Watching our Children Die on the Ice

Somebody do Something … just don’t ask me to perform CPR

For nine years I was the Public Access Defibrillation (PAD) Program Co-ordinator for a municipality with a population of just under 500,000. It was an exciting time on the frontier of AED placement in Canadian communities. In five years the number of cardiac arrest survivors in the community more than quadrupled, from 7 in 2005 to 31 in 2010, with many of those additional lives being saved by members of the public performing effective CPR and deploying an AED within minutes of patient collapse.

One life that was not saved was that of a hockey referee. He collapsed during a game that was well attended in an arena equipped with an AED. No one that witnessed the collapse knew where the AED was located or how to use it. No one was able to locate any of the arena staff that were trained to use the AED. CPR was performed but by the time Paramedics arrived it was too late for a defibrillator to be effective. In this earlier blog I share my thoughts on why this should have never happened.  

http://leadingcause.blogspot.ca/2012/12/cancel-one-game.html

A few weeks after the event the EMS Chief and me met with Executives from the Hockey and the Referee’s Associations. There were lots of emotions and lots of suggestions coming from all sides. The consensus was to move forward in a positive manner that would help ensure that the next time resuscitation needed to be performed the hockey community would be better prepared.

I lobbied hard with management to be allowed to offer “free” certification level CPR/AED training to any adult associated with the local minor hockey association – coaches, trainers, referees, officials and parents. In the end I was given the go ahead to offer six free sessions for up to 20 people per session over six consecutive Wednesday evenings in February and March. I would provide the training but the hockey association had to provide the people. The marketing and promotion, the filling of the seats, was entirely their responsibility, a condition which they readily agreed to.  The first week five adults with two teenagers in tow showed up – I had prepared 20 manikins and brought in another trainer to assist. I called the association and they promised more people the next week, four is not more than five.  After three people showed up in week three I spoke to the association and we mutually agreed to end the program. Out of the 120 seats that we had made available to the association 12 were filled.

The following winter good friends of mine that had lost a child on the ice to cardiac arrest (the AED was deployed but could not convert the heart back into a blood pumping rhythm) partnered with a local charity to donate an AED to an arena in their community. After a very nice on ice presentation ceremony that included a long and heartfelt standing ovation in memory of their beautiful son we announced that the following morning in the arena’s community room we would be offering free CPR/AED training to any and all interested parties, the session was also promoted through other means. Three people, plus the three of us attended.

The next time a coach, referee or player collapses to the ice and no one in attendance knows what to do where will the blame lie? In a public sports venue equipped with an AED it is the responsibility of every adult that regularly attends that venue as a coach, trainer, official or spectator, paid or volunteer, to acquire basic resuscitation skills. It is not the sole responsibility of the Zamboni driver to safeguard everyone’s life or to be highly visible whenever someone collapses.  

Again this week a child collapsed after taking a puck in the chest (a phenomenon called “commotio cordis” that claims the lives of about twenty young teens each year in North America) at an arena in Toronto. Thankfully arena staff and trained spectators were able to resuscitate the child. Nice job by Doug Jamieson and team. According to the CBC News story no hockey people – coaches, trainers, referees - helped with the resuscitation effort; if this is not true please let me know. 

The CBC interviewed several parents that witnessed the event and they put forward suggestions on how cardiac emergency response could be improved at Toronto arenas. The suggestions ranged from somewhat plausible to downright silly. However not one parent stepped up and suggested that they themselves and in general more people from the minor hockey community should be trained in CPR and AED use. There was lots of half-baked, buck-passing, ill-informed recommendations but not one person stepping up to take a little personal ownership for resuscitating friends or family members in cardiac arrest.

http://www.cbc.ca/news/canada/toronto/aed-defibrillator-helps-save-teen-hockey-player-s-life-1.2837497

In a related CBC story from June 2014 a senior executive from Hockey Canada explained that despite at least 8 on ice deaths in 9 years Hockey Canada is satisfied with its cardiac emergency response protocols which do not require CPR/AED training for coaches and trainers. In fact the recommendation is that if a coach or trainer suspects a player is in cardiac arrest they should seek out someone in the arena that is trained to manage the situation. This is the stated policy of the governing body of the sport that our entire nation loves so much.

http://www.cbc.ca/news/canada/nova-scotia/cardiac-arrests-kill-8-young-hockey-players-in-9-years-1.2669393

Long before the hockey referee died and every day since (it has been more than 6 years now) I have shouted from the mountaintops the importance of universal user group CPR/AED training. I believe that both minor and adult sport organizations should not be allowed to rent municipal sports venues unless the majority of their members are trained in CPR/AED and in general anyone that lives, works or plays in a building equipped with an AED should be trained.

