The chain of survival saves lives. Is it time to add another link?

By Martin Fagan, National Secretary, The Community Heartbeat Trust charity

The key for saving lives, as amply demonstrated by the saving of Christian Eriksen at the Euro’s, was the application of the ‘Chain of Survival’. Very simply - recognise help is needed, call for help, start CPR and then use a defibrillator, followed by rapid transfer to advanced medical care – 5 stages. The Ericksen incident was singularly the largest training session in life saving process anywhere, with 250m people seeing how to save a life. In communities, where there are predominantly untrained users, helping people step onto this ‘Chain of Survival’ should also include helping them overcome the stress and panic of doing something, rather than doing nothing. Time is of the essence.

Saying panic stops lives from being saved sounds like a big claim – but the numbers stack up.

‘Don’t panic’ came to fame in Douglas Adams’ book the ‘Hitchhikers Guide to the Galaxy’. However, this has its place to play in the Chain of Survival, as the initial or pre-emptory step. Panic at the sight of someone experiencing a sudden cardiac arrest can hold us back from stepping in to help.

The first link of the Chain of Survival is to recognise there is an emergency, and then call 999. A better first step would be, ‘Don’t panic’. Panic, and the inability to begin a process is as big a barrier to saving lives as possibly the fear of undertaking CPR. In CPR people are afraid of causing harm, or being sued, both areas that education can address easily. Panic is psychological.

In a paper in 2015 by Graham, et al, National Academies Press (US); 2015 Sep 29., the researchers found that panic can prevent a bystander from helping someone in sudden cardiac arrest, even if that bystander is familiar with CPR.

“Panic may influence readiness to act in an emergency situation irrespective of prior CPR training.  This may, in part, explain why individuals who have had a cardiac arrest are more likely to receive CPR if the arrest is witnessed by strangers as compared to friends or family members.”

The report states that “The immediate, hands-on response of bystanders to cardiac arrest is critical to improve rates of effective resuscitation and, thereby, increase the likelihood of survival and positive neurologic outcomes for OHCA” and survey and focus group studies have identified multiple theories as to why bystanders do not engage in each of these crucial steps:

  1. An inability to recognize an OHCA followed by a delayed activation of EMS,
  2. A lack of adequate CPR training,
  3. Concerns about possible liability, and
  4. Psychological factors, rescuer confusion, and health concerns.

1-3 are easily addressable via training and education programmes. The summary of this report dedicates as much space to assessing the psychological barriers to bystander intervention, as it does physical impediments like lack of training or access to AEDs (automated external defibrillators).

Panic stops rational brain function.  We may be trained in CPR but, in those high-stress moments when someone has collapsed and may be experiencing a sudden cardiac arrest, panic makes that knowledge and experience inaccessible. In public access defibrillation, where the predominant responders are untrained members of the public, there is no training or rational thought process to fall back on, and do a change in the process of the ‘Chain of Survival’ to add a new first step – ‘Don’t panic’.

CPR training, ready access to easy-to-use AEDs with visual displays, and emergency services responsiveness and support to a 999 caller, all contribute to the solution. In preparing for community training programmes, significant should be given to ensuring confidence in the audience as opposed to just solely technical competence.


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