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Peeking from the blindfold
Resuscitation 96 (2015) A3–A4
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Peeking from the blindfold
Have you ever tried to draw a picture by instructions from someone who is blindfolded? As a party game this may be frustrating for participants while amusing for the spectators. In real life this is the communication challenge for our medical dispatch operators. Their frustration, of course, increases with the knowledge of the devastating consequences of delayed recognition, start of CPR and alarming the responding EMS-resources in the case of cardiac arrest. In 2013 the Danish Cardiac Arrest registry published their 10year material showing concomitant increases in bystander CPR and survival for out-of-hospital cardiac Arrest (OHCA).1 This is in concordance with most published papers from national cardiac arrest registries and scientific reports, and the importance of bystander CPR as one of the links in the chain of survival has been repeatedly justified.2 Telephone-CPR (T-CPR) is recommended for all suspected cases of cardiac arrest,3 well justified by consistent reports of doubled or even tripled chances of survival if bystander CPR has been started before ambulance survival, and the sobering facts telling us that even trained bystanders may hesitate to initiate basic CPR unless they are prompted by the dispatcher.4,5 The specifics on how to best initiate and improve bystander efforts remain a topic for continued research. Solid evidence guides us to restrict guidance of untrained callers to chest compressions only.6 Each incremental revision in dispatcher training and manuscript does not have such potential to change survival, and dissecting harmful and beneficial effects requires other scientific methods than multi-centre randomized trials. Qualitative methods may elucidate and improve our practice, but the very nature of cardiac arrest – it occurs suddenly – limits our possibilities to observe bystanders’ responses to the situation and dispatcher instructions. In this issue of Resuscitation Linderoth and colleagues from the Capital Region of Denmark present novel insights into the communication difficulties of dispatchers and bystanders during OHCA in public locations.7 With what must have been a tremendous effort, they were able to collect video surveillance files from cardiac arrests occurring in the public and to match these with the audio recordings from the dispatch centre. They were able to combine the two data sources in 21 cases and by using a qualitative approach they extracted valuable information. For the first time communication could be evaluated from real situations based on direct observations of conditions and obstacles to good communication. Of course, this is a selected sample and as duly pointed out by the authors cardiac arrests occurring in the public differ from the common case in both patient and bystander characteristics. However,
http://dx.doi.org/10.1016/j.resuscitation.2015.07.012 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
the themes recognized by the review of these cases, are common factors to team-work anywhere: Shared situation awareness is a prerequisite for effective team-work. This is why we always encourage “time-outs” and “summaries” in team-training. Communication is everything that occurs between sender and recipient to convey a meaning between them. When only sound and voice are available, we immediately miss the many visual clues we usually rely on for verification, acknowledgement, and assessment. Good communication is more than mere words and language, but learning to work in a team is often characterized by learning the team-specific language and terms. Last, but not least, the will to communicate and to aid our fellow human needs to be present or be encouraged, the authors summarize this under the heading Attitude/approach. The authors recognize the dispatcher – bystander dyad as the first team of resuscitation. Even if they may be separated by kilometres and limited by only voice communication, they have to collaborate and manage the themes mentioned to succeed in initiating and propagating good CPR. The examples provided shows us that obstacles and challenges can occur on both sides of the telephone line – so how can we improve? If a lay person encounters one cardiac arrest per life-time (excluding one’s own) and maybe calls the emergency number a few times over many years, each operator receives multiple emergency calls every day and even if less than 1/100 is cardiac arrest-related, adequate clarification of patient consciousness and normal breathing is always mandated. Training the dispatchers to provide CPR guiding is a sensible solution and are already effective in many systems. Introduction of systematic CPR instructions from the dispatcher increased the proportion of bystander CPR in Seattle and King County,8 and has been part of the international recommendations since 1986. From simulation studies we have learned that the exact words and previous training influence bystander CPR performance, and that T-CPR should be considered a continuous task until the ambulance arrives, including rapid identification of cardiac arrest, initiation of chest compressions, and coaching and encouragement to maintain high quality CPR.9,10 For previously untrained bystanders, instructions to do only chest compressions are as likely to result in improved survival as instructions for CPR with rescue breaths. For the trained and competent rescuer, ensuring rapid initiation of CPR and coaching to maintain high quality until ambulance arrival may still be one of the most important tasks of the dispatcher. Updated registries of public AEDs add even more possibilities for the dispatcher to take the lead and manage resources on the scene as a team leader.
