Translating Knowledge To Attitude: A Survey On the Perception Towards

Bystander Cardiopulmonary Resuscitation Among Dental Students

and School Teachers In Kota Bharu, Kelantan, Malaysia

KS Chew, MNA YazidEmergency Medicine Department

School of Medical SciencesUniversiti Sains Malaysia

Bystander CPR

• Bystander CPR is CPR performed by any person who is not responding as part of an organized emergency response system approach to a cardiac arrest

• Therefore, doctors and paramedics may be described as performing bystander CPR if they are not part of the patient’s resuscitation team.• (Jacobs et al. 2004)

Early bystander CPR greatly improves (double or triple) the chance of survival of out-of-hospital cardiac arrest victims

(Eisenberg MS, Horwood BT, Cummins RO et al., 1990)(American Heart Association, 2005)

Research Question

How much does what one learn during the practical skill of basic life support actually translate into a more positive and willing attitudes towards performing CPR

in real situations?

Methods• We conducted a voluntary and anonymous

questionnaire survey involving final year dental students for the academic year 2007-2008 in Universiti Sains Malaysia (USM) to look at their attitude towards performing bystander CPR.

• There are a total of 60 dental students, in 3 groups of 20 students each, went through a 2-week clinical rotation in emergency medicine

• Each student is given a survey form at the end of their rotation to assess their willingness to perform bystander CPR under different hypothetical scenarios.

• Realizing the potential vulnerability of the students as study subjects, we emphasized to them that this is an anonymous as well as voluntary survey

• Students are told that they can return the form blank into the provided envelopes if they do not want to fill. Also told not to reveal their names.

• They complete the survey in an unmonitored environment because we do not want them to feel that they are doing it under duress

Methods

Methods• We chose to obtain the opinions of the final year medical and

dental students because they represent the immediate fresh batch of future doctors and dentists in Malaysia.

• If our healthcare providers are not willing to perform bystander CPR when they witness one, how much then can we expect our public perform bystander CPR?

• This survey was repeated to a group of 120 school teachers after a three-day first aid and basic life support workshop training.

• During the workshop, the participants were exposed to lectures as well as practical sessions on performing cardiopulmonary resuscitation.

General Question

In general, what would you do if you witness someone having cardiopulmonary arrest?

A. Pretend you do not see it and walk away

B. Offer to call ambulance, but afraid to offer CPR (while you silently hope that someone else would do the CPR or the ambulance would have arrived quickly)

C. Tell the crowd that you have the skills and offer to do CPR

Question Scenarios

• You are walking alone. You witnessed victim A having cardiopulmonary arrest (no breathing, no pulse) right in front of you. You have no pocket mask with you. Assuming no scene danger and help has already been summoned, would you perform CPR (both mouth-to-mouth and chest compression) if victim A were

1. your own family member?

2. your close friend?

3. of different gender from you?

Question Scenario

1. involved in a motor vehicle accident with some amount of blood on the face?

2. is a child (unknown to you)?

3. is an elderly man/woman from old folks home?

4. Stranger appeared unkempt (probably a beggar/street wanderer/drug addict)?

5. in personal dispute with you or someone whom you don’t like?

Methods

• For each scenario, the respondents are asked to rate their willingness to perform bystander CPR from a four-point Likert Scale

• ‘definitely yes’

• ‘probably yes’

• ‘probably no’

• ‘definitely no’

Methods

• For selected analysis, re-coding of responses done with:

• ‘Definitely yes’ and ‘probably yes’ is defined as a positive response

• Whereas a negative response means either ‘probably no’ or ‘definitely no’.

• Forms returned blank or inappropriately filled are excluded from the analysis

• Comparison between the students’ response of willingness under different scenarios is done using McNemar Test, Chi-square or Fisher-Exact where appropriate, computed with SPSS® version 12.0.1

RESULTS

In general, what would you do if you witness someone having cardiopulmonary arrest?

2%

69%

Number of Positive Responses When The Victim is a Stranger of Different Gender

Results

If Victim A isIf Victim A is Dental StudentsDental Students School TeachersSchool Teachers

A family member 54 (98.2%) 71 (97.3%)

A close friend 51 (92.7%) 69 (94.5%)

Stranger of a different gender 21 (38.2%) 25 (34.3%)

Involved in MVA 9 (16.4%) 13 (17.8%)

An unknown child 39 (70.9%) 54 (74.0%)

An unknown elderly 28 (50.9%) 38 (52.1%)

An unkempt stranger 1 (1.8%) 6 (8.2%)

In Personal Dispute with you 30 (54.5%) 31 (42.4%)

Note: “Positive Response” is a recoded variable of both “Definitely yes” and “Probably yes”

Discussion

• Knowing how to do does not necessarily translate into willing to do

• Except for the categories of victim who is a family member and victim who is a close friend, the positive response rate among both dental students and school teachers is less than 90%.

Discussion

• What is not frequently mentioned in other published articles elsewhere, but is likely a significant factor in our Malaysian culture, is when the victim is of a different gender from the potential responder (in our case, especially in the school teachers group).

Compression-Only CPR

Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. 2008 Apr 22;117(16):2162-7.

Why Compression-Only CPR is preferred in Bystander CPR?

• Advantages to the rescuer

• Simplify technique

• More willing to perform

• Advantages to the patients

• Less interruptions of essential chest compression

• Mouth-to-mouth may actually increase intrathoracic pressure and reduce venous return

• Ventilation maybe unnecessary especially during initial stage when the oxygen tension is still adequate

Conclusion

• In the case of performing bystander CPR, knowing how to do it does not necessarily mean more willing to do it.

• The challenge is ultimately to get more people to perform bystander CPR

• Compression-only CPR is, predictably becoming more important in the future

Limitations

• Responses in hypothetical situations may not necessarily translate into actual behavior should our students encounter one cardiac arrest.

• Emotional make up at that spur of moment, the perceived ability and confidence of the student as well as the ability to speedily recognize a cardiac arrest are some of the confounding factors

• The fact that the students completed the form in an unmonitored environment may actually encourage them to discuss with one another rather than revealing their own true intentions.

References

• Hallstrom A, Cobb L, Johnson E et al. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med 2000; 342 (21):1546-53.

• Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in out-of-hospital cardiopulmonary resuscitation: results from the Amsterdam Resuscitation Study (ARRESUST). Resuscitation 2001; 50 (3):273-9.

• Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study. Lancet 2007; 369 (9565):920-6.

• Iwami T, Kawamura T, Hiraide A et al. Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest. Circulation 2007; 116 (25):2900-7.