Bystander CPR for all

MRC outlines goals for bystander CPR in Malta in an opinion article published in the Talking Point section of the Times of Malta, on 29.5.18.

 

 

In Europe, approximately one person suffers a cardiac arrest every 45 seconds and, in the majority of cases, this proves fatal. The likelihood of survival decreases rapidly from the point the heart stops beating, and irreversible brain damage secondary to the cessation of blood flow is established within just 3-4 minutes. Consequently, for those who are resuscitated after this time interval, survival is unfortunately often associated with significant neurological disability and an inferior quality of life compared with their pre-arrest state. Indeed, survival decreases by 10% for every minute delay in the initiation of cardiopulmonary resuscitation (CPR). The reverse is also true, and many ‘victims’ of cardiac arrest may be rescued with effective CPR. 


However, to be truly ‘effective’, CPR needs to be carried out properly and started early. Given that the vast majority of cardiac arrests occur in the community, away from a suitably equipped medical setting and since, in Malta, 71% are witnessed by laypersons, the importance of good, bystander CPR cannot be underestimated. This requires laypersons to identify the signs of collapse, and be competent to initiate good CPR without delay and certainly before medical help arrives. The average time for an urgent ambulance to reach a victim varies but, even with optimal circumstances, this is unlikely to take anything less than 10 minutes – and is probably too late for most victims of cardiac arrest. At present, the figures for Malta make for dismal reading: in 2016-17, bystander CPR occurred in just 40% of cardiac arrests and the overall survival to discharge from hospital was only 5%. So the timely intervention of laypersons is absolutely crucial if survival figures after an out-of-hospital cardiac arrest are to reach the European Resuscitation Council (ERC) goal of 60%. But is this realistic? Is CPR an easy skill? Can anybody do it? The answer is yes to all: CPR is an uncomplicated skill that does not require a paramedical background. Anyone who is not infirm can deliver effective CPR, including children who master CPR rapidly and retain skills better than adults! 


In many cases of cardiac arrest, especially in adults, the heart muscle stops beating and, in addition, the heart’s electrical impulses become chaotic (fibrillation). By means of administering chest compressions and artificial breaths, CPR provides blood flow through the general circulation and, importantly, pushes blood (with oxygen) to the heart muscle itself. However, if there is fibrillation, CPR alone is rarely sufficient and the chaotic electrical activity needs to be ‘jolted’ back into a regular rhythm. Hence, for these patients, CPR will provide optimal results if external chest compressions are also accompanied with ‘shocks’. Simple, extremely user-friendly machines (automated external defibrillators, AEDs), are now widely available and will deliver these shocks. Again, training in their application is straightforward and easy to master. 


Several bodies in Malta including the Malta Resuscitation Council (MRC), the Red Cross, St John Ambulance, Malta Heart Foundation, Order of St Lazarus and others, provide courses in combined CPR-AED training. These, together with the MRC that runs ERC-certified courses, have set the standard of training required. The initiative has been taken well beyond Mater Dei Hospital and paramedics working within Health disciplines. To-date, the MRC alone has trained more than 2,000 medical personnel and 1,000 laypersons, and has helped train and equip the Health and Safety Unit within the Education Division who, so far, have trained approximately 200 schoolchildren. Whilst CPR training is now mandatory for all medical students, the aim is for CPR-AED skills to be included in the National School Curriculum for all 14 year olds. This goal is championed by the European Resuscitation Council’s aptly named ‘Kids Save Lives’ Campaign, and is supported by the World Health Organisation. So far, very few countries have introduced this into law or onto their Education Curriculum: Malta is well placed to be amongst the first.


However, training alone without the availability of AEDs is suboptimal, especially in the case of cardiac arrest in adults. Presently, there are almost 600 AEDs spread around the island, but most are located in private institutions and are not available to the public. Although the Malta International Airport, Air Malta planes, Gozo ferries, most schools, banks, some hotels, factories and clubs amongst others, do have at least one AED, Malta needs many more in key and accessible locations to be truly ‘covered’. Well done to the Victoria Council responsible for the Gozo Citadel for leading in this regard and, currently, plans are now well advanced to install 8 AEDs with 24/7 public access in Valletta. A mobile phone AED locator app for Malta is also ‘work in progress’. We look forward to seeing the AED locating sign – a green square with a white heart, cross and lightning bolt – throughout the country and certainly in all areas where a significant number of people are likely to aggregate. Only then, together with early and effective bystander intervention, can we be confident that, in the unfortunate event of a cardiac arrest outside hospital, one would have a sporting chance of survival.
 

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