For fire departments that run ambulance services, saving cardiac-arrest patients remains a long shot. In fact, depending on how it's measured, cardiac save rates for major cities hovers between 1% and 3%. But there's a growing body of evidence showing that a protocol that emphasizes chest compressions makes it as much as 10 times more likely that the patient will survive. What's more, those patients are leaving the hospital and returning to their jobs and families. The techniques in this protocol also can improve the chances that a bystander will attempt to save a cardiac victim.

As most know, the American Heart Association's 2005 guidelines say to give cardiac-arrest victims two mouth-to-mouth breaths, 30 chest compressions, and check the pulse before defibrillating. But the AHA's recommendations have been moving toward more chest compressions. From 1990 to 2000, AHA recommended one breath for every five compressions. After 2000, that ratio was increased to two breaths for every 15 compressions. The guidelines come under review again in 2010. And data coming out of places such as Wisconsin and Arizona may influence a change to even more compressions per breath, and possibly eliminating mouth-to-mouth completely with the exception of drowning or electrocution victims.

The new protocol, known as cardiocerebral resuscitation, calls for 200 pre-shock chest compressions, one defibrillation shock, and 200 post-shock chest compressions. It delays establishing endotracheal intubation and eliminates pulse check and rhythm analysis. The idea is that moving away from breaths and checking pulse keeps the responder doing more chest compressions. The amount of time performing chest compressions jumps from 64% when ventilating to 80% under the CCR protocol. This is important because any interruption in compressions decreases the chance of a patient surviving and being neurologically normal.

A recent study conducted in Japan looked at 4,000 cardiac arrest victims and the type of resuscitation they received. That study showed that twice as many patients had better neurological function if they received chest compressions only compared with those who also received mouth-to-mouth breaths.

Dr. Ben Bobrow is the medical director for the Bureau of Emergency Medical Services and Trauma Systems for the Arizona Department of Health Services. He's also an emergency physician at the Mayo Clinic Hospital in Arizona, an assistant professor at the Mayo Clinic College of Medicine, and the medical director for the Scottsdale (Ariz.) Fire Department. He's been an emergency physician for 14 years and spent the last four years studying resuscitation. Dr. Michael Kellum is the medical director in Rock County, Wis. For the last 15 years he has served as an EMS director for Wisconsin fire departments. He began working in emergency-room medicine in 1982 and studying cardiac arrest four years later.

Both men are among the leading champions of the CCR protocol. Both say the reason more people survive with CCR is that interrupting chest compressions, for any reason, stops the flow of blood to the brain. Research shows that the brain is far more susceptible to what is being done during CPR than is the heart. If the first responder can keep the brain going, the heart will follow, Kellum says.

The doctors also agree that providing air during CPR has negative effects on survival for reasons beyond the time it takes away from delivering compressions. Filling the lungs with air puts high positive pressure on the chest and impedes blood flow to the brain. During the excitement of resuscitation, first responders can actually over ventilate patients.

“Oxygen is a good thing,” Bobrow says. “But, positive-pressure ventilation for cardiac arrest is definitely not a good thing. Multiple pulse checks, rhythm analysis and airway intervention interrupts chest compressions. We're very confident that all those interruptions decrease survival.”

There are two other things the protocol does that improve survival, Bobrow says. By giving 200 pre-shock compressions, the heart is essentially being primed. Most patients, he says, are unconscious and in the hemodynamic phase of cardiac arrest. Defibrillating these patients almost always shocks them into cardiac standstill. It is better to re-establish blood flow before defibrillation. Also, since providers using the CCR protocol are not worrying about ventilation, they can administer epinephrine sooner. Bobrow says that if epinephrine is going to improve survival, it must be given as early as possible.

The reason these two know so much is that they've implemented the CCR protocol and are tracking the results.

This method began to show promise as much as 15 years ago when researchers learned that when chest compressions on pigs were interrupted, the pigs died. Similar research on dogs showed that the animals live if chest compressions were started within two minutes after the cardiac arrest. The chance for survival decreased as the duration between the arrest and compressions increased.

Kellum says that a team of Swedish researchers was the first to try this idea on humans. But this protocol made its debut in the United States in November 2003 when Dr. Gordon Ewy, director of the Sarver Heart Center at the University of Arizona in Tucson, took it off the drawing boards and put it to work. Kellum says that when he read about Tucson bucking the AHA recommendations, he began researching this concept and visited Tucson. About six months later, rural Rock County, Wis., became the second area to adopt this protocol.

That county's survival rate of shockable patients whose cardiac arrest was witnessed and were later deemed neurologically normal jumped from 15% to 40% after switching from a CPR protocol based on AHA standards to a CCR protocol.

“When our paramedics get a shockable patient [now], they expect him to live,” Kellum says. “Ninety-two percent of our survivors go back to their jobs, and that's all anyone is shooting for is to send them back to their normal lives.”

One unexpected, but positive, surprise, Kellum says, is that paramedics are reporting that the vomiting common for CPR patients has stopped since switching to the CCR protocol.

In Phoenix, about 2H hours north on Interstate 10 from Tucson, Bobrow also put the new protocol into practice. In 2005, he selected four departments near the Phoenix metropolitan area. Two of those departments switched to the CCR protocol and the other two continued to use standard CPR. He trained the two departments on the new protocol and collected data from all four departments for 18 months.

And similar to what was happening in Wisconsin, Bobrow too saw survival rates go up in the two departments using CCR. The overall survival rate for departments using CPR was 2.6%, but 9.1% for the departments using CCR. The survival rate for patients whose arrest was witnessed was 10.4% compared with 33.9% for the departments using CPR and CCR, respectively.

