2014, January/February Adirondac Adirondoc
First, let’s be very clear. CPR, or cardio-pulmonary resuscitation, in some settings can work wonders if begun in a timely manner by someone who knows what he or she is doing. Knowing how to perform CPR, in my opinion, is almost a requirement of citizenship, one of those things which we should expect of our fellows.
On the other hand, we should also know that many folks have a better opinion of the success of CPR than is realistic. Perhaps the media are to blame for this. A recent study claimed that CPR on a number of American TV “medical shows” was successful in 75 percent of cases. In actuality, CPR that is performed by medical personnel in the hospital leads to a patient surviving to discharge in good condition only about 10 percent of the time, depending upon age and diagnosis. When CPR is begun by a bystander outside the hospital, the results are even more dismal.
But what about CPR in the wilderness? Although CPR training is required as part of wilderness first aid courses, and for trip leaders such as licensed guides, I have never heard of a well-documented situation in which it was successful in a true backcountry setting. This is not for want of finding out: I regularly inquire about it whenever I am attending meetings of wilderness educators or physicians.
Why does CPR not always work? To understand that, we must appreciate what events cause the heart to stop in the first place. For anyone who dies of a severe injury or illness, stopping of the heart is the final event. CPR is unlikely to do anything for such a person unless one can also correct the responsible injury or illness. It is analogous to attempting to jump start a car with major transmission failure. An accident in a remote location resulting in injuries so severe that the heart stops simply cannot be reversed; CPR will be futile.
The second major cause for the need for CPR is a primary insult to the heart, such as could happen with a “heart attack,” a rather imprecise layperson’ s term for myocardial infarction.
In these situations, quickly establishing circulation with CPR is much more likely to be successful. In the front country, success in this setting is much improved if there is access to an automated external defibrillator (AED).
Death from “heart attack” certainly occurs on backcountry trails. If one comes across someone in such a situation, the individual with the most current training and experience should commence CPR immediately. Although the standard teaching is that bystander CPR continues until the rescuer is exhausted or a higher level of care is available, this suggestion may not be realistic in the backcountry. Definitive care may be days away. In such circumstances, beyond rescuer exhaustion or safety concerns, obvious signs of death such as rigor mortis are appropriate reasons to discontinue CPR. Fortunately, most “heart attacks” do not immediately result in cardiac arrest. There are a variety of first aid procedures for someone in whom a cardiac event is suspected; I will cover these in a subsequent column.
Finally, keep in mind that there are some wilderness settings in which CPR may have a better chance of success. An example of this is cold-water drowning. There are well documented instances of survival approaching an hour after such an event, so vigorous, continued CPR would certainly be appropriate. Hypothermia is another oft-cited example, although heart function in severe hypothermia is complicated and controversial.
The bottom line: backcountry users should do their civic duty and maintain certification in CPR. They just need to realize that they are more likely to use the skill in a diner on the way home than on the trek itself. CPR training today has been simplified (“compressions only”), and information on courses can be obtained through the American Red Cross (http://www.redcross.org/ take-a-class) or American Heart Association (http://www.heart.org/ HEARTO RG/ CPRAndECC/Finda Course/ Find-a-Course_ U CM_ 303220_SubHomePage.jsp ).
~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and a certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available at his website and blog: www.adirondoc.com. Drs. Craig Byrum and Jeremy Joslin, avid outdoorsmen and cardiologist and emergency medicine specialists respectively, reviewed this column and provided helpful advice.General First Aid