First, if you are unfamiliar with the story, check out some articles online.  This one from USA Today is pretty good.  If you want more detail and you have the time, check out the unedited interview with Dr Roger White below.  He was the physician who advised the practitioners in the field and also attended to the patient in hospital.  In it he talks in great detail and even shows printouts from the monitors used during the resuscitation.

Essentially, a 54 yo man had a witnessed cardiac arrest in a small town in Minnesota (MN).  CPR was started promptly and was continued by “dozens” of locals, all taking turns in shifts.  They defibrillated him 6 times.  An advanced life support (ALS) team arrived at about 40 minutes into the resuscitation.  They intubated him (placed a breathing tube for ventilations), gave  IV drugs and defibrillated him 6 more times.  Defibrillation established a regular rhythm for very brief periods of time after some of the ALS shocks.  It wasn’t until he was given a large, out of protocol, repeat dose of the anti-dysrhythmic amiodarone that he remained in a rhythm that produced a sustained pulse.  He was then transported the 30+miles to Rochester, MN, for a heart catheterization and other treatment.  He left the hospital after 10 days feeling tired and sore but apparently with his intellect and other body functions intact.

Dr. White admitted that he and the ALS crew questioned the wisdom of continuing in the face of the recalcitrant dysrhythmia.  In the end they chose to continue in large part because they were able to confirm the continuous production of carbon dioxide via one of their monitors.  In essence, this indicated that the CPR was effectively perfusing the lungs, evidenced by the measurable amount of carbon dioxide produced there. This indirect measure of global perfusion gave them hope and thus made it hard to stop.

This gentleman survived because of an extraordinary confluence of circumstances and people, including the online, real-time advice from a “…leading expert in cardiac arrest…”  Take any one or more of those away and the result would have been different.  Most if not all of the capabilities described would be unavailable and/or unrealistic in a wilderness or remote setting in a harsh environment.  This was the quintessential chain of survival.

Bottom line: As amazing as this story is, our CPR protocol still makes sense.

This resuscitation demonstrates that good quality CPR can make a difference.  However, maintaining good quality CPR is not simple.  Fatigue would have set in much more quickly for a significantly smaller crew.  CPR quality and therefore perfusion worsen with rescuer fatigue and maintenance of perfusion is what gave him a chance.  Fatigue in a remote and harsh environment can also put rescuers at risk.  And this success took more than good quality CPR.  Even the AED proved to be of little use without more advanced capabilities.  In the end, the experienced practitioners involved are not sure how or why they succeeded.

Remember too, this was caused by a heart attack with a potentially fixable rhythm and not from trauma or a prolonged submersion.

If you are in a wilderness or remote setting, the simple answer is yes.

In this setting, we believe that if normothermic (normal body temperature) people in full cardiac arrest do not recover within 30 minutes of continuous CPR, they will not survive.  This, even in the unlikely event of the arrival of advanced life support (ALS)/Emergency Medical Services (EMS) at or near that 30 minute mark.  This number is a conservative estimate derived from the medical literature.  The magic number is probably closer to 20 minutes or less.

Large organizations like the American Heart Association (AHA) and the American Red Cross have focused their attention on settings where automatic external defibrillators and ALS are readily available.  As a result they have not addressed this question of futility, leaving it to medical control.  Some EMS regions have, adopting guidelines similar to ours for use in the urban settings.

The AHA continues to downplay the role of pulse checks for lay providers (which would include WAFA-level training) during assessments of unresponsive people.  While it may make sense to start CPR without assessing pulses in unresponsive, non-breathing patients, we will still use no pulse as one of the criteria for stopping.

Although I am not aware of any problems applying this guideline in the field, I am aware of cases where rescues have continued for 2 hours or more, putting themselves and others at risk.  The outcome have been the same.

Bottom line: In the wilderness or remote setting, stop resuscitation if there is no pulse after performing 30 minutes of continuous CPR.

Q: It is my understanding that once you begin CPR you can not stop until the patient’s pulse and breathing resumes or paramedics arrive on the scene. Otherwise, it would be considered an abandonment of care. Is this true and are you familiar with any legal issues of administering CPR in the backcountry?

A: I cannot give you a simple answer to this one.  My opinion is based on my interpretation of published data and personal experience.

Here is what the American Heart Association published last month as part of their 2010 CPR Guidelines:

When not to start:

• Situations where attempts to perform CPR would place the rescuer at risk of serious injury or mortal peril
• Obvious clinical signs of irreversible death (eg, rigor mortis, dependent lividity, decapitation, transection, or decomposition)
• A valid, signed, and dated advance directive indicating that resuscitation is not desired, or a valid, signed, and dated DNAR order

Terminating Resuscitative Efforts in a BLS Out-of-Hospital System

Rescuers who start BLS should continue resuscitation until one of the following occurs:

• Restoration of effective, spontaneous circulation
• Care is transferred to a team providing advanced life support
• The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy
• Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation (TOR) are met.

