The Science of Teaching More Effective CPR Courses

Importance of CPR

Though the vast majority of adults have reported receiving CPR training at some point in their life,^[I] bystander CPR response for out-of-hospital cardiac arrest victims is uncommon.^[ii] For instance, in one study of 3,053 out-of-hospital cardiac arrest events, only 33% of the victims received bystander CPR.^[iii] While dispatchers can help encourage bystanders to perform CPR, bystander intervention remains low, is of poor quality, delayed, and many bystanders fail to recognize cardiac arrest symptoms.^[iv]

CPR saves lives.^[v][vi] In a study of 1,297 people with witnessed out-of-hospital cardiac arrest, physicians Richard O. Cummins, MD, MPH and Mickey S. Eisenberg, MD, PhD found that bystanders independently improved survival. “Bystanders initiated CPR for 579 patients (bystander CPR); for the remaining 718 patients, CPR was delayed until the arrival of EMTs (delayed CPR). Survival was significantly better (P < 0.05) in the bystander-CPR group (32%) than in the delayed-CPR group (22%).”^[vii]

Moreover, bystanders can help prolong “the duration of VF (ventricular defibrillation) after collapse….increasing cardiac susceptibility to defibrillation.” VF, a “shockable” rhythm is critical to the success and survival of victims of out-of-hospital cardiac arrest.^[viii] Studies indicate that victims in ventricular fibrillation who receive CPR prior to defibrillation have a higher survival rate than those who do not receive CPR.^[ix][x]

Even when CPR is performed, many bystanders do not perform efficacious CPR. Thus, their action, while noble, may not lead to increased survival. Good CPR matters. ^{[xi][xii][xiii]} Commonly, bystanders do not begin CPR soon enough, don’t push hard enough or fast enough.

The importance of high retention of CPR instruction, leading to action, can’t be overstated. Higher retention of CPR course curriculum will result in greater CPR response and greater response will save more lives.

Now, how can we teach more effective CPR courses, leading to better comprehension of course material?

Role of the CPR instructor

The goal of CPR training is to learn how and when to perform CPR.^[xiv] During a cardiac arrest event, the patient may be going through many physical symptoms, including agonal breathing, “an abnormal pattern of breathing and brainstem reflex characterized by gasping, labored breathing, accompanied by strange vocalizations.”^[xv] Agonal breathing commonly results in a false perception of life and a delay in performing CPR.^[xvi]

“CPR courses give us an opportunity to share stories and describe the traumatic events related to cardiac arrest. This helps us break down barriers that lead to inaction. Ideally, if we’re able to describe what cardiac response is really like, we can better prepare course participants,” states Ross French, EMT-P, instructor for Annuvia, a national American Heart Association training company. And Ross should know. He, himself, has responded to hundreds of CPR calls and performs CPR on patients daily as a paramedic with the Rural/Metro in the busy Santa Clara County system.

While CPR courses are typically taught to small groups, CPR instructors are public speakers. Using certain techniques, public speakers can improve comprehension of material delivered and engagement of their audience.

In “Talk Like TED: The 9 Public-Speaking Secrets of the World’s Top Minds,”^[xvii] bestselling author and communications coach Carmine Gallo breaks down hundreds of TED Talks – world famous speeches and presentations, which are delivered by the world’s most brilliant thinkers and have been viewed over one billion times – to identify the presentation tactics, skills and commonalities used by the best of the best.

“One thing I learned from studying the world’s best communicators is that they appeal to a listener’s emotions before reaching their head. CPR is all about reviving a heart and so is effective communication. People will only remember tactics, steps, and methods if they have a strong enough emotional connection to the topic.”

As Gallo describes, a physiological impact can be made between speaker and listener. He shares the research of scientist Uri Hassan, assistant professor of psychology at Princeton University, who used a functional MRI (fMRI) to study brain activity by tracking changes in blood flow. More blood flow in more areas of the brain indicates “brain-to-brain coupling” or connection between speaker and listener.

“We connected the extent of neural coupling to a quantitative measure of story comprehension and find that the greater the anticipatory speaker–listener coupling, the greater the understanding. We argue that the observed alignment of production- and comprehension-based processes serves as a mechanism by which brains convey information… the stronger the neural coupling between interlocutors, the better the understanding.”^[xviii]

While traditional CPR courses are heavy on videos, a stronger connection between speaker and listener can be found through storytelling. “Personal stories activate the whole brain, activating language, sensory, visual, and motor areas. Storytelling leads to more blood flow to different parts of the brain, leading to more comprehension and connection between speaker and audience,” states Gallo.                                                                                                                                             

In addition to storytelling, having a conversation with the listener is vital to retention and comprehension. “Communication is a shared activity resulting in a transfer of information across brains. During successful communication, speakers’ and listeners’ brains exhibit joint, temporally coupled, response patterns. Moreover, more extensive speaker–listener neural couplings result in more successful communication,” writes Hasan.

