Training Is Not Enough

Failing to be properly prepared to use an AED or CPR is preparing to fail.

AT one time or another, most of us have secretly harbored the thought--or even boldly uttered the words--"If I were in charge around here, I'd _____ _____ ____ ____." (You can fill in the blanks yourself.) As for me, having been the only male in my class in nursing school, having fathered two (now grown) daughters, and having been married for more than 30 years, I long ago gave up any desire or hope of ever occupying a position of control or authority over anything or anyone.

Nevertheless, if somehow I were magically anointed the "Boss of Bosses" in the realm of AED program development and operation, I would immediately decree that "CPR/AED training" be banned from our lexicon. No, I haven't become an academician who parses words in an esoteric effort to debate "education vs. training." Nor have I totally lost my mind and joined the ranks of certain misguided AED moguls who continually imply AEDs are so simple that "anyone can use them without any training." So before you direct me to get professional help, allow me to explain my secret desire.

Those who are first to detect and care for sudden death and other serious medical emergencies need to be much more than merely "trained" (i.e., listen to a lecture, be observed during a skills practicum and then issued a "card.") If I could, I would replace "CPR/AED training" with "proper preparation" for life-threatening medical emergencies. Preparation for all types of acute medical emergencies certainly includes training, but it's so much more. Proper preparation also incorporates motivation, validation, and the development of "I can do it" confidence and an "I will do it" attitude. Moreover, it also entails customized, detailed planning and ongoing oversight and support from qualified safety and/or health professionals.

The System Is the Solution
The delivery of emergency medical care has come a long way in the 30 years since the late Harvey Grant, a noted EMS/rescue author and pioneer, introduced us to the "chain of human resources" needed to care effectively for suddenly ill and seriously injured patients. Without a coordinated network of independent public safety and health care agencies, organizations, and individuals, the victim of a life-threatening, serious illness or injury usually didn't survive.

After years of documented inadequacies, in the early 1970s, "EMS: A System to Save a Life" became the slogan and the work plan for those committed to improved emergency medical care.

But despite the development and availability of now superior, pre-hospital EMS services, as well as hospital emergency medicine and critical care assets, the outcome of medical emergencies is often determined--not by paramedics, emergency nurses, or a cardiologist--but rather by co-workers, family members, or other "bystanders" who are usually the first persons to detect and react to a medical emergency at home, at work, or elsewhere in the community.

Recognizing that a problem exists, calling for help, and the subsequent initial care actions of these "first detectors" are as essential to reducing the number of premature deaths and preventable disabilities as are the capabilities and proficiency of licensed and certified professionals who labor in the various links of the EMS System. Without a doubt, the EMS System begins with those who are first there and first to apply life-supporting care when a life-threatening emergency occurs.

Unfortunately, the reported incidences of CPR or other life-sustaining actions being delivered by a "non-emergency/critical care" responder when EMS arrives continue to be appallingly low. Combine this fact with the growing number of horror stories of an AED being on site but not used, and it becomes obvious we have much to do if we are going to dramatically increase the opportunity for membership in that wonderful and exclusive new group: the Sudden Cardiac Arrest Survivors Network.

Preparation is the Key to Protection
Recently during dinner with an old friend of mine, he caught me off guard with a deep philosophical statement. "You know," he said, "it really doesn't matter to me when I'm going to die. In fact, I don't really want to know when I'm going to die." But then my friend added, "However, I would like to know where I'm going to die so that I can stay the hell away from that town!"

Despite my friend?s wishful thinking, the reality is that someday. all of us will cease to continue life as we know it on this planet. As unpleasant as it is to consider, death is, after all, a part of life. While death is most often seen as a tragic and always sad event (especially the death of a family member or close friend), our greatest concern is not that people die, but that they die prematurely, well before a normal life span is completed.

