Why Doesn’t Everyone Do Telephone CPR?

When the call came in, the EMD felt helpless. The caller was screaming that his father had a seizure and wasn’t breathing.

“OK, sir, what’s your address?”

The caller spoke with a thick accent. It was more than a minute before the dispatcher could discern the name of the street.

“Please, help my dad! Send an ambulance!” The son was desperate.

“Sir, help is on the way,” the EMD said. “What is your dad doing now? What does he look like? Is he awake?”

“No! I don’t know! This seizure looks different,” he pleaded. “Please help me!”

The dispatcher didn’t know that it’s common for callers to describe a seizure when reporting a cardiac arrest patient. The son was alternately speaking to his family in another language and then getting back on the phone with the dispatcher.

Three minutes had passed.

“Sir, is your father breathing?”

There were clunking noises and fumbling sounds. Muted voices, desperate and frantic. The son came back on the line.

The EMD flipped through his cards for prearrival instructions for the seizure protocol. He remembered that a differential diagnosis was for a choking victim. Perhaps the patient had choked.

“Sir, can you open your dad’s mouth?” the EMD asked. “Does he have anything blocking his airway?”

“What? No, no, no! He is not choking! He had a seizure! Where is the ambulance?”

The dispatcher tried to remember if he had asked the son to open the front door.

“Sir, I need you to make sure the medics can get in. Did you open the front door?”

The caller mumbled something, and the phone suddenly went silent.

Increasing Survival

The job of the 9-1-1 call taker demands a level head so that correct information is gathered and appropriate resources are dispatched. But when the EMD confronts a panicked, helpless caller who is with an apneic patient at a loud, chaotic scene, he/she needs to be able to rely on thorough training and well-established protocols to afford patients the best outcomes possible.

In 2015 approximately 326,000 people experienced out-of-hospital cardiac arrest (OHCA) in the United States.¹ That translates to nearly 1,000 arrests per day, of which fewer than 100 people survived to be discharged from the hospital. But survival rates can double or even triple if those victims receive early CPR,² be it from a bystander or a 9-1-1 caller coached by a dispatcher.

Dispatchers can be trained in a short telephone CPR (TCPR) course to quickly recognize a cardiac arrest and then provide clear and concise instructions to a 9-1-1 caller using a proven written protocol.

With proper quality improvement (QI) follow-up, these dispatchers receive important feedback about their responses.

So why do only about 50% of public safety answering points (PSAPs) across the U.S. actually give TCPR instructions?

Lack of Public Awareness

When a mother dials 9-1-1 because her loved one has collapsed suddenly, she expects an EMD to tell her how to help while awaiting EMS. Whether she is in a big city or a rural town, on a cell phone or land line, she counts on the PSAP to provide guidance with prearrival instructions (PAIs). While this is a well-understood public expectation,³ few 9-1-1 callers know their emergency may be answered by a PSAP that won’t provide them PAIs.

That ignorance is one reason why Michael Kurz, MD, of the University of Alabama at Birmingham, volunteered to chair the American Heart Association’s task force on TCPR. This task force of physicians, medical directors, dispatch administrators and dispatchers has been collaborating since May to contribute to the AHA’s goal of doubling both the survival rate of OHCA and the rate of bystander CPR by 2020.⁴

“We recognized that increasing bystander CPR rates is the single most effective method of improving OHCA survival,” Kurz says. “All patients in the U.S. who experience a sudden cardiac arrest should receive bystander CPR.”

Multiple jurisdictions throughout the U.S. have demonstrated the link between bystander CPR and increased OHCA survival rates.

In Arizona, Bentley J. Bobrow, MD, medical director for the Bureau of Emergency Medicine Services & Trauma System at the Arizona Department of Health Services, has increased his jurisdiction’s survival rates by an additional 30% after focusing on a TCPR initiative.⁵ Multiple stakeholders participate in this effort, including laypersons, dispatchers, PSAPs, EMS and hospitals. Bobrow finds it unacceptable that PSAPs aren’t giving TCPR instructions and thinks citizens should be made more aware of this problem.

“The public doesn’t know what they aren’t getting,” he says. “There has to be some accountability to all of this.”

It is likely the public does not know their loved ones’ chances of survival could hinge on what city they were in when they collapsed.

Inconsistencies in Prearrival Instructions

Bobrow isn’t the only OHCA expert frustrated by the needless deaths.

Brett Patterson, in his role as chair of the Medical Council of Standards with the International Academies of Emergency Dispatch (IAED), has worked to address the great inconsistencies throughout the country in how PAIs are given for suspected cardiac arrest events. His organization supports protocols that help bystanders get hands on chest in as little as 20 seconds.

“It baffles my mind that [standardized instructions] are not out there,” Patterson says. “We’re trying to get people to do it right.”

