Angry Doctor

Tuesday, October 24, 2006

One Life Saved?

One of the problems with being a medical professional is that one tends to view seemingly 'obviously' good ideas with a more calculating eye.

Ideas like this one.

Are teachers trained in basic first aid?

IN SATURDAY'S Straits Times, it was reported that a Primary 6 pupil with a heart disease died in school the previous day.

What I found shocking was that a teacher called the father, who arrived minutes later and performed cardiopulmonary resuscitation (CPR) on the boy.

Why did the teacher not perform CPR first? When someone has a heart attack, every second counts.

Are our teachers not trained in CPR and basic first aid? And if not, why is this so?

First aid should be part of the curriculum for trainee teachers and teachers should be required to go for first-aid refresher courses. Training only the Physical Education teachers is not sufficient.

Goh Lee Jin

The logic seems sound and obvious:

1. Child had heart disease and died suddenly, so he must have had a heart attack.

2. CPR saves lives when it comes to heart attacks, so CPR should have saved his life.

3. The child died after CPR. But since CPR saves lives, it must be the delay in initiating CPR that prevented a life from being saved.

4. Since the teacher, who was on the scene, did not start CPR, the problem must be because teachers are not trained in performing CPR.


Train all teachers in CPR and no child will die needlessly of a heart attack in schools.

Except it's not so simple.

The public has an unrealistic expectation of the efficacy of CPR, something which is often attributed to the common depiction of successful resuscitation on TV and in the movies.

Depending on the patient profile, the exact pathology, and the location of arrest, success rate of CPR will vary.

Specific to out-of-hospital arrests in the paediatric population, the overall survival-to-discharge rate can be as low as 2.6% or 8.6%, although a smaller study suggests that not only is CPR worth performing, it's worth performing for longer than 20 minutes. Presumably if they haven't had any reason to give up on you after 20 minutes, your chances are pretty good to begin with.

(Unfortunately for the 18 to 35 age group, which angry doc assumes many of his readers belong to, the evidence is not very encouraging either.)

All that is not to say that CPR doesn't work at all (it's better than nothing), but the public needs to have a more realistic idea of how often it is unsuccessful.

angry doc does not doubt that training all teachers in CPR will in the long run help save the lives of a few children (and of course it helps too when a teacher gets a heart attack), but he wonders how much it will cost.

Bear with angry doc's bad maths as he tries to count the costs...

There are some 26,382 teachers in Singapore (you can find the exact figure in the Education Statistics Digest on the Ministry's website).

The cost of a Basic Life Support Course locally is in the region of S$80 to 100. (Google 'BCLS Course fees')

Even if you take the higher estimate, it's still around 2.6 million, which is a small percentage of the total Education Budget.

But what is the cost involved per cardio-respiratory arrest? Well, how many cases of cardio-respiratory arrests in school-children occurring *in schools* have you heard of in the past year?

To be even more callous, what will be the cost per successful resuscitation?

How many of teachers, when an arrest does occur, will actually initiate CPR? One study showed that around 80% of the time bystanders may not initiate CPR, even when around half of them have been trained in it.

And what if we decided to equip all schools with automated external defibrillators (AED), which have been shown to double survival rates compared to CPR alone, and train all teachers in their use?

At the cost of S$2500 to S$4000 per AED for each of the 355 schools, and the cost of S$120 to S$200 in training, it will come up to around S$5 million.

Twice the survival rate at twice the cost, so no real bargain there.

But of course, we should never count the costs when it comes to saving children, should we?



  • I agree that training all teachers in CPR is not practical and you have expounded on the explanation for that.

    However I disagree with the way you saw the construction of logic in the letter.

    I don't think the author of the letter actually suggested that "CPR should have saved [the victim's] life" and that "it must be the delay in initiating CPR that prevented a life from being saved". It isn't clear what the author could have thought but he could also have thought that the boy COULD have had a higher chance of survival if CPR had been performed earlier. And with that opinion in mind, the author could then have decided that all teachers should be trained in cpr
    so that should an incident like this happen again, at least the person in distress would have a higher chance of survival.

    I also don't agree with your perceived conclusion of the article which is to "train all teachers in CPR and no child will die needlessly of a heart attack in schools", in particular the last part of the sentence. I don't think the author actually suggested that CPR was 100% effective in saving someone's life.

    In short I don't think the author made the assumptions that you mentioned. So I think we should give him/her the benefit of the doubt.

    Also I think it's not a question of whether to train all teachers in CPR or not but a qns of where the hell the PE teachers supposedly trained in CPR were.

