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Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery

  • Jason Friesen (a1), Dean Patterson (a1) and Kevin Munjal (a2)
Abstract

In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive “chain-of-survival,” which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.

Friesen J , Patterson D , Munjal K . Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery. Prehosp Disaster Med. 2015;30(1):1-5 .

Copyright
Corresponding author
Correspondence: Jason Friesen, MPH, EMT-P Columbia University Mailman School of Public Health Department of Health Policy and Management 375 South End Ave. #35R New York, New York 10280 USA E-mail jfriesen@trekmedics.org
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Conflicts of interest: none

Footnotes
References
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1. Kouwenhoven, W, Jude, J, Knickerbocker, GG. Closed-chest cardiac massage. JAMA. 1960;173(10):1064-1067.
2. Sasser, S, Varghese, M, Kellermann, A, Lormand, JD. Prehospital Trauma Care Systems. Geneva, Switzerland: World Health Organization; 2005.
3. Anderson, PD, Suter, RE, Mulligan, T, et al. World Health Assembly Resolution 60.22 and its importance as health care policy tool for improving emergency care access and availability globally. Ann Emerg Med. 2012;60(1):35-44.
4. Kobusingye, O, Hyder, A, Bishai, D, et al. “Emergency Medical Services.” In: Jamison D, (ed). Disease Control Priorities Project. Washington DC, USA: The World Bank; 2011:1261-1279.
5. Nielsen, K, Mock, C, Joshipura, M, et al. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care. 2012;16(3):381-389.
6. Gilbert, M. Bridging the gap: building local resilience and competencies in remote communities. Prehosp Disaster Med. 2008;23(4):297-300.
7. Morton, MJ, Vu, A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med. 2011;57(5):520-525.
8. Sistenich, V. International emergency medicine: how to train for it. Emerg Med Australas. 2012;24(4):435-441.
9. Meaney, PA, Sutton, RM, Tsima, B, et al. Training hospital providers in basic CPR skills in Botswana: acquisition, retention, and impact of novel training techniques. Resusc. 2012;83(12):1484-1490.
10. Fleischhack, R, Nuernberger, A, Sterz, F, et al. School children sufficiently apply life supporting first aid: a prospective investigation. Crit Care. 2009;13(4):R127.
11. Wampler, DA, Collett, L, Manifold, CA, et al. Cardiac arrest survival is rare without prehospital return of spontaneous circulation. Prehosp Emerg Care. 2012;16(4):451-455.
12. Berdowski, J, Berg, RA, Tijssen, JGP, Koster, RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resusc. 2010;81(11):1479-1487.
13. Sasson, C, Rogers, MAM, Dahl, J, Kellermann, AL. Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis. Circ. 2010;3(1):63-81.
14. Nichol, G, Thomas, E, Callaway, CW, et al. Regional variation in out-of-hospital cardiac arrest incidence and outcome. JAMA. 2008;300(12):1423-1431.
15. Kitamura, T, Iwami, T, Kawamura, T, et al. Nationwide improvements in survival from out-of-hospital cardiac arrest in Japan. Circ. 2012;126(24):2834-2843.
16. Stratton, SJ, Brickett, K, Crammer, T. Prehospital pulseless, unconscious penetrating trauma victims: field assessments associated with survival. J Trauma. 1998;45(1):96-100.
17. Moriwaki, Y, Sugiyama, M, Yamamoto, T, et al. Outcomes from prehospital cardiac arrest in blunt trauma patients. World J. Surg. 2011;35(1):34-42.
18. Battistella, FD, Nugent, W, Owings, JT, Anderson, JT. Field triage of the pulseless trauma patient. Arch Surg. 1999;134(7):742-745.
19. Donoghue, A, Nadkarni, V, Berg, R, et al. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005;46(6):512-522.
20. Young, KD. A prospective, population-based study of the epidemiology and outcome of out-of-hospital pediatric cardiopulmonary arrest. Pediatr. 2004;114(1):157-164.
21. Cummins, RO, Ornato, JP, Thies, WH, Pepe, P. Improving survival from sudden cardiac arrest: the “chain of survival” concept. Circ. 2005;83(5):1832-1847.
22. International Federation of Red Cross. First Aid for a Safer Future – Advocacy Report 2010. Geneva, Switzerland; 2010.
23. Merchant, RM, Yang, L, Becker, LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406.
24. Meaney, PA, Nadkarni, VM, Kern, KB, Indik, JH, Halperin, HR, Berg, RA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010;38(1):101-108.
25. Girotra, S, Nallamothu, BK, Spertus, JA, et al. Trends in survival after in-hospital cardiac arrest. N Engl J Med. 2012;367(20):1912-1920.
26. Nolan, JP. Cardiopulmonary resuscitation. BMJ. 2012;345:e6122.
27. Graf, J, Muhlhoff, C, Doig, GS, et al. Health care costs, long-term survival, and quality of life following intensive care unit admission after cardiac arrest. Crit Care. 2008;12(4):R92.
28. Naess, AC, Steen, PA. Long term survival and costs per life year gained after out-of-hospital cardiac arrest. Resusc. 2004;60(1):57-64.