EMD Matt Kendall has worked in the Franklin County, PA, 9-1-1 center for almost five years. While his dispatch center does not require EMT certification, Kendall has volunteered as an EMT for about 10 years. Aware of the most recent CPR science, such as the emphasis on quality compressions over ventilations, Kendall says it can be frustrating to follow his PSAP’s protocol, which begins with mouth-to-mouth breathing.

“We have to follow this system,” Kendall says. “I know every second counts, so it is a little uncomfortable to wait and count breaths.”

The AHA’s 2015 Emergency Cardiac Care (ECC) Guidelines argue that “untrained lay rescuers should provide compression-only CPR for adult victims of cardiac arrest.”⁶

EMDs know that when the tragedy of a cardiac arrest strikes, callers are often panicked, frantic and difficult to coach. Because almost 70% of OHCAs occur in the home,⁷ it is frequently a loved one who calls 9-1-1. If Jennifer Chap’s husband, Rick, had been in a different city than Orlando when he collapsed in his home, his wife may not have been given the TCPR instructions that helped save his life. She found her husband on the floor, gasping for air, gritting his teeth and hissing.

“His eyes were open, but he was not responsive. I thought he’d had a seizure,” Chap says. “I consider myself an educated person, and I was a bit angry that I didn’t really know this could happen.”

When the EMD gave Chap CPR instructions, she was very relieved. She welcomed the guidance from the well-trained expert.

“If the dispatcher had told me that cutting off my right arm would save my husband, I would have done it,” says Chap.

After the incident, Chap and her husband co-founded BuddyCPR (buddycpr.org), became certified CPR instructors, began to volunteer for the Sudden Cardiac Arrest Foundation, and they learned that, like Rick, many OHCA victims present initially with abnormal breathing or agonal respirations.⁸

“I wish I had known that [before],” she says.

The Need for a Higher Power

There are no national requirements for emergency medical dispatch, nor are there mandates for standardized protocols for all PSAPs nationwide. A variety of organizations can oversee PSAPs, including public safety, municipal agencies, hospitals and law enforcement. Coupled with the fact that cardiac arrest calls may only constitute 1%–2% of all 9-1-1 calls, PSAP management may not prioritize spending money or time improving medical responses.

“From their perspective, PSAP managers tend to think it is asking a lot to say that the next call will be a cardiac arrest,” says Micah Panczyk, 9-1-1 CPR program manager for the Arizona Department of Health. “It is easy to assume a fatalistic attitude—that the chance of survival is so small, they can’t affect the outcome.”

Add a lack of funding to this problem, and the inconsistencies aren’t so surprising.

“TCPR is more of a suggestion, maybe a recommendation, as opposed to a standard or a funded mandate,” says Michael Spath, who serves on the Council of Standards for Quality Assurance for the IAED in addition to working as the communications manager for the city of Sunnyvale, California. “If PSAPs are not required to do it, we aren’t necessarily going to or even have the ability to do it.  Standardized training and quality improvement are important at the state and even federal level.”

Some states, such as Maryland and Massachusetts, have state-funded and mandated standards for dispatcher training. The majority of states do not give PSAPs legislative support or funding. Drew Dawson, former director of NHTSA’s Office of EMS, was also a state EMS official in Montana. Dawson saw firsthand the tendency for states to solve problems by proposing legislation and regulations. He believes additional stakeholders are needed to help champion the cause of a standardized dispatch system.

“Frequently there are laws on the books, [but] no money in the bank and no good way to implement these laws,” Dawson says. “State EMS and public health departments need to come together to make this happen. Sudden cardiac arrest needs to be recognized as a public health problem, just like strokes and heart attacks.”

National organizations like the AHA are spearheading some of these efforts to standardize training, collect data and encourage QI programs. While the TCPR task force appreciates the stumbling blocks PSAPs encounter, it still emphasizes that “meeting this standard saves lives, [and] not meeting this standard results in deaths that are preventable.”⁹

A Formula for Success

Before becoming an instructor for the IAED and working as the QI and training coordinator for a large urban dispatch center in Canada, Kim Rigden was herself a dispatcher. When providing TCPR instructions to 9-1-1 callers, she appreciated using a protocol-based system, rather than a set of suggested guidelines.

“I need to be able to say things clearly and precisely for a panicking caller,” Rigden says. “I don’t have to think about the next steps because it’s on the screen.”

As a trainer Rigden is supported by her organization, and she emphasizes to her students the links in the chain of their training and evaluation.

“It’s a threefold magic formula: There is a protocol to follow, a QI process to follow and an accreditation we have to abide by,” she says. “Because my senior management wants to keep this accreditation, I have a lot of ammunition as a trainer.”

Trainers and senior management who have the support of their agencies report a culture of high-quality training and education in their PSAPs. Paul Stiegler, MD, medical director for OnStar, takes pride in his system’s accreditation as only one of 100 or so IAED-accredited Centers of Excellence. General Motors’ commitment to QI produces well-trained dispatchers. Stiegler also focuses on providing role-plays for his dispatchers so they know their scripts well.

