20200722-FEA-heart attack

You’re walking down the street, wearing a mask and remaining six feet from everyone else, when the person in front of you suddenly topples to the ground. You assume, probably correctly, that it’s a heart attack, and your first impulse is to rush over and start CPR. But then you remember the pandemic and pause.

Please, experts urge, don’t hesitate because of coronavirus fears. “You’re talking about people who need help, and who need people willing to jump in and help them,” says Michael Sayre, professor of emergency medicine at the University of Washington and medical director of the Seattle fire department. “The risk isn’t zero, but it’s low. You’re many times more likely to save someone’s life by intervening than you are to get infected.”

More than 350,000 cardiac arrests occur outside of a hospital annually, and about 90 percent of the victims die, according to 2015 statistics cited by the American Heart Association. CPR — or cardiopulmonary resuscitation, where you use hands-only chest compressions (or, if available, a cardiac defibrillator) to get the heart beating again — can as much as triple an individual’s chances for survival, according to the AHA.

First responders will arrive in gowns, gloves, masks and goggles, but you might have only a mask. How do you help, while protecting yourself, if you see a stranger drop in front of you? Here’s what Jeffrey Goodloe, chief medical officer for the Oklahoma Emergency Medical Services System for metropolitan Oklahoma City/Tulsa, recommends:

“If I am walking down the street, wisely wearing a mask, and see someone collapse, I’m going to rush to them, and check to see if they’re responsive. I will grab their shoulders and say: ‘Hey, are you OK?’ Then I would feel for a pulse, and see if they’re breathing. If they are unresponsive and there is no pulse, I would immediately call 911 and start CPR. If they are wearing a mask, leave it on. If not, pull their shirt up over their face, or put some kind of cloth covering over their nose and mouth.”

If you don’t know CPR — or have forgotten how to do it — the 911 operator can talk you through it, he says.

Risk is low

Experts believe a rescuer’s risk of infection is low. Sayre conducted a study in the Seattle area when at the time the incidence of COVID-19 deaths were 15 per 100,000 population, including fewer than 10 percent who suffered an out-of-hospital cardiac arrest. The researchers concluded it would take treating 100 such cardiac arrests to result in one rescuer infection, and 10,000 bystander CPR interventions for one rescuer to die of COVID-19.

“When we did our calculations, we used the 10 percent number, but it’s probably lower than that,” Sayre says. “Here in the Seattle fire department, we responded to patients in Kirkland who had the disease and had to go to the hospital, but no one realized they had COVID. Early on, our EMS crews took care of them, wearing gloves but no masks, and only one guy got sick, so we decided to take a longer look. We think the risk of getting infected from chest compressions is really low.”

There is no need to initiate mouth-to-mouth resuscitation in adults to restore breathing, experts say.

“With good chest compressions, there is some passive inhalation,” Goodloe says. “They are getting a little bit of ambient air just through the process of chest compression. We have found that is enough for neurological intact survival in adults. Those chest compressions are really the key to survival until trained EMTs or paramedics can arrive.”

Children, however, are different when it comes to breathing. Typically an incident of some kind — choking or submersion in a family pool — impairs their ability to breathe. With kids, it’s more important to focus on their airways.

“Most of the time it’s a child in a backyard pool, and the person pulling them out is a parent,” Sayre says. “We totally want them to do mouth-to-mouth breathing.”

For drownings that occur in public pools or at beaches, lifeguards usually have access to a bag-valve mask or positive-pressure ventilator, with special HEPA or N95 filters. These devices force air into the breathing passages and avoid the need for direct mouth-to-mouth contact.

“Although it’s OK for family members to do, physical mouth-to-mouth is no longer encouraged,” says Thomas Gill, vice president of the United States Lifesaving Association. “It’s not something recommended for the person on the street if you see a stranger lying there.”

Drowning is different from cardiac arrest in that lack of oxygen results from water submersion, so the first response should be to initiate breathing, Gill says. “But if a person is walking down the road and sees [a] neighbor cutting the grass who suddenly is grasping his chest, something else in the body is causing that to happen, and it’s not submersion underwater.”

In a choking emergency, if you see a stranger who seems to be choking on a piece of food, again, don’t hesitate. Ask the person whether he or she is choking. If the person can speak, the airway is not totally blocked, and the person can cough out the object. Otherwise, perform the Heimlich maneuver, applying strong thrusts from behind to the abdomen, between the navel and the rib cage, which should dislodge it from the windpipe.

“Ask ‘are you choking?’ Somehow despite all the languages, it’s universal to clutch our throat when we are as a signal,” Goodloe says. “If they can speak, their airway is not fully occluded, so encourage them to keep coughing to expel the food. Today, we might stand in front of them, but stand to the side a few feet away, and you’ll avoid the mainstream spray of droplets and anything else being coughed out. If they can’t speak, a good Heimlich thrust or two or more can absolutely save a life. Do it. And call 911 or direct someone else to do so.”

He adds one more important piece of advice: “If you direct someone else to call 911, make firm eye contact and look to see they are dialing quickly. You’d be surprised the tragic results from just screaming, ‘Somebody call an ambulance. Call 911,’ and everyone assumes someone else is doing it.”

Heart attacks up

The numbers of non-hospital cardiac arrests are almost certainly higher now because experts say many people are delaying or avoiding care, afraid they will become infected with the novel coronavirus if they go to an emergency room. One recent study, for example, found that out-of-hospital cardiac arrests among New Yorkers rose from 1,336 patients in 2019 to nearly 4,000 this year during the height of the pandemic.

“The most tragic deaths in this era of COVID-19 are the ones in patients reluctant to seek care or the reluctance of others to provide care because of their concerns about COVID-19,” Goodloe says.

Most out-of-hospital attacks occur in the home or in long-term care facilities, with only 18.8 percent happening in public, according to the AHA. With the former, family members or staff in the facility often are available to help. With the latter — especially with the worrisome reluctance to seek care — people are even more vulnerable, and bystander help more crucial than ever.

“We are concerned,” says Goodloe, who also serves on the board of the American College of Emergency Physicians. “We want to maintain — even grow — the levels of bystander CPR. We do not want COVID-19 to negatively impact the willingness of people to provide CPR. If it does, we will assuredly lose saveable lives.”

As scientists continue to study the virus that causes COVID-19, emergency medicine specialists agree that there is more to learn. But current evidence suggests the transmission danger to rescuers of delivering CPR or responding to choking remains low, including for those whose protective gear may not go beyond that of a face mask.

“I think there are unanswered questions, but we don’t get the opportunity to take a time out,” Goodloe says. “Each and every day, over 1,000 Americans are dying from sudden cardiac arrest, most outside the hospital. We have to provide the best care possible as we seek answers to questions that have arisen as a result of this pandemic.”