tag:theconversation.com,2011:/global/topics/cpr-4119/articlesCPR – The Conversation2023-03-06T00:54:00Ztag:theconversation.com,2011:article/2003372023-03-06T00:54:00Z2023-03-06T00:54:00ZAnyone can save a life, including kids. Here’s why they should learn CPR and basic life support<figure><img src="https://images.theconversation.com/files/512112/original/file-20230223-14-bvlg8w.jpg?ixlib=rb-1.1.0&rect=90%2C0%2C3952%2C2697&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/first-aid-cardiopulmonary-resuscitation-course-using-513675865">www.shutterstock.com</a></span></figcaption></figure><p>With over <a href="https://www.resuscitationjournal.com/article/S0300-9572(22)00012-0/fulltext">26,000 cardiac arrests</a> occurring every year in Australia and <a href="https://www.resuscitationjournal.com/article/S0300-9572(22)00012-0/fulltext">over 76% of them occurring in the home</a>, some of our youngest Australians are learning how to help.</p>
<p>But why kids? It’s simple. Anyone can learn to save a life. </p>
<p>Basic life support includes cardiopulmonary resuscitation (CPR) and using a portable defibrillator (AED) if required. These emergency procedures aim to save the lives of people in cardiac arrest. </p>
<h2>What is a cardiac arrest?</h2>
<p>A <a href="https://www.heartfoundation.org.au/bundles/your-heart/cardiac-arrest">cardiac arrest</a> occurs when the heart stops beating. This means the heart stops acting like a pump, which stops oxygen getting to the brain. When this happens, the person quickly becomes unconscious and stops breathing. Without immediate CPR, the person is likely to die.</p>
<p>Performing <a href="https://www.healthdirect.gov.au/how-to-perform-cpr">CPR</a> involves pushing down on the chest, which mimics the pumping action of the heart and pushes blood and oxygen around the body and, importantly, to the brain. </p>
<p>An <a href="https://www.healthdirect.gov.au/defibrillators">AED</a> works by analysing the person’s heart rhythm and delivering an electric shock, if necessary, to restore a normal heartbeat. AEDs are designed to be used by the public, and typically provide recorded audio instruction and visual prompts to guide users through the process.</p>
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Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
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<p>Anyone can perform these life-saving skills, and the quicker they are performed the more likely the person will survive. The <a href="https://resus.org.au/">Australian Resuscitation Council</a>, of which we are both members, believes teaching basic life support skills, CPR and how to use an AED in schools is the best way to reach and train whole generations how to save a life.</p>
<h2>A patchy approach in schools</h2>
<p>The current Australian curriculum supports basic life support education in some years. But schools vary in its implementation. Some schools have organisations come in to teach students, like the Red Cross or St John Ambulance, but teachers are also well placed to provide this education.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="AED on wall" src="https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512595/original/file-20230228-26-vd1jv0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Defibrillators have recorded voice instructions and visual prompts to make them easy to use.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/automated-external-defibrillator-aed-inside-box-1385372999lator">Shutterstock</a></span>
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<p>The <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1742-6723.13840">Aussie Kids Save Lives program</a>, an initiative being run by the Australian Resuscitation Council and partners, is aiming to provide teachers with the resources to be able to teach high school students. </p>
<p>A pilot study is currently underway in Victoria. Teachers are guided in instruction and students are practising skills using Ambulance Victoria’s <a href="https://www.ambulance.vic.gov.au/shocktober/">Call, Push, Shock</a> kits that instruct young people how to call for help, perform push (compressions) and deliver lifesaving shocks with a defibrillator. </p>
<p>So far, more than 550 Victorian Year 7 and 8 students have been taught in the pilot, with more than 3,000 expected to be taught in 2023. Early data from the ongoing evaluation of this program is encouraging, with teachers and students finding the materials engaging and effective. </p>
<p>The Australian Resuscitation Council plans to use a report of the evaluation to lobby the federal government to introduce two hours of mandatory training in every year of school.</p>
<h2>How young is too young?</h2>
<p>The <a href="https://www.resuscitationjournal.com/article/S0300-9572(15)00315-9/fulltext">World Health Organization</a> has endorsed two hours of teaching CPR to children every year from the age of 12. However, this isn’t to say younger children shouldn’t be taught how to respond to emergencies. </p>
<p>Children as young as <a href="https://bmjopen.bmj.com/content/4/9/e005848">four years</a> of age can be taught how to recognise an emergency and how to call an ambulance.</p>
<p>Progressive annual learning can help children of all ages learn how to save a life. Initial learning should use simplified methods of instruction, such as <a href="https://www.ambulance.vic.gov.au/shocktober/">Call, Push Shock</a>. Older students can be taught the more technical <a href="https://www.healthdirect.gov.au/how-to-perform-cpr">DRSABCD</a> acronym that guides them to look for danger and responses, send for help, and check airways and breathing before starting CPR and defibrillation. </p>
<p>There is an added bonus in teaching children, as they can be encouraged to pass their learning on to their family, perhaps as homework. This increases community awareness of basic life support skills.</p>
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<img alt="Small toy ambulance" src="https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=340&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=340&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=340&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=427&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=427&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512104/original/file-20230223-20-vbxzxn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=427&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Teaching kids how to call 000 in an emergency is vital.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/s6Vv9u2qZyc">Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-cases-of-cardiac-arrest-time-is-everything-community-responders-can-save-lives-126491">In cases of cardiac arrest, time is everything. Community responders can save lives</a>
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<h2>Intervention is vital</h2>
<p><a href="https://www.resuscitationjournal.com/article/S0300-9572(22)00012-0/fulltext">Data</a> reported by the <a href="https://www.ausroc.org.au/">Australasian Resuscitation Outcomes Consortium</a> shows that even though CPR instructions are given in 000 calls and the person is asked if there is an AED available, only 38% of Australians in cardiac arrest receive bystander CPR and less than 2% receive an AED shock.</p>
<p>Research listening to emergency calls has uncovered this often happens because the caller <a href="https://www.resuscitationjournal.com/article/S0300-9572(18)30261-2/pdf">lacks confidence</a> in their ability to perform CPR skills. Most <a href="https://www.sciencedirect.com/science/article/pii/S0300957220304548?casa_token=zUZZv5DixNkAAAAA:9KSjfPiMgUG7f5oRRCt-ErwvPvSX0R-SK5z1rQbifReUcre1TW3WpyCJ07tNPlpfRTvdKinF5oQ">callers do not know</a> what a defibrillator is. </p>
<p>But areas of Australia with higher rates of trained community members have <a href="https://pubmed.ncbi.nlm.nih.gov/28584073/">higher rates</a> of bystander CPR.</p>
<h2>Help at home</h2>
<p>We encourage parents to advocate for basic life support training in their children’s schools and even teach their children simple CPR themselves using online videos. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/_kvli78HlRk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Former Yellow Wiggle Greg Page teaches kids about CPR and calling Triple Zero (000).</span></figcaption>
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<p>While it may take some time, it is vital to have every Australian know what to do if they find someone collapsed in cardiac arrest, including our youngest. Without any intervention, the person is likely to die. Any attempt is better than nothing. </p>
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Read more:
<a href="https://theconversation.com/when-is-it-ok-to-call-an-ambulance-91751">When is it OK to call an ambulance?</a>
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<p class="fine-print"><em><span>Associate Professor Janet Bray receives funding from a Heart Foundation of Australia Fellowship, and grants from the National Health and Medical Research Council and the Australian Resuscitation Council.
Associate Professor Janet Bray sits on the Australian Resuscitation Council and the International Liaison Committee on Resuscitation.
