The use of Mechanical CPR Devices in a pre-hospital setting: A review of the literature with recommendations for clinical utilization

Author: Peter Thorpe

Published in: Autumn 2018 Edition of Ambulance Today Magazine

Mechanical cardio pulmonary resuscitation (CPR) has promised to improve outcomes for patients in both hospital and out of hospital setting by improving the quality and consistency of CPR, essential in improving survival rates from cardiac arrest. The efficacy of mechanical CPR has been evidenced in laboratory conditions and staged testing. Results showed more consistent refractory periods, more consistent depth and rate, and when used in a moving vehicle potentially remove the need for paramedics to ride unrestrained. While it is likely that mechanical CPR devices have a role to play in pre-hospital medicine where manual CPR is not possible, difficult or as a bridge to advanced therapies, there are still questions on their role other than in very specific situations and in relation to patient outcomes.

However, despite questions about the clinical effectiveness of mechanical CPR devices many EMS systems and First Responder organizations are deploying these expensive items to an increasing number of ambulances and responder units for general use. In some cases, more effective and evidenced-informed interventions1 may have not been implemented e.g. Telephone CPR, Public Accessible Defibrillator databases, crowd sourced bystander CPR applications and public CPR learning events.

This article looks at the evidence for implementation of a mechanical chest compression device in an EMS System, reviewing literature for both the PhysioControl LUCAS Chest Compression System2 and the ZOLL AutoPulse Resuscitation System3 mechanical CPR devices and is intended to start a conversation. However, an underlying question is that as EMS, either health-based or public safety-based, continues to grow and as we adopt new technologies, do we need to be more rigorous in assessing the clinical effectiveness of the devices we deploy?

To investigate the use of mechanical CPR here in the Canadian province of British Columbia we wanted to understand in more detail the evidence supporting mechanical CPR devices and in particular the LUCAS and AutoPulse devices. We wanted to develop internal BCEHS4 recommendations on the use of mechanical CPR devices as well as outlining areas where we felt more research is needed to support their wider use in pre-hospital medicine.

MARKETING OF MEDICAL DEVICES

Firstly, let’s discuss the marketing associated with medical devices. Manufacturers of medical devices and pharmaceuticals have spent many years honing their skills in selling products to medical professionals and not always to the patient’s good, as we have seen in the current opioid crisis. There is no suggestion of harm being caused on the scale of the current opioid crisis by the use of mechanical CPR devices, but a question: Are we as experienced in dealing with manufacturers as we think we are?

Both PhysioControl (LUCAS) and ZOLL (AutoPulse) as manufacturers have made easily-accessible materials available describing their products and how they can impact outcomes. Obviously, I must state openly for balance that my limited summary below of this information is biased as I have focused on contradictions in these materials. Some of the research quoted does offer support for the use of both LUCAS and AutoPulse in the management of out-of-hospital cardiac arrest. There is also no suggestion that any researchers involved in these trials were not transparent about their industry funding, contracts or positions within the manufacturer’s organizations. However, in my view there is currently no clear high-quality definitive evidence to suggest that mechanical CPR is superior to, or more effective than, manual CPR in a pre-hospital setting in these papers.

The LUCAS Bibliography5 summarises the PARAMEDIC6 trial telling us ‘…there was no evidence of improvement in 30-day survival with LUCAS 2 device compared with manual compressions, but it was noted that actual use of the LUCAS device in the LUCAS group was low’. However, it misses the finding: ‘The trial was unable to show any superiority of mechanical CPR and highlights the difficulties in training and implementation in a real-world EMS setting’.

The ZOLL website7 for AutoPulse makes a number of statements around efficacy of iA-CPR. The website includes the following statement: ‘Multiple trials confirm the AutoPulse is superior to manual CPR when it comes to increasing a patient’s odds of achieving return of spontaneous circulation (ROSC)’.


Of the papers referenced that support this, Steinmetz et al8 investigated the implementation of the 2005 European Resuscitation Council guidelines9. In this investigation data including AutoPulse use was only found in the second arm of the trial after the implementation of the new guidelines were made. In discussion investigators say: ‘We do not know what role the chest compression device played in relation to overall improvement in survival as the apparatus was only associated with improved ROSC at admission but a significantly worse 30 day survival rate. The chest compression device was only used in 77/419 of the cardiac arrests resuscitated. From this we can hardly claim that the AutoPulse was fully implemented in our unit’. Of those studies that did demonstrate improved outcomes for mechanical CPR included in this section of the Zoll website caveats included – ‘not statistically significant’10, ‘…research is needed to further define the value of LDB in resuscitation’11 or ‘…may improve the overall likelihood of sustained ROSC…’12.

The reason I highlight these cases, from both LUCAS and AutoPulse literature, is to highlight the need to evaluate the Class of Recommendations (i.e. strength) and the Level of Evidence (i.e. quality) of evidence we are given on interventions.

Evaluating clinical research using, for example, the AHA framework13 allows consideration of the Class of Recommendations. Language may include words such as ‘indicated/useful/effective/beneficial’ which are strong recommendations or ‘may/might be considered’ which are classed as weak recommendations. For Level of Evidence; Level A is high quality evidence from more than one RCT, while Level C-LD includes randomized or non-randomized observational or registry studies with limitations of design or execution and a lower level of evidence.

Our challenge is to evaluate all available evidence, in a framework that allows us to synthesis findings into a risk-based, decision-making process around the introduction of new technologies, procedures or medications. The point I want to make is this: Are we fully investigating the effectiveness of equipment being deployed or are we willing victims of marketing collateral?

LITERATURE REVIEW

Early Trials: Earlier porcine trials of the mechanical CPR devices14,15, conclude that they contributed to better circulation in resuscitation from Ventricular Fibrillation than manual CPR. A more recent study reported in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine16 also supported this finding using a load-distributing band that improved ventilation and hemodynamics in a porcine model of prolonged arrest. This study found that the use of LDB ‘…significantly improve the hemodynamics and respiratory parameters during resuscitation, dramatically producing greater passive ventilation, which can improve gas exchange during CPR…’

CPR quality during ambulance transport: A series case study17 on the quality of CPR in Europe (n176) found that chest compressions in out-of-hospital cardiac arrest (OHCA) were not delivered consistently and most were too shallow. ECG analysis and defibrillation accounted for only small parts of these gaps. A similar study comparing the LUCAS device and manual CPR using manikins undertook 16 simulated eight-minute ambulance transports18. In the transports using manual CPR there were variations in quality not seen in those involving the LUCAS device. The trial noted limitations but hypothesised that the LUCAS device was a reliable alternative to manual CPR in transport situations, stating that further clinical studies were required to inform this hypothesis.

Paramedic Safety: Provision of manual CPR in a moving vehicle is difficult and increases the risk of paramedic injury; however, there was limited research found in this area. In Hong Kong a study19 found that 60% of responding paramedics (n318) complained of discomfort when delivering CPR (in any setting), with a sub-cohort associating CPR to back injuries. The use of mechanical CPR devices for prolonged periods of CPR may reduce the risk of musculoskeletal injuries to paramedics and other emergency responders.

