CPR Realities

The following is my reply on the FirstAid list to a new EMT who was having some major self-doubts after participating in her first cardiopulmonary resuscitation.

Then another EMT showed up and said I was doing it all wrong ... that I shouldn't stop compressions for the rescue breaths. He's been an EMT-B for probably 10 years and I'm fresh out of school. I didn't know if I'm supposed to do like I was taught or listen to him. (It's HARD to tell a 10-year veteran he's wrong and you're right!) Every book I've read and during the class, we were taught no matter how many rescuers were on the scene, you stopped compressions just long enough for the 2 rescue breaths. How else can you tell if he's got an adequate airway??? And I realize (and I'm sure you all know) that book-learning is great, but it doesn't replace experience.

By the way ... the guy didn't make it. We continued CPR for 10-15 minutes until another volunteer department arrived who had an AED. I've always wondered if I did the right thing by doing what I was taught and not following the directions of the second EMT. (And part of me is scared to find out so be gentle with me!)

I replied as follows: (Note: my reply has been very slightly edited for this website. Please also note that AED stands for Automatic External Defibrillator.)

First, after you've been in this game for a while, you'll discover for yourself that the correlation between somebody's "time in grade" and their expertise can be iffy. The correlation between the initials (or lack thereof) following somebody's name, the position they hold, and the amount of time they've been involved and their personal qualities such as their expertise, open-mindedness, professionalism, and compassion are tenuous at best, and do not _automatically_ improve with height in the pecking order.

As the saying goes, some people have twenty years of experience and some people have one year of experience they repeated nineteen times. The EMT mentioned above may have had a card in his wallet for ten years, but that doesn't speak to how much actual emergency care experience he has, or to how much he learned and grew, both personally and professionally, from whatever experience he has had.

This brings up an important side issue which I have mentioned before. If your schedule allows, one very good way to get some clinical experience is by doing some volunteer shifts in your local ER, particularly something like a trauma center ER if such is reasonably available. While you may not get to do very much, you will get to see and hear a great deal, and that can be invaluable. Short of working for a busy company, this is the best way I know of to get some substantial clinical experience, and it's often fairly readily available.

Footnote # 1: many hospitals have excellent in-house lectures you can usually sneak into. Sit quietly in the back, jot down words that you don't understand so that you can look them up in a medical dictionary, and you'll learn a lot.

Footnote # 2: If you haven't already done so, get an Advanced Cardiac Life Support manual and study it more than thoroughly. I mean _really_ chew it up and digest it, including, if you can, going to the medical library and reading over the cited journal articles -- it's fine to start with the ones that most interest you. As you do so, your understanding of what you see and hear will skyrocket. (You may also learn that sometimes there is a very slight gap between black marks on white paper in a medical journal and How Things Be, but we don't need to get into that just now. Just don't automatically and uncritically accept something just because you read in a journal.)

Returning to the EMT in question, "back in the day" we were taught to not pause compressions to give breaths to an unintubated patient during two-person CPR, and with practice this could be accomplished, but it was kind of a tricky thing to do and often wasn't performed very well in actual practice (this is diplomacy-speak for "was often performed abysmally badly in actual practice" ) so eventually The Powers That Be decided to allow a pause. This major change came about officially in the 1992 guidelines, and anybody who has been paying attention has known about it since then, so maybe the guy above hasn't recertified since his original training.

As to the actual resuscitation attempt, you may find it useful to keep in mind that actual codes, particularly prehospital codes, are not exercises in precision close-order drill. Such codes in fact tend more to resemble rugby scrums that take place during a driving rainstorm. Keep the _really_basic_ principles in mind, apply them as best you can in a given situation, and you'll do OK. The quality of the compressions matters, the quality of the ventilations matters, promptly bringing the AED into play matters. Things like ratios of compressions to ventilations don't matter all that much unless the ratios get totally unreasonable.

Witnessed arrests due to a medical condition that immediately receive adequate basic CPR and have a defibrillator promptly available (please note the four factors) have a reasonable chance of resuscitation -- somewhere roughly around 50%, depending. On the other hand, the survival rate for unwitnessed arrests, or arrests due to trauma, or arrests that receive poor CPR, or arrests in which a defibrillator is not promptly available hovers just above zero. In the case you describe, the underlying cause of the cardiac arrest and the delay in getting an AED were very likely the factors that predicted the outcome. I'm certain the CPR you provided was far more than adequate in that regard and you are to be commended.

This is a very tough league to play in, and the very stark, harsh reality is that we lose a lot more games than we win, no matter how well we play. Nonetheless, we _do_ win one from time to time.

On a clinical note, and just as an FYI, I will mention that I have essentially no confidence at all in the "feeling for a pulse with compressions" test of compression adequacy. I've found it to be a very poor test with so many false positives and false negatives as to make it barely worth the time to perform. (The one consistent exception to this was CPR in which the device known at the Thumper was used.)

I've found that the presence or absence of central cyanosis (blueness of the lips and face) to be a more reliable indicator of how well the patient is being oxygenated. This is particularly true regarding the fairly prompt disappearance of cyanosis upon beginning resuscitation or the reappearance of cyanosis at some point during the code. (I've found that if cyanosis reappears during a code, you've got about 60 seconds to correct whatever's causing it or you're gonna lose the patient.)

Once you get down the road a bit, and you've got some seasoning and time-in-grade, you might want to consider becoming a FA/CPR instructor yourself. Everything else being equal (a _big_ assumption, I'll admit) an instructor with significant field experience is a substantially better instructor than an instructor that lacks such experience. I keep hoping that one of these days the people who write the EMT and Paramedic textbooks will start including a bit of advice along the above lines.