Associate Professor Janet Bray works with Greg Page on the AUSSIE KIDS SAVE LIVES Working Party. </span></em></p><p class="fine-print"><em><span>Dr Kathryn Eastwood receives funding from a Heart Foundation of Australia Postdoctoral Fellowship. Dr Eastwood represents the Australasian College of Paramedicine on the Australian Resuscitation Council and the International Liaison Committee on Resuscitation. </span></em></p>Rates of cardiac arrest are high. So, why don’t more people know CPR?Janet Bray, Associate Professor, Monash UniversityKathryn Eastwood, Lecturer, Paramedicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1973442023-01-08T13:26:19Z2023-01-08T13:26:19ZDamar Hamlin’s cardiac arrest shows need for CPR training and emergency defibrillators in public spaces<figure><img src="https://images.theconversation.com/files/503471/original/file-20230106-16856-utpr0c.jpg?ixlib=rb-1.1.0&rect=0%2C238%2C4016%2C2619&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Buffalo Bills' Damar Hamlin is examined after collapsing on the field on Jan. 2. He received CPR and defibrillation on site before being sent to hospital by ambulance.</span> <span class="attribution"><span class="source"> (AP Photo/Jeff Dean)</span></span></figcaption></figure><p>Football — a sport that involves violent collisions — came under shocking scrutiny on Jan. 2 when Buffalo Bills player Damar Hamlin collapsed from a <a href="https://www.sportingnews.com/ca/nfl/news/damar-hamlin-injury-collapses-field-hit-tackle-cpr-ambulance-bills-bengals/hayshufiopjoaeuomfxagwt4">cardiac event immediately following an on-field collision</a>.</p>
<p>Most fans already knew <a href="https://www.espn.com/nfl/injuries">the sport was dangerous</a>, often leading to broken limbs, torn ligaments and life-altering <a href="https://theconversation.com/nfl-player-tua-tagovailoas-concussion-might-have-been-prevented-with-rugbys-stricter-protocols-191830">concussions</a>. What Damar Hamlin’s catastrophic incident reminded many is that death might be close by if critical medical equipment and care is not readily applied following a cardiac arrest.</p>
<p>Hamlin seems to have benefited from top-notch, immediate care from trained medics and team staff who responded with life-saving speed and skill. Doctors who treated Hamlin told reporters on Jan. 5 that <a href="https://www.usatoday.com/story/sports/nfl/2023/01/05/damar-hamlin-doctors-bills-player-health-recovery/10997780002/">both cardiopulmonary resuscitation (CPR) and an automated external defibrillator (AED) had been used</a> to restart his heart and restore a pulse on the field before being taken to hospital.</p>
<p>They placed a tube down his throat to help him breathe, supplied oxygen and transferred him to hospital where he is receiving intensive care. Later reports indicated that Hamlin was <a href="https://www.usatoday.com/story/sports/nfl/2023/01/06/damar-hamlin-health-updates-what-we-know-friday/10997169002/">responding and communicating</a> to family and doctors.</p>
<p>The average citizen — at home or at play, engaged in contact sports or casual interaction — may not be so lucky.</p>
<h2>Cardiac arrest</h2>
<p>Globally, 3.8 million people experience cardiac arrests outside a hospital setting, according to the <a href="https://doi.org/10.1161/CIR.0000000000001013">American Heart Association</a> (AHA). Fewer than three per cent get CPR and AED. Only eight to 12 per cent survive to hospital discharge.</p>
<p>CPR is the act of applying pressure to the heart manually, until its normal rhythm and activity resumes. An AED, a portable automated device that is easy and safe to use, can help shock the heart back into such an appropriate rhythm in certain circumstances.</p>
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<a href="https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A person in a blue shirt with hands on the chest of a dummy, while other people observe." src="https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/503472/original/file-20230106-9978-znu74w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Demonstration of CPR on a first aid dummy. CPR is the act of applying pressure to the heart manually, until its normal rhythm and activity resumes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p><a href="https://www.heartandstroke.ca/heart-disease/conditions/cardiac-arrest">Cardiac arrests</a> occur when the heart stops beating suddenly. They are not the same as <a href="https://www.heartandstroke.ca/heart-disease/conditions/heart-attack">heart attacks</a>, which are an interruption of blood flow to the heart that leads to damage to the heart muscle. Heart attacks can certainly lead to cardiac arrest, but they are not synonymous. </p>
<p>A third term, <a href="https://www.heartandstroke.ca/heart-disease/conditions/heart-failure">heart failure</a>, similarly represents a distinct condition in which the heart is not able to pump as effectively. Usually this syndrome, which has multiple causes, occurs more chronically to those who have sustained heart damage.</p>
<p>Canadian figures show more than 35,000 cardiac arrests every year — two-thirds of them at home. One in five occur in public where a defibrillator and/or CPR can increase the chance of survival. Bystander intervention with CPR and AED saves more than 400 lives annually, the <a href="https://www.heartandstroke.ca/-/media/pdf-files/canada/2017-position-statements/final-en-addressingcardiacarreststatement-nov-2019.Ashx?Rev=388eeef4069747dcb4ab6353d36b3f7b&hash=9e27a3232e8f908e45e115b0b9dcc9d5">Heart and Stroke Foundation (HSF) reports</a>.</p>
<h2>The life-saving importance of CPR and AEDs</h2>
<p>Academics and scientists who study CPR say cardiac arrest survival rates increase greatly when bystanders use an AED. However, these rates are still low and warrant further public awareness and education efforts as well as increased, widespread access to AEDs. This is especially so in rural, remote, and Indigenous communities, the HSF says.</p>
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<img alt="A white box reading Defibrillator with a red box inside it hanging on a wall" src="https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/503474/original/file-20230106-17-y5vchz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In a cardiac arrest, survival is significantly decreased for every minute without access to CPR or an AED.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Dr. Mike Howlett, president of the Canadian Association of Emergency Physicians, said in an interview that he supports “widespread education for the public on CPR and AED use” as well as “increased availability of AEDs in public settings, especially recreational and sport settings.” This is consistent with the position of the AHA and the HSF.</p>
<p>The <a href="https://www.heartandstroke.ca/-/media/pdf-files/canada/2017-position-statements/final-en-addressingcardiacarreststatement-nov-2019.Ashx?Rev=388eeef4069747dcb4ab6353d36b3f7b&hash=9e27a3232e8f908e45e115b0b9dcc9d5">HSF data shows that when a bystander uses an AED, the chance of survival nearly triples</a>. Survival is significantly decreased for every minute without access to CPR or an AED.</p>
<h2>Installing AEDs in Canada</h2>
<p>Canada has made strides with the increase in AEDs at sporting facilities, notably thousands of arenas. Through a <a href="https://www.canada.ca/en/public-health/services/chronic-diseases/cardiovascular-disease/national-automated-external-defibrillator-initiative.html">pilot program that ran in conjunction with the HSF from 2012 to 2016</a>, officials installed 3,000 AEDs and trained 23,000 Canadians in their use.</p>
<p>Nine lives have been saved to date as a result of this initiative, according to a program summary from the government of Canada. Further expansion to other recreational facilities is planned.</p>
<p>While this is a step in the right direction, hurdles remain. A 2016 article in the <a href="https://doi.org/10.1503/cmaj.150544">Canadian Medical Association Journal</a> showed that living on higher floors in apartment buildings is associated with lower survival rates for cardiac arrest in Canada. The <a href="https://doi.org/10.1016/j.resuscitation.2021.11.001">closer one is</a> to life saving equipment, and providers trained in its use, the better the chance of recovery.</p>
<figure class="align-center ">
<img alt="A sign reading AED with a heart icon in the foreground, with athletes in a gymnasium in the background." src="https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/503473/original/file-20230106-19-ytjfqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canada has made strides with the increase in AEDs at sporting facilities, but more work is needed.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This highlights again the importance of timely recognition and response as well as the availability of equipment in private settings. Survival rates decrease with every minute of delay. AEDs and trained providers need to be as close as possible.</p>
<p>Hamlin’s diagnosis is still unclear but what is evident is that he had a cardiac arrest due to an abnormal heart rhythm, and that prompt resuscitation restored his pulse.</p>
<p>The HSF and AHA both advocate for increased <a href="https://www.heartandstroke.ca/how-you-can-help/learn-cpr">CPR education</a> and AED use for the treatment of acute cardiac events. As Hamlin continues to heal, he provides proof that this approach seems to have merit.</p><img src="https://counter.theconversation.com/content/197344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Pyle currently does education work with the Heart and Stroke Foundation on CPR and AED use.</span></em></p>Survival rates for cardiac arrest outside of hospitals is very low. The fast response to Damar Hamlin’s cardiac arrest during an NFL game shows the value of access to CPR and emergency defibrillators.Adam Pyle, Emergency Medicine Physician and Lecturer, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1685922021-11-04T16:40:32Z2021-11-04T16:40:32ZReversing death: the weird history of resuscitation<p>Most of us probably know – more or less – how to resuscitate one of our fellow human beings. Even if you haven’t taken a course in cardiopulmonary resuscitation (CPR), you’ve probably seen the technique many times on <a href="https://pubmed.ncbi.nlm.nih.gov/8628340/">television or in the movies</a>.</p>
<p>The early history of resuscitation was in many ways also the stuff of drama. On June 1, 1782, for example, a Philadelphia newspaper carried news of the latest resuscitative miracle: a five-year-old child had been restored to life after drowning in the Delaware River. </p>
<p>Little Rowland Oliver was playing on one of the busy wharves that industrialisation had brought to the Delaware’s banks when he tumbled into the water. He struggled for ten minutes, then went limp. Finally, a worker fished him out and carried him home. </p>
<p>Although Rowland was delivered lifeless to his family, the paper reported that his parents recognised he was only “apparently dead”. This energised them into action. They “stripped off all his clothes immediately, slapped him with their hands” and “rubbed him with woollen cloths dipped in spirits”. </p>
<p>The doctor who arrived shortly afterwards did more of the same. They also immersed Rowland’s feet in hot water and thrust an emetic agent down his throat. After about 20 minutes, life returned to the little boy. A little blood-letting eased any after-effects, and Rowland was soon his usual playful self.</p>
<h2>Humane societies</h2>
<p>This account was but one of many stories of resuscitative success seeded into the newspapers by the period’s newly minted <a href="https://www.rcpe.ac.uk/sites/default/files/jrcpe_49_2_mccabe.pdf">humane societies</a>. These societies had originated in mid-18th century Amsterdam, where an increasing number of people were drowning in the city’s canals. The <a href="https://royalhumanesociety.org.uk/the-society-history-and-archives/history/">societies</a> sought to educate the public that death – at least by drowning - was not absolute, and that passers-by had the power to keep the apparently dead from joining the actually dead. </p>
<p>In Philadelphia, Rowland’s resurrection gave credence to these ideas, inspiring the local humane society to install along the city’s rivers kits containing medicines, tools and instructions to revive the drowned.</p>
<p>Methods changed over time, but well into the 19th century, resuscitative efforts were understood to require the stimulation of the body back into mechanical action. Humane societies often recommended warming up the drowning victim and attempting artificial breathing. Whatever the method, most important was jumpstarting the body-machine back to function. </p>
