I know the county was talking about this new technique, as well as another proposition to do away with the breaths. So far they are saying that the chest compressions are shown to let in air. I always found it strange that during the teaching they didn't focus on the breaths very much, but stressed the compressions very hard. Personally at work I am required to carry a barrier device, and I also have on my keys just in case. I would rather look back and say "damn, that guy died, but I did everything I knew to try to save him." Instead of "Damn, he died, and I just sat there watching."

In all the years I have been in EMS (since 1978), I have never had a CPR only save, many combined with meds and electricity, but not CPR alone with one exception. The exception and perhaps my most important save was my mother who coded at the dinner table. I was able to start CPR within 30 seconds and had her breathing and semi-conscious by the time the ambulance arrived.

With the exception of the medic on the scene (who knew me) no one, including the doctors at the ED could believe she really coded, since they had never received anyone from the field (non-hospital) who recovered from CPR alone. I knew her personal cardiologist, who also found it difficult to believe she had coded and was saved by CPR alone, since her EKG and cardiac enzymes showed no evidence of a cardiac event. That was until the next day when she coded in the hospital. Fortunately, the code team did their job and she was transferred down to Washington Hospital Center for a triple bypass. That was over eight years ago, today at 91 she has slowed down some, but still gets around. The next day, when I had the chance to talk to her cardiologist, he apologized for having doubted me, saying he had never had a patient who had successfully recovered from an arrest with CPR only. He knew that I was a paramedic and we discussed perhaps why, he surmised that even though I did not perform a cardiac thump, the initial chest compression performed so early in the arrest, likely acted as such.

Pete

This new method looks interesting and I hope to see further exploration of it.

Various tidbits:

- doctors provide some of the worst CPR I've ever seen

- not too many people mention "time to advanced life support (ALS)" in their CPR success rate discussions. It is very rare for CPR alone to yield a spontaneous return of circulation

- survival rate from cardiac arrest induced by trauma (bleedout) is just about 0% no matter what you do

- doing rescue breathing on strangers without a barrier is insane

- be trained & equipped to do rescue breathing because it is a valid and valuable skill in many situations that have nothing to do with diseased hearts

That concept has been around for a while, there is even a study that discusses doing BOTH chest and abdominal compressions.

The problem with past and even (partially) current AHA (American Heart Association) recommended CPR is that there is too much “hands off chest” time. Watch CPR done by even the most experienced rescuers and you will notice that a significant amount of time is spent without compressions being done. The higher the level of care, the more time spent sans compressions (time spent for other procedures like intubation) even using defibrillators can significantly reduce compression time.

The most recent changes AHA has made to CPR and ACLS (advanced cardiac life support) has started to address these issues by recommending 30:2 compression to ventilation ratios, 5 cycles of compression PRIOR to defibrillation in not witnessed cardiac arrest (non-traumatic).

Before I get ahead of myself, a lot of talk has been about save percentages. Numbers in the high teens, twenties and thirties are optimistic statistics. In the past when you have seen these numbers they represent the percent of patients of ANY cardiac arrest not just Sudden Cardiac Arrest (SCA) most studies don't include traumatic arrest. What is the difference? Let’s use a patient from a few weeks ago as an example, awake and alert when we arrive… late 20’s alcoholic who is having periods of “not breathing” according to his relatives. We already have the patient on the monitor and an IV established when he codes, monitor shows a fatal rhythm (TdP for you medical guys out there). Good compressions (if you aren’t sweating you aren’t doing them right) are begun immediately and the patients converts back in to a perfusing rhythm after some medication is administered prior to defibrillating the patient. We continue care and at the hospital the patient still has a pulse and lives to get drunk and have his family call us numerous times since. Now, you take all the patients like this that experience cardiac arrest in front of a health care provider or team of providers you will see save percentages in the upper 90’s (that is our average) if you just look at ROSC (return of spontaneous circulation). You start looking at survival to discharge from the hospital with similar function prior to cardiac arrest those numbers drop into the high 50’s. Those are still exceptional percentages if you look at them alone but are a complete misrepresentation of overall survival rates and their inclusion in the effectiveness of CPR percentages skew the actually percentage.

When looking at the effectiveness of CPR, using just those patients who experience SCA in the prehospital setting will give you a much more accurate number. SCA is the leading cause of death in America, on average 42 adults experience SCA an hour (over 400,000 annually). In 2003 USA Today did a comprehensive study and even though almost half of the 50 largest cities had almost 0% survival to discharge rates the national average was 2-5% with the large city average of 1-2%! Similar studies have showed nearly identical results.

These numbers have been unchanged since the early 1990’s, the question was why. A few issues surfaced; first while bystander CPR on SCA patients was in the 40-60% range in the 1980s, it is currently under 10%. There is no obvious solution to this issue, however 911 operators instructing callers on how to do JUST compressions have improved numbers in those areas and “layperson” CPR removing ventilations have also improved bystander CPR rates (a move that makes sense, but we will cover that later).

