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Learning from my mistakes

Earlier today I was walking down a street when someone fell to the ground a few metres away from me.

I rushed over and found them lying on the ground breathing noisily. They weren’t responsive and I with some others started to put them in the recovery position. Then I realised something wasn’t right – the patient was still gasping. I couldn’t feel a pulse, realised they had arrested and turned them back over and started CPR – chest compressions. Another doctor came along – it was a busy location – and took over chest compressions from me. I was going to start rescue breaths but he said the guidance didn’t recommend.

Another bystander had already phoned an ambulance and someone else had found a nearby defib. The end result was that the patient was shocked and went back into a normal heart rhythm and started breathing again. I left before they were transferred to hospital but all seemed to be good.

This was the first time that I had witnessed an out of hospital cardiac arrest and I wondered if this was how it normally looked so I googled “what does an ooh arrest look like”. (OOH = out of hospital). The top hit was an article from the University of Arizona “What does Primary Cardiac Arrest Look Like?” and the first two sentences were

“Primary cardiac arrest is recognized by a sudden, unexpected, witnessed (seen or heard) collapse in an individual who is not responsive. Patients with primary cardiac arrest often gasp (an abnormal snoring-like respiration) which provides adequate ventilation, but indicates a cardiac arrest.”

The mention of gasping stood out to me. I had already related the story to some colleagues in a WhatsApp group and noted that the patient was gasping when I came to them. I googled “gasping cardiac arrest” and again the University of Arizona site came top with this article “Gasping is a Sign of Cardiac Arrest”. It noted

Many bystanders are hesitant to perform mouth-to-mouth ventilation, and in a case of a witnessed (seen or heard) collapse, so-called rescue breathing is not necessary and may be harmful. When the patient gasps, there is a negative pressure in the chest, which not only sucks air into the lungs but also draws blood to refill the heart. In contrast, mouth-to-mouth breathing creates overpressure in the chest and actually inhibits blood flow back to the heart. Gasping during cardiac arrest is much better than mouth-to-mouth breathing.

Now it was jumping out at me that many other people might not recognise gasping as a sign of cardiac arrest and start chest compressions. So within an hour of witnessing the arrest tweeted :

*gasping is a sign of cardiac arrest*

*start hands-only CPR immediately*

Please share— Anne Marie Cunningham (@amcunningham) September 17, 2019

I found that it has only been in the last few years that gasping (also known as agonal breathing) has been recognised as an important sign in predicting the chances of recovery in an out of hospital arrest – at least twice the odds of someone who is not gasping.

Later I was searching Twitter for ‘ gasping CPR’ and came across several tweets from resuscitation experts about how bystanders often delayed CPR because they saw gasping. I shared those tweets as replies in a thread and also a video of a simulation of gasping in cardiac arrest.

So far I had not mentioned my involvement in any way in the thread. But as I came across mentions in tweets of people who had made the same mistake as me, I thought it would be more honest and possibly more powerful if I shared that I had not immediately recognised cardiac arrest.

I’m a trained health professional and if I didn’t immediately recognise a cardiac arrest neither might you. So please do share this.— Anne Marie Cunningham (@amcunningham) September 17, 2019

It’s important to me not to breach patient confidentiality in any way, but also to show that we all make mistakes. The essential thing is to learn from them and to try and prevent the same thing happening to others – a good lesson for World Patient Safety Day.

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