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AED, CPR, and First Aid Preparedness

This article appeared in the December 2006 issue of Occupational Health & Safety.

Lay rescuers must possess not only the technical skills, but also the ability to overcome fear and concerns that often accompany emergency situations.
by Ralph M. Shenefelt

The typical response to sudden cardiac arrest is not the stuff of Hollywood movies or TV medical dramas. Rarely is the most-trained, clearest-thinking person on the scene first, taking charge and saving a life against long odds. Rarer still are bystanders who instantly become part of the solution instead of a distraction or impediment. Panic, confusion, fear, people getting in one another's way--now, that's often the real world.

Consider the all-too-typical workplace emergency response when an employee suffers sudden cardiac arrest (SCA): Perhaps only one person in the area has had cardiopulmonary resuscitation training, and that may have been at least a couple of years ago. While precious seconds tick away, human nature takes over and there is a debate about what should be done, who should do it, and a variety of legal and personal concerns.

Finally, someone begins CPR and puts his hands on the victim's chest and pushes hard. Something cracks. He pushes again. Something cracks again--it's the ribs. The sound stuns the rescuer and bystanders. On the third push, lines of thick clear fluid stream down both sides of the victim?s purple-gray face. Concerned about doing more harm than good, the rescuer keeps pushing but not as hard. The rescuer knows he should give mouth-to-mouth resuscitation, but he just cannot bring himself to do it.

Once security arrives, there is a shuffle of equipment, and the guards start CPR. Then an ambulance and fire truck arrive and the professionals take over. They have an automated external defibrillator and place the pads on the victim's chest. After a shock, the pulse returns. The victim arrives at the hospital alive but dies later in the day.

Immediate Action Is Essential


Despite heroic efforts by lay rescuers and professional emergency responders, the scenario above is quite typical. In fact, more than 325,000 Americans die each year from SCA--more than from cancer and automobile accidents combined. And when cardiac arrest occurs outside a hospital setting, fewer than 5 percent of victims survive, primarily because CPR and defibrillation are not performed soon enough.

The brain begins dying within four to six minutes of SCA onset. However, if no more than 3 minutes elapse between collapse and defibrillation, survival rates of 74 percent have been achieved.

So in the real world, what can you do to give an SCA victim the best hope for a second chance at life? Technical training for would-be rescuers remains the most critical component. To be able to make a difference, people from across the workforce and work shifts should be trained in first aid, CPR, and AED use--with all three areas being important. In the workplace, providing first aid training to all employees, rather than limiting it to a small number of designated responders, may help to reduce both the frequency and severity of occupational injury and illness. Training has been shown to improve participants' motivation to avoid injuries.

Lay-rescuer AED programs are becoming common in America's workplaces, but they should not overshadow the more traditional first aid and CPR programs. All three areas are prominent components of a total solution. AEDs on their own are seldom enough to save lives; victims of cardiac arrest need immediate CPR. CPR provides a small but vital amount of blood flow to the heart and brain, and it increases the chances that an AED shock will allow the heart to start working effectively. Eighty percent of SCAs are caused by ventricular fibrillation, a heart rhythm variance for which defibrillation and CPR are the only effective treatments.
Providing first aid training to all employees, rather than limiting it to a small number of designated responders, may reduce the frequency and severity of occupational injury and illness.


Questions & Answers



Q: What can a company do to be better prepare for real world emergencies?

A: Provide first aid training to all employees, rather than limiting it to a small number of designated responders, may reduce the frequency and severity of occupational
injury and illness.

Integrate their first aid, CPR, and AED training programs into their emergency response drills.

Make sure your have all necessary emergencies supplies and equipment on hand and in proper working condition at all times.


Refresher training is also essential, and it is more important than ever now because new first aid, CPR, and AED guidelines have been published. For example, the new CPR guidelines for adults recommend 30 chest compressions for every two rescue breaths (compared with the previous 15-to-2 ratio). The new guidelines also recommend beginning chest compressions immediately after the two rescue breaths--not waiting to check for a pulse or other signs of life, which is often difficult for lay rescuers to do and delays delivering potentially lifesaving chest compressions.

Employers should consider integrating their first aid, CPR, and AED training programs into their emergency response drills.

In addition, the recommendations for combining CPR and defibrillation have changed. The new recommendation is for a single shock from a defibrillator followed by immediate CPR for two minutes, beginning with chest compressions. The 2000 guidelines recommended up to three AED shocks before returning to chest compressions for one minute. There is an important new focus on effective chest compressions to maximize the quality of CPR. Effective means that the rescuer needs to push hard, push fast, allow complete chest recoil, and minimize interruptions in CPR. Rescue breathing without chest compressions is no longer taught in programs that follow the new guidelines.

To help people learn and perform CPR and AED better, all nationally recognized training programs are now encouraging instructors to talk less and help students practice much more. Training is moving away from large-group, instructor-focused, lecture-based programs to small-group, student-focused, scenario-based, interactive programs. But even that is not enough for giving your program the best chance of success in the real world. Employers should consider integrating their first aid, CPR, and AED training programs into their emergency response drills so that would-be rescuers have an opportunity to rescue their manikins in a workplace setting, not just under calm, ideal classroom conditions. These special drills also can be helpful in uncovering any rescue equipment problems and supplies shortage that might have been missed by the ongoing maintenance and recordkeeping program.

What Are You So Afraid Of?


As discussed above, technical training, the right equipment, and timely maintenance are critical for a successful workplace emergency care program. But there is also a softer, more emotional side that can have just as much impact on a company's program. That factor is overcoming people's fears, which can be seen at all levels of an organization.

