Imparting a New Message

Our investment in CPR, AED, and first aid products and training isn't as successful as it should be. The focus of our training must change, this expert says.

Editor's note: The promise of AEDs has not been fully realized for several reasons, most notably our failure to train potential users in a way that truly prepares them for the experience, contends Frank J. Poliafico, RN, director of the Initial Life Support Foundation (www.ilsf.info, 610-566-2824) of Media, Pa. ILSF promotes the development and management of optimal on-site emergency care preparedness--including the availability and use of AEDs--as an integral part of community EMS Systems. Poliafico discussed the need to develop a "mindset for crisis" and other issues in a July 14, 2006, conversation with Occupational Health & Safety's editor. Excerpts from the conversation follow:

Are we as a society really spending more than $1 billion annually on products and training related to first aid, CPR, and AEDs, even as sudden cardiac arrest deaths are rising? Are most people in the field aware we're spending that much?

Frank J. Poliafico: I don't think they are because they're looking in their own little corner of the "pie." The training cost, the first aid kit cost, the AED cost--you put those all together, you're talking a billion dollars a year. Yet EMS professionals confirm that rarely is an average citizen doing CPR or using an AED when EMS arrives at the scene of a cardiac arrest.

That's staggering.
It is [and] in terms of an opportunity to prevent premature deaths, we're not getting maximum benefit. I think the reason is that we've largely used a cosmetic approach. Most on-site emergency medical preparedness has been driven by regulations. OSHA says "you must"; some state authorities say "you have to"; some courts have said "you should have"; and so people buy kits, they're getting training, in some places they're now acquiring AEDs. But the fact remains, most activity is primarily based on regulatory requirements, not functional requirements.

It's been very cosmetic. There are quotas and measurements for sales, but not for preparing people. The focus has been form, not function.

Yes. The focus has been getting these devices deployed to solve the problem. The follow-up seems not to have been stressed nearly as much.
In fact, it hasn't. With AEDs, the focus has been on just getting them out there. And repeatedly now we're hearing of cases where the AED is on scene and not used.

This is another staggering statistic, to me. I've met 53 survivors. That is always an emotionally exciting moment--meeting someone who received CPR, was defibrillated, and benefited from good EMS. Only one of the 53 I've met was defibrillated by a non-emergency person.

So it is--in your experience and from what you've read--a very rare event?
It's a very rare event that a non-emergency person acts. Now, what's an emergency person? EMS, security, emergency nurses, flight attendants--they're emergency people. They have a mindset to respond to emergencies. Casinos have a phenomenal success rate, but it's security who's running the program there. When you take it out into the schools, the schools aren't doing as well.

Many stories of AEDs on the wall, not used, are coming from schools. The reason for this deficit is that we're most often dealing with reluctant, infrequent responders.

You mean it's very hard to coax a bystander, even one who's had some training, to intervene?
Coaxing may not be the right word. It's difficult for them to respond unless they're properly prepared, let's put it that way. And proper preparation doesn't mean just giving them the device and putting a card in their wallet.

Tell me what your concept of proper preparation is.
Proper preparation is having a very user-friendly AED [and] having a good, solid training program that focuses on psychomotor skills and building a comfort level, and provides achievable goals and a sense of accomplishment. And then, there must be an ongoing developmental process.

The day you got your driver's license, Jerry, were you on the interstate highway?

No, of course not.
But you had a driver's license! You weren't yet prepared for the freeway. I grew up outside Philadelphia; I knew if I got on I-95, I wouldn't get off until Miami. So I didn't get on 95 for quite a while.

That mindset, that comfort level to do an intensely emotional thing, is the result of an ongoing learning process. We've learned that with EMTs, and medics, and ER nurses, and ER docs. We don't just put them through school and send them out; we then put them through apprenticeships, internships. We give them a chance to practice and develop.

Well, just having a CPR/AED card in your wallet is not enough. The average person who takes a CPR and AED class isn't going to run into a cardiac arrest very soon, if ever, in their lifetime. They may only see one in a lifetime. Consequently, we have to ask, what are we doing to keep that emotional preparation, that comfort level, up? Or they won't respond when needed.

The way you see it, we're not doing anything?
We're not doing enough. There also have to be drills, scenarios, mental reminders, posters, "magic minute" safety meetings at a work site--there's all kinds of ways to do it. But it's generally not being done. There are some great examples of how this concept is working well, but they are few and far between.

That does seem like a key component, and you've just mentioned several ways it could be accomplished. It does not seem so hard to do.
It's not that hard to do. It's a matter of defining the problem and saying, okay, how do we solve it? We've not defined the problem based on what does the patient need, we've defined the problem as what can we sell?

Good point. You've talked about changing the mindset of the lay responders--the reluctant responders--so they're looking at the process rather than the outcome.
You know who's done some of the best work in this arena? Dr. Scott Geller, the guru of behavioral safety. He may not have intended it for medical response, but most of Scott's work in behavioral--and now I think he now refers to it as people-based safety--applies to on-site emergency response. It's the same concept: Unless you give people the right motivation, they're not going to act. And what Scott has said over and over again: What motivates best are consequences. But those consequences have to be soon, positive, and certain. Negative consequences don't motivate well. If they did, our prisons would be empty, and you and I would never get speeding tickets.

Hence, I believe we need to focus on what the great Dr. Peter Safar, the acknowledged "father of CPR," called "life support," not life saving. Life support's always positive. Not every victim of sudden death will survive, but every one of them should positively have a second chance at life.

