On an otherwise typical Thursday afternoon in the fall of 2016, Heather Johnson saw a young man collapse on the floor at her London, Ont., gym. Johnson was a 21-year-old university student at the time, and she had previously worked as a lifeguard. She reacted immediately: running to the victim’s side, feeling for a pulse and quickly performing cardiopulmonary resuscitation (CPR). Her training paid off, and the young man had been successfully resuscitated when Emergency Medical Services arrived (another bystander had called 911).
But despite the positive outcome Johnson found her memories of the experience to be unsettling and dark. She developed difficulties sleeping and found it hard to concentrate on school work. “I started having nightmares, just seeing his face,” she says. A few days after the incident, doctors diagnosed her with post-traumatic stress disorder (PTSD). She says at no time during her CPR training was she made aware that saving someone else’s life could carry risks to her own.
Johnson is not alone. Professionals in the resuscitation field say there is a growing need to ensure that people understand the emotional risks of performing CPR, and that they are guided to professional help in case they develop emotional distress. “We need to be more tuned into supporting lay rescuers,” says Katie Dainty, a resuscitation researcher who founded the Bystander Support Network in 2017 to help people struggling with the after-effects of an intervention. “We need to let them know that they’re heroes and that we can get them help if they need it.”
The importance of lay-responders performing CPR
Certainly there is great need for lay-responders to perform CPR. Eight in 10 cardiac arrests occur outside of a hospital in Canada, meaning there are approximately 40,000 cases of potential lay-responder CPR attempts each year. The Heart and Stroke Foundation estimates that as few as five percent of people survive a cardiac arrest occurring outside of a hospital, though that number doubles when CPR is administered immediately.
Contrary to the perception of high survival rates suggested by movie and TV dramas, the vast majority of people who receive CPR still die. But while survival rates among cardiac arrest victims are well-documented, there has been little research on the health effects on the lay-responders who try to save them. Yet the potential for emotional trauma and distress may be significant. One U.S. study in 2015 showed that as many as 28 percent of internal medicine residents involved in performing CPR experienced PTSD symptoms, suggesting even professionals face difficulties coping.
Changing CPR training programs
For the most part, emergency response teams have few or no protocols on how to support lay-responders. Nor do the main CPR curriculums used in Canada, which make no more than a passing reference to the potential for any after-the-act distress. Currently, the Canadian Red Cross, the Heart and Stroke Foundation of Canada and St. John Ambulance develop curriculums for instructors, and each organization certifies more than 500,000 people in CPR each year.
But there are nascent signs of a shift in how CPR is taught. Don Marentette, national manager of first aid programs at the Canadian Red Cross, says his organization is working on adding a section to its CPR curriculum on the risks of developing emotional distress, though he was unable to offer a firm timeline as to when the changes would be implemented. He says that currently instructors can talk about PTSD or emotional distress in their classrooms if they want to, but there has been some resistance to altering the curriculum from instructors who take a “legacy approach” to CPR teaching. “It’s also perhaps due to the fact that many instructors are not prepared to have the conversation about distress and PTSD,” he adds.
The Heart and Stroke Foundation of Canada is also working on changing its CPR curriculum, and plans to incorporate an educational component on emotional trauma following CPR by the fall of 2019. Shelley Parker, senior manager of Resuscitation Services, Design, and Delivery at Heart & Stroke, acknowledges that the emphasis has always been on getting more people engaged with CPR training. “I think [changing the curriculum] was seen somewhat as detrimental to getting the public trained or getting them to step in,” says Parker. “We’ve all worked to get the public more engaged with responding to cardiac arrests, and we focused so much on that aspect of it.”
Despite the “legacy” approach that some take to teaching CPR, changing the curriculum to include a section on PTSD would be well-received by many instructors. “It would be a really great addition,” says Ashkon Pourheidary, director of Coast2Coast First Aid and Aquatics. His organization’s instructors follow the Canadian Red Cross curriculum, and most are hesitant, he says, to steer away from the prescribed course material.
Creating more support for bystanders who perform CPR
On the other side of things, there is a need to better help lay people who experience PTSD after performing CPR. To this end, the Peel Region of Ontario is piloting a program—the first of its kind in Canada—to offer standardized follow-up and counselling to all lay-responders who administer CPR in public (due to personnel limitations, lay-responders who perform CPR in private homes are not currently included in this program). Paul Snobelen, specialist of community programs at Peel Region Paramedic Services, runs the program and personally contacts lay-responders after an incident for a debriefing session. He notes that many lay-responders find it comforting to learn about the science behind what they saw—for example, why there was blood in the airway, and why victims soil themselves or vomit. “A lot of these people don’t need cognitive therapy for what happened, they need a technical understanding,” he says. He adds that the Red Cross has contacted him about potentially adapting a similar program in other regions across the country.
Snobelen says lay-responders who have participated in the Peel program cite a common theme: Their actual experience of delivering CPR was markedly different from what they had pictured. The current CPR courses “are not doing a realistic job of showing people what it really looks like,” says Snobelen. He has reached out to over 300 bystanders since the program was launched, and only one individual so far has expressed not wanting to be be involved with any follow-up after the resuscitation event.
As further evidence that lay-responders are seeking support, since the Bystander Support Network was established in 2017, over 100 people have signed up to be members, and approximately 30 people who performed CPR have submitted their personal stories. The network serves as a virtual hub where lay-responders can find resources about CPR and connect with other people’s resuscitation experiences. Although the network itself is unable to provide any direct counselling to lay-responders, it will often redirect them to appropriate help.
Whether it’s altering CPR courses to better prepare people or offering support to lay-responders after the event, change is clearly needed. Heather Johnson was certainly surprised to have developed PTSD, but also feels lucky to have had early access to psychological supports through the encouragement of her peers. “I think I would’ve still been having nightmares for sure,” says Johnson when describing an alternate reality where she hadn’t received any proper help. “I would’ve been scared to ever be in another medical situation again.”
Wilson Kwong recently completed his internal medicine training at the University of Toronto and is currently a palliative care fellow at the University Health Network. He is also a freelance writer and is pursuing a Certificate in Health Impact, offered jointly through the Munk School of Global Affairs and Public Policy and Dalla Lana.