Patient Harm: Investigation into harm caused by L-CPR devices20 found that in patients with unsuccessful CPR following OHCA there was no difference in the incidence of sternal fractures compared to patients receiving manual CPR. While the study noted a higher rate of rib fracture, no injury sustained was found to be fatal. Paradis NA et al21. in an abstract for the California AutoPulse Quality Assurance Registry published in Circulation (2009) comments: ‘Adverse events are only rarely reported by EMS personnel and do appear more common in patients treated with the iA-CPR device’. Couper et al22. in their review of mechanical CPR suggest that there is no overall difference in injury rates caused by chest compressions in both the CIRC23 and LINC25 trials, but there are differences they say in the injury patterns. In all of these papers it is stressed that the instance of potential injury was low.

Patient Outcomes: Findings of a large US population-based study (n80861) into survival from OHCA was published in a CARES Research Letter24 (all types of mechanical CPR devices). It concluded that ‘mechanical CPR for routine cardiac arrest care was associated with worse outcomes’. Outcomes were based on survival rates (11.3% manual CPR, 7% mechanical CPR) and favourable neurological outcome survival (9.5% manual CPR, 5.6% mechanical CPR). It noted that data on the time of arrest, time of first CPR and timing of interventions were not reliably reported, including any delays in time to first de defibrillation. Importantly it also highlighted variations in the use of m-CPR across agencies. The median use was 43.9% (21.7% in >75% of responses and 37.7% in <25% of responses). Similar outcomes for both survival and neurological outcomes were evidenced where the use of mechanical CPR exceeded 50% of responses.

The LINC Randomized Trial25, funded by PhysioControl, was a multi-centre clinical trial (n2589) comparing manual CPR and LUCAS device with measures at 4hrs and secondary end points of survival at 6months and CPC score. During the trial changes were made to the resuscitation protocol for patients receiving mechanical CPR with an initial shock prior to analysis and 3min CPR cycles. A noticeable difference in study cohorts was the time to first defibrillation with the mechanical CPR cohort 90 seconds later than the manual CPR cohort. This trial concluded that mechanical CPR using the LUCAS device can be delivered without major complications with no difference in 4hr survival between groups. Researchers stated that mechanical CPR ‘…did not result in improved outcomes compared with manual chest compressions’ and that further investigation of the amended resuscitation protocol was needed.

The CIRC23 trial with centres in the US and Europe, compared manual CPR to mechanical CPR using AutoPulse. In the introduction the researchers acknowledged that mechanical CPR would never fully replace manual CPR however they state that ‘…there was a need for another randomized clinical trial comparing manual and integrated mechanical CPR, where a patient receives manual compressions while the mechanical device is deployed’. The trial enrolled n4753 patients with 49.6% (n2099) receiving CPR using AutoPulse and 50.4% (n2132) receiving manual CPR. The findings across all three measurements: sustained ROSC to ED (iA-CPR 28.6% vs manual CPR 32.3%); 24 hour survival (iA-CPR 21.8% vs manual CPR 25.0%) and to hospital discharge (iA-CPR 9.4% vs manual CPR 11%) met the criteria for equivalence (odds adjusted ration of 1.06).

The trial protocol, developed by ZOLL with the principal investigator, used a complicated double triangle statistical test design which in the author’s own words ‘…is unfamiliar to many in this field’. With this statistical model their conclusion that ‘…compared to high quality manual CPR, iA-CPR resulted in statistically equivalent survival to hospital discharge’ is supported in their findings.

The inclusion of the CIRC 23. trial in a subsequent meta-analysis, Gates et al26. has raised questions around the design, including missing neurological data at discharge and the exclusion of some data from one centre. The authors of this meta-analysis go as far as to suggest that ‘…the conclusion of “equivalence” in this situation is questionable’.

Wyer 27. in commentary of Bonnes et al 28. meta-analysis of randomized and observational studies reminds clinicians and researchers of well-established patterns of effect going on to say: ‘In OHCA, mechanical compression devices and other failed interventions…may restore cardiac function in the field and increase hospital admissions (and the cost of care) but are unlikely to improve patient survival to hospital discharge’. He suggests that: ‘Clinicians should look beyond new drugs and devices, focus on the basics of effective CPR, and await well-controlled clinical trials framed to test basic assumptions.

Neurological Outcomes: Most of the primary end points of trials for mechanical CPR have focused on ROSC. Arguments for this include variations in post-arrest treatments in hospital and post-resuscitative care. These trials have posited that this is the most appropriate measure of effectiveness for these devices, even when the period of ROSC is as low as one minute. Other trials have been poor at collecting neurological data with CIRC 23. missing 27% of data on this outcome at discharge in part due to the study design.

Newberry et al 30. explored this important measure and points to some interesting observations. Their retrospective observational study compared outcomes of n3,469 patients over a 36-month period. While their data showed mechanical CPR as being associated with poor neurological outcomes, once adjusted by logistical regression for confounding variables the outcomes were similar. They suggest that advanced airway management and medications may be the root cause of the poorer outcomes with higher rates of endotracheal intubation and epinephrine use with mechanical CPR devices. They suggest that current resuscitation protocols are developed around manual CPR and the greater efficiency of mechanical CPR may, for example, increase the toxicity of epinephrine. They suggest that due to these poor neurological outcomes: ‘The continued use of mechanical CPR devices should be limited until further investigation better defines the optimal medication dosages and airway management when mechanical CPR devices are utilized’.

DISCUSSION:

Early trials concluded improved consistency with the use of mechanical CPR and improved blood ow during CPR. These factors have not been disproved and subsequent trials have confirmed that these benefits are realistic. However, the advantages they should give during resuscitation have not been clearly evidenced in subsequent clinical trials and particularly in patient-oriented outcomes.

The risk of harm during transport for OHCA patients and paramedics alike has been mitigated significantly as protocols for discontinuation of resuscitation have been adopted. This has reduced the numbers of patients being transported to emergency departments with ongoing CPR in transit. However, for the small number of cardiac arrest patients with a treatable cause being transported this risk still exists. In addition, more at risk cardiac patients 31,32. are now being transported to specialized cardiac services by EMS based air critical care programs. With manual CPR being impossible in aircraft, cardiac arrest protocols for pre-flight application are now common.

While there is some evidence that mechanical CPR devices have caused injury to patients there does not appear to be a body of evidence to call on to support this as a significant factor in their use. In fact, in many cases manual CPR is given prior to the application of mechanical CPR and those injuries may have resulted from the manual CPR. Most of the research in this area, Couper 22. suggests, relies on autopsy and radiography which are not systematically collected or reported. The low level of evidence in this area coupled with the suggestion that there is a potential risk for some patients though cannot be ignored when considering wide spread deployment of these devices.

The CARES Research Letter 24. suggested potential adverse outcomes with low rates of mechanical CPR device application. However, survival and neurological outcomes for patients where the application of mechanical CPR devices was high was consistent with manual CPR, suggesting potential issues with training and confidence in their use. Many trials have raised the need for a comprehensive and ongoing training package to be linked to the use of mechanical CPR. CIRC 23. with its long lead in period and training program reported favourable outcomes. PARAMEDIC6 trial reported concerns around training and maintenance of competency in the use of mechanical CPR devices. During this trial (n4471) 40% of the mechanical CPR cohort did not receive mechanical CPR. Within this group 15% did not receive mechanical CPR ‘because of difficulties inherent with implementation of new equipment and the training and quality issues’, the conclusion recommended that ‘research should look to de ne the optimum method and frequency of such training’.

