'Textbook' resuscitation shows importance of chain of survival

Joy Green

On 5th May 2020, 61-year-old Joy Green suffered a cardiac arrest.  What happened next is a perfect example where the chain of survival was carried out in quick succession.  It is with permission of Joy and her husband David that I share their story.

The previous night Joy had gone to bed to try and sleep off the chest pain she had been experiencing all evening.

At 03:44 her husband Dave woke to find Joy collapsed by the side of their bed and immediately dialled 999. The call was picked up within one second by call handler Damian Pelham who was being mentored by Laura Macdonald.

Call handlers receive specific training enabling them to instruct people to perform CPR over the phone, which is the vital first link in the chain.

Just 29 seconds after the 999 call was picked up, the address had been confirmed and entered into the computer which enabled Hannah Vince to dispatch the nearest resource.

Dave performed CPR as instructed until the ambulance arrived, 4 minutes, 25 seconds after the 999 call started. Diploma student Paramedic Jaynie Sheen and Student Paramedic Callum Marshall-Wyer arrived closely followed almost immediately by Leading Operations Manager Ray McAllister and a second ambulance crewed by Paramedics Anne-Marie Poole and Emma Simpson.

The Dispatch Team Leader in Norwich, Charlotte Pearce, notified the Critical Care Desk (CCD) of this incident. CCD dispatch and coordinate specialist resources across the region which include HEMS, the HART team and Critical Care Paramedics and Doctors who respond from home through the BASICS charity NARS.

I volunteer for NARS and was dispatched from home and arrived on scene within 6 minutes to find the crew performing ALS in Tyvex suits, face masks, gloves and eye protection. Jaynie who is currently completing her Paramedic training through the University of East Anglia (UEA) was leading the arrest, having passed her Advanced Life Support training (which included Covid-19 scenarios) the previous week.

The scene was calm, with clear leadership and with the LUCAS machine delivering compressions. Evidence suggests that manual compressions are as effective as a LUCAS, which may be the case wearing standard uniform, but taking into consideration the impact of wearing level 3 personal protective equipment (PPE) would have impacted on the effectiveness of their chest compressions.

Initially Joy was in VF and received six shocks before her rhythm changed into a broad complex PEA. JRCALC acknowledges PEA presents challenges to decision making and senior clinical advice is advised.  After 35 minutes a team discussion took place as we needed to prepare Dave for what was looking like an unsuccessful outcome. I asked the team if anyone had any objections to terminating the resuscitation and Jaynie said she felt we should continue because the patient had received bystander CPR, a fast response from the crew and also sustained a good ETCO2 throughout the resuscitation. The team agreed to continue for five more minutes and if no change after that, we would discontinue the resuscitation.

It is situations like this where ultrasound can be used to determine if the patient in a PEA or a low perfusion state. At 40 minutes a pulse check was performed and to our surprise a pulse was detected as Joys heart began to beat again. We moved into the post resuscitation phase and completed a full A to E assessment which included an ECG to determine which hospital to transfer to. The ECG showed changes suggesting a cardiac aetiology, but after discussion with the cardiac team at NNUH it was felt that Joy should be taken to the Queen Elizabeth Hospital.

Joy was discharged home on 26th May, three weeks after her cardiac arrest.

I visited Joy at her home this week and was delighted to see how well she was. Although she has some memory loss, Joy is grateful to be alive and they are extremely grateful for the care they received from both the ambulance service and the Queen Elizabeth Hospital.

So why have I shared Joy’s story with you? This was the chain of survival at its best, it was everyone working together, from the staff in control room, Dave providing chest compressions, right through to the crew who delivered advanced life support and transported Joy to hospital. Critical Care Paramedics are sent to support crews at the most serious incidents, and I must admit there was very little needed from me apart from some support with decision making.

Key Points:

  • Members of the public are key in improving the chain of survival.
    The guidance and support provided by dispatch is a vital part of the chain.
  • Be aware of the impact wearing level-three PPE has on your own bandwidth and how it impacts the quality of your compressions.
  • Being part of the team performing resuscitation in level-three PPE makes communication and identifying each other is challenging.
    Train to do ALS in level three PPE and make training realistic to situations we are finding ourselves dealing with.
  • Think about using the LUCAS in appropriate patients early.
  • PEA is a scenario that presents challenges to the decision making about the cardiac arrest management
  • Your patient may well be in a low perfusion state, the use of ultrasound, if available may enable more guided therapy or decision making.
  • The Critical Care Desk is available on 202. Consider the needs of your patient and call for senior support early.


Published 12th June 2020




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