The first 10 minutes

Minutes matter when responding to medical emergencies, with the key to preserving life being preparation ahead of time.

by Lisa Harrison

In the case of cardiac arrest, the chance of survival decreases by up to 10 per cent for every minute without medical intervention.

First responders need travel time, especially in rural areas where they can be delayed by greater distances, patchy cell service and more. Bystanders are left to make a critical choice: stay on the sidelines or help save a life?

The incident of an elderly man who fainted at his Muskoka home sticks in Dr. John Simpson’s mind because it might have ended differently.

“His son witnessed his medical event and had fortunately just completed a community-based first responder course a week prior because both of his parents had had recent heart issues,” recalls Simpson, director and chief of emergency medicine at Muskoka Algonquin Healthcare (MAHC).

The nearest available ambulance was 15 km away, so the son applied cardiopulmonary resuscitation (CPR) until the paramedics arrived about 13 minutes later. They successfully restored a normal heartbeat using defibrillation (shocking the heart back to normal rhythm).

“When he arrived at the hospital, the patient was talking and recounting that he had had a busy day,” says Simpson. “The patient’s son arrived at the hospital shortly after, completely saturated in sweat from doing CPR. I witnessed an embrace, and the dad saying, ‘Son, you saved me. The paramedics told me you saved me.’

“It was a special moment to witness and the paramedics were 100 per cent right. Prompt CPR and then defibrillation saved this man’s life and today he is doing well in his home.”

Dr. John Simpson, director and chief of emergency medicine at Muskoka Algonquin Healthcare, has witnessed positive patient outcomes when bystanders provide emergency CPR.

The drive for healthy outcomes

Cottage Country medical incidents range from fishhook embeddings, insect stings, to heart problems and severe physical trauma resulting from accidents on roads, trails, water and ice.

“Emergencies where patient conditions can deteriorate quickly are the most serious,” says Stuart McKinnon, deputy chief, Muskoka Paramedic Services. “These include issues like cardiac arrest, major trauma, choking, heart attacks and strokes.”

First responders and hospitals work to provide optimum services for their communities, but constraints such as high seasonal populations and staffing shortages can result in different levels of available service.

For example, Ontario paramedic services are governed by an integrated provincial service that can dispatch paramedics outside their geographic area if they are closest to the scene of an incident, which can result in longer response times in their home community.

MAHC increases staff levels at both hospitals – Huntsville District Memorial Hospital and South Muskoka Memorial Hospital – in peak periods to help address the influx of cottagers and visitors, as does Haliburton Highlands Health Services (HHHS), which operates the Haliburton and Minden hospitals. However, Carolyn Plummer, president and CEO, adds that the pandemic has led to a shortage of healthcare professionals worldwide, especially nurses, making it difficult to recruit new staff.

Dr. Ashley White, who works with the emergency department at Quinte Health Care North Hastings Hospital in Bancroft, says that with the current nursing and physician shortage, “we can become spread very thin if we are trying to provide critical care while also covering the rest of the issues that come to the ER.

“There are weekends in the summer when there are no doctors to call in and, if I have to get someone out, I close the hospital,” says White. “That is how close we come to the margin.”

Bystanders to the rescue

“For certain emergencies, management in the first 60 to 90 minutes is very important, and delayed time to reach the scene can pose a challenge,” says Dr. Koushik Krishnan, chief of emergency and clinical director, emergency medicine, at Ross Memorial Hospital in Lindsay.

“First aid training and personal AEDs (automated external defibrillators) can help save lives until first responders arrive. In cardiac arrest, early good quality CPR helps save lives and improves neurologic recovery. Situations where early CPR is initiated immediately by bystanders often improves the chance of recovery.”

The Heart and Stroke Foundation’s 2019 report “Addressing Cardiac Arrest in Canada” confirms the need for bystander intervention in cardiac arrests, which are among the most response-time-sensitive emergencies.

An estimated 35,000 cardiac arrests occur in Canada annually, according to the report. Cardiac arrests have many causes, including heart attack, drug overdose and heart rhythm disorders. They can happen to anyone of any age at any time and they often occur without warning signs.

More than 90 per cent of those who suffer an out-of-hospital cardiac arrest (OHCA) die. But the HSF reported that the survival rate improves significantly when bystanders use CPR and AEDs.

More than 400 lives per year are saved by bystanders use of an AED and the chance of survival triples to 24 per cent. When the AED shock function is administered, the chance of survival increases by five times to 38 per cent.

Dr. Ashley White, who works with the emergency department at Quinte Health Care North Hastings Hospital in Bancroft, bemoans the shortage of doctors and nurses in Cottage Country.

An ounce of prevention

“One of the most important lifesaving steps is always prevention,” says Dr. Devon Tilbrook, who works with the Haliburton hospital emergency department.

“In Cottage Country, that should include water safety – wearing lifejackets when boating, not boating or swimming under the influence of alcohol or drugs, and not diving into water if you are unsure of the depth.”

Prevention can also include measures such as maintaining a healthy lifestyle, ensuring all those who operate a motor vehicle or watercraft are properly trained, and preparing for harsh weather conditions.

“I think what many of us feel is that we are trying our best in an imperfect system and that we all have a responsibility to try to be rational about the use of services,” says White, adding an example: “Drink or drive. Drive or drink. Doing both together causes many stupid things to happen, which means there is no ambulance available for Grandpa when he wakes up at 5 a.m. and has a cardiac arrest.”

Preparation is the best medicine

Another key step towards preserving life is preparing to deal with medical emergencies.

“Knowing CPR and how to treat someone in a near drowning situation is lifesaving,” says Tilbrook. “If you use drugs, or know anyone who uses drugs, whether prescribed or not, having access to a naloxone kit and knowing how to use it is life-saving.”

Knowing it’s best to travel by ambulance in a case of stroke can also save lives, she notes. “Do not come by car. Emergency services have special protocols where they can take you directly to a stroke centre and bypass hospitals that cannot provide definitive stroke care.”

Preparations include:

• Take training in first aid, CPR, AED and naloxone use. Municipalities generally offer training, as do sources such as the Canadian Red Cross, St. John Ambulance and private companies. Depending on the provider and the subject, training may be available online and there may be an option for group training at your location.

• Create a detailed action plan that includes directions to your local ER, maintenance of a proper access route for emergency services and deals with obstacles such as cellphone coverage limits, water-access-only issues and poor road markings.

• Learn the locations of the public AED units in your neighbourhood.

• Purchase an AED for your home and cottage or any place where groups gather. Tell your neighbours so they know you have it and know how to access and use it. “Consider holding a lake party – within COVID guidelines – to promote or facilitate CPR and AED training where neighbours and friends are included,” Simpson says. With the right knowledge, as a bystander you can move quickly and confidently from the sideline to the front line of a medical emergency.

Someone may live to thank you for it.

What to do in an emergency

If a medical emergency occurs, follow these steps from the Canadian Red Cross and Dr. Ashley White:

1. Ensure someone calls 9-1-1 with the necessary information.

2. If it’s safe to do so, check for a pulse. If there’s no pulse after 10 seconds, start the CPR compressions: push hard and fast with the heels of your hands, clasped together, on the centre of the chest at the nipple.

3. Tilt the head back to open the airway and give two breaths in the mouth, then begin alternating the breathing with 30 compressions. If someone is with you, have them do the breathing and switch roles when you get tired.

4.Get the AED if one is available and charged (the batteries should be checked once a year). Open the patient’s shirt and apply the pads according to the diagram on the pads. Turn the machine on and follow the instructions. If it says shock, move away and shock. If it says not to shock, then keep doing CPR, with 30 compressions to two breaths.