*To take the corresponding CDE quiz, visit the College of Emergency Dispatch.*
It’s finally happened. You answer the phone in your usual polite manner, and during Case Entry Questioning, the caller lets you know that the patient is not awake and not breathing. You’ve officially received your first CPR call! Although it’s a weighty responsibility, you’re not too nervous because you’ve been preparing for this day since you first got hired. You’ve practiced delivering the instructions in your most calm, compassionate voice, and you know exactly where the button on ProQA® is to keep the compression counting at a steady pace.
There’s just one problem.
“Listen carefully,” you say, perfectly reading out the instructions ProQA is providing. “Lay him flat on his back on the floor and remove anything under his head.”
“I can’t,” the caller says. "I can’t lay him on his back. He’s lying on his belly, and he’s a lot bigger than me. I can’t roll him over.”
You reiterate how important it is that the patient is on his back so the caller can start chest compressions and ventilations. The caller struggles for a bit, and when he finally comes back to the phone, he tearfully says he can’t do it.
In previous versions of the Medical Priority Dispatch System™ (MPDS®), that’s where your instructions would end. Aside from encouraging the caller to try everything they can to get the patient on their back, there wasn’t much else you could do as the EMD.
The International Academies of Emergency Dispatch® (IAED™) Research Department has heard enough calls where a patient in need of CPR is lying face down on their stomach (also known as “prone”). The solution: a new set of CPR instructions in Protocol C: Airway/Arrest/Choking (Unconscious) – Adult ≥ 8 yrs to provide the caller with a proven technique to get a heavy patient on their back—and if that’s not possible—a technique for completing CPR compressions with the patient in the prone position.
CPR background
Before we dive into what the new instructions are, let’s review why it’s important for the caller to perform CPR on the patient correctly. As it says in the Protocol, chest compressions must be administered with “the heel of your hand on the breastbone (in the center of the chest), right between the nipples.” Performing compressions in that exact spot not only reduces the chance of the caller breaking the patient’s ribs, it’s also the most effective way to compress the heart, mimicking its natural rhythm until there is return of spontaneous circulation. If blood (which carries all-important oxygen) isn’t consistently pumped to the body’s vital organs—especially the brain—there is a high probability the patient will not survive.
Can chest compressions be done on a patient’s back? The short answer is yes, but it’s certainly not ideal. Nearly all the research and study data we have on the efficacy of CPR has been done with the standard chest compression technique that includes hands on the sternum (breastbone). Yet while we don’t have good research demonstrating how well it works, we can observe that compressions done on the upper back, right on the spine, have a similar mechanical effect of compressing the chest cavity—which contains the heart—as those on the front of the chest. In hospitals, medical personnel can administer compressions on a patient’s back—but only when they can provide counter pressure on the sternum.1 In a prehospital setting like a home or a gym, it’s simpler and causes less damage to have the caller turn the patient over.
Similarly, in the hospital, the patient can be given ventilations when they are lying on their front using specialized equipment. In the prehospital—particularly in the remote setting of emergency medical dispatch—this is nearly impossible to accomplish effectively.
New instructions
If your center has updated the MPDS software to version 14.0, you’ll now have access to C-26: Unable to Roll Patient Over (On Belly/Prone). The instructions are as follows:
“Listen carefully and I’ll tell you exactly what to do next.
“Kneel on the floor/ground next to them and push their arm straight in against their side (only on the side you’re on). Tell me when you’ve done that.”
(*If the caller doesn’t understand the instructions, then clarify and reassure.)
“Now, with both of your arms, reach all the way across to the far side of their body and grab their far shoulder with your closest hand (your hand closest to their shoulder). Then, with your other hand on their far side, grab their belt or waistline close to the floor/ground.”
(*If the caller doesn’t understand the instructions, then clarify and reassure.)
Why does it work? There are two key points that make this method of turning the patient over effective. First, the caller uses two hands placed at crucial points on the body to grab the patient. If you’ve ever carried something heavy, you know it’s a lot easier to do so when the weight is distributed over two points of contact rather than one. Imagine carrying a suitcase that weighs 100 pounds using one handle. You can probably do it, but it’s going to be a struggle. Now imagine that the suitcase has two handles, one on each end of the top. It will be awkward to carry, but it will be more manageable.
Second, the caller will be pulling rather than pushing the patient and will be using their knees as a pivot point to turn the patient over. Therefore, when the caller pulls the patient toward them they get more leverage, and at the peak of the turn, gravity will assist in bringing the patient’s mass back to the ground.
If you can’t quite visualize this process, you’re not alone! Like many of the Protocol instructions, it’s easier to clarify them for the caller once you’ve seen it done in person. Try it out with a couple of your coworkers to cement how it should look in your head.
The research behind it
These instructions are the product of the IAED performing some hands-on research—literally! They recruited 32 participants who are employees with the IAED or PDC to find out if the new PAIs resulted in the caller being able to roll the patient onto their back more often than the old PAIs.
The study went like this: the volunteer was brought into a room where someone was lying on their front and simulated calling 911 for help. One of the researchers read out the regular C-2 instructions that simply instruct the caller to get the patient on their back. Out of the 32 times, only 15 of the participants (or 46.9%) were able to get the patient on their back without more specific instructions.
Then the researchers had the participant simulate another 911 call—this time with the new instructions. This time, 28 of the participants (or 87.5%) were able to get the patient from lying on their front to lying on their back.
With the current PAIs, the median time to roll the patient on their back was 30.5 seconds. With the new prone CPR instructions, the median time was 60 seconds. That’s not an improvement, you may be thinking. However, remember that with the current PAIs, only about 50% of the callers were able to roll the patient over. With the new instructions, it took longer on average, but more people were able to do it. For this reason, the new instructions are only used if the caller is unable to turn the prone patient over with the standard panel C-2 instructions—which remain in Protocol C in the same sequence.
Conclusion
So if you’re physically fit, feeling a little adventurous, and can find a willing “patient,” you can try out the new prone CPR instructions yourself. And if you’re feeling extra motivated, send any calls where you’ve used the new prone CPR instructions to the Research Department at ARCresearch@emergencydispatch.org so they can continue to improve the Protocol.
For even more information and training, the College of Emergency Dispatch is updating the Dispatcher-Directed CPR course to include a section on the new prone CPR instructions. Stay tuned!
Source
1. Bhatnagar V, Jinjil K, Dwivedi D, Verma R, Tandon U. “Cardiopulmonary Resuscitation: Unusual Techniques for Unusual Situations.” Journal of Emergencies, Trauma, and Shock. 2018. ncbi.nlm.nih.gov/pmc/articles/PMC5852913 (accessed July 31, 2023).
