Carry Less, Do More: Getting Back to the ‘New’ Basics of CPR
The results of an approach that focuses on optimizing heart and brain flow as the primary foundation of resuscitation for out-of-hospital cardiac arrests are striking. For nearly 60 years, we have followed the A-B-Cs, and more recently the C-A-Bs, of CPR according to American Heart Association guidelines. Using those guidelines, the survival (to hospital discharge) for U.S. patients who experienced out-of-hospital cardiac arrest was only 8.2 percent in 2021.

Further, Cardiac Arrest Registry to Enhance Survival (CARES) data, which might be the best way to track outcomes and compare communities across the nation, indicate that there has been little improvement in overall survival nationwide, even in recent years with the availability of automated external defibrillators (AEDs) in public locations.

In Edina, MN, where outcomes have been tracked with the CARES methodology for a decade, results were shown to be better than the national average. Like many other communities, emphasis was placed on established best practices, including dispatch-assisted CPR and public access to AEDs. There also is a robust 9-1-1 system that leverages a rapid response from law enforcement (equipped with AEDs), which often arrives ahead of the fire/EMS response. Largely because Edina’s survival outcomes were above the national average and because the Edina Fire Department’s (EFD) success rates plateaued, the department tended to accept this as the limit of its capabilities.

Heart and brain blood flow

In late 2019, both the EFD and neighboring Richfield Fire Department (RFD) implemented a strategy that became known as Carry Less, Do More. This innovative approach has become part of a “new” approach to BLS. In addition to starting traditional CPR as soon as possible, new technology was added to really get blood flowing—more than three-fold higher than using just a pair of hands. The results were striking.

The path to surpass stagnant survivor rates was to focus on optimizing heart and brain blood flow as the primary foundation of resuscitation. Specifically, this not only includes ensuring highest quality CPR but also a rapid transition to: suction cup-based mechanical CPR; securing the airway with an impedance threshold device; and automated gradual elevation of the head and thorax.

This approach works by lowering intracranial pressure, enhancing venous return to the heart and improving cerebral blood flow within the first few minutes of a resuscitation. Once firefighters initiate Carry Less, Do More, ALS interventions may be added. If not already attempted by early AED application, further defibrillation attempts can be made at this point for the minority who need therapeutic electricity. On-scene resuscitation, even for nonshockable rhythms, is targeted for a minimum of 30 minutes or until return of pulses.

A pit-crew approach

To accomplish the “new basics,” pre-implementation training, which focuses on the rationale for using the new essential equipment, came first and foremost—and became one secret to success.

As with AEDs, scientific studies now indicate that the sooner the new basics, including the head/thorax elevation, are applied, the better the chances of survival.

Completing each task as efficiently as possible is best facilitated by a pit-crew approach, where each team member has a targeted set of tasks to accomplish. This “medical first attack” allows command to systematically control the scene, the first four tasks and, in the end, the resuscitation. Additional tasks and equipment are controlled similar to the control of additional resources at a fire, and they are staged as needed.

Two backpacks, four minutes

Thanks to fire crews’ critical input, the more efficient Carry Less, Do More strategy involves carrying just two strategically designed backpacks to the scene. This allows for better outcomes using a new BLS pit-crew approach, even with just two basic responders.

One of the easy-to-carry backpacks includes an automated chest compressor, and the other contains supraglottic airways, an airway valve-device that regulates airflow and the automated head/thorax-up positioning (AHUP) device, which is called the EleGARD.

When the backpacks are laid out, the equipment is staged perfectly to rapidly apply the augmented reperfusion “foundation.”

In the EFD’s experience, the entire process is very straightforward and can require no more than four minutes. The EFD has a detailed Cardiac Arrest Guideline, which can be found at https://portal.acidremap.com/sites/EdinaFireParam...

The EFD’s experience also has been that crews restore more patients back to a functional life than the alternatives in cases that usually were unsalvageable previously. This also applies to fellow fire departments that adopted Carry Less, Do More. In fact, a department that’s in St. John’s County, FL, responded to a 50-year-old man who ultimately received CPR for a half-hour before final resuscitation, which included use of the new basics. He survived fully intact. That patient, who is a former firefighter/EMT, now works helping to harvest organs from donors who have permanent brain damage. As an expert on patients who have “brain damage,” he suggested that this new approach be called neuroprotective CPR.

Survival rates in Edina, which now incorporates this neuroprotective CPR strategy, are better than they ever were. For example, in patients who have a witnessed arrest and who have a shockable rhythm, the chances of survival to hospital discharge rose markedly.

Nonshockable patients

The new resuscitation strategy isn’t just for traditionally salvageable witnessed/shockable cases. Outcomes from multiple U.S. fire services that implemented neuroprotective CPR for out-of-hospital cardiac arrest in nonshockable patients, including unwitnessed asystole and pulseless electrical activity (PEA), were tracked carefully.

As with AEDs, the faster that neuroprotective CPR is delivered, the more patients can be saved. In fact, half of the patients who were treated within 11 minutes following the 9-1-1 call receipt showed a greater than five-fold improvement in hospital discharge for these typically poor outcomes.

More lives saved

One final point: Sudden cardiac arrest is the number one killer of adults in the United States but also is a major cause of job-related (and off-duty) death for firefighters. This hit home for us on July 1, 2020.

That day, our colleague, Wayne Kewitsch, who was the fire chief of the RFD at the time, became the beneficiary of the neuroprotective CPR approach that his own department adopted.

When immediate bystander CPR and defibrillation was unsuccessful, neuroprotective CPR was initiated by the EFD in Edina, where Kewitsch lives. After about 15 minutes of persistently recurring ventricular fibrillation, the Carry Less, Do More approach brought Kewitsch back to the living. Despite the lengthy period of CPR, he was wide awake and talking in 15 minutes.

His “widow-maker” coronary artery blockage was fixed, and Kewitsch was home and celebrating the Fourth of July with his family within 52 hours of his cardiac arrest. He remains as productive as ever, now running MnFIRE, which is a statewide program that focuses on health and safety for firefighters.

This case truly emphasized the “need for speed” and the now-obvious benefits of the pit-crew approach. It became a clinical signal that the earlier the intervention, the better the results, which now is proved in scientific studies. It also signaled that the first-in firefighter will be the backbone of the neuroprotective CPR success study and the future of the fire service nationwide.

After more than three years, we can report with complete confidence that a Carry Less, Do More: Getting Back to the “New” Basics program is saving many more lives in Edina—and nationwide—than was the tradition. As a result of these types of efforts, many medical directors across the state of Florida, which is largely a fire-based EMS state, plan to roll out this advance to their communities.