<p>External stimulation - the rubbing and massaging practised by little Rowland’s parents - was essential. So was internal stimulation, typically via the introduction of rum or some rousing concoction into the stomach. Probably most exciting – for the body’s interior – was the <a href="https://www.resuscitationjournal.com/article/S0300-9572(19)30500-3/fulltext">“fumigation with tobacco smoke”</a> of a drowning victim’s colon that humane societies also proposed. Yes: good resuscitative efforts demanded the blowing of smoke up an apparently dead person’s ass.</p>
<figure class="align-center ">
<img alt="Plate illustrating the resuscitation of a drowned woman." src="https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430009/original/file-20211103-21-3hjyf5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A drowned woman being resuscitated with a smoke enema.</span>
<span class="attribution"><span class="source">Wellcome Collection</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>The 20th century brought its own potentially fatal hazards. Just as drownings multiplied in the 18th century because of the increased industrial use of waterways, the advent of widespread electricity – and power lines – and personal-use machinery, such as automobiles, added electrocution and gas poisoning to the causes of apparent death.</p>
<h2>A new locus of stimulation</h2>
<p>Methods also changed. Resuscitative efforts now focused increasingly on stimulating the heart. This might involve manipulating an apparently dead body into a variety of positions. Chest compressions and artificial respiration techniques became increasingly common, too. </p>
<p>But even as techniques shifted, resuscitation retained its democratic bent – almost anyone could undertake it. Its applications, however, remained specific to certain circumstances. After all, only a limited number of situations could render someone apparently dead.</p>
<p>In the mid-20th century, these two consistent themes began to give way. Resuscitation increasingly gained a reputation as a miraculous and widespread treatment for all kinds of death. And the people who could perform these treatments narrowed to medical or emergency practitioners only. There were many reasons for this shift, but a critical precipitating event was the recognition of a new set of causes of apparent death: accidents of surgery. </p>
<p>In his explanation of his own attempts to remake resuscitation over the mid-20th century, American surgeon <a href="https://www.researchgate.net/publication/271915780_Never_a_Simple_Choice_Claude_S_Beck_and_the_Definitional_Surplus_in_Decision-Making_About_CPR">Claude Beck</a> frequently invoked a story from his training in the late 1910s. Back then, he recalled, if a patient’s heart stopped on the operating table, surgeons could do nothing but call the fire brigade and wait for them to deliver a “pulmotor”, the precursor to the artificial respirators familiar today. Suddenly, it seemed that everyone <em>except</em> medical practitioners could perform resuscitation. Finding this unacceptable, Beck joined the hunt to find a resuscitative method suitable for the particular hazards of surgery. </p>
<p>The new techniques that Beck and other surgeons experimented with still rested on stimulation. But they relied on access to the body’s interior, which the surgeon more or less exclusively enjoyed. Applying electricity directly to the heart (defibrillation) was one method. Reaching into the chest and massaging the heart manually was another. </p>
<p>Beck viewed his early successes in the operating theatre as an indication of the more widespread promise of his techniques. Accordingly, he expanded his definition of who could be resuscitated. He added to the relatively limited category of the “apparently dead”, all who were not “absolutely and unquestionably dead”. </p>
<p>Beck made films that testified to his successes. One, the Choir of the Dead, featured the first 11 people he had resuscitated standing awkwardly together, while a jarringly jovial Beck asked each in turn: “What did you die of?” </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1375084086256091136"}"></div></p>
<p>Though initially contextualised as merely the extension of resuscitation into medical spaces, it soon became clear that methods that privileged access to the body’s interior were not easily democratised. That’s not to say that Beck didn’t try. He imagined a world where those trained in his methods would carry the surgeon’s tool - the scalpel - with them, always ready to whip open a chest to massage a heart back into action. </p>
<p>Concerned by the spectre of civilian-surgeons and keen to maintain their professional monopoly over the body’s interior, the medical community revolted. It was only with the advent of the less unseemly closed chest compression method several years later that resuscitation’s democratic imprimatur was restored. </p>
<p>But Beck’s view of death as generally reversible stuck, reaching its zenith in 1960, when a landmark medical study declared resuscitation’s <a href="https://jamanetwork.com/journals/jama/article-abstract/328956">“over-all permanent survival rate”</a> as 70%. <a href="https://jamanetwork.com/journals/jama/fullarticle/656324">Subsequent studies</a> corrected this overly optimistic finding, but resuscitation’s reputation as both widely applicable and wildly successful had already been secured. <a href="https://www.bmj.com/company/newsroom/patients-overestimate-the-success-of-cpr/">Recent reports</a> suggest that this is a reputation it retains to this day.</p><img src="https://counter.theconversation.com/content/168592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caitjan Gainty runs the Wellcome Trust funded Healthy Scepticism project.</span></em></p>Resuscitation has thankfully come a long way since smoke enemas.Caitjan Gainty, Senior Lecturer in the History of Science, Technology and Medicine, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579212021-03-29T15:45:42Z2021-03-29T15:45:42ZCare homes: evidence emerging of inappropriate use of ‘do not attempt CPR’ orders during pandemic<figure><img src="https://images.theconversation.com/files/392226/original/file-20210329-25-1fjhw5n.jpg?ixlib=rb-1.1.0&rect=437%2C112%2C6871%2C3750&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/YuganovKonstantin</span></span></figcaption></figure><p>Imagine that death is just around the corner. How will you spend your final moments? Quietly with loved ones? With a priest giving last rites? Perhaps listening to your favourite music? Or how about being subjected to 300-joule electric shocks while your ribs are broken, undergoing a medical procedure that is <a href="https://journals.sagepub.com/doi/full/10.1177/1751143719832162">unlikely to succeed</a>?</p>
<p>Cardio-pulmonary resuscitation (CPR) is an emergency procedure that can save lives – although less often than your favourite TV drama <a href="https://www.sciencedirect.com/science/article/abs/pii/S0300957215003731">might suggest</a>. It rightly forms a central part of standard first aid courses and clinical training. But as well as knowing how to use CPR, medics also need to know when <em>not</em> to use it – an issue more pertinent than ever as the pandemic has hit care homes with <a href="https://www.nuffieldtrust.org.uk/news-item/covid-19-and-the-deaths-of-care-home-residents?gclid=Cj0KCQjwjPaCBhDkARIsAISZN7R3v-jTRgrYD3JoRyca-f2zM_-wS-ZJrDZf5019_vNRKj8NU6PjCF0aAmHMEALw_wcB">tremendous force</a>.</p>
<p>Whether or not to perform CPR is no easy decision. Several factors have to be taken into account: How fit and healthy is the patient? What is the chance of success of CPR in this patient, right now? How likely are adverse clinical outcomes, such as brain damage? And does this patient even want CPR?</p>
<figure class="align-center ">
<img alt="Hand pressing down on the chest of a medical dummy." src="https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People doing CPR training on a medical dummy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cpr-training-medical-proceduredemonstrating-chest-compressions-649412104">Shutterstock/BlackDuckStyle</a></span>
</figcaption>
</figure>
<p>This decision is often – and ideally – made before an emergency arises. A Do Not Attempt CPR (DNACPR) order is used to let medical professionals know they should not attempt the procedure. This should be an individualised decision, made and recorded in consultation with the person in question. </p>
<p>It should reflect not only their specific medical situation, but also their personal beliefs, values and wishes. For example, someone may prefer to accept death rather than resort to heroic medical measures. This information then informs a “now or never” decision about whether to resort to CPR or not.</p>
<p>But as with so many things at present, COVID has potentially created a problem here. A new report from the <a href="https://www.cqc.org.uk/sites/default/files/20210318_dnacpr_printer-version.pdf">Care Quality Commission</a> (CQC) has revealed that the pandemic may have increased improper use of DNACPR orders in care homes.</p>
<h2>Upsurge during pandemic</h2>
<p>The report shows that DNACPR orders have become more common during the pandemic: the percentage of nursing home residents with an order in place rose from 74% to 92% from March to December 2020. </p>
<p>According to the report, 71% of people with a DNACPR decision in place told the CQC they felt completely or mostly supported to participate in a conversation about this decision and 70% said they felt completely or mostly listened to and able to speak up. While that is not a perfect record, it shows that patients can and do feel empowered by conversations surrounding these orders. </p>
<p>But the report also raises significant concerns. Almost half the respondents to the public survey felt they had been discriminated against or treated unfairly during the DNACPR process. Some 6% of adult social care providers told the CQC that “<a href="https://www.theguardian.com/society/2021/mar/18/blanket-do-not-resuscitate-orders-imposed-on-english-care-homes-finds-cqc">blanket</a>” DNACPR decisions had been made – meaning they were applied across the board rather than on the basis of individual assessment and consultation. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1372479185286012928"}"></div></p>
<p>These figures may point to poor practice and serious violations of anti-discrimination and human rights laws (for example the <a href="https://www.equalityhumanrights.com/en/human-rights-act/article-2-right-life#:%7E:text=1.,penalty%20is%20provided%20by%20law.">right to life</a>).</p>
<p>The CQC report provides some much needed insight into the use of DNACPR orders during the pandemic. But it also leaves a number of important questions unanswered. Why did DNACPR orders became more common? Why were “blanket” decisions made, and how? </p>
<p>The report focuses mainly on how DNACPR orders are adopted and pays little attention to how they are being interpreted and used. Yet scrutiny about their interpretation and use is also important. </p>
<p>As the name suggests, a DNACPR order refers to cardio-pulmonary resuscitation only: it is a narrowly defined medical instruction. It does not apply to other forms of resuscitation – rehydration, for example, or the treatment of shock. Much less does it apply to other forms of care. That’s why it’s dangerous to use shorthands like DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation), which wrongly suggest a broader application. </p>
<p>But are DNACPR orders being used within these boundaries? Or are there forms of mission creep whereby a DNACPR order is used to limit care more broadly? The CQC report mentions anecdotal evidence that one person with a DNACPR order in place was denied treatment altogether, but does not provide further information about the issue.</p>
<p><a href="https://autonomy.essex.ac.uk/covid-19/human-rights-in-care-homes/">Our new study</a> may shed light on some of these unanswered questions, picking up where the CQC report left off. The research we are doing at the <a href="https://www.essex.ac.uk/research-projects/essex-autonomy-project">Essex Autonomy Project</a>, focuses on human rights in locked down care homes. Initial findings from an ongoing <a href="https://essex.eu.qualtrics.com/jfe/form/SV_3kNq1xtDDuHNFnE">online survey</a> suggest that 19% of care professionals working in or with care homes during the pandemic witnessed DNACPRs influencing medical decisions beyond CPR. </p>
