UKC

"In the hills you're likely the first responder—and your actions matter". A heart attack far from the help of the emergency services is a life-threatening situation. Would you recognise one when you saw it, and know what to do? Cory Jones of First Aid Training Co-operative runs through the basics that might save a life.

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Thanks for this Cory. A couple of questions please.

The article says “Encourage the casualty to sit in a comfortable position—preferably upright, supported, and leaning slightly forward”. Is the person in the photograph in the correct position or should they be leaning forward rather than backward?

When discussing a cardiac arrest, it says “If they lose consciousness and stop breathing normally, you'll need to begin CPR”. Is there no need to check the person’s pulse before beginning CPR, just breathing?

Thanks. 

Lots of good stuff in this article.

Modern recommendation is not to check pulse (may well be very tricky outdoors any way).  

My question is when CPR is really appropriate in the outdoors particularly in remote situations (and if you start it when do you stop).  Survival/outcome from out of hospital arrest is poor even in urban situations particularly with no defib access.  (I am a doctor). 

In reply :

The article doesn't really make it clear how poor the outcomes are likely to be.  During a week long first aid course, the nurse said that 90% of cardiac arrests would not be restarted without a defibrillator.  If that's representative, the success rate after doing CPR for an hour or so (until a defib arrives) must be even less.

My vague recollection of MRT stats in the Lakes is that cardiac arrest call-outs do happen but are relatively rare.

Complex stuff with many variables, you can have respiratory arrest, but given the location and physical activity it's more likely breathing stopped because of zero or near zero effective heart activity. Full cpr is the best route, doing compressions on a heart beating so weakly you can't feel a pulse (not easy cold, wet hands etc) isn't going to harm. You have to push oxygen around for them as they've literally got just a few minutes.

I'd make the 999 call on speaker phone as 2mins chatting holding the phone is precious time lost. 

Indeed. If you collapse in the street the odds are still not great.

Side note, my step dad(fit 79 year old) had a heart attack waiting to start the Newcastle 10k last year(that pre race nerves or jitters many of us get), he was beyond lucky. He happened to be stood by the race director who was an ex paramedic, with a radio link direct to the ambulance team on site. Instant CPR, seconds for paramedics, he still crashed again in the ambulance. He survived by the skin of his teeth, beat the odds without doubt. Sometimes the damage to the heart can be so catastrophic rapid cpr, defib, a&e etc.. won't save you. 

A side case would be stage 4 hypothermia and cardiac arrest – "they aren't dead until they are warmed up and dead".

Their prognosis with continued CPR even with an ECMO still hours away might be better. Unless frozen solid, of course.

As for stopping – when it starts to endanger your own survival? It's a very physical activity, after all, and it wouldn't do for the MRT finally arrive only to find two casualties instead of one...

Still, I'd take even a 1% chance of a good outcome over just doing nothing.

I live in Chamonix.  The most likely scenario here is an older person who has a "cardiac arrest" whilst exercising.  I have come across 2 people like this (not in my party) who were dead when I arrived and a friend of mine died like this on his bike (not with me).  If you witness the collapse, start CPR straight away and are good at it and have mobile phone signal may be its worth carrying on.  It would be interesting to see any expert guidelines on this.  I have never done CPR in the outdoors but I would imagine it could be very different than on a hospital bed.  Moving an unconscious body is very difficult.

I'd say it's partially related to the weather and helicopters. You could do good CPR for 20-30mins paramedic/doctor flies in, drugs, o², defib and gets a heart rhythm back. Rubbish weather low cloud, CPR for 1-2hrs, possible paramedic, maybe drugs, o², defib... long stretcher carry out to below cloud base. You can surmise the probably outcomes.

But, if you're first on scene why not, it's your conscience and maybe the statistics swing your way. You'll be likely waiting there with them either way. You'd have spent a hour flogging uphill anyway, spend the energy trying to save them.

In chamonix as you know they can be up, on scene and down in the valley again pretty quick day or night. 

very true about helicopters here.  not so in UK though usually

if there’s a few of you and you can swap out CPR every two minutes, I’d say crack on. You’re no doubt posing the question as you’re aware that survival rates for out of hospital arrests are not great. Even worse with a good neurological outcome.

