Pit Crew Cardiac Arrest Resuscitation

Paramedics and emergency medical technicians (EMTs) are skilled at organizing chaotic situations. We respond to the worst moments in people's lives and provide life-sustaining medical care. We must have a wide breadth of emergency knowledge because it's impossible to guess what's coming in next on the 911 line.

Some of what we do, however, is predictable. We will always respond to vehicle accidents. There will be shootings and stabbings. We plan for several scenarios on a regular basis, but there is nothing more certain than one fact: if the patient's heart isn't beating, he or she will die without intervention.


Lessons from the Racetrack Help Rescuers Save Lives

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There is an open debate about whether or not seconds count in most emergency medical responses. However, in one medical condition, it is undisputed that the faster care is provided, the higher the chance for survival. Sudden cardiac arrest is that one example.

Most experts believe that irreversible brain damage is present within 4-6 minutes after cardiac arrest. The American Heart Association wants everyone to learn Hands-Only CPR so bystanders can help if someone collapses in front of them. Ambulance providers around the country work to minimize their response times, at least to cardiac arrests if not all medical calls for service.

Getting there quickly isn't enough, however. We have to work quickly and efficiently to provide perfusion to the brain and heart muscle. Plus, cardiac resuscitation isn't a one- or two-person job. It takes a team, working together, to save lives.

Pit Crews to the Rescue

NASCAR pit crews have it down. They perform multiple complicated maneuvers in mere seconds. They rarely make mistakes and their movements are choreographed to near perfection. The way they do what they do provides a framework for emergency medical services (EMS) folks to emulate.

Here's how to make the best of what a real pit crew has to offer. There are a few differences since we're not trying to resuscitate people in 12 seconds or less, but the ideas all come from pit row.

  1. Defined roles
  2. Adequate workspace
  3. Rapid assessment
  4. High-performance CPR

Let's start by defining our roles in Pit Crew Resuscitation before we get the call.


Defined Roles

Ambulance and medical personnel scrambling with patient
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You never see a pit crew jump the wall when a car is pulling into pit row without their tools in their hands. Wouldn't it be funny to see a crew hop over the wall and then have a strategic conversation about what to do next?

"Johnny, grab the jack while Bill gets the gas can. Jake and Sean, you each get a tire and follow me. I got the impact wrench."

That's not going to happen. NASCAR pit crews drill repeatedly. They're not ready for prime time until they have the moves down pat. You'll never see a pit crew member get confused during a race.

Well, at least not more than once.

Triangle of Life

There are 4 basic roles in Pit Crew Resuscitation.

  1. Compressor #1 at one shoulder
  2. Compressor #2 at the other shoulder (switching off doing chest compressions with #1)
  3. Head/airway rescuer (maintains the airway and keeps track of time)
  4. ALS rescuer at the waist (advanced EMT or paramedic level)

The first three are commonly referred to as the Triangle of Life. These rescuers provide chest compressions, positive pressure ventilation, and defibrillation. In the American Heart Association's 2010 CPR guidelines (and ACLS guidelines), chest compressions and defibrillation were emphasized above all other interventions. Even ventilation was downplayed, although it was not removed.

The Triangle of Life allows the cardiac arrest patient to receive continuous, uninterrupted chest compressions. Rescuers are positioned on each side of the chest and can switch after each 2-minute cycle of CPR.

The rescuer positioned at the patient's head can maintain a seal with the bag-valve-mask. He or she is in a perfect place to keep track of the time and coach those doing compressions if they need to adjust their depth, recoil or rate.

The ALS rescuer should take a place at the patient's waist. At that level, he or she can establish either intravenous (IV) or intraosseous (IO) access, administer medications and monitor the patient's femoral pulse both during CPR and during rhythm assessment between each 2-minute cycle of CPR.

Know Your Place

In EMS, we regularly show up at the scene of the emergency with an open mind. It's a great gift unless time is truly of the essence. We get to the patient's side and decide how to handle the situation presented to us. Normally, that works very well, but in cardiac arrest, the clock is seriously ticking.

Our first lesson from the pit crew is to know our places before we get to the patient. Defining our roles ahead of time makes the resuscitation go much smoother. Each member of the team slides into his or her position without being told. Each step of the resuscitation is completed automatically.

Some fire departments have added pit crew roles to their daily "shift sheets" alongside other stuff like station chores and the training schedule. Each member of the company knows exactly what he or she is doing in case of a cardiac arrest before the radio ever crackles.