<p>It’s imperative that we understand how COVID-19 has affected the use of DNACPR orders – to ensure everyone gets a say in decisions about their own life and death, but also to help care staff deal with these difficult decisions under the heightened pressures of the pandemic.</p><img src="https://counter.theconversation.com/content/157921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This article was written with the assistance of Vivek Bhatt, with research support provided by Emily Fitton. Financial support was provided by the Arts and Humanities Research Council; Grant Number AH/V012770/1: Ensuring Respect for Human Rights in Locked-Down Care Homes. </span></em></p><p class="fine-print"><em><span>Wayne Martin's research is supported by the Arts and Humanities Research Council and the Wellcome Trust.</span></em></p>Have ‘Do Not Attempt CPR’ orders been misused under the pressures of the pandemic?Margot Kuylen, Senior Researcher for the Human Rights in Care Homes project, University of EssexWayne Martin, Director, Essex Autonomy Project, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1576672021-03-28T13:39:17Z2021-03-28T13:39:17ZThe model minority myth hides the racist and sexist violence experienced by Asian women<figure><img src="https://images.theconversation.com/files/391805/original/file-20210325-15-1fesls5.jpg?ixlib=rb-1.1.0&rect=47%2C26%2C4446%2C2964&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protesters display placards during a rally held to support Stop Asian Hate, March 21, 2021, in Newton, Mass. </span> <span class="attribution"><span class="source">(AP/Steven Senne)</span></span></figcaption></figure><p>Six women of Asian descent were among eight people <a href="https://www.nytimes.com/live/2021/03/17/us/shooting-atlanta-acworth">tragically killed in a targeted shooting</a> on March 16 in Atlanta. The initial <a href="https://www.npr.org/2021/03/18/978680316/atlanta-spa-shootings-expose-frustration-and-debate-over-hate-crime-label">denial by the Atlanta police that this was a hate crime</a>, along with some news reports highlighting the <a href="https://www.bostonglobe.com/2021/03/18/opinion/massacre-targeting-asians-georgia-wasnt-bad-day-it-was-hate-crime/">offender’s version of the incident</a>, evoked a <a href="https://www.cbc.ca/listen/live-radio/1-92-all-in-a-day/clip/15831934-8-killed-atlanta-spa-shootings-sparking">swift reaction by communities all over North America</a>. Many spoke of the invisibility of anti-Asian racism.</p>
<p>One of the reasons for the invisibility of anti-Asian racism is inextricably connected to the model minority myth. The model minority myth focuses on prevailing stereotypes of Asians as hard-working, independent, intelligent and economically prosperous. </p>
<p>But the stereotypes — while seemingly positive — hide many issues, including anti-Asian racism, poverty, labour abuse and psychological needs. It disappears the realities of working-class Asian women’s lives.</p>
<p>The myth has also sometimes <a href="https://www.npr.org/sections/codeswitch/2017/04/19/524571669/model-minority-myth-again-used-as-a-racial-wedge-between-asians-and-blacks">disrupted inter-racial solidarity</a> and has been used against Indigenous, Black <a href="https://press.princeton.edu/books/paperback/9780691168029/the-color-of-success">and other racialized groups</a>. </p>
<h2>The reality of working-class Asians</h2>
<p>The Asian <a href="https://press.princeton.edu/books/paperback/9780691168029/the-color-of-success">model minority myth was popularized by sociologist William Pettersen</a> through a 1966 <em>New York Times</em> article. For the past several decades, the Asian model minority myth has been prevalent in the general public as a counter-argument for anti-Asian racism. </p>
<p>The myth is that Asians are rule-abiding and thus do not have needs that warrant societal and government policy concerns. </p>
<figure class="align-center ">
<img alt="women hold placards at a rally." src="https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391808/original/file-20210325-21-sxsavh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Protesters Dana Liu, centre front, and Kexin Huang, right, display placards during a rally held to support Stop Asian Hate, March 21, 2021, in Newton, Mass.</span>
<span class="attribution"><span class="source">(AP Photo/Steven Senne)</span></span>
</figcaption>
</figure>
<p>Some even talk about reverse discrimination and highlight a few successful stories of Asian Americans and Asian Canadians. Leaders have used examples of Asian Canadian and Asian American success <a href="https://press.princeton.edu/books/paperback/9780691168029/the-color-of-success">to deny deeply rooted systemic racism</a> and instead point to that success as evidence of a “colour-blind” society.</p>
<p>However, this celebratory tone systemically excludes the reality of working-class Asian Canadians and Asian Americans. It also excludes a specific form of <a href="https://www.apa.org/pubs/highlights/spotlight/issue-119">anti-Asian racism against Asian women that is intertwined with gender and sexuality</a>.</p>
<h2>Fear of failure</h2>
<p>The Asian model minority myth produces Asian subjects who are encouraged to be the model, in other words, the non-trouble-making minority. The narrative creates this idea of the essentialist “other” — those who are part of the “model” group. It also discourages that group’s potential collective actions to overcome challenges.</p>
<p>Numerous studies have shown that the model minority myth itself causes a <a href="https://www.press.uillinois.edu/books/catalog/47fea8mk9780252040887.html">fear of failing to conform to the positive stereotype among Asians</a>.</p>
<p>The sentiment that we ought to “take care of the problem ourselves, without troubling others” (as someone said in a research interview) <a href="http://doi.org/10.1007/978-1-60327-437-1">hides socio-economic, political, educational and psychological needs of Asian Canadians from public view</a>. </p>
<h2>High poverty rates</h2>
<p>Contrary to common notions about Asian Canadians’ economic success, an <a href="https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/article/00042-eng.htm">analysis of Canada’s 2016 census data</a> shows that “among Korean, Arab and West Asian Canadians, the poverty rate ranged from 27 per cent to 32 per cent.” Among Chinese and also Black Canadians, the poverty rate reached 20 per cent. Filipinos were the only visible minority group that had a lower poverty rate (7.2 per cent) than the white population (12.2 per cent). </p>
<p>While Asian Canadians are highly represented in skilled occupations, <a href="https://www150.statcan.gc.ca/n1/pub/11f0019m/11f0019m2019006-eng.htm">particularly among those born in Canada</a>, the high poverty rates of Asian Canadians suggest that they are also over-represented in low-paying occupations, particularly among immigrants. </p>
<p>However, these statistics do not clearly show the feminized poverty, violence and exploitation that many Asian women face due to their precarious immigration status, gender stereotyping and fetishization of Asian women’s bodies. </p>
<p>In fact, anti-Asian racism is <a href="https://www.vox.com/22338807/asian-fetish-racism-atlanta-shooting">intertwined with the sexualization of Asian women</a>, a fetishization of Asian women’s bodies and the stigmatization of sex work. </p>
<h2>Colonial ideas of ‘orientalism’</h2>
<p>The sexualization of Asian women stems from a history of European colonization of the Asia Pacific as well as colonial ideas of orientalism that constructed Asian women as “exotic” sexual objects. In North America, settler colonialism constructed <a href="https://doi.org/10.1080/09663690701439751">Asian immigrants as threats to the biological reproduction of the white nation</a>. </p>
<figure class="align-center ">
<img alt="a black and white image of men working on the railway" src="https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=354&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=354&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=354&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=445&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=445&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391977/original/file-20210326-21-zhvxvq.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=445&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chinese men came to work on the construction of the Canadian Pacific Railway as shown here in 1881.</span>
<span class="attribution"><span class="source">(Brown/Library and Archives Canada, C-006686B)</span></span>
</figcaption>
</figure>
<p>One example of this is the <a href="https://humanrights.ca/story/the-chinese-head-tax-and-the-chinese-exclusion-act">Chinese Head Tax and the Chinese Exclusion Act in Canada</a> during the late 19th and early 20th centuries. Surrounding the immigration ban, Chinese women’s sexuality was constructed as immoral compared to white women. Their exclusion to legitimate immigration was justified by constructing Chinese women as potential “sex workers.” </p>
<h2>Femininized workforce</h2>
<p>Asian women migrants are mainly employed in a feminized workforce, including domestic and care work, service industry and the sex industry. These feminized low-paying workforces have traditionally been considered white women’s work but are now mostly taken up by racialized women. In this work, Asian women workers are stereotyped as <a href="https://www.sup.org/books/title/?id=4972">“ideal” docile labour</a>. </p>
<figure class="align-center ">
<img alt="A woman kneels down to place flowers at a memorial. Behind her, a protest." src="https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=410&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=410&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=410&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=515&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=515&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391970/original/file-20210326-17-1hh51iy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=515&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People place flowers during a vigil in Montréal to highlight anti-Asian racism and to remember the victims who were murdered in Atlanta, on March 21, 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>Asian women workers who have precarious migration status are particularly vulnerable to labour exploitation, abuses and police violence from potential deportation threats. However, these women’s stories remain silenced in the celebrated myth of Asian success. </p>
<p>The model minority myth repeats symbolic and racist traps. To move beyond this, alternative narratives are needed to build solidarity both within Asian groups and with other racialized people.</p><img src="https://counter.theconversation.com/content/157667/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The invisibility of anti-Asian racism is inextricably connected to the model minority myth, which serves to disguise the violence experienced by Asian American and Asian Canadian women.Jiyoung Lee-An, Instructor, School of Indigenous and Canadian Studies, Carleton UniversityXiaobei Chen, Professor and Associate Chair Department of Sociology and Anthropology, Carleton UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1055062021-02-11T02:16:38Z2021-02-11T02:16:38ZDo you want to be resuscitated? This is what you should think about before deciding<figure><img src="https://images.theconversation.com/files/267028/original/file-20190402-177181-1efhvsz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4888%2C3254&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Every day, in every hospital, doctors and nurses respond to “code blue” situations. This is an emergency alert for when a patient’s heart stops beating, called a cardiac arrest. </p>
<p>To save the patient’s life, medical and nursing staff will often administer cardiopulmonary resuscitation (<a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/cardiopulmonary-resuscitation-cpr">CPR</a>). CPR involves repeated chest compressions, artificial breathing, use of medications and an electric shock to jump-start the heart (defibrillation).</p>
<p>The aim is to restore a person’s heartbeat and blood pressure to normal, and in turn to restore life. CPR must be initiated quickly as <a href="https://doi.org/10.1016/j.jns.2007.04.042">brain cells rapidly die</a> without blood and oxygen.</p>
