More on more CPR

I already shared a fun, high quality video and great video game, promoting more CPR.

If you want to be more serious, the British Heart Foundation has some new CPR training videos from their Call Push Rescue programme.

Here’s the main (23 minute) video:

And here’s the 3.5 minute video on CPR for children:

The British Heart Foundation know how important more CPR is, and are offering free CPR kits to secondary schools. People in a local community can either purchase a kit or see if there is a local Heartstart scheme nearby.

Heartstart courses take around two hours. They run in the evenings and at weekends. As well as more CPR, trainees can also learn other life saving skills including what to do if someone is choking; bleeding seriously; the recovery position and the signs and the symptoms of a heart attack.

There’s a great British Heart Foundation video ‘Watch your own heart attack’ here:

And dont miss trying the live action movie game Lifesaver. Practising with this means you’ll be better able to help if you ever witness a cardiac arrest in real life. Try it out here (you’ll need to have Flashplayer). 

It takes a few moments for the game to load up: please wait while the circle whizzes round to reach 100. Then you have to Click that you have read and accepted the terms of the Lifesaver website. You don’t have to put your details in unless you want to, but you must press ‘Enter’. Then look down to click on ‘Menu’. Choose ‘Start Now’ for ‘Jake’.

This game is very like real life.

Unlike in real life, though, you can always try againEspecially if you’re as old as me and don’t immediately understand all the fine details of video gaming!

 

What’s are my chances doc? Scenario planning looks better than percentages.

scenario planning

When there’s bad medical news, many people ask: ‘What are my chances, doc?’ But often we develop blind spots for poor outcomes. Margaret Schwarze in the New England Journal of Medicine suggests scenario planning as a great way forward for this.

Dr Schwarze describes a very active 87 year priest, Father Andrew, who goes out for one if his usual drives. But wakes up in the Intensive Care Unit with a tube down his throat, and more tubes in his chest. He has multiple broken ribs and — even worse news — they’ve found cancer spreading through his chest.

The doctor looking after Father Andrew knows that, with his age, this man’s chances of dying just from his many broken ribs are 90%.

Father Andrew’s first question was when he was going to be able to drive again.

This is where doctors often part company from patients and their families.

Sometimes this is because of poor understanding of numbers by patients. The most extreme example of this that I know of was a woman who was counselled that she had a 1 in 2 chance of any children having a rare and always-fatal genetic condition. She wasn’t worried by this — explaining to the doctor (it wasn’t me) that it was just like the lottery, you either won or lost. And she’d never won anything on the lottery, despite doing it for years. So she thought it was all going to be just fine. The doctor realised this lady needed a better explanation

It’s not only patients who don’t always quite understand probabilities. My own work has underlined how many doctors don’t know actual CPR survival rates.

Father Andrew thought he had a 10% chance of getting back to normal. “He’s a fighter”, his sister told the doctors. But all the fighting in the world wasn’t going to get Andrew back to normal.

Instead of percentages,  another approach would be to use scenario planning to think in terms of the possible outcomes. Thinking like this can “help patients look beyond isolated risks to imagine a new potential reality”.

The best case scenario for Father Andrew would mean that he might leave the hospital. Before then, he “would need ventilator support for many days. He would have pain and be unable to talk to his family. He might gain enough strength to be extubated, but given his age and pulmonary function, he would never regain the independence he has enjoyed.” After his discharge, of course, his cancer would continue to grow. With it affecting his breathing, he would “need substantial nursing care; he would never drive again, and he would die.”

The most likely case, was that “he would improve somewhat, but would ultimately struggle to breathe on his own and would die within days.”

The worst case scenario includes lots of fruitless interventions, more pain, less dignity and no communication.

Father Andrew chose to be extubated and talk to his family. Communication with others was, after all, his life’s work. He “died later that day, surrounded by family.”

I think the scenario planning approach could really help in discussions about CPR and DNACPR orders.

Learn CPR from YouTube

Did you know that, in the UK, only 8% of the people who are resuscitated outside a hospital survive to go home? If we all learnt CPR from YouTube, survival rates would improve.

YOU could at least DOUBLE  the person’s chances of survival if you follow the simple instructions here. Outside hospital, most cardiac arrests happen at home, so it is likely to be a member of your family or a friend that you help.

When someone has a cardiac arrest, there’s no time to wait.

Someone has to do something straight away.