Unfortunately, the criteria for TOR referenced generally depend on tools or capabilities that most of us don’t have in the field (e.g., automatic external defibrillator).

There is literature supporting the notion that if spontaneous circulation is not restored within 30 min of initiating resuscitative efforts (some would say 20), the chance of survival is nil.  The outcome is even more grim without an AED and when good quality CPR is not started promptly and sustained without interruption.  Trauma arrests have the worse prognosis of all.  Unfortunately, the AHA, et al have yet to explicitly offer a specific guideline that uses time as a criteria under any circumstances.  Their reluctance and/or lack of interest is understandable because their focus is on situations where a call to and timely response from advanced-level EMS is the norm.

So is it abandonment to stop?  That is a legal concept that one can only speculate about.  It would be unlikely if one made a decision to stop based on the AHA criteria listed above.  In remote, low resource settings (e.g., no likelihood of an AED or advanced capabilities), the physical toll even if one could maintain good quality CPR indefinitely would be substantial making prolonged resuscitation efforts potentially risky for the rescuer(s).  Low benefit and significant risk.  What do you think?

We and others have advocated stopping CPR in non-hypothermic arrests after reasonable efforts have been made, usually after 20 to 30 minutes of continuous CPR.  There are many urban-based EMS systems that use the same time-based benchmark.  Unfortunately, stories of rescuers continuing CPR for time periods up to 2 hours are still reported.  I suspect some do so out of fear they will be accused of abandonment and/or hope their efforts will make a difference.  Not surprisingly, the results are the same; no survival.

Bottom line: The legal system is the final arbiter of what abandonment is and when it has occurred.  CPR, even good CPR, cannot sustain a person’s viability indefinitely.  From published reports and studies, 30 minutes seems to be a reasonable time frame.  Regardless of time, do not put yourselves or others at risk.

http://www.ems1.com/ems-products/cpr/articles/605748-Texas-youths-set-record-for-worlds-largest-CPR-training-class/

No it was not a pie eating contest or sporting event.  Apparently they were certified by the Guinness folks for holding the world’s largest CPR class – 4626 students.

“As expected with thousands of junior high students, there was plenty of goofing around during the lesson. Giggling was common when they first gave their inflatable mannequins mouth-to-mouth resuscitation, and more than a few decided to head butt or slap their Mini Anne CPR dummies. But most appeared to take the lesson seriously.

Cluck (the mayor who helped organize the CPaRlington program)walked several laps around the field during the lesson, and he said most participants understood the techniques and could resuscitate someone if needed. Each student is now required to take the dummies home and teach four other people.”

Although not specifically mentioned, 30 minutes and inflatable CPR dummies sound a lot like the American Heart Association’s (AHA) CPR Anytime. Regardless of whose curriculum, I am assuming that this was not a certifying course.

The CPR Anytimeis a real departure from where the AHA was even 5 years ago.  There was a time when everyone taking one of their courses was hovered over by a hypervigilant instructor making sure that each student’s compressions and ventilations were within an upper and lower limit.  Skill testing success or failure was determined by lines on a piece of graph paper spit out from the side of the testing dummy.  Everyone knew that you had to modify your technique for the testing mannequin used, in order to pass.

Most instructors led their students to believe that if their technique varied in anyway from the norm, those efforts would hasten a patient’s demise.  Everyone assumed that the AHA knew what it was doing and as a result no one else (other than the American Red Cross and a few others) could be trusted to teach CPR.  Now these courses are more user friendly and accessible, engineered to train the masses.  These self-directed offerings are a convenient way for people to learn a skill that could enhance survivability following a cardiac arrest without having to take a course.  No one knows whether or not this new approach will make a difference.  Others of us have been allowed to use our own curricula and ideas to teach this once sacred procedure.  It seems that AHA mantra has become, do something.  Over the years, anecdotal stories suggest that an untrained person doing something is potentially beneficial and not harmful.  Science shows us that early intervention does make a difference.  I agree

Still, this rock concert-like event makes me cringe.  Why not do it right?  Is the time spent in school classrooms so valuable that they don’t have time for this or practical First Aid?   The AHA hopes people taking self-directed courses will in turn teach someone else.  Would these kids do a better job teaching their parents after a course like the one noted above or after a proper course, esepically one that utilized a variety of teaching methodolgies (e.g., fun) and was integrated in with what they are leaning in school?

This is not a criticism of these kids.  This is what they know.  Kudos to them not for the record but for the initiative and sense of civic concern.  But with a little guidance and effort, think about how much more could be done.