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Screened & Examined

Screened & Examined: Even a Third Grader Can Do It

Ballard, Dustin MD

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doi: 10.1097/01.EEM.0000433489.67853.7d
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    I recently observed my 8-year-old daughter's busy morning and decided it was time for a teaching timeout. Sure, she'd already cleared five levels of Angry Birds Star Wars, fed her silk worms a fistful of Mulberry leaves, pounded out 120 seconds of keyboard practice, and growled at her younger brother half a dozen times. Productive, yes, but surely there was more that could be accomplished.

    “Would you like to learn how to save a life … in five minutes or less?” I asked.

    “Huh?” she replied.

    “Yes, it's exciting! Even a third grader can do it. It's hands-only CPR.”

    “Daaaaaad? A third grader? I'm a second grader!” she exclaimed. “And what is C…P…R anyway?”

    Well, if that wasn't an invitation for a demonstration, I'm not sure what is. So, off we went to the living room. Over the next 10 minutes, we covered the essentials of successful hands-only bystander cardiac rescue, a lesson that, in no particular order, included…

    • How to use mom's old iPhone to call 9-1-1.
    • Proper CPR hand positioning — fingers interlaced and placed on the sternum — shown on an adult volunteer (my soon-to-be-gasping-for-air wife).
    • Younger brother launching himself on said adult volunteer and causing her to cackle loudly.
    • Proper CPR technique: push hard and fast on the chest, and don't lean because leaning is lazy.
    • Daughter tackling younger brother onto couch.
    • A viewing of Ken Jeong's (that would be Leslie Chow from “The Hangover”) humorous infomercial about hands-only CPR on the American Heart Association website. (
    • Noting that mobile phones (like mom's old, pink-cased iPhone) without active cell service can still dial 9-1-1. Oops. Sorry, operator.
    • Adult volunteer explaining what “disco music” is while intermittently bopping her head, and singing “Doo-doo-doo-doo … stayin' alive, stayin' alive!”
    • Daughter asking for “alone time;” younger brother requesting boxing gloves.
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    All in all, the teaching timeout was a success although we didn't quite get to the why this is important aspect of the lesson. But, as we all know, the answer to this question is that bystander CPR saves lives.

    We've known this for some time, but the recent accumulation of evidence is pretty remarkable. Four years after starting an annual citizen hands-only CPR training day in my home county of Marin, CA (almost 10,000 trained), our Utstein survival-to-hospital-discharge rate has risen from under 10 percent to 22 percent. Sure, other factors are involved (like cardiac cath lab availability and therapeutic hypothermia), but it is difficult to underestimate the importance of an effective citizen response. Consider the recent advisory statement published by Sasson et al collating data demonstrating tremendous variability in out-of-hospital cardiac arrest (OHCA) outcomes. (Circulation 2013;127[12]:1342.)

    • Some 360,000 OHCAs occur in the United States each year, accounting for 15 percent of all deaths.
    • There's a striking regional variation in outcomes with published survival rates ranging from 0.2 percent to 16 percent.
    • This variation is likely related, or so many think, to the significant variation in bystander CPR rates across the country ranging from 10 percent to 65 percent with only, on average, one of four victims receiving bystander CPR.

    So then, two questions: what are the barriers to citizens performing CPR, and how can we overcome them?

    Lack of access to training can clearly be a barrier, but so can socioeconomic status, language, neighborhood safety, culture, and (mostly unfounded) medicolegal concerns.

    Some of these barriers are easier to overcome than others, but certainly citizen CPR training efforts are a good start. And, what if we, as emergency providers, also recognized the value of hands-only CPR training in the hospital? Consider a 2012 study by Blewer et al that demonstrated that adult family members or friends of inpatients who received video-based training in continuous chest compression (hands-only) versus traditional CPR demonstrated similar technique performance and a significantly higher expressed desire to share their training kit with others (152/207 [73%] vs. 133/199 [67%], p=0.03). (Crit Care Med 2012;40[3]:787.)

    As far as I know, such programs are quite rare, but with the expected benefit of training, there really is no reason they should be. Hands-only CPR training is simple enough that it could be offered to patients and family members at multiple points during their transit through the system: video consoles in the ED waiting room, auxiliary training areas using ED volunteers or FEDs (friends of the ED) and mannequins, supplementary stations in the cafeteria or near the coffee cart, or a self-guided kit for friends and family of inpatients. To me, all this fits under the mission of what we do: catch patients or family members in a teachable moment and convince them to take positive steps to improve their health or that of others. If we view citizen CPR training as a potential intervention with an expected benefit, the value can be expressed not as “number-needed-to-treat,” but “number-needed-to-train.”

    Sure, many other methods can improve OHCA survival rates such as integrated system interventions (instituting EMS dispatch protocols that walk citizens through CPR over the phone) and placing AEDs in strategic locations. And obviously, post-arrest care is extremely important, and hospitals can continue to improve post-arrest cardiac intervention strategies and hypothermia protocols. We, as hospital-based providers, can do a whole lot better about integrating with the other links in the survival chain. A great place to start is with the number-needed-to-train concept.

    Remember, citizen rescue is a skill that even children can learn. As my son summed up in our training debrief, the two steps of citizen cardiac rescue are … “Actually, no secret to it. Call no-no-no, and pump someone's bum … someone's blood.” Well, maybe he's not quite ready to step up and save a life, but his older sister definitely is (she's been practicing on unsuspecting house guests). And, I'm quite certain many others who pass through our EDs each day also would embrace such training.

    © 2013 by Lippincott Williams & Wilkins