Bystander CPR: why all the fuss?

The vast majority of cardiac arrests occur in the community, away from a suitably equipped medical setting and are witnessed by bystanders in around 80% of cases.^10-11In Malta in 2016-17, despite 71% of cardiac arrests being witnessed by laypersons, intervention only occurred in 39% of cases, including bystander defibrillation in 9% (data, MRC). It is not surprising, therefore, that the survival to discharge from hospital after out-of-hospital arrest in Malta was just 6% (data, MRC). The importance of good, bystander CPR cannot be underestimated. This requires laypersons to identify the signs of collapse, and be competent to initiate good CPR without delay and certainly before medical help arrives. In Malta, as elsewhere, the average time for an urgent ambulance to reach a victim varies but, even with optimal circumstances, this is likely to exceed 10 minutes⁸and is probably too late for most victims of cardiac arrest. So the timely intervention of laypersons is absolutely crucial if survival figures after an out-of-hospital cardiac arrest are to reach the European Resuscitation Council (ERC) goal of 60%. CPR and the use of an AED are relatively uncomplicated skills that can be mastered easily by non-medically trained laypersons.^12-13This also applies to children whose retentive skills for the CPR algorithm may be better than adults, provided they are old enough to perform forceful and effective chest compressions.^14-15

Malta is fortunate in that several bodies including the Malta Resuscitation Council (MRC), the Red Cross, St John Ambulance, Malta Heart Foundation, Order of St Lazarus and others, regularly provide courses in combined CPR-AED training. These, together with the MRC that runs ERC-certified courses, have set the standard of training required. To-date, the MRC alone has trained more than 2,000 medical personnel and 1,000 laypersons, and has helped train and equip the Health and Safety Unit within the Education Division who, so far, have trained around 300 schoolchildren. Whilst CPR-AED training is now mandatory for all medical students, General Practitioners and young hospital trainees are also required to complete ILS and more advanced resuscitation courses. Ideally, all doctors, nurses and paramedics should complete basic training in CPR as a ‘core skill’. Ultimately, the aim would be for CPR-AED skills to be included in the National School Curriculum for all 14 year olds (i.e. at an age when children not encumbered with major examinations but mature enough to appreciate the importance of CPR and strong enough to deliver this effectively). This goal has been championed by the European Resuscitation Council’s aptly named ‘Kids Save Lives’^15-16and ‘Restart a Heart’ Campaigns launched in 2013,¹⁷and is supported by the World Health Organisation in 2015.¹⁸So far, five European countries including Belgium, Denmark, France, Italy and Portugal, have mandated the requirement to introduce CPR training onto the Education Curriculum by law, whilst others including Malta have recommended this initiative.¹⁹In practice, however, the introduction of CPR training in schools is still not widespread, even in those countries where this initiative is mandatory.^9,19To-date, both Ministers for Health and Education in Malta have endorsed the ERC’s request to promote the ‘Kids Save Lives’ Campaign and to lobby the World Health Organisation to place CPR training on their annual agenda. Linking CPR training with specific job applications, for example in the hospitality and tourism sector, managerial/supervisory posts in large institutions, factories, etc, and before the award of a valid driving or maritime licence would also boost the number of trained laypersons. The advent of the ‘Good Samaritan’ act that is currently under debate in Parliament will protect both victims and rescuers, and will further encourage bystanders to act without fear ‘of retribution’.

However, training alone without the availability of AEDs is suboptimal, especially in the case of cardiac arrest in adults where fibrillation is present in approximately 25-33% of cases.²⁰At present there are almost 600 AEDs spread around the island, but most are located in private institutions and are not available to the public. Moreover, some of these AEDs are not operative, usually because the battery has lost charge and/or expired.  Although the Malta International Airport, Air Malta planes, Gozo ferries, most schools, banks, some hotels, factories and social clubs, amongst others, do have at least one AED, Malta needs many more in key and accessible locations to be truly ‘covered’. The Victoria Council responsible for the Gozo Citadel has recently taken the lead in this regard and work is ongoing to install 8 AEDs with 24/7 public access in Valletta. A mobile phone AED locator app for Malta is also ‘work in progress’. Malta should strive to install (and maintain) AEDs in most if not all key positions where significant numbers of individuals are likely to aggregate. As in other countries and major cities, the distinctive AED locating sign (a green square with a medical cross, heart and lightning bolt) should be widely distributed and clearly visible in numerous locations. Only this eventuality, combined with a sufficient body of trained bystanders who can initiate CPR and operate an AED, will significantly improve our survival figures for out-of-hospital cardiac arrest and justify all the fuss!

References

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