It's (Almost) Never Too Late

Even if you didn't have a conversation over morning coffee to decide who's doing what, assigning pit crew roles on the way to the call still puts you a step ahead in case the patient happens to be in cardiac arrest. As long as you walk into the scene knowing your role, you're ready to respond appropriately.

Once you get to the scene, you're going to need plenty of space to do the job right.


Adequate Workspace

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It would be wonderful if all of our patients could read EMS books before they collapse from sudden cardiac arrest. Unfortunately, many of them do not have the inclination to attempt death in a suitably adequate location, necessitating their relocation before we attempt to resuscitate them.

If you are currently an EMS worker, you have probably responded to a patient living in a home stacked with items (furniture, clothing, new appliances, and even pet feces or garbage) from floor to ceiling. We in EMS have a habit of attempting to treat those patients in their grossly overstuffed homes, rather than moving them to a better location.

Pit Crews Have Space

If we are going to borrow our cardiac resuscitation style from a NASCAR pit crew, you can't argue that they don't have enough room to work. Let's be clear: pit crews don't have all the room in the world. On the other hand, they have all that they need. It's a balance.

Part of what makes a race car pit crew efficient is that they only take what they need -- in both personnel and equipment -- out to the car. What they have that EMS crews don't is the ability to control their environment.

Identify Your Workspace Before You Need It

When we show up to the scene of a medical emergency, we have a lot of decisions to make. We must assess whether it's safe or not. We have to determine how many additional resources we need if any. We have to establish the number and severity of our patients.

I want you to add one more thing to your list: workspace. If you were to arrive at the scene of a cardiac arrest – whether or not you are expecting to – identify where you would bring the patient to resuscitate him or her.

This is a conversation (internal or external) you need to have before you arrive at the patient's side. figure out the best place to take a patient where you have enough space to do CPR and any advanced life support interventions. Give yourself space all around the patient to work. If you're doing it correctly, you'll need to be able to do chest compressions from either side of the patient.

The idea is to move the patient as quickly as possible after you have identified that he or she is in cardiac arrest. It should be the first thing you do, and it won't be quick if you don't know where you're going.

Of course, moving the patient quickly requires a quick assessment.


Rapid Assessment

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Have you ever seen a person in cardiac arrest?

For those who have not, it might take a minute (at least a few seconds) to identify what you are seeing. Those who have seen cardiac arrest a few times will usually recognize it immediately.

Use that experience. Trust your gut.

Assume the Worst

In years past, the focus in cardiac arrest assessment was on making sure your patient was really in cardiac arrest before initiating CPR. It probably came from a concern that pushing on someone's chest might be detrimental to their health if they weren't already in cardiac arrest.

We now know two important things:

  1. Patients won't die if we push on their chests while they still have a pulse.
  2. Patients will die if we don't push on their chests while they don't have a pulse (this is not new information, but it's very important).

We can always stop CPR if we start on a patient who isn't in cardiac arrest, but we can't go back in time and start earlier on a patient who is. With that in mind, always assume the worst. If you aren't sure, start CPR (after you quickly move the patient to an adequate workspace).

If the patient wakes up and starts yelling at you for pushing on his chest...stop.

How you push on the chest is even more important than when.


High Performance CPR

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The American Heart Association's 2010 CPR Guidelines are very clear:

  • Chest compressions start before positive pressure ventilation
  • Compress the chest at least 2 inches deep
  • Compress the chest at a rate of at least 100 per minute
  • Allow the chest to recoil completely between compressions
  • Ventilations should take no more than one second each
  • Chest compressions should be continuous except for ventilations and pausing to shock
  • If the patient is intubated, chest compressions should not pause for ventilation

High-performance CPR is simply following the letter of the recommendations (unless your area has adjusted the recommendations - then follow that to the letter).

Pit crew style resuscitation allows the team to follow the guidelines better by defining each rescuer's role. There's no secret sauce here; the guidelines tell you what needs to be done.

Don't Stop Trying

Many rescue teams stop trying too early. If the patient is found in a shockable rhythm, he or she has a really good chance of survival. In some areas of the country, it's better than 50%.

If a patient is moved before the resuscitation is complete, you can write off the attempt. Stopping chest compressions to move the patient or during ambulance transport simply halts the resuscitation. Resuscitation attempts of patients in ventricular fibrillation can take much longer than previously thought.

High-performance CPR buys time for drugs and oxygenation to work. As long as the patient remains in ventricular fibrillation, there's a chance for recovery. Don't give up.

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