For Better CPR, Avoid Breaths and Compress the Stomach?

Long an integral component of CPR, mouth-to-mouth breathing is suddenly getting a hard look from researchers who are questioning its role as part of the lifesaving intervention. In a Lancet article published earlier this year, the SOS-KANTO study group reported findings from a prospective, multicenter observational study of more than 4,000 cardiac arrest victims that suggested eliminating the rescue breaths was linked to better 30-day neurological outcomes.

     Following witnessed out-of-hospital arrests, 18% of their study group received conventional CPR, while 11% received cardiac-only bystander resuscitation. Both groups had better outcomes than those receiving no CPR, but the cardiac-only approach had better results in apneic patients (6.2% vs 3.1%; p=0.0195), patients with shockable rhythms (19.4% vs. 11.2%, p=0.041), and patients for whom resuscitation started within four minutes of arrest (10.1% vs. 5.1%, p=0.0221).

     Eliminating the breaths is also a key feature of a new CPR model developed by a Purdue engineering professor. Leslie Geddes, PhD, DSc, is promoting "only rhythmic abdominal compression," or OAC-CPR, which calls for compressing the stomach, rather than the chest. This increases perfusion to the heart by 25% over current practice, says Geddes, and prevents consequences like broken ribs and passing infections through rescue breathing. And it can be done by one rescuer.

     In OAC-CPR, he says, each compression pushes the diaphragm toward the head, forcing air from the lungs and effectively creating a 1:1 compression-to-breath ratio. One person can do this alone. Conversely, the current model of 30 chest compressions to two breaths requires two, and exerts a higher physical toll due to the force required to depress the chest 1½–2 inches.

     Pushing the stomach doesn't require that force or frequency, says Geddes. In tests, however, he's used the AHA standard of pushing with 100 pounds of pressure 100 times a minute. This increased blood flow through the heart by 25% over standard chest-compression CPR, without retrograde flow.
-Purdue University; Lancet; Best Life

     EMS Magazine Editorial Advisory Board Member James J. Augustine, MD, FACEP, comments:

     Keep an eye on this trend. Having a cardiac arrest is still a bad event. Worldwide, the outcome of an event where CPR is needed is still, in most circumstances, death. The primary challenge is creating the correct mechanical methods for restoring some cardiac output until the heart can be restarted. The secondary challenge is to create a method to train the lay public to perform it until rescuers can take over. Simple methods for doing CPR, especially ones that do not require mouth-to-mouth breathing, will be easier to train people on and implement. There needs to be ongoing research into the most effective methods for compression and ventilation, and how to avoid complications for both the victim and the rescuer.

     Beware: There has been 40 years of back and forth on many of these issues. The most effective proven interventions continue to be only two: avoid the cardiac arrest to begin with, and use electricity in an appropriate form to restore a normal perfusing cardiac rhythm.

SIX YEARS AFTER 9/11, ILLNESS still affecting providers
     The sixth anniversary of 9/11 saw a raft of stories documenting ongoing health problems among rescue and recovery workers from the World Trade Center site.

     Newsday reported that the number of first responders and emergency workers sick from exposures at Ground Zero continues to rise. Stony Brook University Medical Center's Long Island World Trade Center Monitoring and Treatment Program, which tracks claims of 9/11-related illness, saw about 1,400 such workers between July 2006 and July 2007--more than two-thirds of them first-time visitors, the paper reported. More than 35% were eventually treated for conditions that included respiratory, gastrointestinal and mental health issues.

     A report by the New York City Health Department found that workers who responded early to the site or were exposed over longer recovery periods developed asthma at a rate 12 times above normal. An estimated 3.6% of rescue and recovery workers who didn't previously have asthma have been diagnosed with it since, according to the Staten Island Advance; among those who worked at least 90 days, the rate is more than 7%.