My final two thoughts on this story:

1. When interviewed  by CBC Ali's sister used the word lucky.  A lot of forethought, planning and training on the part of The City of Toronto and the arena staff went into 13 year old Ali being "lucky" that day.
2. When you buy a Ford Escape everywhere you go you see Ford Escapes. When you take AED training everywhere you go you will notice the AED hanging on the wall. Take the training.

Three Thoughts for CPR Instructors and Students

Every person that attends CPR training represents a potential life giving resource, like a bottle of water in the desert, their attendance cannot be squandered. The next time you teach or take a certification level CPR course it may be helpful to keep these three thoughts in mind.

1. Doing something is NOT better than doing nothing - Instructors give their students a free pass when they utter the dreaded "doing something......" line. In most of the classes that I teach some student knowingly expresses the "doing something" sentiment. I gently correct them and point out that CPR is only effective when it is performed properly. Poor CPR produces results that are exactly equal to, not better than, doing nothing.

The reason that people take four or five hours out of their busy schedule to take a CPR course is to acquire a toolkit for protecting the life of a person experiencing a significant cardiovascular event. The excellent science published over the past decade gives us a clear indication of what works and what doesn't work in cardiac resuscitation. CPR instructors must teach the methods that work and CPR students must endeavour to learn and perform those techniques to the best of their ability. Teaching and learning effective CPR is the only way to improve survival rates for cardiac arrest in our communities. We trivialize and demean the process when we tell students that "doing something is better than doing nothing"

2. You DO NOT have to break ribs to perform effective CPR - I cringe every time I hear this. It seems there is a legion of CPR instructors out there that hammer on the idea that if you're not breaking ribs you're not doing it properly, including professional responders that brag to their students "I've done CPR over a dozen times and broken ribs every time." I don't know where to begin with this one, it is just wrong on so many levels.
First of all the science is clear and unequivocal, the majority of survivors do not have broken ribs. More importantly our job as CPR instructors is to bring down the barriers to the public getting involved with a patient when they witness a cardiac arrest. Telling lay people that in order to help that person they will have to break their ribs has precisely the opposite effect. Effective CPR does not require breaking ribs, it is okay to speak to the possibility of broken ribs, but it should be put in proper perspective and the whole discussion should only take up a few seconds of class time. I ask all instructors to please stop with the broken rib bull, and I implore all students the next time your Instructor plays the broken rib card, call his bluff.

3. Count using numbers, 1 and 2 and 3 and 4 ....  NOT old Bee Gee's songs - The Stayin' Alive gimmick is an excellent tool for promoting Bystander CPR in 60 second Public Service Announcements, it is not an appropriate technique to teach to a student that has signed up for certification level CPR training. I've met hundreds of people that can't remember the name of "that song you're supposed to sing" but I've never had a student that can't remember how to count to 5.
When you count properly, 1 and 2 and 3 and 4 and 5 and 1 and 2 and 3 and 4 and 10 ...... many excellent things happen for the patient. With very little practice students can develop a cadence that will produce a rate of 100 bpm, plus or minus 5, virtually every time. Proper rate makes a huge contribution to survival. When you push down on "One" and come up on "And" work is distributed equally between the two critical functions of chest compressions, pushing blood out to the brain and internal organs and allowing the heart to refill with blood on the upstroke. This drives a nice even circulation pattern that helps keep vital organs oxygenated. Finally when you count out loud using numbers, not Bee Gee's songs, all of the people assisting you with the resuscitation know exactly where you are in the CPR cycle and can perform their tasks accordingly.

The four hours that you spend teaching and  learning CPR and other Basic Life Support skills represent an opportunity to give life to another human being, in all likelihood a co-worker, a family member or a friend. It is a kind of sacred trust and should be treated with the appropriate respect.

Teaching CPR to Adults versus Teens

I write this blog at my own peril. Whenever I promote this concept the push back is always intense, but I remain steadfast. That said I want to be clear right off the top I am not talking about a 90/10 deal but more of a 55/45 arrangement. I simply feel it would be beneficial to re-direct some of the universal enthusiasm for teaching CPR to teenagers toward teaching CPR to Adults. I don't believe teens should not be taught CPR, I just know that more adults should.

Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.

In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.

Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?

In Ontario there is a well supported push to teach CPR to every grade nine student.  My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.

Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.

Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR.  All of the research on improving survival to discharge rates for cardiac arrest  points to other solutions, none of the research suggests that teenagers are the answer.

The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.

Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.