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Life Lines Articles - Disaster First Aid

CPR in Disaster:
In Tough Choices, Save the Living

by Victoria Chames, EMT, EDT

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Disaster is not a normal day. In a major Disaster, when the number of injured is far greater than the number of medical caregivers, there are different medical protocols that are followed - different from normal situations. One of them concerns situations where the "victim" is clinically dead (not-breathing and has no heartbeat). On a normal day, CPR would be started, 911 would be called, and the "chain of survival" would begin. IF all of this happens within minutes of the cardiac arrest, (ambulance, Paramedics, Emergency Room care, and 24 hour Intensive Care Unit nursing care and monitoring) there would still be less than 1% chance of survival and recovery.

In a mass-casualty disaster, for an individual who is not able to breathe after their airway is assisted and/or whose heart is not beating, by protocol, CPR is not advised. This is because it is so likely that it won't do them any good, and the time spent on them may allow others to die (for example, from a correctable airway problem, bleeding, or shock) who might have been saved if time had not been spent on that individual who was already clinically deceased.

Important: PLEASE don't tell people you read an article that said "if there's a disaster you should not give CPR." WE ARE DEFINITELY NOT SAYING THAT. What we are saying is: the primary goal for you, like all of us, will be to save as many lives as possible, with whatever means you have.

In any large disaster anywhere, such as hurricane, tsunami, massive earthquake or terrorist attack, medical resources will be severely stretched beyond their limits, and they will have to choose the best and fairest ways spend those resources. Below you will find an explanation of this. I am writing this because I don't want anyone to be torn with anguish or indecision, false hopes, or feelings of failure or responsibility if someday you find yourself in this situation.

Around the world, the introduction of CPR training for citizens has saved a significant number of lives. It is also commonly practiced by medical professionals on a daily basis whenever it is needed. The function of all CPR, whether citizen or professional, is to "buy time" - a few minutes - so that more actions, medications, and procedures can be attempted. Except for a few, very rare exceptions, CPR by itself cannot save the life of someone whose heart has stopped beating. It's just the crucial first step of a complex process.

Perhaps some of us have learned our CPR too well, and have come to assume that it will fix anything. So strong is this faith, that the average non-medical person when confronted with an emergency of almost any kind where the victim falls down or lies down, the first recourse is to start pounding on their chest, even if they are breathing, their eyes are open, and they may even be speaking - (sure signs that their heart IS beating.) In this situation, pushing hard on their chest is not only unnecessary, but also very dangerous to them.

This happens on TV shows all the time, and it's supposed to be funny. It's NOT funny, and in fact it's very irresponsible and dangerous. This is because people watching, even if they know it's a comedy, still are receiving a subconscious message that this is the right thing to do. In our technologically advanced visual world, the line between reality and TV imagery has become dangerously blurred. They used to call this "brainwashing" and it was feared and frowned upon. Now it's just business as usual in the race for network TV ratings.

I read recently about a study which found that an unusually large number of heart attack deaths occur during or immediately following earthquakes. One reason why so many people die of heart attacks during earthquakes is because more people HAVE heart attacks under such high stress, especially if they were vulnerable or had high-risk factors already.

The other reason, less well known, is that if you have a heart attack during a major disaster, you will not be able to receive the rapid mobilization of extensive, specialized, labor-intensive, multi-personnel & specialsit medical care that you could in a non-disaster. This is a standard disaster response protocol, and the reason for it is based on sound medical judgment and decades of experience by emergency caregivers at all levels.

About 50% of all cardiac arrests (stopping of the heart) are from causes that are not treatable, meaning there is no chance of survival, no matter what. If there is no heart-muscle activity at all, there is little that can be done for them. Of the others, there is still a small chance.

We can treat a "Code 3" heart attack where the heart is not pumping adequately (ie. ventricular tachycardia or fibrillation) BUT THE HEART IS STILL TRYING. This requires medical or paramedic intervention WITHIN THE FIRST SIX MINUTES, then rapid transport to a hospital E.R. by Ambulance Paramedic caregivers with CPR, defibrillation, and when appropriate, cardiac drugs given en route to the hospital, then 6 to 8 nurses, doctors, and technicians to "work the Code 3" in E.R. and then 24 hours (or more) of one-to-one nursing care in an Intensive Care Unit. Even with all that, they may not survive.

When hundreds or thousands are injured, there may be many for whom prompt medical care (the Golden Hour*) will save their lives, whereas waiting too long may result in their death. In a case of large-scale disaster, all of that personnel, equipment, and care described above would not be invested on one person who is already clinically dead. The harsh reality is: Medical professionals, if already overwhelmed with a huge number of patients, would be very unethical if they spent so much time and personnel on one patient, and meanwhile, allowed the possibility or probability of many others who could have been saved by quick action, to worsen or die.

Earthquakes and disasters are very bad times to have a heart attack. If you should ever find yourself in a CPR situation in the middle of a severe catastrophic earthquake, where you know there will be hundreds or thousands injured, Please don't expect or demand miracles of yourself. Medical resources are not likely to be available in the 6 to 10 minutes within which that person needs to receive the Chain of Survival.

But - if you think there is a reasonable chance an ambulance could be obtained, and you are not the only person who can help the rest of the injured, you should start CPR. If no ambulance comes and no heart beat is obtained, you must decide how long to go on, and when to let go.

In every case "you can only do what you can do." If it looks very obvious that there's widespread destruction, a great many people injured needing help, and you probably will not get an ambulance in a few minutes - Then you must simply do what you can, whatever the outcome, and know that you have done the best you could. Continue with your S.T.A.R.T. Triage rounds. Go on to the living, the ones you can still save.

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