A4
Editorial / Resuscitation 96 (2015) A3–A4
It takes two to tango, and this study reveals some of the challenges for communication for a team with participants in two locations. The best teams practice. Obviously, preparedness for the demands of communication with the dispatcher should be part of training for bystanders as well. Even a read-through of instructions and answers will prepare the caller, but the main responsibility always belongs to the professional part – to be properly prepared to guide blindfolded. The paper in this edition of Resuscitation provides valuable reminders of the pitfalls and pearls of this task. Conflict of interest statement None declared. References 1. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377–84. 2. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832–47. 3. Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 2010;81:1219–452. 4. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med 2006;13:596–601.
5. Tanigawa K, Iwami T, Nishiyama C, Nonogi H, Kawamura T. Are trained individuals more likely to perform bystander CPR? An observational study. Resuscitation 2011;82:523–8. 6. Hupfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010;376:1552–7. 7. Linderoth G, Hallas P, Lippert FK. Challenges in out-of-hospital cardiac arrest – a study combining closed-circuit television (CCTV) and medical emergency calls. Resuscitation 2015;96:317–22. 8. Eisenberg MS, Hallstrom AP, Carter WB, Cummins RO, Bergner L, Pierce J. Emergency CPR instruction via telephone. Am J Public Health 1985;75: 47–50. 9. Birkenes TS, Myklebust H, Neset A, Kramer-Johansen J. Quality of CPR performed by trained bystanders with optimized pre-arrival instructions. Resuscitation 2014;85:124–30. 10. Birkenes TS, Myklebust H, Neset A, Olasveengen TM, Kramer-Johansen J. Video analysis of dispatcher–rescuer teamwork – effects on CPR technique and performance. Resuscitation 2012;83:494–9.
Jo Kramer-Johansen Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Dept. of Anaesthesiology, Oslo University Hospital and University of Oslo, P.O. box 4956 Nydalen, N-0424 Oslo, Norway E-mail address: [email protected] 12 July 2015
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Editorial
Peeking from the blindfold
Have you ever tried to draw a picture by instructions from someone who is blindfolded? As a party game this may be frustrating for participants while amusing for the spectators. In real life this is the communication challenge for our medical dispatch operators. Their frustration, of course, increases with the knowledge of the devastating consequences of delayed recognition, start of CPR and alarming the responding EMS-resources in the case of cardiac arrest. In 2013 the Danish Cardiac Arrest registry published their 10year material showing concomitant increases in bystander CPR and survival for out-of-hospital cardiac Arrest (OHCA).1 This is in concordance with most published papers from national cardiac arrest registries and scientific reports, and the importance of bystander CPR as one of the links in the chain of survival has been repeatedly justified.2 Telephone-CPR (T-CPR) is recommended for all suspected cases of cardiac arrest,3 well justified by consistent reports of doubled or even tripled chances of survival if bystander CPR has been started before ambulance survival, and the sobering facts telling us that even trained bystanders may hesitate to initiate basic CPR unless they are prompted by the dispatcher.4,5 The specifics on how to best initiate and improve bystander efforts remain a topic for continued research. Solid evidence guides us to restrict guidance of untrained callers to chest compressions only.6 Each incremental revision in dispatcher training and manuscript does not have such potential to change survival, and dissecting harmful and beneficial effects requires other scientific methods than multi-centre randomized trials. Qualitative methods may elucidate and improve our practice, but the very nature of cardiac arrest – it occurs suddenly – limits our possibilities to observe bystanders’ responses to the situation and dispatcher instructions. In this issue of Resuscitation Linderoth and colleagues from the Capital Region of Denmark present novel insights into the communication difficulties of dispatchers and bystanders during OHCA in public locations.7 With what must have been a tremendous effort, they were able to collect video surveillance files from cardiac arrests occurring in the public and to match these with the audio recordings from the dispatch centre. They were able to combine the two data sources in 21 cases and by using a qualitative approach they extracted valuable information. For the first time communication could be evaluated from real situations based on direct observations of conditions and obstacles to good communication. Of course, this is a selected sample and as duly pointed out by the authors cardiac arrests occurring in the public differ from the common case in both patient and bystander characteristics. However,
http://dx.doi.org/10.1016/j.resuscitation.2015.07.012 0300-9572/© 2015 Elsevier Ireland Ltd. All rights reserved.