Targeted rather than general deployment could help with skills retention for practitioners, higher usage rates and allow for easy identification of any remedial training requirement.

The LINC Randomized Trial 25. demonstrated comparable outcomes but involved changes to resuscitation protocols for those receiving mechanical CPR with the authors suggesting further investigation into those changes. Newberry 30. also raises the question of the use of standard resuscitation protocols for mechanical CPR rather than amended protocols that may be better suited to their use. While this is supposition it may in some part explain why survival rates from mechanical CPR do not consistently match or better cases where manual CPR is provided.

RECOMMENDATIONS:

The review found no body of empirical evidence demonstrating improved survival rates associated with the use of mechanical CPR. However, there are occasions when manual CPR is ineffective and mechanical CPR has a place, including as a bridge to advanced therapies. Despite results not confirming the superiority of mechanical over manual CPR many researchers suggest exactly this conclusion while stressing the need for comprehensive training regimes. Taking these factors in to account we developed three internal BCEHS recommendations:

1. Mechanical CPR devices may be used in the following circumstances: transfers with medical/hospital teams; approved clinical trials; high angle patient rescue; confined space retrieval or transport e.g. airvac; hypothermic cardiac arrest retrieval and transport.

High quality manual CPR would be difficult in all these circumstances. The risk of re-arrest in some cases may be high and the pre-placement of a mechanical CPR device could be considered in confined spaces such as aircraft. Mechanical CPR devices may have been placed correctly by hospital teams prior to arrest or during advanced therapies e.g. ECPR and removing them would cause patient harm or the cessation of those therapies.

2. If already applied by an appropriately trained person and the number of responders does not allow for an appropriate rotation for HQ-CPR then the device can remain in situ until enough responders are available. In addition, if the patient is transported then it may be left in situ to reduce the risks associated with CPR in a moving vehicle.

One explanation for poorer survivability rates with mechanical CPR devices are delays in treatment while devices are applied. Removing them therefore may also cause further delays in treatment. Misplacement of devices or technical issues with them may raise the risk of injury to patients and delay other treatments, therefore requiring trained staff to travel with the patient. The numbers of patients being transported with CPR enroute is low and often this is with treatable causes e.g. post-trauma, immersion or hypothermic arrest. If CPR is indicated for treatment and a device has been applied unless high quality CPR is possible it should ideally not be removed.

3. The term ‘appropriately trained person’ includes: First Responders dispatched by BCEHS who have advised of their intent to use; hospital medical teams; members of the BC Search and Rescue Association (BCSARA) and Canadian Coast Guard and/or Canadian Armed Forces Medical Teams, if trained and used by them.

Currently BCEHS is a partner in the CanROC ECPR (ECMO)33 study for refractory out-of-hospital cardiac arrest with the study protocol including the pre-hospital placement of LUCAS device on the study population. It may be possible depending on evidence from that trial that at a later stage a cohort of BCEHS Specialist Paramedics or Advanced Care Paramedics may join this list of appropriately trained persons.

CONCLUSION

Many studies and meta-analyses have recognised that outcomes with mechanical CPR especially survival to discharge, neurological status and in some cases ROSC alone, do not either match or surpass results where high quality manual CPR is possible and provided. However, it’s clear that mechanical CPR has its place where manual CPR is not possible or difficult, or as a bridge to advanced therapies.

The question though remains why mechanical CPR with its advantages does not perform as well as manual CPR with all its inherent challenges? The fact that one of the biggest trials, CIRC23 of a mechanical CPR device involved a complex statistical analysis to evidence only equivalency adds to the concerns regarding the empirical evidence supporting mechanical CPR.

Evidence suggests that use of mechanical CPR does not lead to improved survival rates and neurological outcomes, but have we truly compared consistent measures in these trials? Wyer27 reminds us that we need to understand patterns of effect. Is there bias in the belief that the use of mechanical CPR leads to worse outcomes because it’s not proven otherwise, or is the reality that the use of mechanical CPR restores cardiac output temporarily for patients that previously would have treatment terminated on scene? Meta-analysis of data relating to in-field discontinuation of resuscitation between mechanical CPR and manual CPR may also inform the discussion around differences in survival rates.

Has statistical analysis truly compensated for confounding variables when looking at survival rates between manual CPR and mechanical CPR? The reality may be that 30- day survival rates are no worse or even better for mechanical CPR than when every cardiac arrest patient was transported to hospital with no in-field discontinuation of resuscitation.

Newberry et al.30. also questions treatment guidelines and protocols used for resuscitation with mechanical CPR devices as they are based on the research and physiological response to manual CPR. LINC25 addressed this with changes to the resuscitation protocol for those patients being treated with the LUCAS device, suggesting that further understanding of the impact of these changes was required.

New evidence may come from clinical trials looking at outcomes for OHCA patients with resuscitation protocols around airway management, pharmacological protocols and discontinuation of resuscitation designed specifically for use with mechanical CPR devices. These may answer the question of why mechanical CPR does not appear to perform as well as manual CPR.

It is obvious that mechanical CPR technology should not be dismissed or ignored for OHCA. The value of mechanical CPR devices in the field to support ongoing hospital therapies is recognised, many post-arrest patients are being transported by air medical transport to centres of care and no doubt there will be improvements in design and training for their use.

LOOKING TO THE FUTURE?

It is said that one should always end on a positive note. A 2009 French34 study took three groups of French Red Cross First aiders (n80) who were unfamiliar with AutoPulse and with minimal awareness (one group had two illustrations, one had four illustrations and the final one had a five minute video and familiarisation time with the device) and asked them to place on a manikin. With this small amount of training the last group (video and handling) were able to place the device with no errors in placement in 19 seconds and the time to first compression was 48 seconds.

In an environment where we coach CPR and guide the use of an AED on the phone, is it unreasonable to expect to see the use of mechanical CPR devices by the general public and for them be as common as AED’s or re extinguishers in buildings once we have the answer to the questions posed here?

REFERENCES

1. 10 Steps for Improving Survival from Sudden Cardiac Arrest, Resuscitation Academy, Seattle: http://www.resuscitationacademy.org/downloads/ebook/TenStepsforImprovingSurvivalFromSudde nCardiacArrest-RA-eBook-PDFFinal-v1_2.pdf

2. PhysioControl LUCAS http://www.lucas-cpr.com/en/lucas_cpr/lucas_cpr

3. Zoll AutoPulse https://www.zoll.com/medical-products/resuscitation-system/autopulse/ems

4. http://www.bcehs.ca/ and http://www.bcehs.ca/about-site/Documents/Fact%20Sheet%20BCEHS.pdf

5. http://www.lucas-cpr.com/doc_en/LUCAS%20Selected%20Bibliography%20Summaries_3312304_C_ LR.pdf

6. Perkins et al. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial. Lancet 2015; 385: 947-55

7. ZOLL AutoPulse Clinical Studies

8. Steinmetz J, et al. Improved survival after an out-of-hospital cardiac arrest using new guidelines. ACTA ANAESTHESIOLOGICA SCANDINAVICA doi: 10.1111/j.1399-6576.2008.01657.x

9. https://www.resus.org.uk/archive/guidelines-2005/

10. Jennings PA. at al. Ef cacy of AutoPulse compared with standard chest compressions for out- of-hospital resuscitation: A matched case–control study. Resuscitation Vol 81 Issue 2 Supplement Page S20

11. Ong MEH et al. Use of an Automated, Load-Distributing Band Chest Compression Device for Out-of-Hospital Cardiac Arrest Resuscitation JAMA, June 14, 2006—Vol 295, No. 22
12. Casner M, et al. The impact of a new CPR assist device on rate of return of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2005 Jan-Mar:9(1):61-7.