<p>Patients admitted to hospital are often surprised when their doctors ask: “If your heart were to stop beating, would you want CPR or not?” But in every code blue doctors need answers to the same two questions. First, whether the clinical team considers CPR would be an effective treatment; and second, whether the patient wants CPR.</p>
<h2>First response</h2>
<p>If a person has a cardiac arrest outside hospital, it is usual, and expected, that bystanders begin CPR, use a defibrillator if available, and call an ambulance. </p>
<p>CPR is taught in first aid courses and defibrillators are <a href="https://www.mja.com.au/journal/2017/206/4/public-access-defibrillation-emerging-importance-automated-external">widely available</a> in public places such as airports and sports grounds. Time is of the essence, so having trained community members is important.</p>
<p>In a hospital setting, though, the decision to administer CPR is more nuanced. It’s built on a discussion around the patient’s medical condition and, importantly, takes into account their wishes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-cases-of-cardiac-arrest-time-is-everything-community-responders-can-save-lives-126491">In cases of cardiac arrest, time is everything. Community responders can save lives</a>
</strong>
</em>
</p>
<hr>
<p>Clinicians in Australia <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1445-5994.2012.02841.x">have provided examples</a> of some different perspectives on this discussion:</p>
<blockquote>
<p>Some of [the patients’ relatives] are absolutely aghast that we might even suggest not to resuscitate […] they bring their loved one into hospital to get better.</p>
<p>A lot of people […] just say, ‘No, I’ve had a good innings, just let me die.’ […] Often I find it’s families who have the objection.</p>
</blockquote>
<h2>A bit of background</h2>
<p>CPR was developed and initially applied to resuscitate people with specific medical conditions such as an acute myocardial infarction (a heart attack).</p>
<p>When a cardiac arrest occurs because of a heart attack or other heart condition, there’s <a href="https://academic.oup.com/fampra/article/28/5/505/827846">a reasonable chance</a> CPR will re-start the heart and save the person’s life. A recent <a href="https://doi.org/10.1016/j.resuscitation.2020.07.007">Australian study</a> looking at people who had a cardiac arrest in hospital showed 41.5% of people who were admitted due to heart problems survived with good neurological function.</p>
<p>Expanding the use of CPR more broadly to every disease that causes the heart to stop beating seems like common sense. But this is not necessarily the case.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/267029/original/file-20190402-177171-j8yxsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Talking about whether you want to be resuscitated, although difficult, is important.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>For older hospitalised patients (aged over 67 years in this research) with chronic diseases — such as heart failure, kidney disease, cancer or diabetes — their chance of surviving a cardiac arrest and leaving the hospital alive is <a href="https://journal.chestnet.org/article/S0012-3692(15)52389-1/fulltext">around 11-15%</a>. Chances of survival are slightly better in older patients without a chronic illness (17%).</p>
<p>For patients in the late stage of their life, due to advanced illness or <a href="https://pubmed.ncbi.nlm.nih.gov/32500916/">severe frailty</a>, their chance of survival is almost zero.</p>
<p>CPR is not always an appropriate treatment. The decision to perform it needs to be made carefully, especially when it’s highly unlikely to restore a patient’s heartbeat.</p>
<h2>Outcomes after CPR</h2>
<p>Unlike the <a href="https://www.ncbi.nlm.nih.gov/pubmed/19699021">popular media portrayal</a> of CPR, not every survivor of cardiac arrest returns to their previous level of functioning. </p>
<p>Patients may survive but <a href="https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.108.190652">with some brain damage</a>. This could range from minor damage with trivial functional effects such as being forgetful; to moderate damage with serious functional effects such as a change in personality and needing help with everyday activities; to severe damage with catastrophic functional impairment eventually leading to death.</p>
<p>CPR may revive a heart that has stopped beating, but it doesn’t always restore a person back to a life they had or want. It may also do harm by reviving a person who does not want to continue living and would have preferred their disease to follow its natural course. When CPR is performed on a patient who doesn’t want it, it disrupts a gentler dying process, transforming it into an impersonal medical event.</p>
<p>When a cardiac arrest happens, there’s no opportunity to ask the patient what they want at that time. In hospital, it’s routine to provide CPR for patients in cardiac arrest unless there is a medical order to withhold it, or if the patient has completed an advance care directive refusing CPR. This is often referred to as a “do not rescusitate” order.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-your-choice-how-to-plan-for-a-better-death-32327">It's your choice: how to plan for a better death</a>
</strong>
</em>
</p>
<hr>
<h2>Talk about it</h2>
<p>Avoiding harm from inappropriate or unwanted CPR requires planning ahead and being prepared to have a difficult conversation. </p>
<p>We have launched an animated film, The Inappropriate Question, to help people <a href="https://www.nh.org.au/service/advance-care-planning/">better understand</a> why these conversations are important.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/brIXfGkohDY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>Discussing CPR is upsetting for some patients, because raising the possibility of death is confronting. It’s also harder to discuss this when a person has just been admitted to hospital for treatment and is expecting to recover. </p>
<p>But patients have the right, and usually want, to be involved in their own treatment decisions. The challenge is how we reconcile this wanting to know and wanting to be involved in decisions, with not wanting to be upset by knowing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-happens-during-a-heart-attack-and-how-is-one-diagnosed-55874">Explainer: what happens during a heart attack and how is one diagnosed?</a>
</strong>
</em>
</p>
<hr>
<p>CPR is an important treatment. When used appropriately, <a href="https://www.sca-aware.org/survivor-stories">it saves lives</a>. But when applied injudiciously it can cause distress and avoidable harm.</p>
<p><a href="https://www.advancecareplanning.org.au">Advance care planning</a> is one way to start thinking about this long before a person is seriously ill. Particularly if you’re older and have chronic medical conditions, have that discussion with yourself, your loved ones and your medical team.</p><img src="https://counter.theconversation.com/content/105506/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Hayes receives funding from Victorian Department of Health and Human Services for:
- developing a Consumer Education Video about CPR decision-making.
- project 'What can be learned from hospital interpreters about cultural issues related to end-of-life and advance care planning'.
Board Chair, Palliative Care Victoria</span></em></p><p class="fine-print"><em><span>Joseph Ibrahim has received funding from Commonwealth and State Health Departments for research, education and consultancies into residential aged care services and health care services. He contributed to this project funded by the Department of Health and Human Services (Victoria) in an honorary capacity. Two other animated films which the author contributed to are available at <a href="https://www.profjoe.com.au/">https://www.profjoe.com.au/</a></span></em></p>Whether CPR is performed in hospital will depend on the patient’s prospects of survival and recovery. But the doctors are also concerned about what the patient wants.Barbara Jean Hayes, Honorary Academic, The University of MelbourneJoseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1264912020-01-17T01:05:54Z2020-01-17T01:05:54ZIn cases of cardiac arrest, time is everything. Community responders can save lives<figure><img src="https://images.theconversation.com/files/309896/original/file-20200114-103971-utmijk.jpg?ixlib=rb-1.1.0&rect=18%2C9%2C5988%2C3998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cardiac arrest can occur with little or no warning in people who were previously healthy, including young people.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Each year more than <a href="https://www.resuscitationjournal.com/article/S0300-9572(18)30106-0/fulltext">24,000</a> Australians experience a sudden cardiac arrest. This means their heart unexpectedly stops beating. A cardiac arrest leads to loss of consciousness and will result in death if not recognised and treated immediately.</p>
<p>While <a href="https://www.ncbi.nlm.nih.gov/pubmed/20828914">survival rates vary</a> depending on the exact cause of the cardiac arrest, the person’s age and other factors, survival invariably depends on <a href="https://www.ahajournals.org/doi/full/10.1161/circoutcomes.109.889576">early cardiopulmonary resuscitation (CPR) and defibrillation</a>. Each minute of defibrillation delay significantly decreases the person’s chance of <a href="https://www.ncbi.nlm.nih.gov/pubmed/29483086">survival</a>. </p>
<p>So in the instance of a cardiac arrest, in the time before emergency services arrive, help from members of the public can be critical in saving a person’s life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/tom-petty-died-from-a-cardiac-arrest-what-makes-this-different-to-a-heart-attack-and-heart-failure-85245">Tom Petty died from a cardiac arrest – what makes this different to a heart attack and heart failure?</a>
</strong>
</em>
</p>
<hr>
<h2>Anyone can have a cardiac arrest</h2>
<p>Many cases of cardiac arrest occur in older people due to underlying heart disease. But cardiac arrest can occur with little or no warning in people who were previously well, including <a href="https://theconversation.com/childhood-heart-disease-has-a-profound-impact-and-is-under-recognised-84377">children</a> and young adults. This can be due to heart disease or cardiac rhythm disorders that may be undiagnosed.</p>
<p>Immediate treatment involves CPR. CPR is not the cure, but can save a person’s life by maintaining some blood flow to vital organs until the underlying cause of the cardiac arrest can be treated.</p>
<p>Most cases of cardiac arrest are a result of heart disease that can produce a <a href="https://www.victorchang.edu.au/arrhythmia">sudden disruption</a> to the heart’s normal rhythm. Resuscitation in these cases depends on the use of a defibrillator to deliver a calculated electrical current or “shock” through electrodes applied to the patient’s chest. This aims to return the heart to a normal rhythm, which is essential to restore blood flow from the heart.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/309899/original/file-20200114-103990-iu4i7x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">First aid training includes learning how to operate a defibrillator.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<h2>Defibrillators in public places</h2>
<p>A paramedic or other first responder has traditionally performed defibrillation. But there can be a delay from the time of the emergency call to the arrival of emergency service personnel, due to factors like the location of the incident and traffic conditions.</p>
<p>Public health initiatives to reduce the time to defibrillation have installed automated external defibrillators (AED) in public places. These devices are designed to be used by members of the public without prior training. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/according-to-tv-heart-attack-victims-are-rich-white-men-who-clutch-their-hearts-and-collapse-heres-why-thats-a-worry-120894">According to TV, heart attack victims are rich, white men who clutch their hearts and collapse. Here's why that's a worry</a>
</strong>
</em>
</p>
<hr>
<p>The number of AEDs in public spaces has increased significantly in the past few years. AEDs are now commonly found in workplaces and public spaces such as airports, casinos, sporting venues, and shopping centres. Both <a href="https://www.woolworthsgroup.com.au/page/media/Latest_News/woolworths-to-roll-out-defibrillators-across-all-stores-nationally-to-treat-sudden-cardiac-arrest">Woolworths</a> and Coles have recently installed AEDs in stores across Australia.</p>
<h2>Bystanders can save more lives</h2>
