The recent tragic death of a young lady doctor at Thrissur by choking on her own food raised many eyebrows among the medical fraternity. How could such an incident happen in a crowded mall in Kerala, a place known for its high literacy rate?
Why did the onlookers not offer help, when a simple three-second Heimlich manoeuvre (an abrupt inward and upward thrust using the fist on the victim’s upper abdomen) could have saved her life? Wouldn’t at least a few of the onlookers have attended a first aid class in their lifetime?
The answer could be three-pronged.
1. According to mob psychology expert Gustave Le Bon, as a crowd initially gathers, individuals lose their identity, and the anonymity factor gets established. The next stage, called ‘contagion’ refers to the tendency for individuals in the crowd to unquestioningly follow the predominant ideas and emotions of the crowd. As a result, if the majority are passive onlookers, a potential helper could change his mind and turn into an onlooker.
“In a crowd … a man descends several rungs in the ladder of civilization. Isolated, he may be a cultivated individual; in a crowd, he is a barbarian.” -Gustave Le Bon
2. The instinct for not getting into trouble: people may deem it safer to do nothing, than to act and invite trouble.
3. Ignorance, which means the onlooker has no idea how to react when a person collapses.
The purpose of this article is to address the third issue. If ignorance can be dealt with, then the onlooker might be able to overcome the first two hurdles too, instantly converting himself into a lifesaver.
Trouble is, even after attending a life-support lecture, one might still not know how to react when a real-life situation happens later on. Information overload (knowing too much) can be a problem too, it could freeze you into inactivity.
What is the solution then? Could knowing less be the answer?
Instead of presenting basic life support in the conventional ‘classroom format’, this article is written from the onlooker’s perspective (read: ‘user-friendly’). Medical decision-making is presented here in the simplest format possible.
Let us analyze how to approach a person who suddenly collapses in a restaurant.
First up, let us use some common sense. A young person, while having a hamburger or a piece of chicken at a food court, suddenly collapses to the ground in a heap, clutching her neck, unable to talk or even breathe.
One does not need a medical degree to figure out that her wind-pipe (not food-pipe) is blocked with food, and that she is therefore unable to breathe. Anyone who has tried holding their breath for fun in childhood, or even watched crime films would know that once our airway is blocked, death will occur in just a few minutes.
This means that we don’t have a lot of time to react. If there is no doctor or nurse nearby who is already offering help, the correct thing to do is to calmly explain what you are going to do and why, and then go ahead quickly with the Heimlich manoeuvre (see picture and video). The piece of meat that is blocking the windpipe will come flying out, almost like a cork flying off a bottle’s neck, and the victim will be able to breathe again. You have saved a life. End of story.
Next, let us consider the case of a person walking along in front of you in the shopping mall and collapsing on to the ground. It is obvious this isn’t a case of choking. Why would a person suddenly collapse while walking?
The top reason for this would be a heart problem: this middle-aged overweight man could be having a heart attack. A block in his coronary arteries can make the heart beat ineffectively, causing the collapse from impaired blood flow to the brain.
Hypoglycaemia, seizure, stroke and alcohol intoxication are a few other reasons, all of which have distinct recognisable features. (A detailed discussion of each disease is not the purpose of this article)
So, what do you do? You are almost alone now with this collapsed person, in a public place. You want to help, but have no idea what CPR means, and you are afraid to touch the victim.
Well, the best thing to do is to remain calm, and not to lose your head. Unlike the choking victim who, without help, will die within minutes, this person might remain alive for a longer period of time, if he is still able to breathe. You have time at hand.
Look around for anyone who can help you, call for a doctor or a nurse. Ask someone to call an ambulance. Have someone block off and evacuate the lifts beforehand: this saves valuable time while moving the victim to ground floor.
Calling and alerting the casualty doctor ahead of the patient reaching the hospital helps the patient receive faster treatment, as they will be better prepared. Besides, talking with the doctor by phone could also help you perform crucial tasks while aiding such a victim.
In the case of a heart attack or stroke, reaching the hospital just a few minutes sooner can mean life or death for the patient. Most people are now aware of 'clot-busting' injections that can open up blocked blood vessels. The sooner this is given, the better the outcome is. In medical jargon, this is called “door-to-needle time”.
Thus, even if your involvement with the victim is facilitating prompt transfer to hospital, you are still a life-saver.
Please note that the steps above require no medical training whatsoever; all that's needed from you are common sense, some leadership and a willingness to help others.
Let us now move up one level of expertise. You have some basic knowledge in life support, but you are not an expert. You are attending the same victim above.
What is the victim's status?
If the person can talk, it generally means he can breathe and his circulation is intact. Arrange for fast transfer to hospital and don't leave his side till he is moved.
If the person is completely unresponsive with laboured breathing after collapsing, don’t waste even a second. Start chest compressions and continue till professional help arrives or the victim recovers. (Don’t worry, you are not required to establish a medical diagnosis before doing this. In fact, delay in starting chest compressions from self-doubt contributes to more deaths than any other factor in this situation)
How to give chest compressions?
You must have seen this in the movies. It is easy to do: put the person flat on firm ground, kneel down beside him, keep both hands on the mid-chest, between the nipples, and quickly thrust downward a good 2 inches, at a rate of 100-120 times a minute. If you get an assistant, you can take turns.
An easy way to maintain the correct rate is to give compressions according to the beat of the song 'Stayin’ alive' or 'Ashtamudi Kaayalile' playing in your mind.
How does CPR help?
It maintains some blood flow and oxygen supply to vital organs including the brain, until medical help arrives. You are not only preventing immediate death, but reducing the chance of the person ending up as a ‘vegetable’ or brain-dead person if and when he eventually survives the incident.
Will I have to give mouth-to-mouth breathing?
The latest recommendations suggest that a lay person need not attempt mouth-to-mouth respiration while doing the rescue unless he is an expert. Doing chest compression alone will suffice.
Get a defibrillator - fast!
Most public places have portable defibrillators now, therefore ask someone to go get one. Obviously, they will need to ask the security or local staff about the location of the defibrillator in the building.
The advantage of the defibrillator is that it can quickly convert abnormal, ineffective heart rhythms into stable ones, thus restoring blood flow to the brain and other organs. Most defibrillators have operating instructions; some even give audio feedback. Having the defibrillator plugged in and ready by the side of the victim will save precious time when a professional arrives on the scene.
So, the 6 steps are:
1. Take a quick history from the victim or bystander. If choking is suspected, perform Heimlich manoeuvre.
2. Call for help: is there a doctor or nurse nearby.
3. Send for an ambulance. Look for an assistant to help you.
4. Call for a defibrillator, keep it ready.
5. If unconscious and not breathing well, give chest compressions till help arrives.
6. Arrange for fast transfer to the nearest hospital.
This article is specifically written for the real-life situations described above, carefully adapted from the latest manuals on Cardiopulmonary resuscitation.
To put the whole article in one sentence: if a person falls down unresponsive and is not breathing well, start chest compressions, and call an ambulance.
It is useful to attend basic life support classes. There are training videos on YouTube that will boost your confidence levels.
Tip: Teaching your family members the above steps could potentially save your life too in the future.
Let’s go out there and save a few lives now!
(The author is a Senior Consultant Gastroenterologist and the Deputy Medical Director, Sunrise Group of Hospitals, Kochi.)