As inhabitants and members of civilized society, we go to great lengths to ensure against premature death. Risk management and corporate safety programs, as well as numerous government regulations (e.g., requiring airbags in cars) and the science and practice of medicine, have as their principal objective the protection of human life. Now, even if sudden cardiac death occurs, medical science combined with computer technology offers--via the availability of an AED--one final opportunity to protect our most treasured possession, life itself.

However, it is only with proper preparation that average people are likely to have the skills and courage required to "take the AED off the wall and use it," as well as perform other essential life-supporting actions should they ever be needed.

For most people, developing and maintaining the ability to respond to the most extreme emotional situation they will ever experience certainly requires completion of a valid CPR/AED curriculum and access to a working AED. But equally important, if not more so, it also necessitates the "personal touch" and ongoing assistance of a skilled and caring tutor and guide. It is CPR/AED instructors, who are committed to their students' being "ready, willing, and able" to respond--as well as to their own professional development--who are the "worker bees" in the process of emergency preparedness. Without the invaluable work of capable and competent instructors and emergency response program specialists, proper preparation for on-site, initial life support is not likely to occur.

Much like the broader EMS System of which it is a part, on-site emergency medical response systems require planning, instruction, and management. Moreover, the individuals (most often, CPR/AED instructors) who lead this effort also need detailed and effective grounding. There are four major components/functions essential to the process of proper preparation for optimal initial response to life-threatening medical events.

1. Program Planning
"Failing to plan" really is "planning to fail." At a recent national AED symposium, Dr. Bob Bass, director of the one of the premier EMS organizations in the world, the Maryland Institute for Emergency Medical Services (MIEMS), made a simple but profound statement: "AEDs don't save lives. AED programs do!" Obviously, AED programs and on-site emergency preparedness don't just happen, nor do they come in the box with the AED.

The most modern piece of medical technology (such as an AED); the most dedicated Emergency Response Team; or certification from the most prestigious training organization will probably be of little value to a seriously ill or injured person if the emergency care needed is not provided within the context of a well-designed and -managed Emergency Medical Response System. As in any organized effort to deliver medical care, developing and implementing a reasonable and effective Emergency Medical Response Plan requires the integration and cooperation of several separate but interdependent activities, components, and services.

The variety of activities and services that must be provided to implement effective on-site emergency medical response and AED programs must start with the preparation of a simple but detailed Emergency Medical Response Plan. Such a plan should include a determination of needs for all types of serious medical emergencies ("I have an AED, but you're not dead yet" is not a consoling comment for someone having an MI.), as well as a description of the appropriate roles and responsibilities of all participants/stakeholders.

Although it also should contain actual protocols for treatment and emergency actions to be followed, it is not a "cookbook" to be read during a crisis, but rather a template and action guide to be referred to frequently in maintaining and managing a particular on-site emergency response program. It also must reflect the needs of each specific site/environment for which it was designed and in which it will be utilized.

In addition to the AED, the plan should list needed and authorized emergency care supplies and equipment to be maintained and used. It also should note procedures for recording life support actions taken, as well as guidelines for case/incident review and program management. The importance of and a strategy for conducting and evaluating periodic emergency care drills, scenarios, and role-playing are vital parts of effective on-site emergency preparedness.

Implementing and managing emergency preparedness requires a concerted effort of planning, support, and assistance from qualified individuals. Much more than just the "classroom presenter" of old, modern-day initial emergency care instructors usually are the ones who have met and are meeting this need in currently successful programs.

2. Effective Instruction
If a sudden death occurs, the life-supporting actions of CPR and the prompt application of an AED have been proven absolutely necessary and are certainly simple enough to do. But as stated in the National Association of EMS Educators' Position Paper "Pre-EMS Education and Instructor Development," published in 2003, "for such care to be appropriately and consistently rendered, the lay people, public safety professionals and health care professionals who do not normally work as emergency care clinicians, must be prepared to assume and carry out their important role in the EMS 'chain of human resources.' This preparation requires sound, effective and convenient training from a qualified/certified initial emergency care instructor utilizing approved curricula. These instructors in turn, need to have optimal preparation and resources."