So, how can CPR instructors become better speakers?

“I believe storytelling can help CPR instructors become better communicators,” says Gallo. “Stories of personal experiences or stories about other people (case studies) are highly effective learning tools. Stories inform, illuminate, and inspire. Tell more of them!” Better comprehension of a CPR instructor’s message, through storytelling, will lead to increased bystander intervention, thus saving more lives. Who ever thought telling a story could save lives?

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^I Kristen Sipsma, Benjamin A. Stubbs, Michele Plorde. “Training rates and willingness to perform CPR in King County, Washington: A community survey.” Resuscitation. Volume 82, Issue 5, May 2011, Pages 564–567. Web. June 29, 2015

ⁱⁱ Christian Vaillancourt MD, MSc. “Evaluating the Effectiveness of Dispatch-assistedCardiopulmonary Resuscitation Instructions.” Academic Emergency Medicine. Volume 14, Issue 10, pages 877-833, October 2007. Web. June 29, 2015.

ⁱⁱⁱ L. Bossaert. “Bystander cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest.” Resuscitation. Volume 17, Supplement, 1989, Pages S55–S69. Web. June 29, 2015

^iv Christian Vaillancourt MD, MSc. “Evaluating the Effectiveness of Dispatch-assisted Cardiopulmonary
Resuscitation Instructions.” Academic Emergency Medicine. Volume 14, Issue 10, pages 877-833 October 2007. Web. June 29, 2015.

^v  George Ritter, M.D. “The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims.” American Heart Journal. Volume 110, Issue 5, November 1985, Pages 932–937. Web. June 29, 2015

^vi MD, FACEP Daniel W Spaite. “Prehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times” Annals of Emergency Medicine. Volume 19, Issue 11, November 1990, Pages 1264–1269. Web. June 29, 2015

^vii Richard O. Cummins, MD, MPH. “Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation.” The American Journal of Emergengy Medicine. March 1985 Volume 3, Issue 2, Pages 114–119. Web. June 30, 2015

^viii Roger D White, MD. “High Discharge Survival Rate After Out-of-Hospital Ventricular Fibrillation With Rapid Defibrillation by Police and Paramedics” Annals of Emergency Medicine. November 1996 Volume 28, Issue 5, Pages 480–485. Web. June 30, 2015

^ix Lars Wik, MD, PhD. “Delaying Defibrillation to Give Basic Cardiopulmonary Resuscitation to Patients With Out-of-Hospital Ventricular Fibrillation” The Journal of American Medical Association. March 19, 2003, Vol 289, No. 11. Web. June 30, 2015

^x Robert A Swor, DO, FACEP. “Bystander CPR, Ventricular Fibrillation, and Survival in Witnessed, Unmonitored Out-of-Hospital Cardiac Arrest” Annals of Emergency Medicine. Volume 25, Issue 6, June 1995, Pages 780–784. Web. June 30, 2015

^xi Jim Christenson, MD. “Resuscitation Science; Chest Compression Fraction Determines Survival in Patients With Out-of-Hospital Ventricular Fibrillation.” Circulation, American Heart Association. Circulation.2009; 120: 1241-1247. Published online before print September 14, 2009. Web. June 30, 2015

^xii Raf J Van Hoeyweghen. “Quality and efficiency of bystander CPR.” Resuscitation. Volume 26, Issue 1, August 1993, Pages 47–52. Web. June 30, 2015

^xiii MD, FACEP Daniel W Spaite. “Prehospital cardiac arrest: The impact of witnessed collapse and bystander CPR in a metropolitan EMS system with short response times.” Annals of Emergency Medicine. Volume 19, Issue 11, November 1990, Pages 1264–1269. Web. June 30, 2015

^xiv Åsa Axelsson. “How bystanders perceive their cardiopulmonary resuscitation intervention; a qualitative study” Resuscitation. Volume 47, Issue 1, September 2000, Pages 71–81. Web. June 30, 2015

^xv Perkin RM1, Resnik DB. “The agony of agonal respiration: is the last gasp necessary?” PubMed. 2002 Jun;28(3):164-9. Web. June 30, 2015

^xvi Angela Bång. “Interaction between emergency medical dispatcher and caller in suspected out-of-hospital cardiac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases” Resuscitation. Volume 56, Issue 1, January 2003, Pages 25–34. Web. June 30, 2015

^xvii Carmine Gallo. “Talk Like TED: The 9 Public-Speaking Secrets of the World’s Top Minds.” St. Martin’s Griffin. March 10, 2015. Print.

^xviii Greg J. Stephens. “Speaker–listener neural coupling underlies successful communication” PNAS. 2010 Aug 10; 107(32): 14425–14430. Published online 2010 Jul 26. Web. June 30, 2015