the themes recognized by the review of these cases, are common factors to team-work anywhere: Shared situation awareness is a prerequisite for effective team-work. This is why we always encourage “time-outs” and “summaries” in team-training. Communication is everything that occurs between sender and recipient to convey a meaning between them. When only sound and voice are available, we immediately miss the many visual clues we usually rely on for verification, acknowledgement, and assessment. Good communication is more than mere words and language, but learning to work in a team is often characterized by learning the team-specific language and terms. Last, but not least, the will to communicate and to aid our fellow human needs to be present or be encouraged, the authors summarize this under the heading Attitude/approach. The authors recognize the dispatcher – bystander dyad as the first team of resuscitation. Even if they may be separated by kilometres and limited by only voice communication, they have to collaborate and manage the themes mentioned to succeed in initiating and propagating good CPR. The examples provided shows us that obstacles and challenges can occur on both sides of the telephone line – so how can we improve? If a lay person encounters one cardiac arrest per life-time (excluding one’s own) and maybe calls the emergency number a few times over many years, each operator receives multiple emergency calls every day and even if less than 1/100 is cardiac arrest-related, adequate clarification of patient consciousness and normal breathing is always mandated. Training the dispatchers to provide CPR guiding is a sensible solution and are already effective in many systems. Introduction of systematic CPR instructions from the dispatcher increased the proportion of bystander CPR in Seattle and King County,8 and has been part of the international recommendations since 1986. From simulation studies we have learned that the exact words and previous training influence bystander CPR performance, and that T-CPR should be considered a continuous task until the ambulance arrives, including rapid identification of cardiac arrest, initiation of chest compressions, and coaching and encouragement to maintain high quality CPR.9,10 For previously untrained bystanders, instructions to do only chest compressions are as likely to result in improved survival as instructions for CPR with rescue breaths. For the trained and competent rescuer, ensuring rapid initiation of CPR and coaching to maintain high quality until ambulance arrival may still be one of the most important tasks of the dispatcher. Updated registries of public AEDs add even more possibilities for the dispatcher to take the lead and manage resources on the scene as a team leader.
A4
Editorial / Resuscitation 96 (2015) A3–A4
It takes two to tango, and this study reveals some of the challenges for communication for a team with participants in two locations. The best teams practice. Obviously, preparedness for the demands of communication with the dispatcher should be part of training for bystanders as well. Even a read-through of instructions and answers will prepare the caller, but the main responsibility always belongs to the professional part – to be properly prepared to guide blindfolded. The paper in this edition of Resuscitation provides valuable reminders of the pitfalls and pearls of this task. Conflict of interest statement None declared. References 1. Wissenberg M, Lippert FK, Folke F, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. JAMA 2013;310:1377–84. 2. Cummins RO, Ornato JP, Thies WH, Pepe PE. Improving survival from sudden cardiac arrest: the “chain of survival” concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation 1991;83:1832–47. 3. Nolan JP. European Resuscitation Council Guidelines for Resuscitation 2010. Resuscitation 2010;81:1219–452. 4. Swor R, Khan I, Domeier R, Honeycutt L, Chu K, Compton S. CPR training and CPR performance: do CPR-trained bystanders perform CPR? Acad Emerg Med 2006;13:596–601.
5. Tanigawa K, Iwami T, Nishiyama C, Nonogi H, Kawamura T. Are trained individuals more likely to perform bystander CPR? An observational study. Resuscitation 2011;82:523–8. 6. Hupfl M, Selig HF, Nagele P. Chest-compression-only versus standard cardiopulmonary resuscitation: a meta-analysis. Lancet 2010;376:1552–7. 7. Linderoth G, Hallas P, Lippert FK. Challenges in out-of-hospital cardiac arrest – a study combining closed-circuit television (CCTV) and medical emergency calls. Resuscitation 2015;96:317–22. 8. Eisenberg MS, Hallstrom AP, Carter WB, Cummins RO, Bergner L, Pierce J. Emergency CPR instruction via telephone. Am J Public Health 1985;75: 47–50. 9. Birkenes TS, Myklebust H, Neset A, Kramer-Johansen J. Quality of CPR performed by trained bystanders with optimized pre-arrival instructions. Resuscitation 2014;85:124–30. 10. Birkenes TS, Myklebust H, Neset A, Olasveengen TM, Kramer-Johansen J. Video analysis of dispatcher–rescuer teamwork – effects on CPR technique and performance. Resuscitation 2012;83:494–9.
Jo Kramer-Johansen Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Dept. of Anaesthesiology, Oslo University Hospital and University of Oslo, P.O. box 4956 Nydalen, N-0424 Oslo, Norway E-mail address: [email protected] 12 July 2015