Viewed outside a full resuscitation effort (i.e., the Chain of Survival), AEDs have little or no value. If ventricular fibrillation is not converted by an AED, a rescuer must at the very least continue CPR. Even if successful at converting v-fib, the rescuer still must be prepared to continue life-supporting actions until EMS arrives. The "father of resuscitation," Dr. Peter Safar, said it best when he noted, "I fear that AEDs will convert patients from v-fib only to have them die from hypoxia because no one maintained their airway."

Initial emergency care instructors are very fortunate that the American Heart Association and numerous other private and voluntary organizations have created such a wealth of well-designed CPR/AED training curricula and vivid training materials. In the past 10 years, the competition that's evolved among and between these purveyors of training program materials has certainly resulted in marked improvements in the quality and relevance of these initial care training programs. Likewise, thanks to manufacturers, well-designed (with good medical science), safe, and highly effective approved AEDs are widely available for purchase.

But as good and as important as they are, CPR/AED training program materials and AED devices are merely "vehicles." Generally, as with any vehicle, some will have more remarkable features than others, and most of us are likely to develop our own "likes and dislikes." (For example, my father drove Chevys only. I don't think he really knew why, except that his first car was a Chevy. Anyhow, it got him to and from work so he could support his family. So, as a young boy, I learned from my dad that what matters most about having and using any "vehicle" is not the brand name, but where it can take you.)

For CPR/AED training and AED technology, the ultimate destination is optimal patient care and the protection of "hearts and brains too good to die." The goal is not sales quotas, market share, gross revenue, numbers of books sold, or number of "cards" issued. When the means becomes the end, all sorts of distractions mar the process of preparing people and communities for the desired emergency response. Behaviors such as scare tactics, competition bashing, burdensome bureaucratic regulations, and public ranting regarding legitimate differences of opinion on AED science and technology serve only to create fear, foster confusion, and hinder expansion of early defibrillation programs.

It is widely accepted that early recognition of a medical emergency, combined with immediate summoning of EMS and the delivery of initial life support, can be the difference between life and death, rapid vs. prolonged recovery, and/or temporary vs. permanent disability. In reaching this desired destination and regardless of the vehicles chosen to best meet the emergency preparedness needs and abilities of clients and communities, it is dedicated, competent, and professional instructors who are unquestionably the essential "driver" in the development and operation of effective on-scene initial emergency care.

Those who must be "driven" (i.e., motivated, prepared, and assisted) are the ones who will provide needed immediate on-site care and life support. In most cases, those first to detect and respond to a life-threatening medical emergency will be a family member, a co-worker, or a bystander--ordinary folks who intuitively don't want to be near anyone who looks dead or is likely to be dead soon. It should also be noted that unless they are emergency, critical care, and/or public safety professionals, most health care professionals also fall into this category of "first responders" and need to be prepared accordingly.

Regardless whether the initial care provider is required to act (as part of his job), a concerned family member, or a "good Samaritan" who's just passing by, how these infrequent and generally reluctant responders are "driven" is absolutely critical to the likelihood they are going to act--and act appropriately--at the time of a perceived medical emergency. They certainly need to know when to provide CPR and how to use an AED and have an opportunity to practice both. But focusing on psychomotor skills and cognitive learning alone will produce little benefit unless significant attention is also paid to affective learning (attitude and motivation), as well. Knowing what to do and how to do it are of little value if people aren't willing and able to do it when and if it's ever needed.

What influences affective learning the most is the instructional methodology utilized (especially, lots and lots of hands-on practice and simulated scenarios) and the relevance of the content to the expected performance (i.e., achievable goals and a sense of accomplishment.) Furthermore, optimal preparation does not end with the issuing of a certification card, no matter how long the card is "good for." It's an ongoing process. As Harvey Grant stated so eloquently, the primary job of emergency care educators is not merely to convey information, but rather to "breathe life into the subject matter . . . and life is not a one-breath event."