    By Anonymous Anonymous, At October 24, 2006 6:32 pm  

  • Agreed. The question ringing in my mind from the start of the article was, if the teacher knew that PE teachers are trained in first aid, why did she go call the father instead of running out to the field and dragging one of them bloomin' PE teachers?

    By Anonymous Anonymous, At October 24, 2006 9:02 pm  

  • Do you it is worth training staff at MRT stations, CCs and other public venues in CPR? And maybe keeping an AED at these venues as well?

    Just wondering if the figures make more sense in that context, especially since there will be many adults around -- including aged, high cardiac risk adults.

    By Anonymous Anonymous, At October 24, 2006 10:36 pm  

  • Isn't it a good idea for there to be some sort of first aid training and paediatric basic life support for teachers anyway? I mean, there's supposed to be one first aider for every 20 people in the workplace, so it follows on that teachers would be trained in first aid.

    By Blogger tscd, At October 25, 2006 8:23 am  

  • i always find that CPR trainig shld be mandatory for teachers and students alike. this training when equipped doesnt only serve them well when the need arises in school, but also at home, within their community etc etc.

    Its a basic lifeskill that should be possessed by all. Although success rate may not be high, its way better than not being equipped to "try".

    In terms of cost, when theres a high demand as such, surely prices will drop. In my opinion cost should not be a reason for not implementing CPR training at all.

    By Anonymous Anonymous, At October 25, 2006 10:09 am  

  • Aiyah.....frankly training all the teachers and staff in the school (the more the merrier, consider training the cleaners, and tuckshop vendors even!) is something that MOE can do if they want to.

    Basically you just need someone senior and powerful enough in the M of E to say do it and it's a case of "your wish is my command"

    Seen this again and again in the S aye F.

    No point discussing anything in Singapore frankly.

    By Blogger Dr Oz bloke, At October 25, 2006 1:02 pm  

  • The upfront cost of training say all public transport staff (angry doc is not sure, but maybe MRT staff are already trained in CPR?), all security staff, and maybe even all civil servants in CPR, and in keeping an AED in all MRT stations and bus depots, all shopping centre security posts, and all civil service buildings may not be high compared to the total turnover or budget of the institutions. And that's probably true even after you factor in the hidden costs like man-hours required in the training and re-training, as well as servicing and maintenance of the equipment.

    Cost is not an issue - cost-effectiveness is. There is much evidence that early defibrillation does improve survival rates in most (not all) cardiac arrests. The question then is how often you expect the 'investments' to be used, and how often you expect them to make a difference. Society needs to know the odds, and answer the question: is it worth the money?

    Siting the AEDs in the right places will definitely be a right thing to do, but angry doc does not have the figures to comment meaningfully on how many AEDs to deploy and where best to deploy them.

    Perhaps Dr Spacefan can help? :)

    First-aid training is another matter. It takes a lot more time to train someone in first-aid compared to CPR as the former encompasses more conditions and require more skills and knowledge - CPR protocols are designed to be as simple as possible to allow laymen to pick up and remember the drill.

    Having said that, first-aid skills are more likely to be utilised than CPR skills, so I guess that is something to look into too. First-aid kits are also cheaper than AEDs, and they are already on every bus.

    By Blogger angry doc, At October 25, 2006 5:16 pm  

  • Actually, all teachers are trained (or should be trained) in basic (very basic) first aid and CPR. :)

    At least I did, like once many many years ago, and how often do we ever get to do CPR? And it wasn't exactly an intensive course (one day only). I remember that the instructor also mentioned that if CPR was not done properly, the results would be worse and you need to be confident in doing it.

    That teacher probably freaked out.

    By Anonymous Anonymous, At October 25, 2006 9:59 pm  

  • Thanks for the info!

    The standard CPR/BCLS course is a one-day course, as its purpose is to 'mass produce' life-savers.

    It is easy to panic if one is faced with an arrest situation suddenly. I don't think I have ever had to do CPR 'unexpectedly'.

    In a way having been trained in CPR must be worse for the teacher, as the feeling of guilt will be greater. I hope I have not caused further distress to the teacher by blogging on this issue.

    Perhaps the study I quoted will give some comfort:

    "In 21.2% of patients, the bystander immediately started CPR, and in 33.6% of cases, someone started CPR before the arrival of emergency medical services (EMS)."

    "Common reasons that the CPR-trained bystanders cited for not performing CPR were the following: 37.5% stated that they panicked, 9.1% perceived that they would not be able to do CPR correctly, and 1.1% thought that they would hurt the patient. Surprisingly, only 1.1% objected to performing mouth-to-mouth resuscitation."

    By Blogger angry doc, At October 25, 2006 10:28 pm  

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