At the management level, the safety and health professional has to be concerned about the compliance obligations, including protection against bloodborne pathogens. The CFO may be focused on costs and return on investment in these programs, while the legal folks know that the American judicial system is fraught with complexities and time-consuming, costly litigation. Any one of these issues could cause an organization to drop or severely cut back its emergency care program, with potentially tragic consequences. The best way to address these concerns is to involve the key stakeholders in the creation, implementation, evaluation, and reauthorization of the program.

At the individual level, several recent studies have shown that both trained and untrained bystanders are reluctant to perform CPR and use an AED. For example, a six-year study in Michigan, published in 2006, interviewed 684 bystanders in SCA cases. Seventy percent of the bystanders were family members, and 54 percent of those family members had been taught CPR. And yet, only 21 percent were actually willing to start CPR. The rest said they were not willing to because they panicked, thought they would not do it correctly, were afraid they would hurt the person, or were concerned about contracting a disease or infection by performing mouth-to-mouth resuscitation.

There is an extremely low liability risk in establishing AED programs.

A 2003 study of North Carolina high school students found that 86 percent of students surveyed were trained in CPR and 21 percent were trained in AED use. However, only 32 percent of the students trained said they were actually willing to use an AED and around 50 percent were willing to perform CPR. Again, they were held back by fear of infection, legal consequences, and harming the victim.

Overcoming the Fear Factor
Legal issues and health concerns are among individuals' primary fears. Overcoming these fears is paramount to reducing a leading cause of death for Americans. Quality training materials cover these issues, and a good trainer will take the time to share the knowledge and skills that can help students manage these fears.
Here is advice on how to tackle the most common fears:

  • Fear of infection: Much-publicized health risks, which include everything from AIDS and hepatitis C to staph infections and bird flu, have had a chilling effect on people's willingness to perform CPR. Scientifically speaking, however, the estimated risk for acquiring infection during CPR is extremely low, about one in a million. Simple infection control measures, including use of barrier devices, can significantly reduce the risk of acquiring an infection disease during both CPR and CPR training. If no mask or shield is immediately available, rescuers can still perform compression-only CPR by placing the victim on his or her back and using two hands (one on top of the other) to push hard and fast on the center of a victim's chest.
  • Fear of legal consequences: Good Samaritan laws protect people who gratuitously and in good faith give CPR or use an AED. There has never been a successful lawsuit in the United States against a person providing first aid/CPR in good faith. However, to protect yourself, once you start CPR, do not stop until a person with equal or more training takes over, you are exhausted, or the scene becomes too dangerous to continue. For AEDs, there is an extremely low liability risk in establishing AED programs; most lawsuits result from lack of an AED program.
  • Fear of harming the victim: Rib and breastbone fractures occur frequently during chest compressions in adult CPR but are not major complications. Although CPR should be done right and with high quality, remember that a person in cardiac arrest is dead (without breathing or a pulse); it is hard to make them any worse. Mistakes in CPR may reduce the chances for successfully resuscitating a victim, but they do not kill the person. Their original condition is the cause.
  • Fear of failure: Lay people who participate in first aid, CPR, and AED training programs provide a great service to their families, workplaces, and communities. They want to make a difference, and there are many wonderful stories of lives saved. But there are many more, unfortunately, where the victim cannot be saved. Perhaps nowhere else in American society is a 5 percent success rate celebrated--and it should be; without the fast response, there would be no survivals. However, employers and safety and health trainers must manage would-be rescuers' expectations. They need to know that situations where victims cannot be saved do not represent failure on their part. The root of the word resuscitate is from the Latin revivere, which translates as to live again.

The underlying lesson is that even the best equipment, even the best training, can take you only so far in emergency response. At some point, you have to deal with the emotional issues and overcome people's base fears. My best-practices recommendation is to deal with these real-world preparedness issues now, long before a would-be rescuer is thrust into service in a last-ditch attempt to save a co-worker, family member, friend, or stranger.


References

  1. 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations hosted by the American Heart Association in Dallas, Texas, Jan. 23-30, 2005. Circulation 2005; 112: III-5-III-16 and Resuscitation Volume 67, Supplement 1, Pages S1-S190 December 2005 International Liaison Committee on Resuscitation, American Heart Association, Inc., and European Resuscitation Council.
  2. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2005; 112:IV-1--IV-211 2005 American Heart Association, Inc.
  3. Swor, et al. CPR training and CPR performance: Do CPR-trained bystanders perform CPR? Acad Emerg Med. 2006 Jun;13(6):596-601.
  4. Hubble MW, et al. Willingness of high school students to perform cardiopulmonary resuscitation and automated external defibrillation. Prehosp Emerg Care. 2003 Apr-Jun;7(2)219-24.
  5. Lingard H.J. The effect of first aid training on Australian construction workers' occupational health and safety motivation and risk control behavior. Safety Re. 2002 Summer; 33(2):209-30.
  6. Mejicano GC, Maki DG, Infections acquired during cardiopulmonary resuscitation: estimating the risk and defining strategies for prevention. Ann Intern Med. 1998 Nov 15: 129(10):813-28.

Ralph M. Shenefelt, EMT-P, is a former firefighter/paramedic, a member of the National First Aid Science Advisory Board, and the executive program director of the American Safety and Health Institute, the third-largest CPR and AED training and accreditation organization in the United States. He can be reached at rshenefelt@ashinstitute.org

Please Note: The information contained in this publication is intended for general information purposes only. This publication is not a substitute for review of the applicable government regulations and standards, and should not be construed as legal advice or opinion. Readers with specific questions should refer to the cited regulation or consult with an attorney.

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