Basic life support. Military background and influence in contemporary teaching of cardiopulmonary resuscitation

Abstract
Cardiopulmonary resuscitation (CPR) is the core component of both Basic Life Support and Advanced Life Support skills. Modern first aid, as a discipline of drills and skills to preserve life and limb, had its genesis in military surgery albeit with a history of barely two centuries. The extension of teaching of first aid skills to members of the lay public was the result of advocacy of military surgeons initially in London in 1878 and subsequently in Australia from 1881. The Australian Defence Force was a foundation member of The Australian Resuscitation Council which was established under the auspices of The Royal Australasian College of Surgeons in 1976, and since that time uniformed members have maintained a significant influence in the sequential development of the policies and practice of CPR teaching in both the military and civilian domains in Australia. This paper reviews the range of high-risk scenarios that may confront any individual, uniformed or civilian, where on-site CPR may be required at any time. The historic and contemporary close links which exist between uniformed health personnel and those of The Australian Red Cross, St John Ambulance Australia and The Royal Life Saving Society are reviewed in this paper. Continued advocacy of “first aid – a skill for all” remains core doctrine for all members of the Defence Health Service Branch within The Australian Defence Force.

Key Words: Cardiopulmonary resuscitation (CPR); Australian Defence Force; Defence Health Service Branch; first aid; military medicine; teaching CPR.

The series of drills and skills that we under¬ stand today as cardiopulmonary resuscitation (CPR) has a history of barely two centuries. 1-3 The development of the doctrine and the teaching of life support skills owes much to military surgeons. Baron Larrey in the Penin¬sula Wars, von Esmarch in Prussia in 1851, and Holger-Nielson in Paris in 1943 each de¬veloped principles of self-help and buddy¬ help, primarily for sick and injured soldiers, on which the concepts of later twentieth century life support techniques have been built (Table 1, over page).

The best discoveries and inventions will not save lives unless bystanders and first responders are trained in the delivery of the system. The military was the fundamental catalyst that enabled the new discoveries of life support to be disseminated to the general civilian public.

When the Imperial troops were removed from Australia in 1870, six of the States developed their own militia volunteer forces, each responsible independently to the Crown in London. Four of these militia forces developed their own Ambulance Corps.

In Melbourne, Surgeon-Major Robert Robertson delivered four public lectures on military first aid between March 1880 and February 1881.3 His unit, the St Kilda Artillery – established to defend the city of St Kilda in Melbourne – opened its teaching classes (segregated by sex) to the public in a pioneering move that was soon to have repercussions throughout Australia. The first civilian ambulance service in Australasia, The City Ambulance Transport Brigade, was established in Brisbane in 1892,4 modelled along the lines of and containing many cross posted positions of the militia Ambulance Corps of the Queensland Defence Force.

Table 1: A chronology of some milestones in the evolution of best-practice Basic and Advance Life Support.

Subsequently, the evolution of lay teaching, 2.3 and the development of pre-hospital systems of trauma care, 6-8 developed into a history of the lay teaching of CPR which has proved to be as important as that of the technical dis-coveries and the development of new equip¬ments themselves (Table 2).

All who work in the area of both training and delivery of pre-hospital CPR feel an identity, indeed a justifiable pride, in being a part of this vigorous development for the better preservation of life. An auditor of life support would, however, point out some chastening contemporary facts. Such are the sobering realities of the new millennium:

• Less than 20% of cardiac arrest victims, in developed countries, receive bystander CPR.
• Survival following cardiac arrest due to ventricular fibrillation is only 9%.
• Survival rates following cardiac arrest in neonatal septicaemic shock remain zero.
• Best-practice survival (40%) for cardiac arrest are associated with call-to-shock times of 5.6 minutes; with non-survivors having a mean call-to-shock response time of 6.9 minutes. Yet best-practice, median response times in metropolitan Australia (some of the best professional ambulance responses anywhere) are 9.5 minutes.
• Only 1.5% of Australians are trained in first aid each year.
• First responders, including doctors in hospital, 15 and CPR instructors, 16 do not like performing mouth-to-mouth resusci¬tation.
• The majority of doctors (UK figures) have received no CPR training in the last five years.
• Only 38% (NZ figures) of junior paediatric doctors know that cardiopulmonary arrest in children is almost always due to hy¬poxia or apnoeic events.

What are the portals by which CPR survival can be improved? The military has a major potential role in this field. This paper discusses some approaches to this issue.

