Basic Life Support: Need of the Hour—A Study on the Knowledge of Basic Life Support among Young Doctors in India

INTRODUCTION

Cardiac arrest is the sudden cessation of cardiac function resulting in respiratory and circulatory standstill.¹ Most cardiac arrests in adults are sudden, resulting from a primary cardiac cause and hence, circulation produced by chest compressions is of paramount importance.¹ The value of early cardiopulmonary resuscitation (CPR) is that it can buy time for the primary cardiac arrest patient by producing enough blood flow to the central nervous system and the myocardium to maintain temporary viability. To do so, however, CPR must be started early.² Timely CPR improves the likelihood of survival by two to four times.² Basic life support (BLS) comprises of the very basic tasks of resuscitation including CPR. The American Heart Association (AHA) guidelines for BLS include recognition and management of cardiac arrest, respiratory arrest, and choking in adults and the pediatric age group.³ Management of cardiac arrest includes a series of life-saving interventions like immediate recognition of cardiac arrest and activation of the emergency response team, early CPR, rapid defibrillation, effective advanced life support, and integrated post cardiac arrest care.¹ Further, BLS techniques have a global implication because of the fact that it requires nothing other than manpower as far as resources are concerned. Proper practice of the techniques and maneuvers enables a person to effectively resuscitate a victim.⁴

Awareness and understanding about the basic concepts of resuscitation is expected from every medical personnel involved in treating the patients. Researches have implicated poor awareness of BLS among doctors, interns, medical/dental students, and paramedics in the country.^5–9 But unlike this study, only a few have followed up the BLS knowledge retention among the participants who have undergone the course.

MATERIALS AND METHODS

STATISTICAL ANALYSIS

The collected data were coded and entered into Microsoft Excel to make a spreadsheet. Statistical analyzes were done using the Statistical Package Software for Social sciences (SPSS) version 20.0. The descriptive and frequency analysis has been done for counts, means, and percentages. A repeated measure of analysis of variance (ANOVA) with Bonferroni and McNemar tests was used to compare the measurements in the study. The p value less than 0.05 was taken as the criteria for statistical significance.

RESULTS

Of the total study population (n = 50), 82% interns were females and 18% were males. About 96% of the group had attended some form of BLS classes in the past. In the pretest scenario, only 56% could recognize a cardiac arrest scenario and 28% were unsure of it. Immediately after the class, all the interns were confident in recognizing an arrest scenario. In the post 1-year test, still 86% were sure of recognizing an arrest and 14% were unsure. In the pretest period, when the interns were just starting their internship, half of them (54%) haven’t seen a patient losing consciousness and only 8% had ever done a CPR. After 1 year of internship, 92% had performed CPR and 88% had seen someone losing consciousness.

Interns were asked to scale their skills in various aspects related to BLS from a scale of 1 to 5, with scale 1 being least and scale 5 being the highest. When interns were asked about their knowledge in BLS in the pretest session, the pretest score mean was 2.32 ± 0.95 and the immediate post-session score mean was 4.16 ± 0.17. Post 1-year test, the mean value was 3.30 ± 0.81. A repeated measures of ANOVA determined that mean score of knowledge (1 to 5) differed statistically significant between different time intervals of the training period (p = 0.000). The post hoc test using Bonferroni revealed that there are statistically significant difference between pre-training and post-session (p = 0.000); pre-training and post 1 year (p = 0.000); and post-session and post 1 year (p = 0.000) (Table 1).

The question regarding confidence in performing CPR also followed a similar trend. More than 90% of participants had rated their skill around scale 1 to 3 in the pretest period (mean value 2.30 ± 0.83) whereas in posttest to a mean value of 4 ± 0.75, but post 1 year it was around scale 3 to 4 (3.36 ± 0.85). A repeated measure of ANOVA and the post hoc test using Bonferroni determined that mean score of performance (1 to 5) differed statistically significant between different time intervals of the training period (p = 0.000). With regards to skill in rescue breathing, in the pretest period, most of them were around scale 1 to 3 (mean 2.08 ± 0.80), immediate posttest to a mean of 4 ± 0.88, and post 1-year period, to around scale 2 to 4 (mean 3.08 ± 0.92). A repeated measures of ANOVA and the post hoc test using Bonferroni determined that mean score of rescue breathing (1 to 5) differed statistically significant between different time intervals of the training period (p = 0.000) (Table 1).

Questions were also asked regarding the theoretical knowledge about performing a CPR. Both in pretest and posttest periods, most of them were aware about the CPR ratio 30:2 (78% in pretest vs 86% in post 1-year test) (p = 0.049) (Table 2).

Only 22% had answered correctly regarding hand position in CPR in the pretest session, which improved to 76% posttest and 56% post 1-year test. The McNemar-Bowker test reveals that there is statistically significant difference in the knowledge of hand position in chest compression between pre-training and post-training (p = 0.000); pre-training and post 1 year (p = 0.029); and post-training and post 1 year (p = 0.034) too.

Only 44% was aware about the actual required depth of compression in the pretest session as compared to 74% in post 1-year session. Data reveal that all participants’ answers regarding depth of chest compression in post-training session are 100% correct but after 1 year of training many answers were wrong. The McNemar test declared that there is statistically significant difference (p = 0.028) between pre and post 1-year session.