Outside a hospital that means whoever gets there first. Whether or not they – that’s YOU, actually! – have had any training with the necessary CPR.

CPR is nothing like it is on the TV. But it’s not as hard as it looks. Even if you’ve not been to a formal training session, you can learn CPR from YouTube. Vinnie Jones has already made a video with a ‘CPR lesson you’ll never forget’ . But the CPR on YouTube video below is even better. Mini Vinnie demonstrates that hands-only CPR is – literally – childsplay:

CPR is all about Call, Push, Rescue:

Call 999 for help.

Push hard and fast on the centre of the chest 30 times.

Give two Rescue breaths, if you are able and willing. It’s still worthwhile to do hands only CPR. So if you don’t want to, just don’t do the Rescue breaths.

And keep going.

Remember, you’ll at least DOUBLE the person’s chances of survival if you keep going with CPR until the ambulance arrives.

In England, we only do this so-called “bystander CPR” for around 40% of out-of-hospital cardiac arrests. In Norway, bystanders do CPR nearly twice as often, and their survival rates are MUCH better than in the UK.

We – you and me – could do much better!

As well as calling 999, the other thing to Call for, if you’re in a public place, is a defibrillator. Some hearts are what is described as ‘shockable’. In these cases, then for every MINUTE defibrillation is delayed, the chances of survival fall by around 10%.

So don’t wait for the Ambulance to get there. If you’re in a station or a shopping centre, get someone to ask for their defibrillator whilst you’re doing CPR.

Here’s what to look for in the UK:

This is what defibrillators look like in places in the UK. Image: Mirror newspaper

Most defibrillators ‘talk’ to you to tell you what to do when you open them up. If not, there are always easy instructions inside all defibrillator boxes.

To remind you exactly what to do for hands-only CPR, and to check that you are pushing hard enough and fast enough, you can get the free British Heart Foundation PocketCPR app here.

But if you really want to try doing CPR, the nearest you’re going to get to real life without it actually happening is the crisis simulator Lifesaver.

Practicing what to do in this live action movie game means you’ll be better able to help if you ever witness a cardiac arrest in real life. Try it out here (you’ll need to have Flashplayer). 

It takes a few moments for the game to load up: please wait while the circle whizzes round to reach 100. Then you have to Click that you have read and accepted the terms of the Lifesaver website. You don’t have to put your details in unless you want to, but you must press ‘Enter’. Then look down to click on ‘Menu’. Choose ‘Start Now’ for ‘Jake’.

This game is very like real life.

Pay attention! You’re about to try to restart a heart!

Although this video game is very realistic then, unlike in real life, you can always try again. Especially if you’re as old as me and don’t immediately understand all the fine details of video gaming!

Please let me know how it went!

I’m at caroline.mawer@gmail.com

A patients eye view of CPR?

Mark Murphy’s Out of This World is billed as “genre-defying action packed theatre”— but I wonder if it is also trying to give a patients eye view of CPR / ICU?

I watched Mark Murphy and VTOL decades ago, when they first mixed dance and film: and remember how entrancing it was to see people dancing with projected versions of themselves, and with film back-projected to look like someone was falling — or were they pushed? — out of a very tall building.

I knew Mark was bound to have thought up something very different. And so he has for Out of this World.

The storyline is based on a car crash — a woman, we quickly realise, is put in a medically induced coma, and her new husband ends up brain dead. There’s what looks like a fair few professionals looming over the victim/survivor. With views in the middle of above from someone who is, presumably, nearly dying.

Although the story is supposed to be about love, I couldn’t get too interested in that element. It’s not only me who felt like that — see the Guardian review here.

But the technical parts of the show are amazing. People walk up — and down — walls in the smoothest of ways. Look at the rehearsal footage above to get an idea of the mouthdropping aerial work. The nightmare of the coma / memories of the crash / the scan(s) is all definitely nightmarish.

The representations of resuscitation / CPR blend eery accuracy (the doctor’s words) with unsettling images of what it might be like  — or maybe it is like? — from inside the head of a patient.

I avoid watching Holby City / Casualty etc since they never seem very life-like to me. But the words and tone here were just like the ED/A&E Department I (relatively!) recently worked in. So it seems like V-Tol took careful notice of their Medical Research Consultants: an anaesthetist who also leads an air and land ambulance service, and two neurosurgeons.

I want to ask two questions.