Children – An Audit of Preventible Deaths
Children have comprised a significant com¬ponent of the clinical contacts involving health personnel in Australia’s recent over¬ seas deployments. Can child mortality be re¬duced by a higher rate of better quality, par¬ent and bystander CPR in the community? The overall causes of child mortality in Aus¬tralia are shown in Table 3.

Any reductions in childhood deaths, using CPR as one engine for improvement, must, therefore, focus particularly on road trauma, drowning, burns and mechanical suffoca¬tion. 21 Although accidental poisoning is com¬mon in the 1-3 year age group in Australia and New Zealand, it is very rarely fatal; 22 and in the case of the Sudden Infant Death Syn¬ drome (SIDS), which kills 1 in every 700 chil¬dren in the first year of life, the dead infants are almost always found hours rather than minutes after death, 23 and extensive anecdo¬tal experience suggests that CPR, unlike the preferred face-up sleeping position for in¬fants, will do little to reduce deaths from this enigmatic disease.

Road trauma kills children as occupants of cars, 24,25 as the result of bicycle trauma, 26 and as victims of pedestrian run¬ downs. An extensive autopsy analysis of Australian child road trauma victims, un¬dertaken in my own research unit, has shown that better accident-site maintenance of the airway will save perhaps an extra 8% of such victims. 24 In this study, 48% of 1,369 chil¬dren killed on the road had significant facial trauma and 33% of these had aspirated blood or foreign material prior to cardiac asystole. Similarly, a recent study of fatally burnt chil¬dren, as part of the Brisbane Child Trauma Study, has shown that 5% could probably be salvaged by airway clearing and maintenance in the pre-hospital phase. 27

It is in the area of accidental drowning that the greatest window-of-opportunity ex¬ists for further CPR-driven mortality reduc¬tion. Drowning in Australia continues to cause a third of all deaths in the 0-4-year-old group; 20 and the rate, always high in the past two decades, continues as one of the highest by international comparison. 26

My own research in the Brisbane Drowning Study has shown that 30% of tod¬dler drowning fatalities can be turned into survivors, simply by the first responder hav¬ing been trained in CPR. 29,30I believe the reason for this is not simply the better technical CPR delivered by a trained first responder (almost always a parent, grandparent, sib, neighbour or childcarer), although such is very important. I believe such improved sur¬vival is due also to the fact that trained first aiders are more likely to initiate CPR earlier than those who have never attended a basic life support course. A number of those re¬suscitators, accidentally “on-the-spot”, were ADF or ex-ADF personnel who had been trained in first aid. The difference between potential fatality on the one hand and salvage on the other is a brain hypoxic time of less than 5 minutes in this age group. 30,31

Timely and skilled CPR not only saves lives, but it saves brains in survivors. Al¬though 97% of near-drowning survivors do not have hard neurological signs, 30,32 one third have some impairment of the islets of higher intellectual functioning. Such chronic hypoxic damage is measured by wide sub¬scale disparities on formal psychometric testing of survivors. 33 The “urgency of immer¬sions”, as a major preventable cause of toddler mortality and morbidity, remains topical in all tropical and subtropical countries of the developed world, as the new millennium commences.

Children – Cardiopulmonary Arrest
Almost all paediatric cardiopulmonary arrests are due to hypoxia, 11.18 irrespective of whether such arrests involve neonates, in¬fants or older children. 11 Cardiac dysrhythmias are rare and account for less than 5% of cardiac arrests that affect neonates who re¬quire CPR; 11,15 and less than 8% of children up to the age of 15 years who suffer cardiac arrest.

The principal causes of cardiac arrest in children are SIDS, drowning and asthma. Studies of 12,490 persons with cardiac arrest treated by the Ambulance Service of New South Wales have shown that in the case of children under 5 years of age, defibrillation for ventricular fibrillation (VF) comprises less than 0.02% (9 of 5,047) of all cases of VF. In current practice, even with high rates of pre¬ hospital paramedic-administered defibrilla¬tion, young children with VF have zero sur¬vival.

A summary of realistic salvage by improved first-responder CPR, which involves child victims, is shown in Table 4.

How can these potential improvements be translated into practice? How can motivation or legislative requirements for CPR be im¬proved? Two obvious suggestions are (a) cur¬rent first aid certificates should be a require¬ment for the issue of all new driving licences, and (b) a current first aid certificate should be held by all owners of swimming pools. Such requirements have long been sug¬gested, 36-39 but one maintains an unapologetic advocacy concerning their desirability. The young heart is a great substrate for CPR. In the case of neonates who have suffered a cardiac arrest precipitated by an acute and reversible event, 64% will survive CPR to leave hospital. 11 Our analyses as part of the Brisbane Trauma Study suggest that the cor¬responding figure for infants and older children exceeds 35%, and that more than 95% of these will have intact brains.