3. Management, Support & Evaluation
Hanging an AED on the wall and handing out CPR/AED cards does not an AED program make. Ongoing management and support from knowledgeable and experienced safety and/or health professionals is essential if a company, home, or community location is to maintain optimal readiness for serious medical emergencies.

It is a common practice in the world of business and industry to utilize the services of management consultants for expert assistance in specific services or functions for which the company or organization needs periodic help and support. Because emergency medical care is generally not the mission or primary objective of most community locations and/or business sites where an AED will be placed, someone or some group of qualified individuals needs to be available to oversee and help guide the on-site AED/emergency care program. These services include helping to determine the number needed and where best to place AEDs, as well as ensuring (or, in some cases, actually performing) routine inspection of the unit and making regular site visits to review and or update emergency response operational protocols. One of the most vital services that should be performed on a regular basis is the conduct of drills and scenarios.

Such medical oversight and leadership from qualified emergency care/health care professionals is especially important post-incident. After an AED is used, the recorded data must be downloaded and analyzed, and required reports (if any) prepared and submitted to appropriate agencies. In addition, the actions of the responders should be reviewed to reassure them and make any necessary changes in the site's emergency response plans. If needed, responders also can be directed to available employee assistance or community Critical Incident Stress Debriefing programs.

Creating and operating an AED program need not be a complicated and burdensome task; however, it involves attention to a few key implementation details and requires some help and guidance from a competent AED/CPR instructor and AED program manager. EMS personnel acting as either entrepreneurs or "intrapreneurs" have the overall knowledge and credibility to take this leadership role in AED and PAD programs. By doing so, individuals, agencies, and institutions in the EMS System can provide an additional, valuable service to local companies and communities at times other than disaster or crisis and in many cases have an opportunity to generate much-needed additional revenue.

4. Instructor Mentoring & Modeling
Great CPR/AED instructors are not born great instructors; they must be developed, sustained, and supported. While the developers and purveyors of CPR/AED training curricula and materials certainly have a responsibility to help develop and support instructors wishing to utilize their programs, the ultimate responsibility to strive for and sustain optimal effectiveness (i.e., greatness) remains the personal responsibly of each instructor.

The measure of a great instructor is the competence and courage of his or her students to respond to a perceived life-threatening medical event. But the process of becoming and staying a great instructor is a commitment to lifelong learning. Those who prepare ordinary people to provide initial life support are responsible for their own development, but they don't do so alone.

In the field of emergency care instruction, the "self-made" man or woman is a myth. Great instructors are great because they have emulated the best qualities of the great teachers they have encountered throughout their lives. An essential tool to developing and maintaining optimal instructor skills and proficiency is the ancient practice of mentoring and "modeling." These have been shown to be the principal methods by which great instructors develop and maintain their proficiency.

Unfortunately, very few CPR/AED instructors spend much time seeking out and sitting in on the programs conducted by those known to be outstanding and successful instructors. Yet it's a fact that we learned most of the important and mundane functions of day-to-day living from the process of modeling after others. From learning to walk and talk as toddlers to riding a bike or driving a car, from playing sports or a musical instrument to becoming a proficient emergency care clinician, we learned largely from watching or being coached by someone else.

Yet when it comes to guiding others as they learn to provide CPR or utilize an AED, we are largely left to our own devices to strive for and achieve excellence as instructors. What is it, therefore, that makes a great CPR/AED instructor? How does one achieve such success?

The obvious answers are someone who is clinically proficient (i.e., processes good emergency skills). He or she also must be knowledgeable regarding the art and science of teaching and must possess a high degree of integrity and a strong code of ethics. Actual clinical experience can be an added credibility touch but is not essential. Great instructors certainly must have the ability to communicate with others using words, pictures, and demonstrations. But above all, they must be able to inspire others to provide initial life support (if and whenever needed) and to maintain the proficiency to do so.