Factor in that even if you’re fit and healthy, after a couple of minutes, the quality of CPR compressions declines very rapidly, hence the necessity of swapping out every two minutes.

So why start if it’s just you and the casualty?

Probably the best reason is psychological preservation after the event. In the following days you can take some comfort in the fact that you stepped up and didn’t just sit by a cooling corpse waiting for someone else to rescue you.

Exiled Scot knows an awful lot about UK helicopter rescue

I did in the past (Ex mil SAR), response is airborne under 15mins daytime, 45 night unless it's changed. But you have to fly to maintain currency, so it's prudent to fly the hot spots at peak times on a weekend. Even if a helicopter isn't so near, it's already airborne and on a clear day above the summits, Snowdon to Cadar, Cairngorm to Meggie etc.. is surprisingly fast.

Alps and other places it varies, but generally very fast as they are primarily hill rescuers, 24/7,  long lines or land on etc.. UK airborne SAR is slightly more geared towards emptying a trawler or oil rig than just mountain work. 

Plus there are air ambulances. Overall the answer is always start cpr immediately and if there is more than one of you get them to ring 999, otherwise as I said speaker phone yourself. 

Still grateful for your help setting up my SAR observer shift. Cheers

I was speaking to one of the people who does our annual resus refresher training last week, and she was saying to us that women are less likely to receive bystander CPR than men. It's probably a mixture of worry over getting accused of indecent assault, or uncertainty over exactly where to put your hands - not helped by the fact that every CPR mannequin I've ever used (in the ambulance service, hospital or in the community) has been a nice flat chested one, so I assume that's what any member of the public who has received any basic training will have used too. 

Having had an arrest myself out of hospital (before I became a paramedic) and being female, it seems I'm doubly lucky to have survived 😂

(Fortunately I didn't arrest until the Medic One team from Edinburgh and several ambulances had arrived, otherwise I'd have been at the whim of whether anyone was willing to push on my non-flat chest it seems!)

Yeah, at my last but one FAW requal I was the only woman and all the blokes worked in heavy industry. All of them were hesitant about the prospect of doing CPR on a woman because of concerns about where to position the hands and handling breasts. I told them I'd rather have them handling my breasts than being dead. They're now starting to produce female CPR training manikins (womanikins?)

On giving CPR on the hill - I'd go for it and call for help. Help might come in a helo or on foot (in the latter case doing CPR until a foot party arrives is probably only tenable if you're with others). Quite a few MRTs now have an autopulse so can evacuate on a stretcher whilst the CPR is continuing, and IIRC the Coastguard helos carry an autopulse.

Keep on going until help arrives and takes over, or until you can't continue any further. Don't put yourself at risk - the rescue mantra is 'self, team, casualty' in terms of priorities, and if you're on your own it's just 'self, casualty' in that order.

Obviously the casualty's chances of survival are minimal; I've attended several cardiac arrest MRT callouts and none of them made it. But minimal chances of survival are infinitely better than the no chance of survival if no attempt is made.

Will air ambulances do mountain rescue work?

One point of real significance in terms of long term outcome is the use of aspirin in suspected myocardial ischaemia (MI insufficient oxygen supply to heart muscle)

If there's no history of aspirin allergy or significant risk of bleeding then giving aspirin has the potential to decrease risk of death and disability. 

Take home point. Always carry aspirin and use it if heat attack suspected and above contraindications not present. 

Heart attack in the outdoors will become more frequent with an increasing numbers of active older people ( people continuing the activities they did when younger but now with  more time) with underlying silent heart disease. 

On a recent climbing trip to Spain two of us had had heart vessel surgery and one had a pacemaker. 

( I am a doctor)

I carry an aspirin in the little pocket on my chalk bag and one in my wallet. So got one on me most of the time.

What is the advice for people having a heart attack on blood thinners who aren't bleeding? 

300 mg of aspirin chewed regardless of prescribed thinners.

