December 2012 Tom Rea Harborview Medical Center King County EMS Strengthening the Chain of Survival The Role of the Emergency Dispatcher December 2012 Tom Rea Harborview Medical Center King County EMS

Qualifying Comments www.nena.org/cardiac 1. I am a physician – not a dispatcher. 2. What I will discuss may be obvious, but I challenge you to reflect on your system’s approach. 3. I am an employee of the University of Washington and King County Public Health. 4. I do receive grant support from the Medtronic Foundation’s Heart Rescue Program. 5. Technology risk-taker www.nena.org/cardiac

Strengthening the Chain of Survival The Role of the Dispatcher Overview: Emergency dispatchers can have a meaningful impact on survival following cardiac arrest. Objectives – Understand: What is cardiac arrest? Dispatcher interface with the chain of survival Challenges of identification Challenges of rescuer engagement Details of CPR instruction Programmatic quality assurance www.nena.org/cardiac

A Fundamental Philosophy You must understand local circumstances ……….in order to achieve success. www.nena.org/cardiac

What is cardiac arrest? Sudden unexpected cardiovascular collapse

Links in the Chain of Survival • Prompt activation of emergency care 9-1-1 • Early CPR • Early Defibrillation • Timely advanced care • Timely post-resuscitation care

Key to Success – It takes a community • Prompt activation of emergency care 9-1-1 • Early CPR • Early Defibrillation • Timely advanced care • Timely post-arrest care

Pyramid of Resuscitation Expert Post Resuscitation Care Expert ACLS Early Defibrillation Early CPR Early Recognition

Pyramid of Resuscitation Expert Post Resuscitation Care Expert ACLS Early Defibrillation Early CPR Early Recognition

Pyramid of Resuscitation Expert Post Resuscitation Care Expert ACLS Early Defibrillation Early CPR Early Recognition

The Most Important First Responder

A carefully reasoned explanation

Early (Bystander) CPR…….? Resuscitation 101 Early (Bystander) CPR…….? A. Improves blood flow to the brain Improves blood flow to the heart C. Improves the chance of survival

Early (Bystander) CPR…….? A. Improves blood flow to the brain B. Improves blood flow to the left ventricle C. Improves the chance of survival

The rate of bystander CPR in most communities is..? 10% 25% 50% 70%

The rate of bystander in most communities is ...? 10% 25% 50% 70% An effective strategy to improve resuscitation …… implemented in only about a quarter of those in need.

What are the roadblocks to bystander CPR? Cardiac arrest is hard to recognize. Rescuers do not have confidence to act. Traditional CPR is technically too difficult.

What are the roadblocks to bystander CPR? Cardiac arrest is hard to recognize. Rescuers do not have confidence to act. CPR is technically too difficult. YES YES YES ………….What to do?

Option 1: CPR Training Programs

The rate of bystander in most communities is ...? 10% 25% 50% 70%

Option 2: Dispatcher-Assisted CPR

Option 2: Dispatcher-Directed CPR

Yes……..but address the roadblocks Cardiac arrest is hard to recognize Laypersons may not have confidence CPR can be technically difficult

Cardiac Arrest Recognition

Cardiac Arrest Recognition A cardiac arrest patient is (True or False) : 1. Not responsive (not awake/ not conscious) 2. Not breathing

Cardiac Arrest Recognition True - Not responsive (not awake/not conscious) Sometimes - Not breathing

Cardiac Arrest Recognition True - Not responsive (not awake/not conscious) True - Not breathing……normally Agonal Breaths “Gasping” “Snoring” “Snorting” “Sighing” “Gurgling” “Puffing” “Light” “Labored” “Shallow” Audio 1 www.nena.org/cardiac

How often are agonal gasps apparent in cardiac arrest? 10% 20% 33% Mask

How often are agonal gasps apparent in cardiac arrest? 10% 20% 33% Mask

Cardiac Arrest Recognition Not responsive (not awake/not conscious) Not breathing normally Audio 2 www.nena.org/cardiac

Are we casting the net too widely? Post-ictal Hypoglycemia Intoxication

Let’s apply the 2 question approach: Not responsive (not awake/not conscious) Not breathing normally True Arrest No arrest

For every 100 true cardiac arrests you identify with the 2 question approach, you will also identify ? not in arrest? 5 25 50 100 500 True Arrest No arrest