Exactly. Life support is positive and achievable.
We have to start focusing the training and the preparation on the way the human mind works. I think of myself as a guru of human nature. What's human nature dictate, and how can we help that human-nature do something?

Death is the greatest fear in life. Failing in public is the second-greatest fear in life. Put those two together and you have paralysis. Now, with the AED, add the concept of: You must touch them, you must bare their chest. (When's the last time you ripped off a woman's clothes in public?)

The training class, the hands-on practice, has to be as realistic as we can make it without harming people, and then we have to have validation of learned skills. What ultimately made it work for [an executive Poliafico had trained that day] was this instructor standing there and saying, "Good job. You did that right." Human nature again: We spent most of our youth and adolescence trying to get our parents' approval. Well, in class we must get that instructor's approval, or we don't develop a sense of accomplishment.

Very interesting. That's not the way I experienced CPR training. The manikin experience is not what you're looking for?
For CPR, certainly you need a manikin to practice pumping and blowing--you can't pump and blow on a real person. But as much as possible in class, before I have students work on the manikins, I suggest you open the airway of the person next to you. You look and feel for the breathing of the person next to you. So you're getting a human experience, and then you actually pump on the manikin.

But then, the ultimate success is, how are they staying current? Are they discussing this? Are they having a mental drill: "Okay, Jerry just went down. What would you do for him? When you call 911, what would you say? How would you find your hand position on his chest ? Who's going out to meet the ambulance?"

If you don't go through those mental machinations--I'd much rather have a real, live drill, and occasionally we encourage and support those--but at least there has to be this mental drilling of what's going on.

One question I intended to ask you seems ironic now: How close are we to a national public access defibrillation capability? Even if we get there, we don't have the follow-up we need, in your opinion.
In terms of the number of units out there, we're 25 percent of the way. There's less than a million units on the street. Probably around 750,000 to 800,000. The promise to the venture capital people four and five years ago, when all these manufacturers were raising their money to do these things, was that we'd have 3 million to 4 million out there by now.

Really? I think the number you just quoted is impressive, given how recently AEDs were introduced.
AEDs were introduced 12 years ago. Let's go back to the '70s. You know, I used to be director of EMS in New York City. When I got there in 1977, I heard this braggadocio: "We have two paramedic units!" And I said, "Good start, but we need a hundred. You can't rely on two units to cover 10 million people all day. What are we doing to get the other 98?" Similarly, three quarters of a million AEDs are not enough.

By the way, half of those [AED] units that are currently sold are in emergency services. They are not public access. Let's translate that: So we're really not a quarter of the way there, and of the public access ones that are there, how often are regular people using them? Not often. Are there some cases? Absolutely. Are there a lot of cases? No.

It's this process again. I think it is a phenomenal tool to help us deal with this condition called sudden death, but it's also a tool to help communities and individuals deal with emergency preparedness in general. The mindset to deal with a cardiac arrest is the same mindset I need, if I'm an average person, to deal with a hurricane, weapons of mass destruction, a plane crash--you name the crisis. I have to develop a mindset for crisis. And we haven't done that because we've put in too much hyperbole and superfluous information in the curricula.

What's your solution? What's the strategy that gets us there?
First thing, let's use terminology and objectives that are realistic. A great example is the airline industry. Have you flown recently? Before the plane takes off, do you hear the flight attendant do a safety briefing or a survival briefing?

A safety briefing is what I would call it.
That's what they call it, too, but it's not. It's a survival briefing. Other than "buckle up," what did that flight attendant tell you that had anything to do with safety?

The airlines have long believed that if they started talking survival, they might frighten the passengers. . . . They're going to get us to do what we need to do to protect ourselves, but not by scaring us. So in the initial emergency care arena, we have to start using terminology that focuses people on what we want them to do without scaring them, or they don't do anything.

And that's why we need words like "life support, preparation, protection" not "life saving and resuscitation." Those are the concepts that we have to get across to people, and then focus on teaching that behavior, and then validating that behavior, and then maintaining the comfort to perform that behavior.

Don't you need to get some of the major training organizations on your side?
We do. The major training organizations should be involved, but remember, their major focus is education, and curriculum development, and materials development. The major EMS organizations and local EMS agencies need to be leading the way. But what we believe the ultimate focus should be--and the primary reason we started the AED Instructor Foundation [ILSF's previous name]--was to focus on the people who are doing the preparation.

Based on current medical science, if we are going to deliver reasonable and appropriate on-site emergency care, we need to think of a triangle: one side is the patient, one side is the provider of care, and the other side is the preparer of the provider of care. And we need to address all three. What we've failed to do, for whatever reason, is to focus on the preparer. Because that provider, who is an infrequent and reluctant responder, is going to do nothing for that patient unless that preparer has helped that provider develop and maintain the right physical and mental tools.

Right. And the preparer is the training organization.
Well, it's the instructor, who really isn't just an instructor any more. You know what he or she is?

What?
They're emergency care management consultants. Conceptually, that's what they are. I didn't figure it out, my corporate clients figured it out for me. Because I wasn't just their first aid instructor and CPR instructor; I was helping them design their emergency response plans. . . .

AED sales quotas and the numbers of people "trained" cannot be our primary objective. Success without significance is a sham.

We could get this whole effort regenerated by asking one question: What's in the best interests of the patients? The best interest of the patient is that the provider is properly prepared and will respond.

This Q&A appeared in the September 2006 issue of Occupational Health & Safety.

This article originally appeared in the September 2006 issue of Occupational Health & Safety.

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