Edit: to add contra indications 

 every CPR mannequin I've ever used (in the ambulance service, hospital or in the community) has been a nice flat chested one,

A popular mannequin was called rescuscie - annie, but as it apperaed to have a mans flat chest with a womans head, on my courses it was always refereed to as trannie-annie 

maybe not so politically correct but it did make the point that CPR can be different for large chested female patients

Yes and no. They can attend and land on etc if possible. There is coordination between the agencies, as it's about getting the right help as fast as possible, a doctor on an air ambulance is potentially better than a coastguard paramedic depending on incident. They obviously can't winch and many pilots have mountain flying SAR experience, but there are limitations, it can be hard for controllers to get enough information as to if the location is ok for air ambulances etc... Some fly at night, some don't. What they try to avoid is sending an air ambulance and standing down the coastguard only to then find the location is beyond the air ambulance's parameters. The aircraft (and it's crew) are never endangered for the sake of a rescue, push to the limits yes, but not over step. 

As with most things like this the answer is it depends. 

I was impressed to see the para and tech on the back of coastguard SAR helicopters are issued Scarpa mantas as work boots. They’ll also carry axes and crampons in Winter. 
No such kit available to HEMS air ambulances.

Because they can often be dropped on scene and the helicopter will depart until they radio for it to return, or it might head off to even refuel if on the limit(there certainly were or still are remote fuel tanks at strategic points in the Highlands so they don't necessarily need to go to a military or civil airfield). Holding there in the hover is very fuel expensive not to mention the down draft. Also decent footwear is needed if they end up on wrecked warm metal at aircraft crashes, rigs, ferries, trawlers... incidents. 

I was wondering at the efficacy of B2 boots on the greasy, rolling deck of a stricken trawler. 
 

Certainly not a job for those of a nervous disposition.

I think this is true and important.  I've only had to do CPR for real once - neighbour had a cardiac event taking his dog out on a cold morning.  It didn't work, but it was a forlorn hope anyway.  It did help the next-of-kin psychologically, and at least I tried to do something. 

The other learning point for me was that if this isn't your daily world (like Stichtplate's, I guess) then it can take an appreciable time to go 'this isn't right -> this is a crisis -> must do something'.

I did a First Aid at work course where they spoke about the modern defibs, the ones that talk you through what to do. The trainer said, that if the woman has an under wired bra, it should be removed, as it can interfere with the process and also cause a burn, when they get the shock! There was quite a lot of concern and discussion amongst the, mostly, male participants. Later courses with the same company, didn't have that advice.

OP: 

Is having the casualty sitting, now preferred to having them lie down? The advice used to say it was less effort for the heart to pump blood around.

From personal experience I can say that they do.

We came across a man who had had a heart attack while out mountain biking in the Peak. One of his friends was already doing CPR and the other on the phone to 999. We joined in so then 3 of us carrying out CPR and the other on the phone until Yorkshire Air Ambulance arrived.

Sadly he didn't survive, but I hope it gave his friends and family some comfort to know we tried our best. It certainly helped me process it.

Witnessed arrest I'd say crack on as per Stichtplate, even in the middle of nowhere (though I completely get where your question is coming from) Coastguard heli with a winch and Paramedic level skills and drugs could be 5 minutes away. I'm stating the obvious here but the article isn't aimed at us (Paramedic here) and others used to making decisions like that around OOH cardiac arrests. 

If nothing else at least trying will help the bystander that has had someone they've been looking after for however long arrest on them. 

I think it's a decent article, keeps everything nice and simple without skimping on the important stuff.

This. Add in if it's an MI as per the article they've perhaps been sat looking after them for a while and seen them go unresponsive. Always a "Holy Sht!!!" moment for even the most experience of ambulance clinicians...

Edit to add that was to the thread rather than you personally haha ;p

Fair enough though. Normal course of events, we make the patient feel better or a least get them stable, or at the very least get them to hospital with a pulse. 

I vividly remember the first patient that actually died in the back of my truck. Truly horrible and stuck with me for weeks. Especially tough to process as there was no clear clinical cause.

Fortunately (or unfortunately) such jobs get a little easier with repetition and you begin to accept there’s only so much that you can do.

I thought the common mannequin was modelled on a drowned woman?

https://en.m.wikipedia.org/wiki/Resusci_Anne

That's the face, though...