For every 100 true cardiac arrests you identify with the 2 question approach, you will also identify ? not in arrest? 5 25 50 100 500 True Arrest No arrest

Dispatcher Instructions: Who gets CPR? Not responsive (not awake/not conscious) Not breathing normally True Arrest No Arrest

Dispatcher Instructions: Who gets CPR? Not responsive (not awake/not conscious) Not breathing normally Minimal risk of major injury 1 : 1000 True Arrest No Arrest

Challenges of Early CPR Cardiac arrest is hard to recognize Laypersons may not have confidence CPR can be technically difficult

Confidence Predicts Action

How do we gain confidence? Education Practice Experience Encouragement

How do we gain confidence? Education Practice Experience Encouragement

Challenges of Early CPR Cardiac arrest is hard to recognize Laypersons may not have confidence CPR can be technically difficult

The average time required to open the airway and provide 2 breaths for bystanders during the first cycle is…..? 10 seconds 20 seconds 30 seconds 60 seconds Initial airway management

The average time required to open the airway and provide 2 breaths for bystanders during the first cycle is…..? 10 seconds 20 seconds 30 seconds 60 seconds Initial airway management

During subsequent cycles of CPR by the bystander, ventilations interrupt chest compressions …..? 5 seconds 10 seconds 15 seconds 20 seconds Subsequent CPR cycles

During subsequent cycles of CPR by the bystander, ventilations interrupt chest compressions …..? 5 seconds 10 seconds 15 seconds 20 seconds Subsequent CPR cycles

Solution? Eliminate ventilations Focus on chest compressions

Eliminate ventilations Focus on chest compressions Survival 15% 10% Hands Only Rescue Breathing + Chest Compressions

Details

Dispatcher CPR Instructions All caller questions – Conscious / Breathing Normally Medical help is getting there as fast as they can. We need to help (them) right now. I will tell you what to do. Get them flat on their back on the floor. Kneel by their side. Put your hand on the center of their chest, right between the nipples, and put your other hand on top of that hand. With straight arms push down as hard as you can, just like you’re pumping the chest. Let’s start.  Push and count out loud 1, 2, 3, 1, 2, 3… Audio 3 www.nena.org/cardiac

A tale of dispatcher CPR Directed CPR King County, WA

Seattle - King County experience (1978 - 1984) The Story of Dispatcher Assisted CPR Seattle - King County experience (1978 - 1984) 50% 25% Bystander-initiated (no dispatcher assist)

The Story of Dispatcher Assisted CPR Dispatcher program increased the rates of bystander CPR by……? A. 10% B. 15% C. 20% D. 25% 25% Bystander-initiated (no dispatcher assist)

Bystander CPR since initiation of dispatcher assistance (1985 - 2010) The Story of Dispatcher Assisted CPR Bystander CPR since initiation of dispatcher assistance (1985 - 2010) 50% Dispatcher-assisted 25% 25% Bystander-initiated (no dispatch assist) 25% Potential to double proportion who receive CPR

Is Dispatcher CPR Effective? 20% Survival A. Bystander CPR – No DA B. DA CPR C. No Bystander CPR ? ? 10% ? 0%

Dispatcher CPR Saves Lives 20% Survival A. Bystander CPR – No DA B. DA CPR C. No Bystander CPR A B 10% C 0%

Dispatcher CPR Saves Lives 20% Survival A. Bystander CPR – No DA B. DA CPR C. No Bystander CPR A B 10% Can double the rate of effective bystander CPR C 0%

Simple Math Train ~5000 laypersons = 1 bystander CPR

Simple Math Train single dispatcher = 2 bystander CPR

Making It Happen

A Basic Plan Measure and Improve

A Basic Plan And Improve

A Basic Plan A Basic Plan

A Basic Plan A Basic Plan No-cost curriculum

Conceptual Role of the Dispatcher Passive Transfer information Allocate Resources Active Interpret information Engage Resources Deliver Training

Pyramid of Survival Hospital Care Expert ACLS Early Defibrillation Early recognition + Early CPR

The Most Important First Responder Dispatchers Can Save Lives

Acknowledgements rea123@uw.edu King County EMS Cleo Subido Megan Bloomingdale Linda Culley Mickey Eisenberg King County EMS Cleo Subido Megan Bloomingdale Linda Culley Mickey Eisenberg rea123@uw.edu