By Mike McEvoy, Ph.D., REMT-P, RN, CCRN
A 42-year-old firefighter collapses in your station locker room after a morning fitness session. Applying the most recent information about early defibrillation and CPR will play a critical role in your brother firefighter’s chances for survival. Don’t get me wrong: Some cardiac events are unsurvivable from the start. Most, however, depend entirely on the initial actions taken and the readiness of those first on the scene.
First, a quick review of what we know about time. Remember that nearly all persons who collapse with sudden cardiac death usually collapse in a shockable rhythm. The ability to restore a normal rhythm and blood pressure declines by 10 percent each minute they remain in cardiac arrest. By this formula, nearly all persons in cardiac arrest will die if they are not defibrillated within 10 minutes from the time they collapsed.
The means by which a person dies can sometimes cause delays in treatment. Once the heart stops normal pumping, a person will lose consciousness somewhere between 5 seconds and 2 minutes later. Breathing will usually continue for 5 to 8 minutes after collapse, although the pattern changes from normal to a slower (4-5 breaths/minute) gasping pattern. Emergency medical dispatchers label this abnormal breathing “agonal respirations.” The latest CPR guidelines emphasize the need to begin CPR when a pulse (or other signs of circulation) is absent, even if agonal breathing is present.
Back to the locker room. What is the most critical action to maximize this firefighter’s chance for survival? The automated external defibrillator (AED)! Every six seconds that passes without a shock drops this firefighter’s odds of survival by 1 percent. We practice initiation of CPR, calling 911 for EMS, and attaching the AED. In reality, when an AED is initially available, there should never come a time when it can’t be attached and used before others have a chance to start CPR. People who suffer cardiac arrests in intensive care units almost never die because the ICU nurses grab a defibrillator and use it before CPR can be initiated. Time is your ultimate enemy in cardiac arrest. The AED is your ultimate weapon against time.
In drills, I recommend training evolutions that simulate actual arrest calls to which you might respond. Emphasize the need for immediate connection of the AED. Many experts would recommend that the first shock be delivered no more than 20 seconds after arrival at the scene. In addition to each of your AED operators training to compete in this battle against time, it is important to ensure they have the right tools to win. Consider the supplies carried with the AED, preferably in the AED case. These should include scissors to quickly remove clothing, a towel to wipe away excessive sweat from the skin where pads are placed, a razor to shave chest hair, and a spare set of pads in case the first set fails. Preconnected pads also trim seconds off the time to first shock. Having an AED on every piece of apparatus is only half the battle. A race against time will ultimately determine the winner. When seconds count, practice matters. The life you save may be someone you know.
Mike McEvoy, Ph.D., REMT-P, RN, CCRN, is the EMS coordinator for Saratoga County, New York. For the past 13 years, he has worked in the Cardiac Surgical ICU at Albany Medical Center. He teaches at Albany Medical College and lectures at hospitals, colleges, and conferences. McEvoy is a paramedic for Clifton Park-Halfmoon Ambulance Corps and medical advisor for the West Crescent (NY) Fire Department. He currently serves as a member of the New York State EMS Council and the State Emergency Medical Advisory Council and chairs the EMS Section of the New York State Association of Fire Chiefs. His first career was with the Justice Department as a forensic psychologist.