13. https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-2-evidence- evaluation-and-management-of-con icts-of-interest/
14. Steen S et al. Evaluation of LUCAS, a new device for automatic mechanical compression and active decompression resuscitation. Resuscitation 55 (2002) 285-299

15. Rubertsson S, Karlsten R. Increased cortical cerebral blood ow with LUCAS; a new device for mechanical chest compression compared to standard external compressions during experimental cardiopulmonary resuscitation. Resuscitation 65 (2005) 357-363
16. Wang et al. Load-distributing band improves ventilation and hemodynamics during resuscitation in a porcine model of prolonged cardiac arrest. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:59

17. Wik L et al. Quality of Cardiopulmonary Resuscitation during out-of-hospital Cardiac Arrest. JAMA (2005) Vol 293, 299-304
18. Fox J, Fiechter R et al. Mechanical versus manual chest compression CPR under ground ambulance transport conditions. Acute Cardiac Care, 15:1, 1-6

19. Jones AYM, Lee RTW (2005) Cardiopulmonary resuscitation and back injury in ambulance of cers. Int. J Occup Environ Health 78: 332-336


20. Smekal D, Lindgren E, Sandler H, Johanseen J, Rubertsson S. CPR-related injuries after manual or mechanical chest compressions with LUCASTM device: A multicentre study of victims after unsuccessful resuscitation. Resuscitation 85 (2014) 1708-1712

21. Paradis NA et al. Abstract P74: The California AutoPulse Quality Assurance Registry. Circulation 2009; 120:S1457

22. Couper et al. Mechanical devices for chest compression: to use or not to use. Curr Opin Crit Care 2015, 21:188-194

23. Wik et al. Manual vs. integrated automatic load-distributing band CPR with equal survival after out of hospital cardiac arrest. The randomized CIRC trial. Resuscitation 85 (2014) 741-748

24. Buckler DG, Burke RV, Naim MY, MacPherson A, Bradley RN, Abella BS, Rossano JW for the CARES Surveillance Group. Association of Mechanical Cardiopulmonary Resuscitation Device Use With Cardiac Arrest Outcomes. Nov 2016.

25. Rubertsson S et al. Mechanical Chest Compressions and Simultaneous De brillation vs Conventional Cardiopulmonary Resuscitation in Out-Of-Hospital Cardiac Arrest: The LINC Trial. JAMA. 2014; 311(1); 53-61

26. Gates et al. Mechanical chest compression for out of hospital cardiac arrest: Systematic review and meta-analysis. Resuscitation 94 (2015) 91-97

27. Wyer P. Review: Mechanical and Manual CPR do not differ for survival or neurological outcome in out-of-hospital cardiac arrest. Annals of Emergency Medicine ACP Journal Club April 2016

28. Bonnes JL et al. Manual Cardiopulmonary Resuscitation versus CPR Including a Mechanical Chest Compression Device in Out-of-Hospital Cardiac Arrest: A Comprehensive Meta-analysis From Randomized and Observational Studies. Annals of Emergency Medicine 2016 Mar;67(3): 349-360

29. Westfall et al. Mechanical Versus Manual Chest Compressions in Out-of-Hospital Cardiac Arrest: A Meta-Analysis. Crit Care Med. 2013 Jul;41 (7): 1782-1789

30. Newberry R et al. No Bene t in Neurologic Outcomes of Survivors of Out-of-Hospital
Cardiac Arrest with Mechanical Compression Device. Prehospital Emergency Care, 2018 May- Jun;22(3):338-344

31. Salcido et al. Incidence and outcomes of rearrest following out-of-hospital cardiac arrest. Resuscitation 2015 Jan;86:19-24

32. Jabbari et al. Incidence and risk factors of ventricular brillation before primary angioplasty in patients with rst ST-elevation myocardial infarction: a nationwide study in Denmark. J Amer Heart Assosc. 2015;4:e001399

33. Extracorporeal Cardio-Pulmonary Resuscitation (ECPR) using Extracorporeal Membrane Oxygenation (ECMO) BC ECPR Trial for Out-of-Hospital Cardiac Arrest NCT02832752

34. Lapostolle et al. Use of an Automated Device for External Chest Compressions by First-aid

The value of clinical innovation in enhanced ambulance simulation training

Authors: Prof. Andy Newton and Darren Best

Published in: Autumn 2018 Edition of Ambulance Today Magazine

The value of innovation to patient care cannot be overstated, but its further benefits of efficiency and cost-effectiveness within the NHS make it a vital and ongoing campaign. In this joint article, Professor Andy Newton offers some valuable insights into the value of continued innovation across the NHS before shining some light on clinical simulation in particular. Senior Education Manager at SCAS, Darren Best, then introduces us to the advanced facilities and training going on at their new Education and Enhanced Simulation Centre in Newbury, Berkshire.

Innovation and why patient care needs more of this elixir

Healthcare is no stranger to innovation, and to its credit, the National Health Service has an enviable track record of deploying new methods and technology across a spectrum of patient needs. Examples such as Magnetic Resonance and Computer Tomography, are well known and many others across the spectrum of therapeutics, prosthetics, the application of genetics and more recently robotics continue to capture the imagination of the public and those who work in healthcare alike. South Central Ambulance Service’s new Education and Enhanced Simulation Centre is a forward-thinking example of innovation which applies directly to the field of paramedicine.

The NHS even has an ‘Innovation Accelerator’ programme and a well-promoted list of innovations, including items of direct relevance to those who have an interest in Paramedic and Ambulance matters generally, such as the National Early Warning Score, NEWS. Innovation therefore doesn’t have to be about new products, but can extend to new methods of assessment, new ways of designing, clinical process, where telephone triage could be viewed as a highly relevant example, or in services and new ways of training, about which more in a moment, as well as to many other aspects of care and quality improvement.

But innovation is hard, it is not always welcomed and can often be resisted by those who, for whatever reason, are less attuned to change, not least by those in authority or their confederates who seek the status quo and an easy life free from excitement and risk. It is therefore particularly welcome when innovation works, because it is very likely that the innovation concerned will have been in no small part a function of effective leadership. Leadership that will have come from the hard work, blood, sweat and tears of a few highly energetic individuals who have battled against inertia and the often-lukewarm desire of bureaucratic organisations to modernise. All because the personalities involved have a desire to see services improve for patients and staff alike.

The Innovation of Clinical Simulation

South Central Ambulance Service’s new simulation centre will be judged by the above criteria– the innovation of simulation applies directly to the work of ambulance crews and holds out the promise of raising the quality of patient care. Clinical simulation has a surprisingly long history and demonstrates how several trends have come together to create a series of technologies and teaching methods which, in the right hands, are much more than the sum of their parts. Simulation training represents the vital partnerships that are so necessary between industry and clinicians, with the skills and abilities of both groups demonstrating the very positive results of pooling their talents.