Seven of the last ten of Australia’s international operational deployments have involved humanitarian health care of indigenous children in Africa, Asia and Papua New Guinea. All servicemen and women – not just military doctors, dentists, nurses and medics – need to be skilled in paediatric CPR, just as they are in adult life support skills.

Pre-Emptive Action – Early Recognition of Symptoms
Cardiopulmonary resuscitation will be inevitable for many potential adult victims of cardiac arrest. One way of improving the success of CPR is to delay those factors that precipitate its necessity from out-of-hospital sites to a place where skilled techniques with on site defibrillation are available. This apparently cold-blooded, but realistic approach means better education of the public about premonitory signs and symptoms of diseases that will progress to cardiac arrest. Dr Ian Banks, chair of the [U.K.] Men’s Health Forum, notes that: –

The [UK] Doctor Patient Partnership has joined forces with the Men’s Health Forum and the British Heart Foundation to launch the campaign entitled “Chest Pain: What men should know”. Clinical details in lay-friendly language have been placed in the Angling Times and in the programmes of four premiership football games. Currently, on-site defibrillation teams of St John Ambulance Australia personnel who support the public at the Australian Football League (AFL) in Melbourne have highlighted the particular risks of football-crowd excitement to the cardiac arrest-prone group. Successful resuscitation rates for VF, exceeding 45%, have been achieved and long-term survival follow-up rates are awaited with great interest.

A similar approach – first aid training to promote the earlier recognition of symptoms before out-of-hospital cardiac arrest occurs – offers a hope of reducing the need for CPR, and of increasing post-CPR survival rates for children with cardiac complication of bacteraernic shock. First aid classes offer an important portal of teaching about the natural history of serious illness in all age groups. Currently, in-hospital CPR success rates for children who sustain cardiac arrest in bacteraernic shock remain close to zero

High Risk Adult Patients
One obvious stratagem to ensure that first¬ responders are trained in CPR is to target the families of high-risk patients. Although such seems obvious, 41 in practice the students in first aid classes tend to be younger adults or those in the occupational work force. Training needs to be targeted to those who are most likely to be bystanders at a cardiopulmonary arrest. 42

A good place to start is with doctors themselves, whose relatively poor perform¬ance of CPR skills has been described in several studies. 43 General medical practitioners and hospital doctors are frequently called upon to perform CPR, usually on patients in the GP’s surgery, during therapy sessions or sometimes in X-ray departments. 44 The initial survival rates from such are high, 43 a testa¬ment to the value of early bystander CPR, a factor independent of quality reperfusion of the hypoxic brain and heart.

One area where high-risk patients oc¬cur in a closed environment is that of inter¬national air travel In-flight and in-terminal incidents requiring first aid are not uncom¬mon. 45 In 1995, 1.5 billion passengers flew on the world’s commercial airlines; and of these four million suffered sudden illness or were injured and required first aid. 46 The number of air passengers is expected to dou¬ble by 2005. 46 Currently, 1,000 lives are lost annually, in-flight, from cardiac arrest on the world’s commercial aircraft. 47 Until Qantas’ pioneering use of in-flight semiautomatic de¬ fibrillation,48 most US and Australian carriers diverted to the nearest airport after in-flight cardiac arrest. In spite of this (expensive, dis¬ruptive but altruistic) policy, no passenger survived asystole or idioventricular rhythm (IVR). Within five years of the introduction of in-flight semiautomatic defibrillators (with flight attendants trained in their use) by Qantas in August 1992. the monitoring defi¬brillator had been used in 46 cases of cardiac arrest which had occurred in-flight or at an airline terminal Twenty-three of these had VF, and of these 6 (26%) have
been long term survivors. 48 My personal experience with St John Ambulance Australia courses for defi¬brillation is that a major benefit is the win¬dow-of-opportunity which is opened to reskill the drills of airway clearance, expired air re¬suscitation (EAR) and external cardiac corn¬ pression (ECC). Military personnel in uniform, travelling in the air, have an inescapable duty to help with in-flight emergencies.

Matching potential patients together with potential resuscitators, the latter equipped with automatic defibrillators, is a challenge to all charged with the community training of CPR. The St John Ambulance Australia programme, “Every Parent a First Aider”, exemplifies this point. 49-51 The most obvious group for targeting for improved CPR training comprise the partners of older sub¬jects who are at high-risk for cardiac arrest. Research has shown, however, that motiva¬tion to learn CPR skills is not naturally or spontaneously high in this group of “at-risk relatives”.41 This is probably because of ego¬ defence mechanisms of denial of the potential risk of death in a loved one, or for aesthetic reasons, or perhaps because of a fear of po¬tential failure should one’s skills be insuffi¬cient to save the life of a loved one. Whatever are the reasons, the potential matching of high-probability resuscitators with their CPR instructors remains an unmet challenge the contemporary Australian community.