<p>Research shows <a href="https://www.ncbi.nlm.nih.gov/pubmed/31430512">a marked improvement</a> in survival from cardiac arrest in the past two decades. One study reviewed cases of cardiac arrest in adults attended by Ambulance Victoria from 2000 to 2017 to examine trends in the number of survivors.</p>
<p>This research found an eight-fold increase in patients shocked by bystanders where the cardiac arrest occurred in a public place, from 2.9% in 2000-2002 to 23.5% in 2015-2017. Compared to patients in cardiac arrest shocked by paramedics, those shocked in the first instance by bystanders had double the chance of surviving to hospital discharge (55.5% versus 28.8%). </p>
<p>These results are consistent with international research, which shows defibrillation by members of the public using AEDs is associated with significantly improved <a href="https://www.ncbi.nlm.nih.gov/m/pubmed/28687709/">chances of survival</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">How Australians Die: cause #1 – heart diseases and stroke</a>
</strong>
</em>
</p>
<hr>
<h2>Mobilising trained volunteers</h2>
<p>The Heart Foundation found <a href="https://www.heartfoundation.org.au/campaigns/big-heart-appeal/lifesaving-research-cant-happen-without-you/cardiac-arrest-survey">70% of adults</a> would be willing to use an AED to help someone in an emergency. But only about one-third of respondents would feel confident doing so.</p>
<p>The need to reduce time to CPR as well as the need to quickly locate and operate AEDs in an emergency has led to the development of smartphone apps that enable members of the public to register as volunteer responders. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=928&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=928&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=928&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1166&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1166&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308240/original/file-20191226-11946-io50hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1166&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A screenshot from the GoodSAM app.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>One of the most widely used apps in Australia and New Zealand is <a href="https://www.goodsamapp.org/">GoodSAM</a> (Smartphone Activated Medics), which Ambulance Victoria has recently integrated with its emergency call-taking and dispatch system.</p>
<p>This app allows people with approved first aid or emergency health-care qualifications to register as a responder. Ambulance services that have integrated GoodSAM within their dispatch systems can alert a registered <a href="https://www.ambulance.vic.gov.au/goodsam-responder-helps-save-swiss-tourists-life/">GoodSAM responder</a> at the same time an ambulance is dispatched. So the responder receives the location of the suspected cardiac arrest – as well as the location of the nearest AED – often enabling care prior to the arrival of emergency services. </p>
<p><a href="https://www.ambulance.vic.gov.au/goodsam/">Ambulance Victoria</a> and the <a href="https://www.premier.vic.gov.au/victorias-army-of-smartphone-lifesavers-to-grow/">Victorian government</a> have been active in promoting GoodSAM, and the large number of responders currently available in Victoria makes this state one of the <a href="https://www.ambulance.vic.gov.au/defibrillator-saves-a-hat-trick-of-lives-in-record-year-for-bystanders/">safest places in the world to have a cardiac arrest</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=295&fit=crop&dpr=1 600w, https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=295&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=295&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=371&fit=crop&dpr=1 754w, https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=371&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/301439/original/file-20191113-77291-p5897a.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=371&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A map of the GoodSAM responders around Melbourne as of November 2019.</span>
<span class="attribution"><a class="source" href="https://www.goodsamapp.org/mapOfResponders">GoodSAM</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Both the South Australian Ambulance Service and NSW Ambulance Service are planning to follow Victoria and integrate the app into their operations. In order to save more lives, all state ambulance services should fully integrate GoodSAM with their ambulance dispatch systems.</p>
<p>And what can you do? Everyone who is able to should undertake first aid and CPR training. If you have the relevant training, I would urge you to sign up to GoodSAM. You never know when you may be able to save a life.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-is-it-ok-to-call-an-ambulance-91751">When is it OK to call an ambulance?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/126491/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Lord does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Immediate CPR and defibrillation can be key to surviving a cardiac arrest. A smartphone app is mobilising community responders who can help before emergency services arrive.Bill Lord, Adjunct Associate Professor, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1000792018-07-30T10:32:33Z2018-07-30T10:32:33ZArrested development: Can we improve cardiac arrest survival in hospitals?<figure><img src="https://images.theconversation.com/files/229670/original/file-20180727-106496-1f8coyx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How teams respond to cardiac arrests in hospitals can make all the difference, a new study suggests. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-doctors-giving-cardiac-massage-resuscitation-1082552168?src=T670DGsWChezqbGZEcY35Q-1-3">antoniodiaz/Shutterstock.com</a></span></figcaption></figure><p>Each July brings residents – recent graduates from medical schools – to the inpatient wards of major teaching hospitals across the United States. Among the many new responsibilities these young doctors will be taking on, one of the oldest and most critical will be their role on Code Blue teams, or groups of caregivers who respond to cardiac arrests.</p>
<p>About 200,000 cardiac arrests happen each year in U.S. hospitals. Nearly <a href="https://www.ncbi.nlm.nih.gov/pubmed/23150959">80 percent</a> of patients do not survive.</p>
<p>This begs an important question. In 2018, do hospital leaders even know how Code Blue teams should be optimally designed and deployed to tackle in-hospital cardiac arrests? I recently led a research team to assess response to cardiac arrest at nine hospitals. After collecting and reviewing nearly 80 hours of interviews, we found striking and humbling results: Top hospitals designed, deployed and trained their Code Blue teams, which respond to cardiac emergencies, in fundamentally different ways. Our results were <a href="http://circ.ahajournals.org/content/138/2/154">published</a> recently in Circulation, a journal of the American Heart Association.</p>
<h2>Heart-stopping emergencies</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229642/original/file-20180727-106527-1ffe5gt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A doctor administers hands-only CPR to a patient in a hospital.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cpr-cardio-pulmonary-resuscitation-cardiac-arrest-737302675?src=R-BIJmy149GYshBwF7atHQ-1-45">Akkawat Sripoomsawatt/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="http://www.nationalacademies.org/hmd/Reports/2015/Strategies-to-Improve-Cardiac-Arrest-Survival.aspx">Cardiac arrests</a> are medical emergencies that occur when the heart stops beating. They typically result from either primary diseases of the heart, like congestive heart failure and heart attacks, or from sudden stresses on the heart due to other underlying conditions, like trauma or <a href="https://theconversation.com/george-h-w-bush-has-sepsis-why-is-it-so-dangerous-95693">sepsis</a>. They can happen when patients slowly deteriorate over time due to progressive illness or as sudden events.</p>
<p>Some treatments, like <a href="https://medical-dictionary.thefreedictionary.com/defibrillation">defibrillation</a>, can reverse cardiac arrest if applied promptly. If delayed, however, death is inevitable, even with treatment. About <a href="https://www.ncbi.nlm.nih.gov/pubmed/23150959">4 of 5 patients</a> who have cardiac arrests in the hospital do not survive. </p>
<p>Such poor outcomes are explained, in part, by the serious nature of the illnesses that trigger cardiac arrest. But what is more troubling is evidence by my research team and others that suggests similar patients may have widely variable outcomes across different hospitals. </p>
<p>In one <a href="https://www.ncbi.nlm.nih.gov/pubmed/24487717">study</a>, for example, differences in death rates between the top and bottom 10 percent of hospitals were almost two-fold. My colleagues and I have spent the last two years trying to understand potential reasons for why such variability exists. </p>
<p>This is especially puzzling since providers typically follow the same <a href="https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/">guidelines</a> for CPR and advanced cardiac life support that are established regularly by the American Heart Association. </p>
<h2>A look at the best</h2>
<p>To understand this issue better, we performed a qualitative study by visiting nine hospitals over the last two years at the extremes of performance for cardiac arrest and talked with administrators, quality and patient safety personnel, and most importantly, doctors, nurses and other clinical staff that were boots on the ground. We visited both types to get a sense of performance across the spectrum - five hospitals were top, and four were non-top performers. This type of study focuses on what experts have called a <a href="https://www.ncbi.nlm.nih.gov/pubmed/19426507">“positive” deviance approach</a> – that is, figure out what outlier facilities, or those with the highest performance, are doing differently that may explain their extraordinary results and then share this knowledge across numerous facilities. </p>
<p>Probably the most crucial lesson our study team learned was that there isn’t a single “blueprint” that exists for what a successful team should be like. So hospitals have been forced to figure this out on their own by balancing the unique needs of their patients with available resources. And this makes sense for the most part. </p>
<p>On television, Code Blue teams are often portrayed like a <a href="https://www.businessinsider.com/5-key-differences-between-delta-force-and-seal-team-6-2018-2">Navy SEAL Team 6</a> of health care – a group of seasoned professionals responding immediately with stunning coordination to deploy heroic interventions with <a href="https://www.ncbi.nlm.nih.gov/pubmed/8628340">amazing success</a> in these fictitious environments. In theory, this is what we also want in the real world since survival in cardiac arrest patients depends upon prompt care.</p>
<p>Yet at many hospitals, the reality may be far different given the challenges with having such expertise readily available at all times. We found that some top hospitals had teams with members dedicated to responding to cardiac arrests around the clock. Others we discovered had members who could be responsible for other patients during work hours, but, preemptively, systems were set in place for them to immediately drop these duties and respond when needed.</p>
<p>Another example was in how hospitals constructed, led and trained teams. This is an area of intense <a href="https://www.ncbi.nlm.nih.gov/pubmed/21658557">research</a> in simulated environments but with little empirical data. For instance, residents frequently make up a big part of Code Blue teams at major teaching hospitals when they rotate through services in cardiology or the ICU for a few short weeks. Part of this reason is because residents are typically in “house” at all hours of the day.</p>
<p>But reliance on residents can potentially lead to gaps in care given that experiences of residents during critical scenarios may vary. Our research found that top hospitals have explored innovative models to get more consistent results. One hospital with residents had senior doctors with more experience also respond to support residents. At another hospital without residents immediately available, teams were co-led by nurses that included a core group of individuals specifically trained to handle cardiac arrests and other emergencies. This allowed for intimate familiarity between team members on a day-to-day basis that is critical for teams to succeed during high-stakes situations like cardiac arrest.</p>
