BystanderCardiopulmonary Resuscitation(CPR): The Next Decade The 1980s has been a decade of continuous progress in emergency cardiac care (ECC). Technologic developments have impacted all aspects of this health care delivery, from the community to the catheterization laboratory. In most states, there are prehospital automatic external defibrillator (AED) training programs; emergency physicians are well versed in the administration of tibrinolytic agents; and interventional cardiologists are exploring new techniques for therapeutic angioplasty. such as the laser. But what of the basic approach to cardiopulmonary resuscitation (CPR), now standing in the shadow of impressive scientific developments? Especially now worth pondering is the role of the community bystander in ECC in the 1990s. The 1985 Conference on Standards and Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care reafirmed that bystander CPR remains a critical element in the prevention of sudden death.’ Numerous studies from Oslo to Seattle have compared the effectiveness of bystander-versus medic-initiated CPR with respect to survival and functional outcome.’ Early bystander-initiated CPR. when coupled with advanced life support (ALS), can improve outcome (ie, hospital discharge of a neurologically functional patient) by up to 25%. Statistics in these same populations reveal only a 5% to 8% survivorship for medicinitiated CPR alone.’ The superior survival in bystanderCPR groups appears to be due to much earlier initiation of CPR and the probable prolongation of ventricular fibrillation.4.5 Even in a study finding no statistical significance between bystander- and medic-initiated CPR, a high degree of correlation was found between decreased response time and survivorship. A number of studies have evaluated the feasibility of recruitment of lay persons to operate AEDs at home and in the community.‘*’ It has been shown that after organized training programs, the lay person can successfully and safely operate these devices. These skills appear to have good retention.’ Also, eight minutes was eliminated from the average time to defibrillation by paramedics.’ Recommendations as to the appropriate use of AEDs in society should be forthcoming from our professional organizations. But have physicians done enough to support basic life support training in the community? In one survey only 6% of physicians encouraged families of cardiac patients to seek CPR training, contrasting to the 60% responding that they desired such training.’ Many other questions require consideration. The effect of disagreeable physical characteristics of cardiac arrest vic-

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tims was reviewed and appeared to be of little detriment to willingness to provide CPR.4 Interestingly, cardiac arrests at work were more likely to receive bystander CPR (62.7%) and be discharged alive (21.7%). than those who were at home (18.2% and 6.4%, respectively).5 Health concerns related to potential disease transmission during community resuscitation efforts must be addressed and evaluated. Protective ventilatory devices, and increased citizen training in their use, may be a feasible option for public places. In 1986 there were 1.5 million victims of myocardial infarction (MI) in the United States. Five hundred thousand of these died (350,000 during the first two hours) of cardiac arrest. The majority of these out-of-hospital deaths did not receive bystander CPR. Are we, emergency physicians, on the front line of ECC, underemphasizing the importance of bystander CPR training and research? Should our organizations be taking a more active role in the training, use and distribution of new technology for the lay public (AEDs and ventilatory devices)? Many new advances in ECC are inevitable in the 1990s. In the meantime, let’s not neglect these fundamental issues. RICHARD M. SOBEL, MD Mr Sinai Medical Center Miami Beach. FL

REFERENCES 1. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 1986;255: 2905-2914 2. Cummins RO, Eisenberg M: Pre-hospital cardiopulmonary resuscitation: Is it effective? JAMA 1985;253:2408-2412 3. Montgomery WH: The 1985 conference on standards and guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1986;255:2990-2992 4. Cummins RO, Eisenberg M, et al: Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation. JAMA 1985;3:114-119 5. Ritter G, Wolfe RA, et al: The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J 1965;110:932-937 6. Stueven H, Troiano P, et al: Bystander/first responder CPR: ten years. Med Coll Wisconsin, Milwaukee, WI 7. Moore JE, Eisenberg MS, et al: Lay person use of automatic external defibrillation. Ann Emerg Med 1987;16:669-672 8. Cummins RO, Schubach JA, et al: Training lay persons to use automatic external defibrillators: success of initial training and one-year retention of skills. Am J Emerg Med 1989;7:143149 9. Dracup K, Heaney D, et al: Can family members of high-risk cardiac patients learn cardiopulmonary resuscitation? Arch Intern Med 1989;149:61-64