Barriers to dispatcher-assisted telephone cardiopulmonary resuscitation

Abstract

Most people who witness a person in cardiac arrest have not been trained in cardiopulmonary resuscitation (CPR).1 The person most likely to witness a cardiac arrest event is a relative because most of these events occur in the home.2 Although a close relative is more willing to give CPR than a stranger, unfortunately, they often lack the knowledge to provide this life-saving intervention.3,4 Investigators demonstrated that one effective way to close this knowledge gap is to have emergency medical dispatchers who receive 911 calls give bystanders “onthe-spot” teaching in CPR over the telephone.3 Most victims who could benefit from dispatcher-assisted telephone instruction in CPR have their cardiac arrest at home.3 Of great importance, telephone CPR is associated with a 50% improvement in the odds of survival to hospital discharge compared with those who received no CPR before the arrival of emergency medical services (EMS).3 However, even where a telephone CPR program is well-established, nearly one half of victims still do not receive CPR before the arrival of EMS.3 In this issue of Annals, Hauff et al4 present important information regarding barriers to implementation of telephone CPR. The investigators separated the reasons why dispatcher CPR instructions are not implemented into 3 main phases: (1) the dispatcher did not offer CPR instructions; (2) instructions were offered, but the caller declined to implement the instructions; and (3) instructions were offered and accepted, but CPR still was not given. The most frequent reason that cardiac arrest victims did not receive bystander CPR was because the victim was believed to have signs of life. In the first phase, CPR instructions were not given for 64% of patients with cardiac arrest because they were believed to have signs of life, most likely because of the presence of agonal respirations. On review of the dispatch tapes, in instances where the telephone was near the victim, agonal respirations were identified in 5/7 cases. In all 3 phases, 34% (56/166) of cardiac arrest patients did not receive CPR because they were thought to have signs of life. How can we improve this situation? Clearly, we need to have better ways to recognize when a person is in cardiac arrest. Very little research is available regarding recognition of signs of life, which now is a critical first step for the lay rescuer to initiate CPR. Investigators reported the presence of agonal respirations in as many as 55% of witnessed cardiac arrest victims.5,6 It is also clear that the way dispatchers ask a question over the telephone is extremely important. For example, CPR was withheld inappropriately when dispatchers omitted such questions as “Is the person breathing normally?” or “Is the person awake and conscious?”6,7 Thus, there are possible solutions that can be used to eliminate barriers for people to take action to increase the frequency of bystander CPR. Notably, emotional distress, concerns about disease transmission, disagreeable victim characteristics, or medicolegal concerns rarely impeded bystander CPR in the present study. Barriers to CPR and possible ways to eliminate them include: 1. Signs of life, particularly agonal respirations, impede recognition of sudden cardiac arrest. In the 2000 revision of guidelines for CPR, the American Heart Association deleted using the pulse check for lay rescuers to initiate CPR and instead recommended using absence of “signs of life” or “signs of circulation” (ie, normal breathing, coughing, movement) as a signal to begin CPR.8 The pulse check was deleted for lay rescuers because studies showed that rescuers require more than 24 seconds to decide whether a pulse is present, they miss the pulse when it is present in 4 of 10 times (poor specificity), and when E M E R G E N C Y M E D I C A L S E R V I C E S / E D I T O R I A L