Angry Doctor

Thursday, March 15, 2007

One Life Saved? 2

As we move more and more towards the idea of patient-autonomy, patient-education becomes a more important part of our role as doctors. angry doc believes that patient-education must go beyond feeding patients with facts; we must teach patients how to look at arguments pitched at them and decide for themselves whether they should be persuaded by certain health claims and information regarding the healthcare system and their health.

Letters like this one don't help.

Cardiac arrest: Stick to chest compressions

DR ANDY Ho raised a few heartbeats with his article, 'CPR may not be the best option' (ST, March 12), on the value of cardio-cerebral resuscitation (CCR) versus cardio-pulmonary resuscitation (CPR).

I wish to relate a real-life experience during the Prime Minister's National Day Rally at the Kallang Indoor Stadium in 1988, when Mr S. D. Maniam collapsed, followed by fits and loss of consciousness. I was seated a few rows behind him when I realised he was in cardiac arrest.

He was pulseless and I immediately started rapid chest compressions. He survived. He was later taken to hospital, where an ECG confirmed an acute heart attack. A coronary angiogram done later confirmed severe coronary-artery disease. He then underwent successful triple-vessel coronary-artery bypass surgery.

Today, 19 years after CCR and subsequent definitive therapy, Mr Maniam is hale and hearty.

The heart-warming moral of this 1988 experience: CCR is the best modality of treatment in a cardiac arrest.

There has been plenty of discussion on the effects and methodology of CPR versus CCR.

The time-honoured CPR underwent dramatic changes from the initial five to two, meaning five chest compressions to two mouth-to- mouth respiration (occasionally mouth-to-nose respiration), about four decades ago, to 15 to two, and, recently, 30 to two, and, now, 100 to zero, meaning 100 chest compressions to zero or no mouth-to-mouth respiration.

The compressions remain at 11/2 to 2 inches, or 4 to 5 cm depth.

In my humble opinion, Singapore should change the guidelines, to do CCR for all cardiac-arrest patients at a rate of roughly 100 compressions per minute till definite medical help arrives. This will certainly save more lives.

Interruption of chest compressions even for a few seconds, such as to do mouth-to-mouth respiration, will impede blood flow to central circulation, such as the heart and the brain.

Moreover, CCR will save one from getting incidental cross infections.

With enough proof from the United States and Japan, which saw an enhanced survival rate of 300 per cent with CCR, this methodology must be seriously considered.

However, CPR still has a place for resuscitation of the lungs in cases of drowning or drug overdose.

Dr V. P. Nair
Consultant cardiologist

I hope Dr Nair doesn't really expect us to change our resuscitation protocol based on his one successful use of CCR, because angry doc can certainly quote more than one instance where CPR has been successful. Science just isn't done like that, Dr Nair.

Frankly, angry doc thinks the letter would have been more convincing had Dr Nair omitted his anecdote.

Is CCR better than CPR? Certainly there is evidence that CCR is better than CPR for out-of-hospital cardiac arrests. This Medscape interview tells us more about CCR.

The situation is more complex in the context of training large numbers of the lay public to perform resuscitation in the out-of-hospital setting. CCR is designed only for unexpected, witnessed, cardiac arrests. Will laymen be able to decide when CCR is indicated, and when CPR would be more appropriate? After all, it has been shown that laymen often have difficulty feeling the pulse of a collapsed victim. Or does it matter, since it has also been shown that many of them do not perform mouth-to-mouth ventilation anyway?

There will probably be more debate and discussion on the issue before Singapore decides if we should change our protocol for the lay public.

Whatever the case, I can tell you something: doing 200 chest compressions in 2 minutes can be really hard on your arms.



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