     A 2006 study by the Mt. Sinai School of Medicine found that 70% of Ground Zero workers exhibited new or worse respiratory problems after exposure to WTC debris. Earlier this year, doctors in a 9/11 worker health program overseen by Mt. Sinai saw more than 2,300 workers over a three-month period, and found upper respiratory conditions in 59%; lower respiratory problems in 40%; mental health problems, most commonly post-traumatic stress disorder and depression, in 36%; and asthma and related diseases in 30%.
-From staff

Computer-Based Testing a Success, NREMT Says
     Six months in, computer-based testing (CBT) is getting a thumbs-up from the National Registry.

     The NREMT began offering CBT in January, and as of April, more than 16,000 prospective providers had tested at authorized testing centers. "The biggest change in the history" of the NREMT, CBT promises multiple benefits, including faster results, better reliability and security, and increased flexibility for testing sites and times. A whopping 94% of surveyed candidates reported being able to test in their preferred location.

     The NREMT produced a DVD, Making the Switch, to explain the new process; it can be viewed on the organization's website, www.nremt.org.
-NREMT

FOR SERIOUSLY ILL, distance = death, study says
     For every 6.2 miles (10 km) an ambulance has to take them, a seriously ill patient's risk of dying increases by 1%, a study of English transports published in the September Emergency Medicine Journal concludes.

     Authors led by the University of Sheffield's Jon Nicholl reviewed five years' worth of data from urban, rural, remote and mixed services, focusing on calls for unconsciousness, chest pain or difficulty breathing. Surveyed patients' transport distances ranged from 0–36 miles (0–58 km), with an average of 3.1 (5 km). Overall, slightly more than 6% died, but the risk increased with distance: For transports of 6.2–12.4 miles (10–20 km), it was 13%; for transports of more than 12.4 miles, it rose to 20%. Patients with difficulty breathing appeared to be at highest risk.

     The results could have implications for systems that transport such patients to more-distant specialized care centers, rather than local emergency departments, the authors say.
-Emergency Medicine Journal

FCC OKAYS TOUGHER RULES FOR E9-1-1 LOCATION
     The Federal Communications Commission has given preliminary approval to a proposal to hold providers of cellular and VoIP phone service to a stricter standard in locating callers to 9-1-1.

     These providers have previously been allowed to test their location capabilities across wide areas, potentially camouflaging weak spots. Good location capability in urban areas within a state, for instance, might disguise a lack of it in rural areas. Under the new plan, supported by the Association of Public-Safety Communications Officials (APCO) International, these providers would instead gauge their capabilities by individual community or PSAP. For more, see www.fcc.gov.
-FCC, APCO Int'l.

ITC RULING COULD HARM 9-1-1 USERS, NENA WARNS
     A ruling by the International Trade Commission may have negative consequences for the delivery of 9-1-1 service in the U.S., the National Emergency Number Association warned.

     As part of a patent dispute between Broadcom and Qualcomm, the ITC banned importation of certain cellular handsets used by major U.S. carriers, potentially preventing their customers from upgrading to newer models that provide better location capabilities.

     "First responders will potentially have inferior information when trying to locate 9-1-1 callers in time of need," NENA warned in a release decrying the move. "Additionally, first responders themselves will be denied the opportunity to use many devices that would improve interoperable first responder communications in the field. The decision of the ITC is not a positive result for public safety or the emergency-calling public."
-NENA

TWO WAYS TO REDUCE DOOR-TO-BALLOON TIMES
     A pair of studies in the Annals of Emergency Medicine suggest ways to reduce door-to-balloon times for heart attack patients to closer to the 90 minutes recommended by the American Heart Association.

     Allowing emergency physicians to initiate angioplasty as soon as they diagnose a heart attack, without seeking a cardiologist's authorization, reduced average times from 131 to 91 minutes, according to a team at Virginia Commonwealth University. Concurrent activation of the cardiac catheterization team and a cardiologist cut it from 147 to 106 minutes. For more, see www.annemergmed.com.
-ACEP

NAEMT Members Overwhelmingly Approve Changes to Group's Bylaws
     Members of the National Association of EMTs will now vote directly for their officers and directors following approval of changes to the organization's bylaws by a member vote in August.