Among the group, 54% were aware about the CAB sequence of resuscitation in the pretest whereas in post 1-year test, it increased only to 66% and around 26% opted for the ABC sequence. The McNemar-Bowker test reveals that there is statistically significant difference in the knowledge of sequence of CPR between pre-training and post (p = 0.000); post-session and after 1 year of training (p = 0.001), but when the time goes, knowledge attrition occurs and shows no significant changes (p = 0.465) between pre and post 1 year of training.

In the pretest, only 56% were confident in helping a choking victim whereas in the post 1-year test, it rose to 78%. The McNemar test reveals that there is statistically significant difference in the knowledge of helping chocking adult between pre-training and post (p = 0.000); pre-training and post 1 year (p = 0.015), but there is no significant change (p = 0.065) in their knowledge between post-session and after 1 year of training.

In the pretest period, most of the interns were unsure about the ways of stabilizing cervical spine and most of them were around scale 1 and 2 (mean 1.58 ± 0.99) in their knowledge on cervical spine stabilization. Post 1 year most of them were around scale 2 to scale 4 (mean 3.1 ± 1.14) A repeated measures of ANOVA determined that mean score of knowledge (1 to 5) in stabilizing a cervical spine of a trauma victim differed statistically significant between different time intervals of the training period (p = 0.000). The post hoc test using Bonferroni revealed that there are statistically significant difference between pre-training and post-session (p = 0.000); pre-training and post 1 year (p = 0.000); but no statistical significance between post-session and post 1 year (p = 0.048).

Knowledge about log roll was also poor among interns in the pretest period (mean 1.48 ± 0.99). About 74% were around scale 1 in the pretest period whereas in post 1-year test, most of them were around scale 3 to 5 (mean 3.52 ± 0.11) (Table 1). Finally, all students were willing to attend courses to improve their basic resuscitation skills.

DISCUSSION

This study was intended to assess the knowledge of interns about BLS and to reassess them after giving training. As the study shows, though most of them had attended some BLS training previously, the knowledge about BLS was poor. According to previous studies, the knowledge about BLS among medical students across the subcontinent was found to be low.^4–6 The results of this study also showed a similar trend. But the knowledge and confidence in performing BLS among the interns in this study improved steeply after attending a structured course on BLS. The students were confident enough to recognize a cardiac arrest and to perform necessary lifesaving procedures and to help a choking victim. They also gained confidence in basic trauma assessment and management procedures like cervical spine stabilization and log rolling. The study also points toward the necessity of reinforcing the knowledge from time to time to prevent skill and knowledge attrition. Studies have also stressed the importance of reinforcement to attain adequate CPR skills and maintain continued competency in the technique.^7,8 Also, it is necessary to update the knowledge regularly. In our study, posttest 2 showed that students were better equipped with managing a cardiac arrest scenario but had attrition in knowledge and skills over the course of 1 year. Therefore, this calls up for a recurrent revision and retraining in the skills.

According to Pande et al., the proper time seems to be the incorporation of BLS training in the medical curriculum in the first year itself and the reinforcement of the skills every year.⁹ After graduation, there is hardly any time for students to practice the skill. The right time to foster any skill is during graduation. Zaheer et al. also concluded that the inclusion of a BLS course will increase awareness and application of this valuable lifesaving maneuver.⁴ Therefore, BLS and advanced cardiovascular life support training programs should be mandatory for all medical and paramedical staff. Educating medical undergraduates about BLS may turn out to be an excellent strategy to reach the community at large if students share the acquired knowledge with their families and friends.

CONCLUSION

The BLS knowledge among young doctors in India is very low as evidenced by poor performance in the pretest.

Regular BLS courses with frequent follow-up classes are necessary to improve the knowledge, to prepare them to respond to a medical emergency, and also to prevent knowledge attrition among them.

CLINICAL SIGNIFICANCE

Knowledge about BLS is mandatory for health professionals. This study shows that knowledge about BLS and basic resuscitation skills are poor among young doctors in a tertiary care center in southern part of India. A suggestion would be to include these skills in undergraduate medical curriculum. Also, this study signifies the need for regular update classes and mock drills to help students retain their knowledge and skill sets.

REFERENCES

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2. Cummins R, Ornato J, Thies W, Pepe P. Improving survival from sudden cardiac arrest: the ‘chain of survival’ concept. A statement for health professionals from the Advanced Cardiac Life Support Subcommittee and the Emergency Cardiac Care Committee, American Heart Association. Circulation. 1991;83(5):1832–1847.

3. Hazinki M. BLS for healthcare providers. Dallas, Tex.: American Heart Association; 2011.

4. Zaheer H, Haque Z. Awareness about BLS (CPR) among medical students: status and requirements. J Pak Med Assoc 2009;5(1):57–59.

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8. Roshana S, Batajoo KH, Piryani RM, Sharma MW. Basic life support: knowledge and attitude of medical/paramedical professionals. World J Emerg Med 2012;3(2):141–144. DOI: 10.5847/wjem.j.issn.1920-8642.2012.02.011.

9. Pande S, Pande S, Parate V, Pande S, Sukhsohale N. Evaluation of retention of knowledge and skills imparted to first-year medical students through basic life support training. Adv Physiol Educ 2014;38(1):42–45. DOI: 10.1152/advan.00102.2013.