Government cutbacks save lives

There are four types of heart rhythm that we (as Community Responders and First Aiders) are taught about. The squiggles that you see on a chart show the varying levels of electrical activity over time and by analysing these, medical staff are able to diagnose, not only specific problems but also the likely location of the problem (e.g. blockage), It's still mainly a black art to me, but I'm getting there.

Normal Sinus Rhythm (NSR)

This is the normal state of affairs for a heart, when it is beating regularly and is the one that most people will associate with a regular heartbeat, thanks to it popping up everywhere, Medical drama opening credits and documentaries especially. Heart muscle contracts if you apply electricity to it. The more electricity that is applied, the greater the contracting force. It is enough force to squeeze a lump of blood out from the heart and into the Main artery (the Aorta). Thus begins its journey around the body. It is this regular lump of blood travelling along the Arteries that we can detect as a pulse.

(Picture Wikipedia:https://en.wikipedia.org/wiki/Sinus_rhythm)

Asystole (flatline)

This is a straight line across the chart and indicates that there is no electrical activity in the heart at all. Or that you haven't yet connected the leads. Or that one has fallen off...

If all is well with the measuring equipment, then it would be fair to say that the patient is medically dead.

(Picture Wikipedia: https://en.wikipedia.org/wiki/Asystole)

This strip shows a heartbeat stopping and going into asystole

Ventricular Fibrillation (VF)

The heart consists of four chambers. The two at the top are called 'Atria' and the two at the bottom 'Ventricles'. The Left Atrium and left Ventricle work together, as do the right pair. Normally the electrical system causes the Ventricle heart muscle to contract and relax in one smooth flowing movement. However, if electrical anarchists gain the upper hand, each bit of muscle in the Ventricle will contract when it wants. With such disorder, it does not squeeze the blood out effectively and no reliable pulse can be found The squiggles show pretty much random activity.

(Picture Wikipedia: https://en.wikipedia.org/wiki/Ventricular_fibrillation)

Ventricular tachycardia (VT)

'Tachy' means 'going fast', 'cardia' is to do with the heart. Says it all, really. Your heart is beating too fast so the Ventricles do not get a chance to fill with blood before squeezing it out. Again, no decent pulse is detectable.

(Picture Wikipedia:  https://en.wikipedia.org/wiki/Ventricular_tachycardia)

There are other rhythms (or variations of the above) but this is all we need for now. What you need to know is that a defibrillator will not shock NSR (bad move if it tried), It also will not shock Asystole as, generally speaking, shocking it will not help. It will recognise and shock VF or VT in the hope of converting those rhythms to NSR again.
What you also need to know is that since you cannot shock Asystole, if your patient has that, then they are in a pretty bad way, much worse than the others.

Anyway, back to the story..another CFR story...

An elderly gentleman had been out shopping with his daughter. On getting back in her car, he had suddenly gone unconscious. Cue 999 call and I rocked up about three minutes later, immediately in front of a technician in a Rapid Response Vehicle (RRV - as opposed to my people carrier, a SRV).

Can't do a lot with him in the seat and as there was no trauma involved, neck and spine injuries were non-existent, so we rapidly lifted him out and lay him on the ground. I started CPR whilst the other Responder put his Defibrillator on the patient. His has a screen and we could see immediately that the patient was in Asystole. Nothing the Defibrillator can do (see above), so we crack on with CPR. Every now and again, we stop to check the rhythm, but still asystole. One of my CFR team stops by (happened to be passing) and lends a hand with the compressions.

After, what felt like 10-15 minutes an ambulance arrives. The crew jump out, one gets the handover, the other the stretcher. We lift the patient onto the stretcher and wheel him to the ambulance tail lift, cursing the potholes in the road.

Into the ambulance he goes and with three of them plus the patient and the daughter now inside, I stay outside and tidy up a bit.