First, although all the medical words felt impressively real to me, most of this went over the head of the super-intelligent non-medical friend I went with. Has the non-medical public seen so much of the soap stereotypes that they can’t see beyond them? Is this one of the reasons why the public still have such wildly optimistic ideas about CPR success?

Secondly, the visuals here sucked me into a patients-eye view. Maybe the anaesthetist/neurosurgeons know what it’s like for this sort of patient? Though presumably not for the patients who die? I have  myself shared rare stories from relatives involved in CPR — see here and here. But while doctors (relatively) frequently talk about broken ribs and bruised mouths with CPR, I don’t know of any patient openly talking about what CPR is like. The ones who live are grateful, of course. Presumably the experience is too short for the sort of PTSD that is increasingly recognised for ICU survivors?

The official 1 minute trailer for Out of this World is here

But I think the rehearsal footage is more fun – more aerial, more extreme – and gives a better idea of what I think are the best bits.

Are you going to have a natural death? Or be subjected to CPR?

When the time comes, very many people want a peaceful death. Even so, there’s always lots more discussion and planning about cardiopulmonary resuscitation (CPR).

Several studies have shown that patients – prudent as they usually are – change their resuscitation preferences depending on what outcome they expect.

But patients and staff have unrealistic expectations about CPR survival. Patients are wildly ambitious. And I was surprised to discover that some staff are unrealistically negative. How can anyone make decisions about resuscitation status, if they have the wrong idea about survival rates after CPR?

So is it ever possible to predict CPR survival rates for an individual?

Stepping right back, there is a fundamental difference between CPR for people who are generally well, but have a cardiac problem: we should be doing MORE CPR for them. Then there’s CPR when someone is in the final stages of a chronic medical condition. For those individuals, their hearts are bound to eventually stop beating as what the Resuscitation Council describes as an “integral part of the natural process of dying”. I think we should be attempting LESS undignified and unsuccessful CPR for them.

To try to help with individual predictions, I carried out a literature review to consider CPR survival rates in terminally and chronically ill patients. I specially focused on high burden clinical conditions. The potential effects of patient age and functional status were also considered. With the increasing focus on home deaths, I concentrated on Out of Hospital Cardiac Arrests.

Some of my results are published in the June 2016 edition of Palliative Medicine: vol. 30 no. 6 Abstract number: PO183

But to summarise – and comment – here:

The first thing I found was how little evidence there is. Although death after chronic illness is something that will affect the vast majority of us, many more researchers concentrate on CPR for the acute-cardiac patients, and how to increase survival for them. Rather than natural deaths.

Part of the problem is methodological. Importantly, more of the sicker patients have Do Not Attempt CPR orders – so they are taken out of the numbers. This artificially increases CPR survival rates for those left in any studies.

Even so, there is a decrease in CPR survival with increasing patient age. This is not linear – there seems to be an especial dip after age 70. All the researchers –  and me too! – are not here saying that some older patients are not successfully resuscitated, just sharing some of the information.

CPR survival rates are especially low for patients with advanced cancer, or advanced liver disease, or with dementia.

Most patients have more than one thing wrong with them. Even so, there is an especial lack of studies for patients with multi-morbidity. Some morbidities are almost ‘positive’ – for example, those who have the cardiac conditions which produce ‘shockable’ rhythms with cardiac arrest have better (if still very low) survival.

Most importantly, the biggest practical – and methodological – problem is that everything keeps on changing. As patients get older and sicker, CPR survival rates decrease. We’re back to the fundamental point that everyone’s heart – including mine, including yours – is going to stop sometime.

I think it would be helpful to be more explicit about this. And to be more explicit that, when a heart stops for someone who has a terminal, chronic disease then often it’s the body’s way of saying that it’s time to die. Although doctors can sometimes make miracles happen then often, even if a heart is restarted beating, patients often die shortly afterwards, in pain (from all the broken ribs)

The other big thing I think we should do is to start collecting different sorts of data. Routine data sources define ‘success’  in terms of getting the heart beating again (return of spontaneous circulation: ROSC); survival to hospital discharge (SHD); or longer term survival. But what about those who had an unsuccessful CPR? Those who died shortly afterwards? And those who chose to have a DNACPR order? We especially need more information about natural deaths.  But we don’t ever collect data about this.

I think we need to start collecting information on good deaths, so that more of us can have them!

 

[I’ve included some links here – there are lots more relevant studies, and if anyone wants to discuss these, please don’t hesitate to contact me!]

 


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