There is no doubt that clinical simulation, when applied to the education of ambulance staff, as with other groups of health care workers, can have a very positive effect on raising competence and greatly helps to prepare for the challenging world of pre-hospital care delivery. This area has also become a much better researched area of practice and while there is insufficient time to do this important aspect justice in this short piece, the evidence base is growing at a rapid rate. It is, however, very important never to over-emphasize the role of the technology over the role of the teaching faculty, the quality of teaching scenarios and the process of debriefing, as well as the reflection of the processes of learning generally. Clinical is therefore one of those innovations that few in the business of clinical education would wish to be without. It is a set of methods that, at its best, integrates sound educational approaches, with a well-designed curriculum and teaching methods, with digital and physical technologies that increase the changes of producing high quality practitioners and that is a goal worthy of the leadership efforts involved.

Andy Newton, 27th August, 2018

The SCAS Education and Enhanced Simulation Centre

In the last three years, South Central Ambulance Service’s Education team has revolutionised the delivery of pre-hospital education and training. The SCAS Education and Enhanced Simulation Centre based in Newbury, Berkshire provides high-technology learning environment facilities that simulate settings ambulance crews would encounter daily. Six purpose- built training and environment rooms allow recreation of the patient’s journey, from their home environment (including a bathroom, kitchen and bedroom) through treatment enroute to hospital in the Mobile Simulated Ambulance (Simbulance) to handing over the patient in the Emergency Department (ED) resuscitation bay. The centre also houses a multi-purpose skills room for delivery of a range of skills from manual handling training for patient transport staff to invasive cannulation and suturing for specialist urgent care paramedic/ practitioners. Collaborative multi-agency working is facilitated in a mock flat which has been used to great effect in joint police and ambulance mental health awareness training.

The pièce de résistance is a fully immersive projection room enabling multi-environment training. This places ambulance staff at a variety of locations such as on a motorway, in a children’s playground or even at a marina!

Education sessions are controlled via a central control room where the simulation technologist can operate all rooms with interactive bespoke software and tablet technology designed specifically for the centre. This allows the creation of safe, realistic scenarios conducive to learning. All training rooms have audio and video capability with playback analysis and feedback available in a dedicated debriefing room on an interactive SMART TV, with the addition of glass whiteboards with street-map view projection for major incident table-top exercise learning.

Simbulance is housed within the centre, and when docked, it can be used as an integrated training area connected to the network and controlled via the central control room. Undocked, Simbulance can be driven to local or cross-border ambulance stations to be used as a standalone simulation facility. This increases the capacity and capability to deliver dedicated training sessions without placing strain on ambulance operational demand.

I am proud to lead the Newbury Education and Simulation training centre alongside a dedicated team of clinical (doctors, paramedics and midwives) and non-clinical educators on the teaching faculty. Together they facilitate a range of sessions from Trust statutory and mandatory education to partnership community maternity and mental health training. The facility has been utilised by all grades of staff including patient transport staff, front-line paramedics and specialist operational teams such as HART. Importantly, the centre also provides a safe space for operational officers to develop and retain clinical and non-technical skills.

The Education and Simulation Centre team has provided pre- hospital training to multi-disciplinary and inter-professional healthcare groups by delivering previously unheard-of immersive capabilities. By promoting and expanding training realism, we have enabled role advancement, staff development and workforce stability, thereby providing safer patient awareness and patient care.

Darren Best, Senior Education Manager, SCAS

To find out more about South Central Ambulance Service, please visit their website: www.scas.nhs.uk

Or send direct enquiries to: simulation@scas.nhs.uk

The Miscarriage Association launches new e-learning resource for medical professionals

Date: 7 August 2019

The Miscarriage Association has developed a new e-learning resource to support medical professionals in providing the best care they can to women experiencing pregnancy loss. 

The resource is based on the real experiences of health professionals and those who have experienced miscarriage, ectopic or molar pregnancy, and includes films and interactive activities.

The resource takes around two hours to complete, and is an excellent tool for continuing professional development and learning towards revalidation.

Ruth Bender Atik, National Director at the Miscarriage Association, said: “Pregnancy loss can be a deeply distressing experience and the support health professionals give can make all the difference to helping women through this difficult time.

“We know it isn’t always easy for those working in clinical environments to find the time to reflect on the care they provide. This is why we wanted to create a resource that they can dip in and out of and access easily from their phone, iPad or computer, so the training is available to them anytime.” 

The five units focus on different aspects of care, such as having difficult conversations, considering language, and taking care of your own wellbeing while providing care.

Cerian Gingell has experienced two miscarriages and is passionate about improving the care that is provided to those who experience pregnancy loss. 

Cerian, said: “Miscarriage is a devastating loss, often without explanation. Nothing can take the pain away, but a kind word, the correct information on what to expect next, the truth about what’s happening – these things can all help make a horrible experience slightly less horrible.

“To me, good care is saying ‘I’m sorry your baby’s gone, it wasn’t your fault’. It’s letting me cry, answering my questions with honesty and sensitivity, reassuring me that because it’s happened once it doesn’t mean it’ll happen again. It’s about respect, sympathy and honesty.

“I think this resource is so important and will help create more consistent care across the country. Every single person that goes through pregnancy loss deserves to be treated with dignity and compassion.  Whether they’re speaking to their GP or being treated in hospital, every contact can have a huge impact on the way that person copes with their loss.” 

The resource was peer reviewed and produced with the help of Janet Birrell, Gynaecology Matron at Western Sussex Hospitals NHS Foundation Trust, Dr Nicola Davies, GP at The Pinn Medical Centre, Annmaria Ellard, Miscarriage Specialist Nurse at Liverpool Women’s NHS Foundation Trust, Amanda Mansfield, Consultant Midwife at  London Ambulance Service NHS Trust, and the Association of Early Pregnancy Units.

Dr. Sarah Bailey, Lead Nurse Recurrent Miscarriage Care and Clinical Research Specialist at University Hospitals Southampton, said: “The Miscarriage Association’s e-learning resource is extremely useful, informative and easily accessible. 

“I would thoroughly recommend this excellent training package to any care professional who is involved in caring for women with miscarriage.”

You can access the e-learning resource at: Bit.ly/2Gtniu9 or call the Miscarriage Association on 01924 200795to find out more.

Brother and ambulance crew get Carter – just in time

Date: 29 July 2019

A Newcastle man was effectively dead for 20 minutes, but Bruce Carter is alive thanks to his brother, a passer-by and a team from the North East Ambulance Service.

Bruce, a 61 year-old self-employed plumber, suffered a cardiac arrest while out cycling around Tyneside with his brother Tristram.  The brothers were reunited with the ambulance crew so Bruce could thank them.

Tristram takes up the story of what happened on the day.

“We had cycled to North Shields and got the ferry.  He said he felt uncomfortable, with pains in his shoulders, but I put that down to the fact that he hadn’t been on a bike for quite some time.  We were going to get the Metro back.  We were pushing our bikes up a road to Chichester station.

“I was slightly ahead of him but when I looked back he was down on the ground.  I was expecting him to be dehydrated and suffering from heat exhaustion but when I got to him he was totally lifeless.  I started CPR (cardiopulmonary resuscitation).  A passer-by called Peter offered to help, so he took over while I rang for an ambulance.”

Clinical advisor Lisa Ahmed took the call from Tristram.   “It was clear he and the passer-by were doing a really good job with CPR.  They were very focussed and it was crucial that CPR was administered so quickly.”

