Cardiac arrest month: why do we need four clinicians there?

EEAST RRVs and amb on scene

Cardiac arrests are unpredictable and catastrophic in nature, with a brief therapeutic window of opportunity. Therefore, every element of our system is of vital importance.

I have written in a previous issue of Clinical Quality Matters about the role of the emergency medical dispatcher in an arrest, and how important it is to patient outcome. Though it may be individuals who perform CPR, attach the defibrillator, secure the airway, and administer medications, it is our excellent system that makes it all possible, and that starts in EOC with our call handlers and dispatchers.

Call handlers are the starting point, as they help us to identify that there’s an actual or potential arrest. The role of the dispatcher then becomes vital, as they need to have an immediate awareness of what resources are available (for example community first responders, ambulances, cars, critical care, duty locality officers etc.). They then have to make sure that at least four individuals are immediately dispatched. But why do we need a minimum of four people?

Well, the system requires technical and non-technical skills, like teamwork, situational awareness, leadership, and decision making. So between them, these four people at the scene will undertake roles as team leader, managing the airway, alternating in the delivery of chest compressions and assisting with vascular access and drug delivery.

So let’s take a look at that in more detail…

A team leader should be appointed as early as possible, and ideally they should be a paramedic or clinician experienced in prehospital resuscitation.

The leader assigns other team members specific roles, making sure they clearly understand and are capable of undertaking what’s been asked of them. This promotes teamwork, reduces confusion, and ensures organised and effective management of resuscitation.

Ensuring there is 360° access to the patient is vital, and this is commonly known as  the ‘circle of life’:

  • Position one: Team leader (stands back) - oversees the resuscitation attempt, only becoming involved if required. The team leader will have an awareness of the whole incident and ensure high quality resuscitation is maintained and appropriate decisions are made.
  • Position two: Airway (at head of patient) – the person must be trained and equipped to provide the full range of airway skills.
  • Position three: Chest compressions and defibrillation (at the patient’s left side) - be prepared to alternate with the team member in position four to avoid fatigue.
  • Position four: Chest compressions and circulation (at the patient’s right side) - access to the circulation includes intravenous and intraosseous.

The team leader coordinates all roles and ensures that interruptions to chest compressions are kept to a minimum. Any planned pauses in chest compressions are discussed by the team whilst chest compressions are ongoing.

Interruptions during CPR are associated with worse survival. Common causes of prolonged pauses in chest compression during CPR are:

  • advanced airway insertion (tracheal intubation, supraglottic airway)
  • pulse checks and cardiac rhythm assessment
  • excessive hands-off time during defibrillation.

Every part of our service has a role to play in ensuring their part in the chain of survival.

Dave Allen, Area Clinical Lead

Published 28th November, 2016

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