High-Performance CPR Leaders Show the Impact of Standardized Training and Performance

Matthew Huei-Ming Ma, MD, Taipei City’s medical director, speaks to a cardiac arrest survivor summit in Seattle. (Photos by A.J. Heightman, unless otherwise noted.)

Editor’s note: This is a special feature report by JEMS Editor-Emeritus A.J. Heightman from a cardiac arrest survivor summit he attended in Seattle.


Michael Sayre, MD, Medical Director of the Seattle Fire Department Medic One System, and Matthew Huei-Ming Ma, MD, Taipei City’s medical director, are both leaders in high-performance CPR (HP-CPR) systems. On December 13, they shared their experiences, implementation strategies and methods of maintaining and sustaining their HP-CPR programs in Seattle at a cardiac arrest survivor’s summit.

Taipei City Training Efforts and Results

Dr. Ma spoke about efforts in Taipei to increase resuscitations by high-performance CPR (H-CPR), use of mechanical compression devices (ZOLL Autopulse), and use of telephone CPR instructions by emergency dispatchers. Interestingly, the prevalence of ventricular fibrillation as the initial rhythm recorded is lower in Taipei City compared to western countries. Perhaps it is because of the lower chance of coronary heart disease in Taiwan. (See photo 1).

Photo 1: A slide from the presentation.

Nonetheless, community-wide use of automatic external defibrillators was launched in 2000 and the survival-to-discharge rate of OHCA patients improved after the introduction of the AEDs.

The quality of CPR, especially effective cardiac compressions, through significant training of crews in HP-CPR, has been proved to be key to improving the outcomes of resuscitated patients in Taipei.1

With the use of cardiac rhythm and voice recording by AEDs in the field, CPR quality was found to be a major determinant for survival to discharge among OHCA patients. Patients with adequate CPR, defined as more than 50 effective cardiac compressions per minute and limited hands-off time, had a 53% chance of survival to discharge compared to only 8% for those without adequate CPR performance.2

The use of prompting devices, such as an audio prompt, also improved CPR quality by enhancing the cardiac compression rate and limited the hands-off time and has resulted in a 42% survival rate to hospital discharge in Taipei City.3 (See Photo 5).

Repetitive training, retraining, surprise drills and group critiques of cardiac arrest cases has been invaluable. In addition, crews and dispatchers gave also received special training in the recognition of agonal breathing. (See photos 2, 3 & 4).

Training staff are involved in extensive testing to keep them sharp and ensure they are training according to rigid Taipei City standards

In a unique approach, dispatchers have been given financial bonuses if they present telephone CPR instructions to callers and the patient survives. (See photo 5).

Photo 2: A slide from the presentation.
Photo 3: A slide from the presentation.
Photo 4: A slide from the presentation.
Photo 5: A slide from the presentation.

The Seattle Fire Department – Medic One Resuscitation Approach

The Seattle Fire Department Medic One system, along with all other King County, Washington Fire Department systems, participate with, and follow protocols recommended by, the internationally recognized “Resuscitation Academy,” founded by Mickey Eisenberg, MD, Leonard Cobb, MD, and Michael Copass, MD. Their county-wide standardized protocol system has saved over 7,500 cardiac arrest victims since 1970 as a result of a tight critical care teamwork approach.

As a special surprise for the summit’s attendees, Medical Director Sayre offered a realistic cardiac arrest scenario, beginning with a man in a wheelchair who suffered a heart attack in the audience. The man was brought up on stage and “arrested.” A bystander then started CPR on him as he was a sophisticated, wireless Laerdal QCPR manikin. (See photo 6).

Photo 6

Crews from two Seattle Fire Department BLS engine companies soon arrived on scene. As photos 7 and 8 illustrate, Seattle has a unique “MED 7″ response system, with two BLS engine companies and a Medic One ALS Ambulance dispatched to cardiac arrest cases.

Photo 7

Unlike many cities/systems that deploy ALS engines, Seattle always focused on, and has had outstanding success with, early citizen CPR initiation and highly trained EMTs on their response engines and Aid Cars that know the cardiac arrest protocol and team approach to resuscitation. (See photos 8 to 10).

