PROFESSIONAL PRACTICE

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CARDIOPULMONARY RESUSCITATION – WOULD YOU DO IT?

Liew Su-May MMed (FamMed, UM)
University of Malaya

Address for correspondence: Dr Liew Su May, Lecturer, Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Tel: 03-79492626 Fax: 09-79577941 Email: sumayliew@gmail.com

Liew SM. Cardiopulmonary resuscitation – would you do it? Malaysian Family Physician. 2006;1(2&3):91-93

The use of cardiopulmonary resuscitation or CPR as it is better known, as a means of prolonging life in a pulseless and non-breathing person, has almost universally been accepted as sacrosanct in the practice of medicine. Mouth-to-mouth ventilation was first recommended by the National Research Council of USA in 1957 ¹ and the first reported out-of-hospital resuscitation took place in 1960.¹ It has been reported that survival rates and hospital discharge of up to 43% can be achieved when CPR is started within 3 to 4 minutes.¹  Also, the combination of CPR with immediate on-site defibrillation may achieve survival rates as great as 70%.1 In Malaysia, CPR is taught to medical personnel, trainees, first-aiders, lifeguards and the police as well as the navy. The Malaysian Clinical Practice Guidelines on Acute Myocardial Infarction (AMI)² strongly urged the teaching of CPR to the general public. The authors wrote “About 30% of deaths due to AMI occur within the first hour; 60% of deaths occur outside the hospital. Thus the general public and the family of patients with CHD should learn cardiopulmonary resuscitation and basic life support.”

Yet practice may be very far from what is advocated. In the middle of this year, my husband and I drove to an a five-star hotel in Kuala Lumpur to pick up a friend and his family for dinner. He waited in the car whilst I ran in to wait for them. I noticed a large crowd in the lobby café surrounding a prostrate man. My medical training clicked and I quickly established that he was not breathing and pulseless.

The people standing around told me that the ambulance had been called for and that he had simply collapsed ten minutes before whilst walking. No one had started CPR! There were not even hotel personnel around to help. I proceeded to carry out mouth-to-mouth resuscitation (MMR) and external chest compression. A bystander handed me a handkerchief which he advised me to use over the mouth. I simply used it to wipe the collapsed man’s mouth and continued. Five minutes later, another man approached and identified himself as a doctor. We proceeded to do two-rescuer CPR. This continued satisfactorily for a while until, exhausted, I asked him to change and take over MMR. He was obviously reluctant although he did change with me. He then covered the victim’s mouth with a

handkerchief and tried to blow through the cloth. Respiration was unsuccessful as evidenced by the absence of chest rising. This continued for a while making me anxious. I was ready to take over MMR again when the ambulance arrived.

Several issues relating to this case disturbed me as a health worker. First, no one had attempted CPR in the first ten minutes. Not a single person in the large crowd had tried to resuscitate the collapsed man. This was worrying as the first few minutes after collapse are the most crucial. The American Heart Association states, “A first responder must be willing to act without hesitation”.¹  Furthermore, it was apparent that there was no preparation by the hotel to prepare its workers for such an emergency. Thirdly, the hesitation by the second doctor on the scene was disturbing. It was apparent that infection was the danger he was worried about. This fear of catching an infectious disease had affected the efficacy of his resuscitation method.

Undoubtedly, the fear of catching an infectious disease is paramount in the minds of any health worker when confronted with a similar situation. This is the era of AIDS and SARS. Indeed, I immediately proceeded to wash my mouth several times after the resuscitation. However, is this fear real or imagined?

The World Health Organisation’s stand is that “mouth-to-mouth resuscitation is a life-saving procedure and should not be withheld through fear of contracting HIV or other infections.”³  A review by Mejicano and Maki¹ noted that, as of 1998, only 15 cases of transmission of infection through saliva had been documented and that the majority involved a bacterial pathogen. Examples of bacterial pathogens that have been reported include Neisseria meningitidis, Mycobacterium tuberculosis, Shigella sonnei and Salmonella infantis. The review stated that there was no reported transmission of HIV, hepatitis B, hepatitis C or cytomegalovirus by mouth-to-mouth ventilation¹. The risk for acquiring HIV infection during MMR has been estimated to be less than 1 in a million⁴. This estimate may be perceived to be too high by some health care workers.

 

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