<p>Finally, the top hospitals also trained providers – including residents – differently, using strategies like “realistic” mock codes. Mock codes are practice runs where teams are activated and members go through a simulated cardiac arrest under the supervision of instructors. These mock codes at top hospitals were used regularly and in real-world environments (not just simulation labs) to help provide team members with training relevant to their care.</p>
<p>In the 1960s, the <a href="https://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRFirstAid/HistoryofCPR/UCM_475751_History-of-CPR.jsp">fundamental aspects of CPR</a> and resuscitation were uncovered, transforming the care of patients with cardiac arrest in the hospital. This told us “what” we should be doing to provide the best care possible. Our study is a first look at the next step of “how” hospitals can improve Code Blue teams to deliver these complex procedures and services in the best possible manner with top hospitals serving as guideposts for excellence and innovation.</p><img src="https://counter.theconversation.com/content/100079/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brahmajee Nallamothu receives funding from the National Institutes of Health, the Veterans Affairs Administration, the Agency for Healthcare Research and Quality, and the American Heart Assocation. He is affiliated with the American Heart Association where he serves as editor-in-chief of one of its journals - Circulation: Cardiovascular Quality & Outcomes. </span></em></p>Cardiac arrest is a major complication and killer of hospitalized patients, with only about 1 in 5 surviving. A recent study compared responses within hospitals to learn how to improve outcomes.Brahmajee Nallamothu, Professor of Internal Medicine, Division of Cardiovascular Diseases, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/816142017-07-30T20:10:53Z2017-07-30T20:10:53ZSnakebites are rarer than you think, but if you collapse, CPR can save your life<figure><img src="https://images.theconversation.com/files/180118/original/file-20170727-28974-7lutuk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bites from brown snakes like this one were the most common, followed by
tiger snakes, then red-bellied black snakes.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Eastern_Brown_Snake_(Pseudonaja_textilis)_(8582601994).jpg">Matt Clancy/SunOfErat/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Despite the common belief that Australia has some of the most venomous snakes in the world, our <a href="http://www.mja.com.au">new research shows</a> being bitten by a snake is uncommon in Australia and dying from a snakebite is very rare. </p>
<p>And of the few unlucky people to collapse after venom enters their bloodstream, a bystander performing cardiopulmonary resuscitation (CPR) is the most likely thing to save them.</p>
<p>These are just some of the findings from 10 years of data from the Australian Snakebite Project published <a href="http://www.mja.com.au">today</a> in the Medical Journal of Australia.</p>
<p>Although many people go to hospital with a suspected snakebite, many do not turn out to have envenomation (when venom enters the bloodstream) after all.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/12675626">In more than 90% of cases</a> people are bitten by a non-venomous snake, venom is not injected when the snake bites (known as a “dry bite”) or are not even bitten by a snake (known as a “stick” bite).</p>
<p>Our analysis of about 1,548 cases of suspected snakebites from all around Australia, showed there were on average just under 100 snake envenomations a year, and about two deaths a year. </p>
<p>The most common snakebites were from brown snakes, then tiger snakes and red-bellied black snakes. Brown snakes were responsible for 40% of envenomations. Collapsing, then having a heart attack out of hospital was the most common cause of death (ten out of 23), and most deaths were from brown snakes.</p>
<h2>What happens after a snakebite and how can CPR help?</h2>
<p>Venom from a snakebite travels via the <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/lymphatic-system">lymphatic system</a> to the bloodstream. There, it circulates to nerves and muscles where it can cause paralysis and muscle damage. In the blood itself, the venom destroys clotting factors, which makes the blood unable to clot, increasing the risk of bleeding. </p>
<p>In the most severe cases, most commonly in brown snake bites, someone can collapse because they have low blood pressure (we don’t know for certain what causes the low blood pressure). In this situation, insufficient blood is pumped around the body for the brain and other vital organs. </p>
<p>Clearly the accurate diagnosis of snake envenomation and the timely administration of antivenom are essential to treating snakebites in hospital.</p>
<p>But when people collapse, CPR will keep the blood circulating to the vital organs – and is life-saving – however inexpertly a bystander performs it.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180113/original/file-20170727-9209-wva510.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If a snakebite victim collapses, CPR is vital to keep the blood circulating to the vital organs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/657810997?src=gSIYdvpfkdaGnxGsgex89A-1-50&size=medium_jpg">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>In other words, we found basic first aid <em>before</em> people reached hospital, of which bystander CPR is one, may be more important than any changes in how people are treated <em>in</em> hospital to improve people’s chance of survival. People who survived after collapsing received CPR on average within one minute of being bitten compared with 15 minutes for those who died.</p>
<p>Our study also showed that in most cases, people used <a href="https://theconversation.com/explainer-what-should-you-do-if-youre-bitten-by-a-snake-34238">other first-aid measures</a> (pressure bandages and immobilising both the limb and the patient). These aim to prevent the venom travelling from the bite site, via the lymphatic system, to the bloodstream.</p>
<h2>Antivenom saves lives for those who need it</h2>
<p>Our study confirmed the role of antivenom in treating snakebites and the need for it to be administered before irreversible damage is done to the nervous system and paralysis occurs. </p>
<p>However, we found one in four patients given antivenom had an allergic reaction to it and about one in 20 have severe anaphylaxis requiring urgent treatment. </p>
<p>So it is essential only patients with snake envenomation, and not just a suspected snakebite, are treated with antivenom. We found 49 patients (around 6%) were given antivenom unnecessarily, out of the total 755 patients who received it.</p>
<h2>What needs to change?</h2>
<p>We know <a href="https://www.ncbi.nlm.nih.gov/pubmed/27903075">the earlier</a> someone receives antivenom <a href="https://www.ncbi.nlm.nih.gov/pubmed/21143062">the better</a>. Yet our study found that the time from being bitten until receiving antivenom had not improved over the study period.</p>
<p>So we need to find ways to make sure patients get antivenom as early as possible. This requires laboratory tests that can identify patients with snake envenomation in the first couple of hours after the bite. </p>
<p>It is also essential anyone bitten by a snake or suspected to be bitten by a snake seeks immediate medical attention and goes to hospital by ambulance.</p>
<p>But the best thing is to avoid being bitten in the first place:</p>
<ul>
<li><strong>avoid snakes</strong>, difficult if you’re a snake handler (up to 11% of cases in our study), and take care if trying to catch or kill a snake (which led to a bite in 14% of cases)</li>
<li><strong>wear long pants and sturdy shoes</strong> when walking in the bush or rural areas (47% of snakebites were when people didn’t know one was nearby) or when gardening (8% of cases)</li>
<li><strong>be alert inside too</strong>, with 31% of snakebites near houses and 14% in buildings.</li>
</ul>
<p>Our study confirms Australian snakes <a href="https://theconversation.com/a-venomous-paradox-how-deadly-are-australias-snakes-79433">don’t really deserve</a> their deadly reputation, <a href="https://theconversation.com/yes-australian-snakes-will-definitely-kill-you-if-youre-a-mouse-51809">unless you’re a mouse</a>. But if you are bitten, or think you have been, hospital is still the best place for you.</p><img src="https://counter.theconversation.com/content/81614/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Geoff Isbister receives funding from the National Health and Medical Research Council. </span></em></p>Don’t hold back. Performing CPR on a snakebite victim who has collapsed can save their life, however imperfect your technique.Geoff Isbister, Director, Clinical Toxicology Research Group, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/167082013-08-05T20:15:49Z2013-08-05T20:15:49ZWaking the dead? Some things you should know about dying<figure><img src="https://images.theconversation.com/files/28631/original/smh7wf44-1375674302.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cardiopulmonary resuscitation (CPR) prevents many deaths across the world, but it doesn't bring dead people back to life.</span> <span class="attribution"><span class="source">NATO Training Mission-Afghanistan</span></span></figcaption></figure><p>Not content with saving lives, doctors are now credited with (accused of?) bringing the dead back to life. But how true are the stories we hear about people “coming back” from being dead and how does it work? </p>
<p>Here’s a <a href="http://www.medterms.com/script/main/art.asp?articlekey=33438">definition of death</a> that gets to the heart of why this is all very complicated:</p>
<blockquote>
<p>Death: 1. The end of life. The cessation of life. (These common definitions of death ultimately depend upon the definition of life, upon which there is no consensus.)</p>
</blockquote>
<p>Cardiopulmonary resuscitation (CPR), first popularised in the 1960s and widely taught to both first responders and the general public, prevents many deaths across the world. </p>
<p>But it doesn’t bring dead people back to life. And the distinction is an important one.</p>
<p>The problem can be easily stated – death is a process, but is forced to be an event. Organisms die in a piecemeal manner, with the most vulnerable bits going quickest. </p>
<p>Some residual function can be found up to several hours past the point where the heart has stopped beating (though, contrary to myth, the fingernails do not continue to grow).</p>
<h2>Why “when” is important</h2>
<p>But there are cogent medical, legal and philosophical reasons for death to be considered an event. </p>
<p>Medically, there has to be a moment at which attempts to prolong life should cease (organ donation being a rare but important reason). Organ donation puts great pressure on doctors to define a moment of death. This is to honour the “dead donor rule”, which states that only dead people can be donors. </p>
<p>Legally, time of death is important for determining who out-survived whom, and thus how the deceased person’s possessions will be distributed. </p>
<p>Philosophically, it appears, at least to some, that the categories “alive” and “dead” are to have no overlap. Consider this <a href="http://www.ncbi.nlm.nih.gov/pubmed/7224389">from a research paper</a> about defining death:</p>
<blockquote>
<p>If we regard death as a process, then either the process starts when the person is still living, which confuses the “process of death” with the process of dying, for we all regard someone who is dying as not yet dead, or the “process of death” starts when the person is no longer alive, which confuses death with the process of disintegration. </p>
</blockquote>
<p>Hmmmm.</p>
<p>Now we have a problem: we need to know what death is, and we need irrefutable tests to prove it. How are we doing?</p>
<h2>Kinds of death</h2>
<p>Obviously, it all got much harder when laws were introduced that defined two distinct kinds of death – circulatory (traditional) death and the new kid on the block, brain death. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/28630/original/9rwdxkwz-1375673863.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Brain death is the ‘irreversible cessation of all function of the person’s brain’.</span>
<span class="attribution"><span class="source">Its.MJ/Flickr</span></span>
</figcaption>
