1. 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

2. 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

3. 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

4. A Fundamental Philosophy
You must understand local circumstances ……….in order to achieve success.

5. What is cardiac arrest?
Sudden unexpected cardiovascular collapse

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

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

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

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

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

11. The Most Important First Responder

12. A carefully reasoned explanation

13. 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

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

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

16. 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.

17. 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.

18. 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?

19. Option 1: CPR Training Programs

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

21. Option 2: Dispatcher-Assisted CPR

22. Option 2: Dispatcher-Directed CPR

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

24. Cardiac Arrest Recognition

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

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

27. 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

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

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

30. Cardiac Arrest Recognition
Not responsive (not awake/not conscious)
Not breathing normally
Audio 2

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

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

33. 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

34. 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

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

36. 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

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

38. Confidence Predicts Action

40. How do we gain confidence?
Education
Practice
Experience
Encouragement

41. How do we gain confidence?
Education
Practice
Experience
Encouragement

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

43. 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

44. 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

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

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

47. Solution?
Eliminate ventilations
Focus on chest compressions

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

49. Details

50. 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

51. A tale of dispatcher CPR
Directed
CPR
King County, WA

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

53. 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)

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

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

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

57. 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%

58. Simple Math
Train ~5000 laypersons = 1 bystander CPR

59. Simple Math
Train single dispatcher = 2 bystander CPR

60. Making It Happen

61. A Basic Plan
Measure and Improve

62. A Basic Plan
And Improve

63. A Basic Plan
A Basic Plan

64. A Basic Plan
A Basic Plan
No-cost curriculum

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

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

67. The Most Important First Responder
Dispatchers Can Save Lives

68. 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