The Monkton-based crew of paramedic Michael Hugo, student paramedic Paul Wales and emergency care assistant Emma Newton were only minutes away when they got the call to respond.

Michael said:  “Paul took over CPR and we realised he was in ventricular fibrillation which is a cardiac arrest and required a defibrillation shock so his heart could then be re-started.  After the shock CPR continued and eventually his heart went into a normal rhythm.

“We got him on to a stretcher and into the ambulance.  By the time he woke up, he was understandably very confused and didn’t know where he was.  The one thing he did say was that he didn’t want to go to a ‘red and white’ hospital!

“Effectively he had died for 20 minutes – he had stopped breathing and didn’t have a pulse.  His brother and the passer-by helped to save Mr Carter’s life – he needed CPR with the initial cardiac arrest.”

Paul said:  “Tristram and the passer-by were doing excellent compressions when we arrived.”  While for Emma, it was the most dramatic case after changing jobs a couple of months ago from being an office-based health advisor to working on an ambulance.

Mr Carter was taken to South Tyneside Hospital, and then transferred to the Sunderland Royal Hospital where he had stents inserted.

Bruce, from Thorntree Drive in Newcastle, said:  “My brother is trained in first aid and used CPR – that’s probably what saved me – meaning my brain wasn’t starved of oxygen.

“I’m very grateful to the crew.  They were fantastic, helping to treat me and reassuring me.  I just wanted to thank them personally for what they did.  At first I was making light of what happened, but after a couple of days the seriousness of what happened struck home.”

Tristram, an RAF Squadron Leader who works in air safety, added:  “The ambulance crew were wonderful, they were the ones who brought him round.”

Interrupting Prayers To Save A Choking Infant

Date: 7 August 2019

Jerusalem, July 2nd, 2019 – United Hatzalah volunteer Yisrael Shavit saved a young girl in Hadera from choking on Sunday evening. After arriving in less than a minute at the scene of the incident, Shavit managed to single-handedly treat and rescue an infant from what could have been her death. 

Shavit described the dramatic story. “I was davening Mincha at Shul and I received an alert on my bluebird radio from dispatch. The alert said that a young toddler, about six-months-old was choking right near my location. I raced to my ambucycle and jumped on and rushed to the address. I saw a group of people standing around two parents who were holding their child in front of them. The father was slapping an infant girl on the back. I asked to take the child. She was making choking noises which meant that her airway was partially blocked. She had started to turn blue. 

I looked inside her mouth and saw a small edge of what looked to be a bit of plastic stuck in her trachea. When I slapped her back, a bit more popped up. I stuck my finger in her mouth and after a few tries, was able to grab hold of and remove the plastic. It was a wrapper from an ice pop. Once the blockage was removed the child once again began crying.   

The girl’s parents were so thankful for my quick arrival and successful assistance that they kissed me on the forehead in the middle of the street just as other EMS volunteers began arriving. 

It was a few minutes before the ambulance came, they had a very healthy and stable patient who was taken to the hospital for follow-up care.

I’ve been at choking calls before but usually, you arrive after the person has choked and you need to do CPR. This is the first time I was able to arrive while it was still happening. I am happy that I was able to help and that I was a messenger of salvation in this instance. This is why I joined United Hatzalah. It is the reason the organization exists and why all of the volunteers do what we do.” 

Treating My Own Mother

Jerusalem, June 12th, 2019 – United Hatzalah volunteer EMT Noa Salant was shocked when she responded to an emergency incident to find her mother to be the patient in need of medical care.

The family was supposed to get together for some quality time and both Noa and her mother were arriving by bicycle from different locations. “As I was driving, I heard screams from up ahead of me and saw a few people standing around someone lying on the street,” said Salant sometime after the incident which occurred two weeks ago.   

When Salant arrived at the scene she saw a very familiar woman lying on the sidewalk injured-  her mother. “I immediately went into EMT mode and began triaging her. I took her pulse while simultaneously calling for an ambulance. I asked the people around her if anyone saw what happened and all they would share was that she fell.”

Noa (right) and her mother.

Salant relived the dramatic moments of the treatment. “I noticed that my mother could not move her pelvis. I began treating her for her injuries and immobilizing her so that none of the injuries would get worse. Other volunteers from United Hatzalah began arriving and they assisted me in providing treatment. When the ambulance came some ten minutes later, I joined the team on the ambulance and kept watch over my mother the entire way to the hospital. When we arrived at the emergency room we found out that she had broken her hip.”

Salant spent the next few days visiting and caring for her mother in the hospital. “The doctors told us that this is the type of injury where there is no corrective surgery and that the best medicine is to keep my mother stable and her spirits up in order to give her body time to heal. They added that the care I gave at the scene prevented the injury from getting worse. It is thanks to the training that I received from United Hatzalah that I was able to keep my cool and follow all the procedures and protocols necessary even though I was treating my own mother,” Salant concluded.  

Reducing accidents in the emergency response sector

Date: 22 May 2019

The incidence of collisions in the emergency sector remains high around the world. Emily Hardy, from vehicle safety experts Brigade Electronics, runs through the technology that can help prevent accidents and save lives.  

Collisions involving emergency vehicles are a frequent occurrence across the world. Ambulances, fire appliances and police cars are involved in hundreds of accidents on the road as they respond to emergency situations. 

Figures obtained under the Freedom of Information Act show that in the south east, ambulances were involved in 665 accidents in the year to March 2018, equating to 1.8 collisions per day.   

In Wales, emergency service vehicles were involved in more than 3,500 crashes in the five years to March 2016. North Wales Police recorded the most incidents – 331 collisions in 2015-16, but the majority of these involved minor damage. The Welsh Ambulance Service recorded 735 incidents.

Technology can help

Emergency response vehicle drivers face a unique set of challenges. Travelling at high speeds while weaving through traffic, manoeuvring in tight spaces and operating in dangerous, noisy environments are everyday hazards for emergency responders to negotiate. They also encounter adverse weather conditions and night-time call-outs in often high-risk situations.

Incidents can be costly and distressing for all involved, yet many could be avoided if organisations invested in the use of readily-available vehicle safety systems. Much of this technology can be retro-fitted to vehicles, giving emergency service operators instant results.

Safety camera systems

Retro-fitting vehicles with commercial vehicle safety systems, such as Brigade Electronics’ best-selling Backeye®360, allows drivers to keep a close eye on all possible blind spots of their vehicle so they can instantly see other vehicles, cyclists or pedestrians.

This intelligent four-camera technology is designed to eliminate vehicle blind spots and assist manoeuvrability in challenging situations by providing the driver with a complete 360 degree view of their vehicle in a single image. The system combines images from four ultra-wide-angle cameras, providing a real-time view on the driver’s monitor. The result is a ‘bird’s-eye-view’ of the vehicle and surrounding area.

Ultrasonic Obstacle Detection

Ultrasonic obstacle detection technology can detect stationary and moving objects and are perfect for road-going commercial vehicles, such as ambulances and fire engines. The ultrasonic proximity sensors minimise both vehicle damage and collisions with pedestrians, cyclists, and objects. The detection system alerts the driver with an audible and visible in-cab warning when objects are within a certain distance. 

Mobile recording

When camera systems are linked to a mobile digital recording set-up (MDR), the recorded footage can provide irrefutable evidence in the event of a collision, or any kind of incident, such as vandalism or theft from a vehicle.