“PAIs are very complicated, and there are lots of different pathways. You don’t want to memorize the lines, because you may get it wrong if you forget,” he says.

The structure of an established protocol and frequent training levels the playing field for all employees, new or seasoned. An EMD’s performance can be affected by the stress of a cardiac arrest call, lack of sleep or a particularly difficult shift.

“With the right training you can have a workforce that provides the same level of service to all callers,” Rigden says.

“Protocols never have a bad hair day,” says Jeff Clawson, MD, director of research standards and academics for the IAED and inventor of Priority Dispatch. “Using the interrogation format during call-taking means we aren’t just asking questions; we are satisfying clinical and situational objectives.”

No amount of training, standardized or not, matters unless there is follow-up with continuing education and a QI system to give feedback to the EMDs. Kurz’s task force recommends a QI program that has a “close engagement with the EMS agency” in order to improve performance.

“Without this communication, it is impossible for a dispatch center to know whether or not they are correctly recognizing the need for CPR instructions in all circumstances,” says Kurz.

Bobrow and his team knew that despite the time and expense of reviewing calls and playing back audio recordings, QI is well worth the effort. Panczyk doesn’t accept the “too expensive” or “too difficult” excuse.

“Even [reviewing] 15 or 20 calls can speak a lot to your overall numbers,” Panczyk says. “Dispatchers really want to be useful. They need feedback on their performance.”

Feedback to dispatchers about patient outcomes is not always given consistently and sometimes not even given by PSAPs. After her husband recovered, Chap sought out the dispatcher, firefighters and medical personnel at the hospital who were involved in his care. She and her husband wanted to thank them personally.

“The dispatcher was overjoyed. It was his first save,” Chap says. “I told him I was sorry I wasn’t at my best on the phone.”

On the 10-year anniversary of one of her cardiac arrest saves as a dispatcher, Rigden was contacted by the mother of the 7-year-old victim who was still alive thanks in part to Rigden’s TCPR instructions.

“It was 10 years ago today that we almost lost our daughter,” the child’s mother said. “She’s here because of you.”

Are You Ready?

When the call came in, the emergency medical dispatcher was prepared. A frantic mother on the other end of the line was screaming that her daughter was unconscious.

“Please send an ambulance! There’s something wrong with my daughter!”

The EMD replied calmly and began to click through the protocols on her computer console. “OK, ma’am. What’s your address?” The EMD determined the caller’s name (Barbara), the patient’s age (45) and that the patient was lying on the floor of her home.

Less than a minute into the call, the EMD asked two simple questions that would ultimately contribute to the patient’s survival.

“Is the patient awake and alert?”

The answer was no.

“Is she breathing normally?”

Another no. “She’s gasping for air, and she’s starting to turn blue!” Barbara added.

Before the second minute of the call had elapsed, the EMD determined that the patient was in cardiac arrest and launched into prearrival instructions.

“OK, Barbara, listen to me carefully. You need to do CPR. I’m going coach you and be here with you every step of the way,” the EMD assured her. “Are you ready?”

EMS World acknowledges the Sudden Cardiac Arrest Foundation for identifying individuals who benefited from T-CPR for this article.

References

1. American Heart Association. CPR and First Aid: Emergency Cardiovascular Care, 2016.

2. Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med, 2015 Jun 11; 372(24):2,307–15.

3. Clawson A. Public expectations of receiving telephone pre-arrival instructions from emergency medical dispatchers at 3 decades post origination at first scripted site. The Journal, May/June, 2011. 

4. American Heart Association. Emergency Cardiovascular Care 2020 Impact Goals, January 23, 2015.

5. Bobrow BJ, Spaite DW, Vadeboncoeur TF, et al. Implementation of a regional telephone cardiopulmonary resuscitation program and outcomes after out-of-hospital cardiac arrest. JAMA Cardiol, 2016; 1(3):294–302.

6. American Heart Association. Highlights of the 2015 American Heart Association Guidelines Update for CPR and ECC.

7. American Heart Association. Heart disease and stroke statistics—2015 update. Circulation, 2015; 131(4):e29–322.

8. Clark JJ, Larsen MP, Culley LL, Graves JR, Eisenberg MS. Incidence of agonal respirations in sudden cardiac arrest. Annals of Emergency Medicine, 1992; 21(12):1464–1467.

9. American Heart Association. Introduction and Welcome, 2016.

Hilary Gates, MEd, NRP, is a paramedic in Alexandria, VA. She is an EMT instructor and teaches in the School of Education at American University. She began her career as a volunteer with the Bethesda-Chevy Chase Rescue Squad. Gates has experience as an EMS educator and symposium presenter and is involved in quality management and training for the fire department.