A second issue was brought to light by a study in Seattle (who has the highest SCA save percentages) brought to light another interesting fact; patients who initially received BLS (basic life support) WITHOUT defibrillators had higher survival rates than those who initially received BLS or ALS (advanced life support) WTH defibrillators. When they looked at why, they noticed that good quality CPR was done by the BLS crews without defibrillation prior to a unit arriving with a defibrillator (this is also thought to be why the nationwide survival rate was higher than urban survival rates). The solution, add a period of CPR prior to defibrillation on not witnessed SCA with no GOOD bystander CPR performed prior to arrival and survival rates improved dramatically.

While we know that defibrillators make a huge difference in survival rates, statistics from airports and casinos where there is a proliferation of public access AEDs proves their effectiveness. The problem with these statistics is the patient receives their first shock from a defibrillator most often in the first 3 minutes AND good CPR is performed prior to an AED being applied to the patient.

While we have always treated cardiac arrest patients the same, we realize now that patients need to be treated differently giving how long they have been down. That difference is simply providing good quality compressions early in the event prior using a defibrillator UNLESS the patient actually codes in front of you and you have the defibrillator in your hand. We also discover that the old 15:2 compression to ventilation ratio assured that the patient never maintained a perfusable pressure. So by increasing the ratio to 30:2 (or even higher as some areas are currently doing) and providing 5 cycles at a rate of 100 compressions a minute PRIOR to applying the defibrillator (or doing any other interventions like advanced airways) in the unwitnessed/no good bystander CPR prior to arrival patients we can increase survival percentages significantly (from 2-3% to 10-11% in recent studies). In AZ (and other areas) we have started to use what we call CCR (Cardio-cerebral resuscitation) also called Continuous Compressions Resuscitation by the providers. CCR completely removes the ventilations for the first 6 minutes of patient care and dramatically increased the “hands on chest” time (and to not make this post any longer than it already is) improving survival rates (from 3% to 17% in a few months for a local agency) by allowing the heart to return to the initial phase of cardiac arrest where it is more susceptible to being “shocked” into a perfusing rhythm. This protocol requires cycles of 200 uninterrupted compressions at 100 compressions per minute… we call them “gorilla compressions” because you have to push hard, deep and fast. And it does kick the crap out of providers. This is the way AHA is going with their recommendations in the future.

In the end the solution is simple, better education… for the laypeople and the providers!

Edited to add: Glock-A-Roo makes a great point about docs and the quality of the CPR they provide

Damn dude -- to save your mother's life with your bare hands, how cool is that!!! Well done. Glad she's still with the family.

Yes it was cool, but it was not just me, it was very much a team effort.

My wife immediately called 911 and relayed critical information from me to the dispatcher, then went outside to wait for the ambulance. My oldest daughter moved furniture out of the way so I had room to work and the ambulance crew could get a cot/equipment in the house quickly. Middle daughter took our youngest (and the dog) into the bedroom so she (they) would not be in the way and kept them calm.

It all fell together like a well-oiled machine. It was nothing we practiced, previously discussed or preplanned, but everyone knew they had a job to perform and did so immediately.

I rode in the back of the ambulance to the hospital and assisted with care and treatment, so my mind was occupied with tasks. As we approached the hospital and the tasks were pretty much completed, it all began to hit me and I know I started to shake. It took me a few minutes to regain my composure before I could continue on into the hospital.

Pete

They let you ride in the back of the rig with your own mom? Amazing...

-Yes, docs do the worst CPR. When was the last time you saw a doc chest-thumping? As for not training med students, that's insane!
-"Vomiting" I've never really seen during CPR. A bit of regurgitation, but nothing more than a quick finger sweep fixed.
-Rib fractures. So what? He's dead... Also, ramming down on the abdomen is bound to cause injuries (the GI tract is a hollow organ, after all).
-PM-Pete, I've got you beat (EMS since '96): 2 CPR-only saves: my younger brother (2 years old, drowning), and a guy that coded as we transferred him to the gurney (my quick thump brought him back and gave him a hell of a bruise). Interestingly, precordial thump is no longer taught in current ACLS.

Lastly, as much as this is an important topic, let's not forget that even 30% is an amazing number. The statistic includes everything from the motorcycle rider hit by a semi, the 95 y/o vegetative coma patient in the nursing home, and the 20 year old college football player. Given the huge number of reasons that the heart stops, is it any reason that it won't start up again? It's not like we can just switch out the spark plugs: when an organ fails, it stays broke (hence the demand for transplants). Medicine isn't at the point yet where it can fix an organ that has no functionality.

I have yet to see significant vomiting in a pulseless patient... I have seen patients vomit significantly after a ROSC though!

Funny how so many people focus on the broken rib thing, sure it happens (but not as often as the public believes) but I have yet to see adverse effects in saves... and like MDiana says there are DEAD! Besides, how many broken ribs in "healthy" patients lead to injuries to underlying organs?

I've seen a doctor once that performed mouth-to-mouth on a patient with a tracheostomy...

Could you expand on that? Presumably you are concerned about infections? Are there specific diseases that are a problem?