Since then, 12 Arizona fire departments have signed on to Bobrow's protocol and he continues to track the results. This tracking involves maintaining a database with statistics coming in from 62 Arizona departments, 50 of which are using a variation of the standard CPR protocol. The program is growing in Wisconsin, too. Kellum recently conducted a training session for the Madison (Wis.) Fire Department.

Bobrow admits there are flaws in his data. For starters, his initial study was not random or controlled; it was observational. And although he trained the trainers in CCR, he really has no idea if it was correctly performed in the field. Then there's the Hawthorne Effect. The Hawthorne Effect, named for a researcher who studied factory workers' efficiency at Western Electric Co. in the late 1920s by altering such things as the amount of light in the factory, essentially means that individuals will perform differently if they know they are being observed. Bobrow also speculates that the departments that signed up for the new protocol may be ones that are naturally more progressive and try harder. Those objections aside, it is difficult to dismiss the results.

“We can save a lot more people if we do it properly,” Bobrow says of the protocol. “Three to 10 fold more people survive.” He says there was some resistance to this protocol in the beginning. “We actually have 125 survivors in the state after this three-year program. You can't argue with that.”

Kellum agrees. “At first, people think it is statistical monkey business,” he says. Yet, when they see and experience the results, they tend to become local champions for the new protocol, he says.

Heart disease is the leading cause of death in the United States, and Bobrow says there has not been significant improvement in saving cardiac-arrest patients in 25 years. Of course some of a patient's chances of survival boils down to luck. A patient is nine times more likely to survive if he is observed having the arrest. And, about three out of four bystanders who have a chance to perform some type of resuscitation choose not to.

Once a department has bought into this protocol, training is relatively simple. For Bobrow, it is a matter of training the trainer. Those trained in the CCR protocol then train the members of their departments. He estimates that there are 3,000 first responders in Arizona trained in CCR.

Bobrow says that because of the grassroots nature of the data collection and CCR adoption, there are no hard costs associated with switching protocols. However, he is beginning to look at the cost associated with the saves. He wants to learn how many years of life were saved, the financial impact of those added years and the investment to make the save. But Bobrow's team is not heavily staffed or funded, which makes such data collection difficult.

“There are only three of us and there is a lot of work yet to be done,” Bobrow says. But not having a mountain of data shouldn't dissuade departments from adopting this protocol.

“This is something any fire department can do,” Bobrow says. “I'm not talking about buying mechanical CPR machines for $15,000 or new monitors. It is basically training people to press on the chest with their hands properly. We're teaching people to do what they already know how to do, but do it better.”

But it is the word “properly” that is critical to CCR. Kellum says that he's found it necessary to have refresher training for first responders about every three months. This is due partly to the low call volume in rural Wisconsin. Without continued training, some first responders will slip back into their old CPR habits, he says.

“We initially thought we could throw the training at them all at once,” Kellum says. Doing poor chest compressions in a CCR protocol is no better than doing standard CPR. Good chest compressions are harder to do, but deliver the results.

The good chest compression involves pushing down about two inches at a rate of 100 per minute. Another critical factor, and one often overlooked in the heat of a save situation, is allowing the chest to recoil after each compression.

The Glendale (Ariz.) Fire Department was one of those that made the switch. Chief Mark Burdick says that once his crew saw Bobrow's save statistics, they were eager to use the new protocol. It is simple to teach and only took a few months to implement, Burdick says. But, like Kellum, he says refresher training is important to reinforce the new method. The change also comes easier when it is top down. Burdick and Kellum say that having the medical directors' onboard with the new protocol removes many of the roadblocks.

Glendale also is one of the departments paring this protocol down to the Basic Life Support level and teaching it to the public, and with good reason. For humans, as with the study on dogs, the time between cardiac arrest and chest compressions is a crucial factor in whether the patient survives. Therefore, the patient whose arrest is witnessed and resuscitation begun immediately has the best chance of survival, and those whose arrest is not witnessed have almost no chance of living. But just having the arrest witnessed isn't enough. Bobrow says part of the reason 75% of bystanders are reluctant to begin CPR has to do with not wanting to perform mouth-to-mouth, especially on a stranger. Not knowing what to do, fear of contracting a disease and fear of hurting the patient also keeps bystanders from starting CPR.

And moving from compressions to breaths is complex and difficult to perform for those not practiced in this skill. In fact, the AHA advises that ventilation is optional for bystander CPR. It's Bobrow's hope that teaching the public chest-compression-only CPR, will move more bystanders from spectators to participants, which doubles the chances that a patient will survive.

“It is one of the great opportunities for fire departments to do public education and training,” Bobrow says. “Glendale is really going to town on this.” The fire department holds free monthly chest-compression-only CPR training and has its sights set on training 50,000 people per year.

Burdick says the cost to train the public is relatively low because area hospitals have donated space and resources and the local newspaper has give free advertisements announcing the training times and places.

Bobrow is excited by the idea of what it will mean to survival chances for cardiac patients to have a city teeming with people trained in chest-compression CPR.

Bobrow says that although cardiac arrest may account for only 1% of a department's EMS calls, it is the true measure of a department's ability. These are the life-or-death calls and survival depends on dispatch, response time, and the quality and timing of resuscitation efforts.

“I want fire departments to understand that they can save people from cardiac arrest; we've seen it now all across our state,” Bobrow says. “They should not have this fatalistic attitude that they cannot save anyone because they couldn't in the past.”