomit? Who actually carries their pocket mask or barrier?

For simple lay rescuer CPR, eliminate rescue breaths. Rely on, and explain, un-metabolized oxygen and proper compressions to preserve brain function until the arrival of EMS.

Throw out the extremely exact depth of 2.4 inches. Tell them, “Push about a third of the thickness of the patient’s chest, regardless of size, and always let the chest fully recoil.  Don’t lean on the chest.”

Once you start, don’t stop until help arrives and takes over. Acknowledge what you’re looking at: Collapse, unresponsive, seizure, no chest rise, groaning or any combination of these equals SCA … Get to work! Don’t waste your time hoping this isn’t a cardiac arrest; a life is depending on it.

7) Make classes shorter!

If someone wants to know more, encourage them to take a more comprehensive course. Lay rescuer CPR needs to be simple. Explain the goal: The lay rescuer goal is to buy time until trained first responders arrive to help.

8) Lay rescuers do not fail CPR or receive a grade.

If a student fails CPR class or gets a poor, but passing grade, where’s their confidence in their abilities? Will that effect willingness to perform CPR? Will the bystander effect creep in while they wait for a more qualified caregiver? The lay rescuer should make the easy choice to do CPR, simply because it needs to be done.

9) Show videos of actual cardiac arrests.

Show real videos of actual people in cardiac arrest. There’s no better way to prepare people for the reality of what they will see than to actually watch a real world SCA.

This will prepare them and give them a vivid real-life example of what they’ll see in their moment of crisis.

The best videos I’ve seen on YouTube are “Bondi Beach Agonal” and “Helicopter Hero’s Chris Soloman.”

These videos clearly show seizures, agonal respirations, victims who look dead, are immediately treated and were shot live! Show real life video of inaction, such as the YouTube video “Tim Buck Quick Actions.”

Get them angry over the public’s apathetic response. Videos like these put the student in an environment they could see themselves in.

Shift the focus of our training to start inspiring and empowering the general public to render aid.

Back to 3343 Main Street

Below is the actual police reports and the difference one lay rescuer made to the 29-year-old mother of a 10-year-old daughter.

Original Officer Narrative:

ON 2-6-17, AT 1009 HRS, I RESPONDED TO LOI REPORT OF A 29 Y/O FEMALE IN SEIZURES. I ARRIVED ALONG WITH CRFD AND THE ALLINA PARAMEDICS.

I APPROACHED “J,” WHO WAS LAYING ON THE FLOOR INSIDE.

SHE WAS IN CARDIAC ARREST AND I BEGAN LIFE SAVING MEASURES BY ADMINISTERING CPR. CRFD AND THE PARAMEDICS CONTINUED ADVANCED TREATMENTS AND JOHNSON HAD REGAINED A PULSE AFTER A SHORT TIME OF CPR AND ONE DEFIBRILLATION PROCEDURE FROM THE PARAMEDIC’S MONITOR.

I CONTINUED TO ASSIST THE PARAMEDICS AS NEEDED AND I LEARNED FROM STAFF THAT J COLLAPSED AT HER DESK WHILE SITTING IN HER CHAIR.

STAFF ASSISTED HER TO THE GROUND WHERE THEY WERE DOING COMPRESSION AT ONE POINT PRIOR TO FIRST RESPONDERS ARRIVING.

THE PARAMEDICS TRANSPORTED JOHNSON EMERGENT TO MERCY HOSPITAL FOR CONTINUAL CARE. NOTHING FURTHER.

Follow-Up Investigation:

ON 2/22/17 I, CAPTAIN H, DID FURTHER FOLLOW UP ON THIS CASE AFTER LEARNING THAT FORMER CITY COUNCIL MEMBER, DK, HAD PERFORMED CPR ON THE VICTIM IN THIS CASE UNTIL RESCUE WORKERS HAD ARRIVED, LIKELY SAVING THE VICTIM’S LIFE. 

I SPOKE WITH OFFICER F WHO CONFIRMED THIS.

I ALSO SPOKE WITH THE HR MANAGER AT THE BUSINESS, H, WHO CONFIRMED THAT WHEN THE VICTIM COLLAPSED AT HER DESK DK IMMEDIATELY STARTED LIFE SAVING CPR UNTIL RESCUE WORKERS ARRIVED ON SCENE. THE VICTIM IN THIS CASE, J, IS AT HOME RECOVERING AND DOING FINE. END.

Be the Help

We use all the Take Heart America tools. This stuff really works. Without the whole toolkit, J would most likely be dead.

Lay rescuers are our front lines, and our message during training needs to be clear: CPR is your civic duty and a moral obligation. Don’t wait for the help … be the help.