It is very difficult (and ineffective) to do compressions whilst on the move, so normally the ambulance crew will work on a patient on site to try and get a heartbeat back or, as is often the case, call it a day after about 20 minutes (the protocol dictates that they try for 20 minutes) and declare the person dead (Recognise Life Extinct or ROLE for short). As our patient had been in asystole for so long, I fully expected the second outcome after 20 minutes or so.

I have been chatting to a couple of off duty nurses (this road seems to be a hotbed for off-duty medics) whilst this is going on and we all agree that the prognosis is not good (they could see and understand the waveform as well). Suddenly, the ambulance blue lights go on, the engine starts up and it takes off down the road. Gone. Just like that. We're left scratching our heads. Can't be giving up as that wasn't 20 minutes and if they were then there would be no reason to then rush off. Can't be alive as that rhythm was pretty terminal and it was a very quick time for them to have brought him back to a viable rhythm. Perhaps we've been dealing with Schrödinger's cat in disguise.

Epilogue

I caught up later that evening with one of the crew and found out a bit more. Apparently, in the few paces from the pavement to the ambulance, the potholes in the road jolted the heart enough to stimulate it into beating again! They got a rhythm back and so rushed him into hospital for more advanced treatment.

The patient survived (and was conscious) for a few more hours but, unfortunately died later that evening. However, in those few hours the family (including the daughter) were able to have their final chats and say their goodbyes properly. To me, that's a success of sorts and will have helped the family gain closure.

So 'thank you', Council, for your budget cuts, for without them he probably would have died in the back of an anonymous ambulance in an anonymous street.

Perhaps there's the makings of a dissertation or case study for someone here? Curiouser and curiouser.

Doctor knows best

One in a series of stories about patients that stand out for one reason or another. No names, no pack drill, no dates.


As a Community Responder, I get called out to many things (mostly chest pains where the patient clearly has forgotten where his or her chest is) but occasionally (on average 1 in 20 calls) it is a Cardiac Arrest.

A Cardiac Arrest is where the heart has stopped beating effectively (no pulse detected), as opposed to a heart attack, which is where most of the heart is working (beating) but part of it is being killed off by a clot.

Myself and a colleague had just cleared from a Job and were being sent to another. We had (at the time) pagers that sent through details of all jobs in the area, whether or not we were allocated to them. The details all included a Job code in the form 'number letter number'. (AMPDS for those that know). This job came through as a 6A1, which is a cardiac arrest - the most serious - and also showed the road, which I was just about to pass. I called in to Ambulance Control and was rapidly stood down from the job I was on my way to and reallocated to this. 30 seconds later I reached the door......


......only to be shown into a very much alive patient.

I started to get a history and it turns out that he'd jut been discharged from Hospital after receiving heart bypass surgery and was told to go home and take it easy. He did as anyone would do, given those instructions and took himself off to the pub for a smoke and some beers to celebrate.

Upon returning home, he had, indeed, gone into cardiac arrest, but had come round by the time that I, hotly followed by an Ambulance Solo Responder, arrived. As we started to get all this history, his heart stopped again. A quick precordial thump (not by me, I hasten to add) and the old ticker was running again....until it stopped.

It probably stopped and restarted 3 or 4 times by the time that an ambulance crew arrived to take him to hospital and we managed to get it going each time. Inbetween, he was perfectly awake, sat up and chatting away to us.

As far as I know he is still alive today, he certainly survived that day. Blokes (I'm sure this has to be a male trait) if your doctor tells you to take it easy as your heart has just been through hell and back, trust me. (S)he knows what he/she is talking about. Put your feet up, moderate exercise and lay off the stuff that earned you the bypass in the first place.

It's funny the things that stick out. Obviously, for the reasons above, the job itself sticks out, but I also remember him wearing a jacket, taking an interest in his appearance. Never mind his heart stopping from all those cigarettes, at least he looked presentable.


PS. Why do I go to a lot of patients with emphysema / COPD from years of smoking. They are on permanent Oxygen therapy, piped around the house for their benefit, catching their breath yet the rest of the household still see fit to puff away. Quite often I come home and shower as the air is so thick with tobacco fumes it gets everywhere. Spare a thought for your family member struggling to breathe in the next room.