Elitism and CPR
There is an attitude abroad that the drills and skills of CPR are somehow the province of the medical domain, rather than being a skill of equal validity and status for every citizen; and for every serviceman and woman. Such an attitude also exists in some groups within the Defence forces. Studies have demonstrated consistently that it does not matter who ad¬ministers CPR. 12.47,52,53 Paramedics achieve the same or better survival results when compared with doctors, and trained fireman and police have the same success rates as ambulance officers. In doctor-lifesaver teams on the Australian beach, trained surf life¬ savers act with equal validity as the principal with the doctor as assistant.

In the Brisbane Drowning Study one-third of rescuers were older children; 29-31,33 and in two instances in which I was profes¬sionally involved, it was pre-adolescent sibs who had been coincidentally trained in Royal Life Saving Association classes at school, who unquestionably successfully resuscitated ap¬noeic and pulseless victims whom they had pulled from the water. The need for CPR training in secondary schools, long advocated, 30,54 remains the exception rather than the rule. An exception are the splendid rescue and resuscitation training programmes con¬ ducted by the Royal Life Saving Society of Australia. Video and multi-media self-training CPR programmes have the potential to reach some individuals unlikely to participate in traditional classes. 55 Peter Safar, the founder of expired air CPR in 1958, has noted 40 years later that it is the motivation and skill acquisition of all members of the public which has the current highest priority – higher even than some of the minutiae of the hands-on CPR techniques themselves.

Prevention
In one sense, the need for CPR is a failure – a failure of preventative approaches. In that CPR offers a second chance for life itself, it offers afresh a second chance of effective prevention. This applies as equally to the potential victims of myocardial infarction as it does to the apparently drowned child pulled from a back garden swimming pool. In the context of severe trauma there are three portals for primary prevention:

• education and public media campaigns;
• better ergonomic design to reduce poten¬tially fatal hazards in the environment; 36 and safety legislation.

First aid and improved systems of pre hospital care are a fourth portal of prevention. Such is secondary prevention; and from the purist point of view of public health, in one sense such attempt to shut the stable door on death after the spark of life has all but bolted.

If one takes childhood drowning as an example, we have been able to identify 16 potential links in the drowning chain of any individual child. 35 Such start with a toddler wandering into the vicinity of an unprotected water hazard and end with a non-responding hypoxic heart in asystole in the emergency room of the local hospital. This “hypoxic march” can be reversed at any step between the moment of voluntary breath-holding to the final point of irreversible hypoxic brain damage. 30 Effective and timely bystander¬ operated CPR does not prevent the drowning episode in the first place; but, from the vic¬tim’s point of view, recovery with an intact brain is all that matters. If this is achieved through secondary prevention – good CPR – then that is all that matters.

Preventive First Aid
CPR as secondary prevention of death or hy¬poxic brain damage is a concept distinct from that of preventive first aid. This latter term, 59 first coined in 1989, 60 has as its fundamental ethos the philosophy that a component of all CPR and first aid courses should contain an explicit, preventative module. There are as yet no reported studies to show the preventive effectiveness of CPR courses that would with¬ stand the audit of the contemporary demands of evidence-based medicine. However, experi¬ence of injury reduction following saturation first aid courses in the mining industry in Tasmania and in the timber industry in Can¬ada are very encouraging indeed in this re¬gard. Many volunteers who attend courses of first aid are by their nature caring and con¬cerned individuals who have already recognised the risks; and are by nature just the sort of person who will take steps to reduce hazards which might lead to the necessity for CPR. In other words, there may not be a di¬rect cause-and-effect relationship between CPR training and subsequent reduced rates of illness and injury. Much research needs to be undertaken in this area. Currently, Rotary International in Australia is promoting a tri¬ennium of research that will offer an oppor¬tunity to study further the preventive power of CPR. That body, together with the 16 or¬ganisations which comprise the Australian Resuscitation Council, 61do much to reduce the need for CPR in the first place. The Australian Defence Force is one of these compo¬nent organisations which acknowledges that life-support skills, when needed, respect no rank, corps, posting or status. For those who are confronted with an apnoeic or pulseless casualty, skilled resuscitation offers the won¬drous opportunity of reigniting the spark on which we all depend.