One major benefit of MDR is its ability to support drivers who can often be the subject of increased scrutiny after an incident. The latest MDR systems, such as Brigade’s, also have 3G and 4G connectivity, meaning that data can be live-streamed remotely with real time GPS tracking.

Smart Reversing Alarms

Warning alarms are audible devices to alert pedestrians and workers when a vehicle is manoeuvring. Unlike traditional ‘beep beep’ tonal alarms, which can be almost impossible to pinpoint, the latest technology creates a ‘ssh-ssh’ sound and uses smart technology to adjust sound levels in line with the ambient noise in the immediate vicinity. Utilising a wide range of frequencies, smart reversing alarms also enable the listener to instantly locate what direction the sound is coming from. In adverse conditions, for example if rain is pounding down, the warning decibel level will be increased.

“If it wasn’t for the London Ambulance Service, my wife and daughter, I wouldn’t be here now.” Chingford cardiac arrest survivor thanks staff who saved his life

Date: 24 July 2019

A man has been reunited with staff from London Ambulance Service who saved his life after he collapsed at home in cardiac arrest.

Andreas Kallis, 68, and his family visited Walthamstow ambulance station recently for the opportunity to meet and personally thank all those involved.

His wife Tina, 63, recalls the moment her daughter, Christina, 37, alerted her to Andreas’s collapse at their home back in February 2018: “All of a sudden my daughter came to me and said: ‘Mum, I don’t know if dads asleep or ignoring me’.”

After running into the sitting room and checking if he was breathing, they immediately dialled 999.  They spoke to Emergency Call Coordinator, Fran De Wet, working in the London Ambulance Service control room, who started directing them through cardiopulmonary resuscitation (CPR).

“Fran told us precisely how to do CPR and the rhythm as well. I did so much better than I thought and that’s because of her help.”

An ambulance was quickly dispatched and London Ambulance Service paramedic crew Esme Choonara and Amanda Gowing responded to the scene.

They managed to get a pulse and rushed Andreas into Barts Heart Centre at St Bartholomew’s Hospital, where with the help of doctors and nurses has made a full recovery.

At the emotional reunion Andreas and Tina were joined by Fran, Esme and Amanda.

Andreas said: “I must be really lucky to survive. If it wasn’t for the London Ambulance Service, my wife and daughter I wouldn’t be here now. It was wonderful to be able to thank them all personally.”

Call handler Fran said: “This is why we do the job. That feeling of knowing that something you’ve done has really helped someone and their family.”

“In over twelve years working for the Service I have taken several cardiac arrest calls. But I have only ever received three letters to tell me that those patients have returned to normal life and have walked out of hospital. So to actually meet Mr Kallis is truly amazing.

“The whole experience has been overwhelming – I promised I wouldn’t cry but I did.”

The family wants to raise awareness of the importance of the general public learning lifesaving skills such as CPR. Tina said: “I had done a bit of CPR training years ago, but you never really think that something like this is going to happen to you.

“I just feel so good that I was able to help save him.”

“We are so grateful to all of the ambulance staff and everyone at St Bartholomew’s Hospital, the nurses, the doctors and the police who also attended that day. It feels like it is the closure we needed.  To thank them and to see them in lovely surroundings not in that traumatic, horrendous way.”

Improving the chances of surviving a cardiac arrest in the North East

Improving the chances of survival for cardiac arrest patients is something close to North East Ambulance Service’s heart and their latest initiative is set to do just that.

If you or someone you cared about was having a cardiac arrest and just a short walk away from where you were, there was someone trained in lifesaving skills, would you want them to come and help?

Approximately 60,000 people suffer a cardiac arrest out of hospital in England every year and of these, 28,000 patients will have resuscitation started or continued by the ambulance service. Survival rates for these patients is 8.6%. This is significantly lower than for populations in other developed countries like Holland (21%), Seattle (20%) and Norway (25%).

The current rate of initial bystander CPR in England is reported as being 43% compared to up to 73% in other countries.

North East Ambulance Service has now switched on GoodSam, a mobile app that alerts community first responders to an incident, in an attempt to boost the numbers of people who survive cardiac arrest in the region.

GoodSAM connects with a community of first aid trained responders, willing to assist during a cardiac arrest.

NEAS will be switching on the system in the North East and inviting its clinically trained staff, trained in basic first aid and qualified to perform lifesaving cardiopulmonary resuscitation, to register initially.

GoodSAM will automatically notify nearby GoodSAM responders of a medical emergency. The platform connects those in need with those who have the skills to provide critical help before the emergency services arrive. The app is free to download on all smartphones.

GoodSAM is already working in partnership with ambulance services in London, North West, Wales and East Midlands as well as further afield in Australia, New Zealand, Ireland, USA, Canada and South Africa.

Gareth Campbell, Clinical Operations Manager says, “This is excellent news for the North East population and means that those special skills our workforce uses every day to help save lives are even more accessible.  By ensuring a patient has a clear airway and quality CPR is in place in those first few minutes, they are more likely to achieve a good outcome.”

With the system now switched on, the NEAS emergency operations centre will alert the three nearest responders to life threatening incidents and simultaneously dispatch an ambulance, giving the patient the best possible chance of survival. The partnership will not impact on or substitute standard ambulance dispatch, with crews continuing to be sent to scene in the usual way.

When a volunteer is alerted, they will be able to accept the alert via the GoodSAM app and make their way to the location of the incident. If a volunteer responder is not in a position to accept the alert, it can be declined and diverted to the next nearest responder.

Campbell continues, “Having seen how successfully this app works elsewhere, we wanted to bring GoodSAM to the North East for the benefit of our region’s patients. Thanks to funding from NESTA, we have been able to work in partnership with the GoodSAM team to bring this app to the North East.”


NEAS already has a team of Community First Responders who are everyday members of the general public trained by NEAS in basic first aid and life support. They are provided with oxygen and a defibrillator and are deployed by NEAS to life threatening emergencies, such as chest pain, breathing difficulties, cardiac arrests, and unconsciousness, if they are the nearest resource, followed by the next nearest emergency care crew.

This app provides an opportunity for those with first aid skills who volunteer and work for the service to join the robust community of first responders already working within the North East.

Campbell adds, “Responders will be able to provide immediate care to a patient where every second counts, administering life-saving first aid while an ambulance is on its way. A patient who suffers a cardiac arrest stands a much better chance of survival if someone with a defibrillator can attend the patient in the first minutes of collapse.”

Professor Mark Wilson, GoodSAM’s Medical Director and Co-Founder, said: “If a patient has a cardiac arrest, it’s the first few minutes after the incident that determine the outcome – life, death, or long-term brain damage”. 


“There are first aid trained people all around us but usually the first they know of a neighbour having a cardiac arrest is an ambulance appearing in their street. Our work with Ambulance Services, allows us to harness the lifesaving skills in the minutes before ambulance arrival. GoodSAM has saved lives globally and we look forward to working with NEAS to bring the benefits to the North East.”

Steve Dunn from Newton Aycliffe in County Durham has been a community first responder in the North East for eight years after he found himself coincidentally at the scene of two serious road traffic collisions in which he assisted patients whilst an ambulance was travelling.  Having formerly been registered with GoodSam in London, he’s really pleased to be able to connect in his own region.