29. Duncan, HP, Frew, E. Short-term health system costs of paediatric in-hospital acute life-threatening events including cardiac arrest. Resusc. 2009;80(5):529-534.
30. Suominen, P, Baillie, C, Korpela, R, Rautanen, S, Ranta, S, Olkkola, KT. Impact of age, submersion time, and water temperature on outcome in near-drowning. Resusc. 2002;52(3):247-254.
31. Hilberman, M, Kutner, J, Parsons, D, Murphy, DJ. Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR). J Med Ethics. 1997;23(6):361-367.
32. Iserson, KV, Biros, MH, Holliman, CJ. Challenges in international medicine: ethical dilemmas, unanticipated consequences, and accepting limitations. Acad Emerg Med. 2012;19(6):683-692.
33. Ardagh, M. Resurrecting autonomy during resuscitation--the concept of professional substituted judgment. J Med Ethics. 1999;25(5):375-378.
34. Guru, V, Verbeek, PR, Morrison, LJ. Response of paramedics to terminally ill patients with cardiac arrest: an ethical dilemma. CMAJ. 1999;161(10):1251-1254.
35. Sheng, CK, Lim, CK, Rashidi, A. A multi-center study on the attitudes of Malaysian emergency health care staff towards allowing family presence during resuscitation of adult patients. Int J Emerg Med. 2010;3(4):287-291.
36. Sasson, C, Forman, J, Krass, D, Macy, M, Kellermann, AL, McNally, BF. A qualitative study to identify barriers to local implementation of prehospital termination of resuscitation protocols. Circulation: cardiovascular quality and outcomes. Am Heart Assoc. 2009;2(4):361-368.
37. Miljeteig, II, Norheim, OFO. My job is to keep him alive, but what about his brother and sister? How Indian doctors experience ethical dilemmas in neonatal medicine. Developing World Bioethics. 2006;6(1):23-32.
38. Amy, Wilentz. “A Zombie Is A Slave Forever.” New York Times, New York USA; Op-Ed. October 30, 2012.
39. Hariharan, S, Moseley, HSL, Kumar, AY, Walrond, ER, Jonnalagadda, R. Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country. Can J Anaesth. 2003;50(8):847-852.
40. Illich, I. Medical nemesis. Lancet. 1974;1(7863):918-921.
41. Ardagh, M. Futility has no utility in resuscitation medicine. J Med Ethics. 2000;26(5):396-399.
42. Timmermans, S. High touch in high tech: the presence of relatives and friends during resuscitative efforts. Sch Inq Nurs Pract. 1997;11(2):153-168; discussion 169-173.
43. Iserson, KV. Resuscitation strategies in the United States: realities of hospital and prehospital treatment. Am J Bioethics. 2010;10(1):72-73.
44. Handley, AJ. Compression-only CPR—to teach or not to teach? Resusc. 2009;80(7):752-754.
45. Kämäräinen, A, Virkkunen, I, Yli-Hankala, A, Silfvast, T. Presumed futility in paramedic-treated out-of-hospital cardiac arrest: an Utstein style analysis in Tampere, Finland. Resusc. 2007;75(2):235-243.
46. Glover, BM, Brown, SP, Morrison, L, et al. Wide variability in drug use in out-of-hospital cardiac arrest: a report from the resuscitation outcomes consortium. Resusc. 2011;83(11):1324-1330.
47. Diem, SJ, Lantos, JD, Tulsky, JA. Cardiopulmonary resuscitation on television: miracles and misinformation. N Engl J Med. 1996;334(24):1578-1582.
48. Miljeteig, I, Sayeed, SA, Jesani, A, Johansson, KA, Norheim, OF. Impact of ethics and economics on end-of-life decisions in an Indian neonatal unit. Pediatrs. 2009;124(2):e322-e328.
49. Timmermans, S. When death isn't dead: implicit social rationing during resuscitative efforts. Sociol Inq. 2007;69(1):51-75.
50. Brindis, SL, Gausche-Hill, M, Young, KD, Putnam, B. Universally poor outcomes of pediatric traumatic arrest: a prospective case series and review of the literature. Pediatr Emerg Care. 2011;27(7):616-621.
51. Mock, CN, Tiska, M, Adu-Ampofo, M, Boakye, G. Improvements in prehospital trauma care in an African country with no formal Emergency Medical Services. J Trauma. 2002;53(1):90-97.
52. Lawn, JE, Zupan, J, Begkoyian, G, Knippenberg, R. “Newborn Survival.” In: Jamison DT, Breman JG, Measham AR, et al, (eds). Disease Control Priorities in Developing Countries. 2nd ed. New York, New York USA: Oxford University Press; 2006:531-549.
53. Atkins, DL, Everson-Stewart, S, Sears, GK, et al. Epidemiology and outcomes from out-of-hospital cardiac arrest in children. Circ. 2009;119(11):1484-1491.
54. Herlitz, J, Bahr, J, Fischer, M, KUISMA, M, Lexow, K, Thorgeirsson, G. Resuscitation in Europe: a tale of five European regions. Resuscitation. 1999;41(2):121-131.
55. Maguire, B. Transportation-related injuries and fatalities among Emergency Medical Technicans and Paramedics. Prehosp Disaster Med. 2011;26(4):1-7.
56. Rosemurgy, AS, Norris, PA, Olson, SM, Hurst, JM, Albrink, MH. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma. 1993;35(3):468-473; discussion 473-474.
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Prehospital and Disaster Medicine
  • ISSN: 1049-023X
  • EISSN: 1945-1938
  • URL: /core/journals/prehospital-and-disaster-medicine
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