     Leaders were previously elected by a Board of Governors that represented affiliated state EMS organizations. That board was dissolved following last month's NAEMT Annual Meeting in Orlando, where it voted to fill three open positions on the Board of Directors.

     "Even with the bylaws change," NAEMT President Jerry Johnston emphasized in announcing the vote's results, "it's critical to keep the states engaged in NAEMT, and I'm hopeful that all of the governors will remain active in the association."

     The new bylaws also expand the NAEMT's Board of Directors from 11 members to 15. The four new directors will be a chosen by a vote of members at a date to be announced. That board must approve a transition plan for implementing the bylaws changes, which Johnston believes will occur by year's end.

     Of more than 1,000 votes cast in the August polling, 94% approved the changes. For more, see www.naemt.org.
-NAEMT

MEETING TO CONSIDER ways to make kids safer at school
     More than 1,000 government and school officials, law enforcement providers and youth experts will convene in New Orleans next month for a two-day meeting aimed at finding ways to make kids safer at school.

     The "Safeguarding Our Schools" event will be held Dec. 3–4 at the Morial Convention Center as part of the 2007 Educational Security Congress. It will include presentations, think tank sessions, workshops and panel discussions.

     Part of the revenue generated by the event will go to fund a two-year school-safety study by the RAND Corp., which will work to recommend new policies and procedures for reducing threats in the school environment.

     For more, see www.virtusinternational.com/us/home.html.
-Virtus International

TASER DEMO CAUSES SEVERE SPINAL DAMAGE
     A Taser demonstration left a police volunteer with fractures in his spine, an Annals of Emergency Medicine case study reported in September. It is the first such case documented in medical literature.

     The officer, 38, received a five-second discharge from a model X26 Taser. He was transported when severe pain from the demonstration didn't subside. Physicians found compression fractures in his spine they believed were caused by muscle spasms precipitated by the electrical jolt.

     "Although rare, vertebral fractures as a result of severe muscle contractions induced by the Taser are a possibility, as this case makes clear," lead author James Winslow, MD, of the Wake Forest University School of Medicine said. "Medical personnel and law enforcement officers should recognize that these weapons are still associated with injury."
-ACEP

USFA ANNOUNCES NEW TASK BOOKS FOR ICS POSITIONS
     The U.S. Fire Administration has announced new position task books for members of all-hazard incident-management teams. The books, developed in conjunction with the NIMS Integration Center and National Wildfire Coordinating Group, are based on ICS position competencies identified by the USFA and NWCG. They describe competencies and behaviors for each position for purposes of evaluating trainees.

     Books are available for Incident Commanders, Operations Chiefs, Planning Chiefs, Logistics Chiefs, Finance/Administration Chiefs, Safety Officers, Liaison Officers and Public Information Officers. They can be downloaded from the USFA website, www.usfa.dhs.gov.
-USFA

MRSA CASES BESET FRESNO FIREFIGHTERS
     Thirteen Fresno firefighters have filed workers' comp claims after contracting methicillin-resistant Staphylococcus aureus they believe is job-related, the Fresno Bee reported.

     The actual extent of the outbreak is uncertain; a city official said only four of the 13 tested positive for MRSA bacteria. Among the others, he said, infections had cleared by the time they were tested or found to be related to other causes.

     Staph infections are, however, a known risk for public-safety providers. The bacteria can thrive in close quarters such as stationhouses, and emergency workers often have contact with populations with poor hygiene, such as the homeless. In 2005, Los Angeles authorities documented 20 cases of skin infections among firefighters who worked on L.A.'s Skid Row.

     "We are, daily, coming into contact with people on the street," Fresno fire chief Randy Bruegman told the Bee. "I'm worried about bringing all kinds of things to the firehouse."
-Fresno Bee