Photo 8

The BLS engine crews, trained to perform exceptional quality and continuous compressions (with less than four seconds interruption at any time), provide early defibrillation with an AED and administer BVM ventilation and oxygen to patients until the arrival of the Medic One paramedics.

Key Aspects to Seattle FD / Medic One Care & Success

Photo 9
Photo 10

Throughout the conference, speakers emphasized the need to keep chest compressions going, the need to allow complete recoil after each compression and the importance of limiting breaks in compressions to <10 seconds at all times for best resuscitation results. The Seattle Fire Department places these important tasks on the BLS SFD crews, with an engine company or two-person Aid Car EMT team leader calling all the shots on the call.

Photo 11

Seattle, unlike most US cities, deploys a limited number of ALS “Medic One” ambulances and seasoned paramedics that respond only to serious ALS cases.(See Photo 10).They accomplish this task through careful dispatch call screening and protocols. This means Seattle paramedics respond to and manage the most serious cases, therefore easily maintaining their ALS skills.

The Medic One medic units are staffed by two paramedics and wear white shirts so they can be easily differentiated from BLS providers at the scene. (See photo 12).

This response model has been a key to Seattle’s internationally recognized success for decades. Deploying a total of just 65 highly trained medics, with only 15 on duty at a time in a community of 725,000 people allows for tight medical control and regular opportunities to use ALS skills. The fire department is not required to do remedial training of a very large number of ALS providers.

The same is true for all King County EMS systems, all of which train via the famed Resuscitation Academy approach to cardiac arrest. Medics arrive on dedicated King County “Medic One” ambulances. With a total of just 250 paramedics deployed to cover the King County population of 2.2 million people (a ratio of one paramedic for every 8,800 people) King County has also been able to achieve a phenomenal number of cardiac arrest resuscitations — 7,500 to date.

Photo 12

In some cities, every engine company is staffed by one or more paramedics who rarely care for critical patients. For example, if a city of 725,000 people deploys 40 engine companies and every shift has two paramedics per engine and rotates three shifts, there are 240 paramedics that must be continually monitored and retrained on skills like needle decompression, endotracheal intubation, external jugular cannulation and code management. If that same city has an all paramedic policy and staffs its engines with four paramedics, that number would climb to 480 paramedics. In such a community, skill decay can be significant and place a financial burden on the training staff and budget.

My Pennsylvania “Medic” System Experience

In the late 1970s, when I was a young ALS/EMS system developer in Eastern Pennsylvania, I asked Jim Page what he recommended as a formula for the placement of ALS units. His reply was, “Use the Seattle Model” and deploy one ALS unit for every 10,000 population. He said too many paramedics would result in fewer cases handled by each paramedic; and he was so correct.

We followed the advice from Jim Page, Mickey Eisenberg, Leonard Cobb, Michael Copass, as well as Miami Fire Dept. Medical Director Gene Nagel, MD, and mirrored our system after theirs in 1976 in the Eastern PA EMS Region. We carefully designated 12 “Medic Unit” regions throughout the region, with very few highly trained paramedics and extremely tight medical control/oversight; and complete QA of every ALS call.

But, when BLS services realized that they could bill a higher rate if they had ALS status, they petitioned (and sued) my office to be able to get ALS status and hire paramedics.

We defended our stance with support from the Director of PA EMS. In the early 1990s, however, an attorney with the Pennsylvania Department of Health interpreted the then-EMS Act in the state to allow any service to have paramedics, declaring, in a memo: “More is better.” Boy was he wrong.

Dozens of BLS services soon “got ALS” and hired medics fresh out of school and from other regions, with little or no experience, and had them respond in service areas that had fewer than 1,500 calls per year.

With only 10% of calls needing critical ALS care, they soon had 12 more expensive employees handling a total of 125 critical cases each year. That equated to an average of just 10.4 true, “working” ALS cases for each paramedic, or less than one each month.

Put another way, if a paramedic worked 5 days a week for 52 weeks (260 days), he or she only managed one true ALS patient every 25 days worked. With cardiac arrests accounting for just 1% of call volume, skill decay and reduced “saves” soon became apparent. But the horse was out of the proverbial “barn” and services began to ignore their reduction in ROSC patients and had a hard time teaching pit crew and “team protocols” to low call volume paramedics and crews.