What price for a life?

So, I've just completed a First Aid in Education questionnaire for some random student that found me online and found this gem during my research:

Average Secondary School spend per pupil in 2014 - £4,550
(http://www.sec-ed.co.uk/news/how-much-per-pupil-funding-will-your-school-get)

At the moment, pupils get no First Aid Training as part of the Curriculum.

If we assume 2 hours First Aid training per pupil per year: Say £100 per class of 30 to bring three Trainers in (at a max 1:12 ratio). That's just over £3 each. 0.06% of the budget. That's Peanuts. So why don't we do it?

How much of that £4,550 goes on, say, Religious Education? Surely £3 off that budget and 2 hours off the RE (RI, whatever) curriculum to save lives rather than souls would be money better spent?

3-year old dials 999

http://www.bbc.co.uk/news/uk-england-kent-38056677

4-year old Suzie calls 999 and saves mum's life

http://www.bbc.co.uk/programmes/p04d3ss8

If you have to do CPR on someone, it's more likely that it is someone that you know than someone you don't know. What more of an incentive do we need?

Can you learn First Aid from a video?

In 2013, the UK's Health and Safety Executive (HSE) - the Body that oversees Health and Safety in the Workplace - approved Blended learning when teaching First Aid.

What Blended learning means is that whilst some aspects of First Aid still need to be taught and practised face to face, a lot of it can be done remotely - for example by using video tutorials online.

On the face of it, this seems to be a strange move. First Aid is very much a practical skill. There is already a layman's fear of doing harm to a patient. To now say that you can try to save someone's life using techniques that you have watched online does not completely sit comfortably. How do you know that what you are doing is correct in terms of depth, speed, positioning and so on?

Perception vs Reality

Of course, it is not quite that bad. In practice, there are no completely online First Aid courses (Refreshers, yes. Initial courses, no). If you wish to obtain a (Emergency) First Aid at Work ( (E)FAW ) qualification, or one of the child / paediatric certificates you have to demonstrate practical skills at some point. However, a lot of the course groundwork can be undertaken online before the classroom session. The concepts and principles can be stepped through using videos and online question papers. Once the student can demonstrate a suitable level of understanding, (s)he can be signed off and allowed to attend the remainder of the course in a classroom.

What's in it for me?

The advantages of blended learning boil down to time and money.

Time

First Aid at Work is a three day course, Ofsted compliant Paediatric is two days. For smaller organisations it can be hard to release an employee for that length of time and still keep the Business going. With one day of online work, this can be carried out whilst at work so that the employee is still available for work-related matters. It's not often that an Employer will encourage employees to sit around watching videos on work time....

Money

As they saying goes, time is money. If you, as an employer send an employee away on a course, you still have to pay them for that day (plus expenses) but also possibly pay for cover. Agencies are not known for their altruism, staff drafted in will invariably cost more than regular staff.

Recording a Training video once and playing it many times is an economical way of delivering material and this is reflected in the cost of courses.  Whereas a typical course in a classroom will cost between £50 and £100 per person, ProTrainings (the certification Company that 4Minutes uses), for example, charges just £25 for the online part.

Precedent already set

Of course, First Aid is not the first to use blended training. Anyone that has taken a driving test in the last few years will know that there is now a Theory part that needs to be passed before the Practical. You still have to learn and take your test in a vehicle, thank goodness. At least for now. Once self-driving cars become more mainstream, I can see a day when there is a theory-only test. Interesting times ahead.

Any downsides?

Well, yes. As already mentioned, there is no feedback from the instructor if you are unsure and just watching someone perform CPR will not give you a feel for just how difficult it can be on a mannikin or a real person.

Summary

Blended learning and online-only learning is here to stay, like it or not. Whilst it has its place, 4Minute's stance is that all courses should have some face to face element when learning the major life-saving techniques. For underpinning knowledge and other parts of the course, then online at your own pace is almost as good as watching a trainer in person step through a series of Powerpoints.

What do you think?