He explains, “I was alerted by GoodSAM to an incident in St Pancras when I was in London recently on a business trip and I was really overwhelmed by the number of people nearby who also got the alert.  I was first on scene and between those of us who attended, the patient had the best chance of a good outcome.  On this occasion it wasn’t a cardiac arrest luckily.  It was really surprising and reassuring that so many people were willing to stop what they were doing and help and it’s great that we can do the same here.”

Compassion Fatigue vs Compassion Satisfaction

Author: Michael Emmerich

Published in: Summer 2019 Edition of Ambulance Today Magazine

“When you’re compassionate, you’re not running away from suffering, you’re not feeling overwhelmed by suffering, and you’re not pretending the suffering doesn’t exist. When you are practicing compassion, you can stay present with suffering.”

  • Sara Shairer: https://eftraining.co.uk/what-is-compassion-fatigue/

In the emergency first responder profession, where we witness trauma first-hand, it is at times difficult to be fully aware of the impact that “direct trauma” has on us as practitioners and how to differentiate between direct trauma and vicarious trauma. Research suggests that EMS personnel experience many reactions after exposure to a traumatic event. Admitting to being emotionally affected is regarded as difficult as it may lead to being perceived by their peers as not tough enough for the job. The attitude of ‘no one dies on my watch’ is common amongst EMS personnel. This leads to EMS personnel often suppressing their emotions and feelings associated with the reality of their work in order to live up to this image of being strong and resilient.

“Injury mortality rates in South Africa are approximately six times higher than the global average. One of a handful of studies conducted amongst EMS personnel in the Western Cape found higher prevalence of exposure to critical incidents compared to their counterparts in other low-income countries.” 

  • African Journal of Emergency Medicine Volume 5, Issue 1, March 2015

This Quarter we attempt to unpack and understand the lived experiences of compassion fatigue, vicarious/secondary trauma (ST), and burnout.

These three terms are complementary and yet different from one another.

-Compassion Fatigue (CF): Also called “vicarious traumatization” or secondary traumatization (Figley, 1995). The emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events. It differs from burn-out but can co-exist. Compassion Fatigue can occur due to exposure on one case or can be due to a “cumulative” level of trauma. 

The American Institute of Stress – https://www.stress.org

-Vicarious Trauma (VT): is a process of change resulting from empathetic engagement with trauma survivors. Anyone who engages empathetically with survivors of traumatic incidents, torture, and material relating to their trauma, is potentially affected.

https://www.bma.org.uk

-Burnout: a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) reduced professional efficacy.

The American Institute of Stress – https://www.stress.org

Despite the differing theories and terminology of the three concepts, each is directly associated with the concept of empathy. There are two key components:cognitive empathy, the ability to take someone’s perspective, and affective empathy, whereby an individual share a similar emotional response to others’ experiences(Smith, 2006).

With empathy holding sway as a common factor in CF, VT and burnout, it would make sense then to conclude that cognitive and affective empathy would impact differently on the life of the practitioner. For example, a professional empathising emotionally may experience more emotional consequences than an individual empathising cognitively. In addition to increased experiences of trauma, increased case load and less clinical experience, it is therefore suggested that the nature of empathetic engagement in work-related scenarios would therefore be an important dimension to consider in understanding the development and intensity of CF as experienced by EMS practitioners.

Conversely, burnout does not necessarily mean that our world views have been damaged or that we have lost the ability to feel compassion for others. Most importantly, burnout can be easily resolved; (but can it be in the current financially driven, dehumanised environment practitioners work in?)Conversely this is not the case for CF and VT.

As one is vicariously exposed to trauma, both directly and indirectly, one begins to exceed one’s resilience (or ability to cope) to these events, and one is then prone to develop CF (or sometimes also referred to as Secondary Distress Syndrome). Once our chronic exposure to trauma exceeds our coping mechanisms, CF then becomes evident. CF has been described as the convergence of secondary traumatic stress (STS) and cumulative burnout (BO); a state of physical and mental exhaustion caused by a depleted ability to cope with one’s everyday environment. This can impact standards of patient care, relationships with colleagues, or lead to more serious mental health conditions such as post-traumatic stress disorder (PTSD), anxiety or depression.

How do we then best protect vulnerable workers, to prevent not only CF, but also the health and economic consequences related to the ensuing, and more disabling, physical and mental health outcomes. To fully understand CF, we possibly need to move away from theoretical explanations and models and focus on a more relational understanding of professionals lived experience of their own and others’ (patients, peers and family) distress. This would involve a narrower focus on problem solving, via person centred compassionate care. Remember authentic and sustainable self-care begins with you. Understand that the pain and stress you feel are normal displays, resulting from the care giving work you perform on a regular basis.

Examine the positive and negative aspects of one’s work influences, and how it affects one’s professional quality of life. This leads us to a better understanding, whilst helping those who experience trauma and suffering. This can in turn improve our ability to aid them and keep our balance in this process.

Compassion Satisfaction and Compassion Fatigue are two aspects of Professional Quality of Life. They encompass the positive (Compassion Satisfaction) and the negative (Compassion Fatigue) parts of helping others who have experienced suffering. Compassion fatigue breaks into two parts. If working with others’ suffering changes you so deeply in negative ways that your understanding of yourself changes, this is vicarious traumatization. Learning from and understanding vicarious traumatization can lead one to vicarious transformation.

  • Dr. Beth Hudnall Stamm – ProQOL
sessional Quality of Life Model (Stamm, 2012)

An excellent article to read is Transforming Compassion Fatigue into Compassion Satisfaction: Top 12 Self-Care Tips for Helpers, by Françoise Mathieu, M.Ed., CCC– see the link below

In closing;

integrated intervention programmes are needed to assist EMS personnel working in this sustained high-stress environment. The findings can assist health care educators in the design of co-curricular activities intended to help in the development of resilience and the psychological wellbeing of EMS personnel.”

Exposure to daily trauma: The experiences and coping mechanism of Emergency – Llizane Minnie a,* Q3 , Suki Goodman b, Lee Wallis

Healing begins from within, and being committed to a self-care plan, with clear boundaries in both your personal and professional life and understanding one’s negative behaviours and their root cause. Internal self-healing in our profession is a life-long management plan, but as you continue to do the necessary internal work, life will and can, begin to change for the better.

References, websites and additional reading:

Cocker, F., & Joss, N. (2016). Compassion fatigue among healthcare, emergency and community service workers: A systematic review. International Journal of Environmental Research and Public Health

Hernandez-Wolfe, P., Killian, K., Engstrom, D., & Gangsei, D. (2015). Vicarious resilience, vicarious trauma, and awareness of equity in trauma work. Journal of Humanistic Psychology

Ray, S. L., Wong, C., White, D., & Heaslip, K. (2013). Compassion satisfaction, compassion fatigue, work life conditions, and burnout among frontline mental health care professionals. Traumatology

Sprang, G., Clark, J. J., & Whitt-Woosley, A. (2007). Compassion fatigue, compassion satisfaction, and burnout: Factors impacting a professional’s quality of life. Journal of Loss and Trauma

Mathhieu, F (2017) Transforming Compassion Fatigue into Compassion Satisfaction: Top 12 self-care tips for helpers. Workshop for helping professionals

Minnie L et al. Exposure to daily trauma: The experiences and coping mechanism of Emergency Medical Personnel. A cross-sectionalstudy, Afr J Emerg Med (2015), http://dx.doi.org/10.1016/j.afjem.2014.10.010