Back to Seattle Fire Dept Medic One System Features

Seattle Fire Department EMTs work closely with the Seattle paramedics and know their care routine. In photos 13 and 14, you can see a paramedic intubating with a bougie catheter in the trachea, while the firefighter-EMT introduces the tube down the bougie so that the paramedic can slide it into the trachea. The firefighter then removes the bougie.

Photo 13
Photo 14

Seattle Medic One paramedics routinely insert two IV lines in cardiac arrest patients to ensure they always have at least one patent line for the injection of medications. In Photo 15, you can see the paramedic positioned at the left shoulder area of the Laerdal Q-CPR manikin, cannulating an external jugular vein.

Photo 15

Seattle’s Medic One System offers exceptional airway care with all personnel maintaining strict sterile conditions around ET tubes and having suction units at the head of critical paramedics, as illustrated here with the firefighters all wearing gloves and an SSCOR suction unit at the patient’s left should area, near the paramedic. (See photos 15, 16 and 17).

Photo 16
Photo 17

Over the past 10 years, hundreds of EMS leaders from communities across the country have travelled to Seattle to attend a Resuscitation Academy. They learned how to train their teams in high-performance CPR. Attendees also meet others who have successfully raised cardiac arrest survival rates in their communities to a level close to, and in some cases, exceeding the survival rates in Seattle. Those communities followed the Resuscitation Academy 10 Steps to Survival.

It is clear from the success achieved by the Seattle and King County Medic One programs that they follow, and achieve great success, from the key aspects of resuscitation: early CPR and AED deployment; telephone CPR instructions; well-trained and coordinated responders; high performance CPR and transfer to centers of excellence.

As resuscitation guru Tom Bouthillet recently reminded us on his “Resuscitation” page, one of the most important takeaways from the Seattle/King County Resuscitation Academy is understanding the “Slope of Death” and how implementing best practices like rapid dispatch, telecommunicator CPR, and high performance CPR can “bend the line” of cardiac arrest survival and result in a save rate >50% for bystander-witnessed, shockable cardiac arrest. (See photo 18).

Photo 18: A slide from the presentation.

Spreading it Internationally

Over the past five years, EMS leaders in Europe, Asia, North American, and Australia have worked together to create the Global Resuscitation Alliance. The Global Resuscitation Alliance focuses on implementation of best practices in resuscitation for victims of out-of-hospital cardiac arrest.

More recently, the Resuscitation Academy Foundation has been working with the American Heart Association and Laerdal Medical to develop training programs that any community can use to raise survival from out-of-hospital cardiac arrest. The Resuscitation Quality Improvement (RQI) Telephone CPR program helps emergency call takers recognize cardiac arrest and deliver effective T-CPR instructions.

A system assessment consultation service has helped communities from Florida to Maryland focus their improvement efforts. The RQI for EMS program helps team members ensure that they have perfect individual CPR skills.

More information is available at the Resuscitation Academy website:

https://www.resuscitationacademy.org/. You can use these tools to raise your performance and the performance of your team to save more lives from cardiac arrest.

Information on how to participate in a free Cardiac Arrest System Assessment from Resuscitation Quality Improvement (RQI) can be obtained at: https://rqipartners.com/our-lifesaving-solutions/rqi-2020-resuscitation-quality-improvement/


  1. Chien-Hua Huang, Matthew Huei-Ming Ma and Wen-Jone Chen: Out-of-Hospital Cardiac Arrest in Taipei, Taiwan. http://www.tsoc.org.tw/upload/journal/1/20060630/2.pdf.
  2. Ko PC, Chen WJ, Lin CH, Ma MH, Lin FY. Evaluating the quality of  cardiopulmonary resuscitation by reviewing automated external defibrillator records and survival for out-of-hospital witnessed arrests. Resuscitation 2005;64:163-169.
  3. Chiang WC, Chen WJ, Chen SY, Ko PC, Lin CH, Tsai MS, Chang WT, Chen SC, Tsan CY, Ma MH. Better adherence to the guidelines during cardiopulmonary resuscitation through the provision of audio-prompts. Resuscitation 2005;64:297-301.
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