Without question, this ability to inspire their students depends on their own passion for caring for seriously ill or injured individuals and a strong desire to prepare others to do the same.

Being a great instructor is a process, not a destination. Teaching is their role, but learning is their ongoing mission. They seek out and attend conferences and workshops, and they read widely on both the subject of emergency medical care and the methodology and technology of instruction. Great instructors must have the wisdom and insight to understand their respective audiences and the ability to structure their programs to fit the context and environment in which their students will normally function.

A great instructor is also willing and eager to share his/her experience and expertise with others instructors. Mentoring is a two-way street; those who have developed any degree of proficiency have a responsibility to share it with others.

Writing articles, papers, and editorials and speaking at industry conferences and seminars are opportunities to help perpetuate what was received from their mentors. Networking with other instructors in person or on "chat-rooms" and discussion lists are other ways to help enhance the development of fellow instructors as well as themselves.

Attending a one-, two-, or three-day instructor course does not make someone a great initial emergency care instructor. Nor does simply teaching a lot of programs. Noted behavior psychologist E. Scott Geller of Virginia Tech University is fond of saying, "Practice does not make perfect; it makes permanence . . . unless there is analysis and feedback." Being open to honest critique and comment from students and peers is essential to measuring your classroom performance.

As noted in the book "Good to Great" by Jim Collins, the principal antagonist and hindrance to great is good. If instructors strive only "to be good," they will settle for mediocrity and never do the work necessary to achieve the optimal effectiveness and the ultimate/most essential measurement of instructional ability: that students actually respond and how well they function in a real emergency.

Conclusion
The terrible events and tragic loss of lives in New York City on Sept. 11, 2001, will never be forgotten. But we also must remember that following the assault on those buildings and their inhabitants, well more than 28,000 people were safely evacuated from the World Trade Center complex and more than 3,000 people were successfully treated for serious and life-threatening injuries. Historians, politicians, and official commissions will spend years studying and debating why the horrific tragedy of 9/11 occurred and who's to blame for the senseless loss of so many precious lives.

However, no commission or extensive inquiry is needed to determine why the loss of life wasn't so much worse. The proficiency and professionalism of NYC's police, fire, and EMS personnel, combined with the building-wide disaster planning that followed the 1993 WTC bombing, resulted in a program of emergency preparedness that saved thousands of lives on that fateful day. Clearly, when it came to saving thousands of lives, preparation was the key to protection. So it is, too, in dealing with the ever-present terror of sudden cardiac death that claims more than 1,000 precious lives in the United States alone each day.

As CPR/AED instructors and on-site emergency response program managers and consultants, none of us may have the title of "ruler of the emergency care world." But we do possess the awesome power and important responsibility to influence, motivate, validate, and guide our initial emergency care students and their organizations and companies in their need to be properly prepared to help prevent countless premature deaths. To quote another recently departed EMS legend, Jim Page, "We must not fear failure, but only the possibility of failing to make a difference."

In the struggle against preventable premature cardiac death and the efforts to prepare people for optimal protection against the leading cause of death, the role of CPR/AED instructors is not just important, it's absolutely essential. It is the responsibility of teachers of initial life support (which now includes use of a readily available AED) to help students and develop--and, equally imperative, to maintain and to utilize--the knowledge, skills, and confidence that is so crucial to giving the victims of sudden cardiac death an opportunity to continue a normal, productive, and loving life.

Sudden cardiac arrest is the cause of far too many premature deaths. Fortunately, we have the technology and the resources to ensure everyone who needs it can receive a second chance at life. Having an AED and being trained to use it is a good start, but they're not enough. We can and must do more, because failing to be properly prepared is preparing to fail.

This article originally appeared in the December 2004 issue of Occupational Health & Safety.

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