</figure>
<p>These laws were introduced in Australia in the early 1980s to legitimise brain death as a form of dying. This had the benefits of allowing treatment withdrawal and permitting organ donation without breaking the “dead donor rule”.</p>
<p>Circulatory death is the “irreversible cessation of circulation of blood in the person’s body”, while brain death is the “<a href="http://www.austlii.edu.au/au/legis/nsw/consol_act/hta1983160/s4.html#function">irreversible cessation of all function</a> of the person’s brain”. </p>
<p>Many researchers are scrambling to <a href="http://www.ncbi.nlm.nih.gov/pubmed/19818892">unify these two definitions</a>, by asserting that loss of circulation would inevitably cause irreversible cessation of all brain function.</p>
<p>But, given that we don’t know how long the circulation has to stop before we can be confident that all brain function has stopped in all cases, it seems we are stuck with two definitions for now. </p>
<p>The operative word in each definition is irreversible. The reason why CPR, however prolonged and enhanced by new technologies, does not bring people back to life is that clearly the cessation of circulation and brain function are not irreversible. </p>
<p>So people who are “brought back to life” were, in retrospect, not dead in the first place.</p>
<h2>Who is responsible?</h2>
<p>But seemingly miraculous results from CPR do pose a serious challenge: how are we then to be certain that cessation of function is irreversible? </p>
<p>The law is steering clear of getting involved in Australia, and the decision is delegated to doctors. This was <a href="http://www.ncbi.nlm.nih.gov/pubmed/19010008">challenged in a legal case</a> but the law, as it stands, was confirmed.</p>
<p>Irreversible loss of brain function does have a set of tests that appear extremely reliable, as long as they are properly conducted. And nobody declared brain dead in Australia has ever lived to tell the tale.</p>
<p>Irreversible loss of circulation is more difficult to certify, and has been brought into sharp focus by the re-introduction of organ donation after circulatory death, which demands both high certainty and an exact time of death. </p>
<p>Organ donation after circulatory death has become widespread in Australia over the past ten years as a response to the very low numbers of donors, and now accounts for about 25% of all donors.</p>
<p>What we know empirically is that a heart that has stopped will not spontaneously start again after quite a short time (so-called <a href="http://www.ncbi.nlm.nih.gov/pubmed/20228683">autoresuscitation</a>).</p>
<p>So cessation of circulation is permanent, but is it irreversible? It is, but only in one context; a morally and medically defensible decision not to keep trying to reverse it. </p>
<p>Such decisions are commonplace in modern medical practice (the no-CPR or “Do Not Resuscitate” order), and have a history almost as long as CPR itself. </p>
<p>There are people who cannot be, should not be, or do not want to be resuscitated. For them, permanent loss of circulation is irreversible. For the rest – go for it!</p><img src="https://counter.theconversation.com/content/16708/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Saul does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Not content with saving lives, doctors are now credited with (accused of?) bringing the dead back to life. But how true are the stories we hear about people “coming back” from being dead and how does it…Peter Saul, Senior Specialist in Intensive Care and Head of Clinical Unit in Ethics and Health Law, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/102272012-10-22T00:05:12Z2012-10-22T00:05:12ZTGA, once again, fails to reign in shonky weight-loss product<figure><img src="https://images.theconversation.com/files/16744/original/3fv9pqgz-1350862500.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">This product is being sold despite being removed from the Australian Register of Therapeutic Goods by the TGA.</span> <span class="attribution"><span class="source">Ken Harvey</span></span></figcaption></figure><p>I submitted a complaint about the promotion of “FatBlaster Reducta” (ARTG no: 176366) to the <a href="http://www.tga.gov.au/">Therapeutic Goods Administration</a> in March 2011. The product is a “complementary medicine” containing an extract of <em>Caralluma fimbriata</em> (a succulent native to India), is sponsored by <a href="http://pharmacare.com.au/">Pharmacare Laboratories</a>, and promoted for weight loss. </p>
<p>And I submitted an additional complaint about the ongoing television promotion of this product in May 2011. </p>
<p>In August 2011, the Therapeutic Goods Advertising <a href="http://www.tgacrp.com.au/">Complaints Resolution Panel</a> (CRP) agreed the promotion breached many provisions of the <a href="http://www.tga.gov.au/industry/legislation-tgac.htm">Therapeutic Goods Advertising Code 2007</a> (determinations <a href="http://tinyurl.com/8krbs7g">2011-03-008</a> and <a href="http://tinyurl.com/98gg4bl">2011-05-008</a>). </p>
<p>Pharmacare Laboratories was “requested” to withdraw the advertisements, the representations made and advise other parties promoting this product that their representations should also be withdrawn.</p>
<p>The CRP’s request included “to withdraw any representations that the advertised product or its ingredients have benefits in relation to weight management or weight control, reducing snacking, or aiding in eating less or reducing portion sizes” and “to withdraw the representations that the advertised product or its ingredients have benefits in relation to reducing feelings of hunger or suppressing appetite, except where those representations are clearly qualified as to the nature of the evidence supporting the claims, through clear statements that the claim is based only on evidence of traditional use.”</p>
<p>Pharmacare Laboratories declined to comply with the CRP’s request. So at the end of August 2011, the CRP recommended that the Therapeutic Goods Administration (TGA) should “order” the company to comply. </p>
<p>Still, the promotion of this product continued.</p>
<p>Over 12 months later, on October 9 2012, the <a href="http://www.tga.gov.au/industry/cm-cancellations-cr.htm">TGA announced the cancellation of FatBlaster Reducta</a> from the <a href="http://www.tga.gov.au/industry/artg.htm">Australian Register of Therapeutic Goods</a> (ARTG) on the grounds that there was insufficient evidence to support the indications for the product, the presentation of the product was unacceptable and the certifications made by the applicant regarding these matters were incorrect.</p>
<p>As of October 22 2012, this delisted product continues to be promoted. <a href="http://www.pharmacyonline.com.au/fatblaster-reducta-500mg-tab-x-40">Pharmacy Online</a>, for example, continues to make the same claims (and use the same video) that the CRP agreed breached the Therapeutic Goods Advertising Code.</p>
<p>The product also remains on the shelves of numerous pharmacies with no indication that it has been removed from the ARTG because “there was insufficient evidence to support the indications for the product.” These indications remain prominently displayed on the pack.</p>
<p>This is merely the latest example of the ongoing failure of the TGA and similar regulatory bodies to protect consumers from the claims made by those promoting and selling shonky “complementary medicines”.</p>
<p>There’s no pre-market assessment by the TGA of the claims made for listed complementary medicines. There’s only limited post-marketing surveillance and that has shown high levels of <a href="http://theconversation.com/flogging-a-dodgy-cancer-cure-say-what-you-like-the-tga-wont-stop-you-3143">regulatory non-compliance</a>. </p>
<p>It can take up to six months for a determination of the CRP to be made public and their “requests” to sponsors to withdraw misleading claims can be readily ignored – as in this case. It can take the TGA far longer to exhaust due process and cancel the product’s listing on the ARTG. And this doesn’t deter pharmacists and other retailers from clearing their stocks of delisted products through continued promotion and sales.</p>
<p>Promoting a delisted product is a breach of the <a href="http://www.austlii.edu.au/au/legis/cth/consol_act/tga1989191/">Therapeutic Goods Act 1989</a> (s.42DL(1)(g)), the <a href="http://www.tga.gov.au/industry/legislation-tgac.htm">Therapeutic Goods Advertising Code 2007</a> (s.4(1)(a)) and for pharmacists, arguably the <a href="http://www.legislation.qld.gov.au/LEGISLTN/ACTS/2009/09AC045.pdf">Health Practitioner Regulation National Law Act 2009</a> (s.133). </p>
<p>To date, complaints under the latter have proved unproductive. </p>
<p>On October 26 2011, for instance, I complained to the Australian Health Practitioner Regulation Agency <a href="http://www.pharmacyboard.gov.au/">(AHPRA) Pharmacy Board</a> about the ongoing promotion of SensaSlim by pharmacists who continued making claims that had been shown to be false, misleading and deceptive by <a href="https://www.comcourts.gov.au/file/Federal/P/NSD1163/2011/actions">Federal Court Orders</a> and <a href="http://tinyurl.com/9hn9b97">CRP determinations</a>. </p>
<p>I received an acknowledgement for the complaint from the Pharmacy Board on November 22, 2011. I subsequently pointed out to the Pharmacy Board that <a href="http://www.tga.gov.au/newsroom/media-2011-sensaslim-111124.htm">SensaSlim was delisted</a> by the TGA on December 1 2011, but promotion by pharmacists continued. </p>
<p>I have yet to receive any further communication from the Board about these matters. I’ve now submitted further complaints to the Pharmacy Board about the ongoing promotion of FatBlaster Reducta by pharmacists.</p>
<p>Clearly, we need a more responsive regulatory system. </p>
<p>Sponsors such as Pharmacare Laboratories, which have had numerous upheld complaints about their products should be targeted for urgent post-market audit by the TGA, as recommended by the <a href="http://www.anao.gov.au/Publications/Audit-Reports/2011-2012/Therapeutic-Goods-Regulation-Complementary-Medicines/Audit-brochure">Australian National Audit Office Report</a>. And it shouldn’t take 12 months or more to remove such products from the ARTG, especially if the audit has resulted from non-compliance with a CRP determination. </p>
<p>Notice of product delisting must be sent to the <a href="http://www.guild.org.au/the_guild">Pharmacy Guild</a>, the <a href="http://www.psa.org.au/">Pharmaceutical Society of Australia</a> and other retailers, advising them that continued promotion of such products is an offence. </p>
<p>Retailers should request the sponsor to remove delisted stock and provide reimbursement. </p>
<p>Finally, it would be helpful if the AHPRA Pharmacy Board wrote to all pharmacists reminding them of their obligations under under the <a href="http://www.pharmacyboard.gov.au/Codes-Guidelines.aspx">Code of Conduct for Registered Health Practitioners</a> (s.8.6), “All advertisements must conform to relevant consumer protection legislation”. </p>
<p>The <a href="http://www.ahpra.gov.au/Legislation-and-Publications/Legislation.aspx">National Law Act</a> is also relevant. Subdivision 4, s.133 says, “a person must not advertise a regulated health service or a business that provides a regulated health service, in a way that: a) is false, misleading or deceptive or is likely to be misleading or deceptive; or b) creates an unreasonable expectation of beneficial treatment.”</p>
<p>We have complementary medicine companies (and pharmacists) who consistently ignore the rules, aided and abetted by bureaucratic red tape and toothless or sleeping tigers – the regulators. The result is that consumers get shafted. Surely, it’s time the government acted to protect its citizens.</p><img src="https://counter.theconversation.com/content/10227/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Harvey has accepted travel expenses only to talk about problems of complementary medicine regulation to pharmaceutical companies and industry associations. He has also been paid travel expenses and sitting fees for his involvement with government inquiries and working groups concerning pharmaceutical promotion and the regulation of complementary medicines. He is regarded by industry as a serial complainant.</span></em></p>I submitted a complaint about the promotion of “FatBlaster Reducta” (ARTG no: 176366) to the Therapeutic Goods Administration in March 2011. The product is a “complementary medicine” containing an extract…Ken Harvey, Adjunct Associate Professor of Public Health, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.