Skills in coaching basic CPR

S Y K Ho 何耀強

Dear Editor

I refer to Dr. M S H Chan's recent letter to the Editor (Feb 2003) on a mnemonic as an aid to basic CPR. According to the Oxford dictionary, mnemonic is an aid to memory. As such, it does not have a specific function of understanding. Memorising without understanding could result in superficial learning. If our memory fails, the whole engine fails.

I have been involved in College CPR activities (training, examination) for some 10 years. Recently I was invited by the College to give a talk on Skills in Coaching Basic CPR. At the talk, I emphasised on Skills in Coaching.....; but not Coaching the Skills in Basic CPR. Two fundamental elements exist in the word Coaching: Teaching and Learning processes. In any Quality Teaching and Learning processes, an interactive phenomenon is at play.

The teacher should teach (and the learner should learn, and learn how to learn) the Patho-physiology in CPR. Why does the mnemonic "2 breaths" follow "10 second 999"? What happens after 2 breaths?; in other words, why does "2 breaths" precede "Check pulse"? If the candidate does not understand the patho-physiology, but only relies on his memory in any emergency situation such as 911 scenario, chances are his memory might fail, and he might put "Check pulse" before the "2 breaths".

The other attribute for a quality teacher to possess is for him/her to update the knowledge component in the teaching materials; with advances in CPR e.g. The International Guidelines 2000 Committee's recommendation on the (i) Compression Rate and (ii) Ventilation Volume to be delivered to the victim over a set time; and (iii) what is Class IIb Evidence, etc. Updated materials can be accessed through research and readings. Research and teaching go hand-in-hand.

Taking a longer view, ability to perform a quality CPR simply cannot rely on some mnemonic that a doctor picked up 10-15 years ago. It is the competence of understanding and capability to learn how to learn in life-long learning that will equip the doctor with the effective skills/tools to revive the patients. This will result in deeper learning. Mnemonic may only be good for the 3 minutes in the examination; and as such it may not hold too long.

S Y K Ho, MBBS, FRACGP, FHKAM(Fam Med), SbStJ
Head/University Health Service,
The Hong Kong Polytechnic University.

Authors' Reply

M S H Chan 陳選豪

Dear Editor,

It is pleasing to learn the letter on "An Aid to Basic Cardiopulmonary Resuscitation (CPR)" published in February (Volume 25) has attracted attention. It is of particular gratitude that a senior member of the profession would take time to remind us of the many more important aspects of teaching and learning.¹

It has been said that CPR - like activities date back to the time of creation, when God created Adam and breathed into his nostrils the breath of life. It is perhaps of such divine tradition that privileged our profession. Our predecessors pursued the very details of cardiac arrest. Physiologists measured chamber pressure changes, wondering whether the heart/thorax acted as a pump or conduit; biochemists match oxygen flux with glucose/metabolic demand, tracing oxygen debt to free radical generation. Studies of acid-base argue against indiscriminate bicarbonate administration. Cardiac electrophysiology dictates the use of anti-arrhythmic agents.

Emergency physicians, trauma psychologists and academics challenge once accepted practices. Standard CPR in the 60s has evolved to Cardiopulmonary-Cerebral Resuscitation (CPCR) in the 70-80s.⁴ Learning the revival time of target organs and analysis of the resuscitation process, formulates the Chain of Survival.^2,3 There are also elements of psychosocial changes. Post-trauma counselling is a standard not seen in the 60-70s. Civilian tragedies, such as the Lan Kwai Fong Incident (1992), raised public concern. Standard of paramedic service is substantially higher since.

In the new millennium, Evidence Based Resuscitation drives. Our response to the poor result of out of hospital arrest is "Public Access Defibrillation" - the fire extinguisher approach.^2,3,5 Post-course evaluations showed widespread learning difficulties with poor retention of Basic Life Support (BLS) skills, attributed to the sequence's complexity and the precision required to perform it; suggesting simplification to improve teachability.^2,3

A mnemonic does not lead to understanding. My 5 years old daughter could recall such after 15 minutes practice. I doubt she has any comprehension of CPR. The role of mnemonic is modest, no more than an adjunct in notes taking. The guidelines change, the mnemonic changes accordingly. Its simplicity is more appropriate in community class for the lay rescuer. For healthcare practitioners, the standard required is higher.

Thanks to Dr. S Ho for cautioning CPR teachers on the use of a memory aid, reminding us of the utmost importance of understanding the intellectual efforts behind the distillated algorithm. CPR requires a level of sophistication that we cannot afford to treat lightly. Many fail to realise the immense task, energy and in-depth considerations of generating a guideline, each step being debated and argued by the most experienced in the field. Interested readers may refer to the related articles.^2-4 As a general practitioner, I read with great admiration, recalling my experience with mammalian heart preparations and past resuscitation scenes.

There is no substitute of continuous learning, research, training, practice and dedicated teachers. The role taken by colleagues as tutors implies responsibility and challenge, to preach the apparently simple with attention to an intellectual level well above the ordinary. It carries the honourable duty and professional satisfaction one deemed to deserve.

M S H Chan, MBBS(UNSW), DFM(CUHK)
General Practitioner.