A pocket sized problem - the view from Australia
Before I tell you about this pocket-sized problem, we need to back up a bit.
To get a decent airway in an unconscious, non-breathing casualty one of your best bets is good old head tilt, chin lift method.
Head tilt lifts the tongue off the back of the throat and chin lift… what does chin lift do?
I see lots of lifeguards doing great head tilt but the chin lift bit they don’t really understand. They look more like they’re trying to open up the casualty or manikin’s mouth. Opening the mouth bigger is a problem when you’re about to place your mouth over theirs and try and get a decent seal.
So, let’s do a quick anatomy lesson. Your mouth is one hole where two very different things go in (food and air) but which obviously go to very different places. What magic is this?
In your throat, down past your tongue you have a little flappy valve thingy made of cartilage called your epiglottis. Right now, you’re breathing, and your epiglottis is in the vertical, the open position allowing air to enter and leave your lungs via your ‘windpipe’.
During lunch however, when you swallowed that mouth full of food, your epiglottis did this neat trick where it lays down and closes the windpipe so that the food parcel will travel to your stomach and not your lungs. It closing over the wind pipe and then standing back up is the what you feel when you swallow.
The problem is that if an unconscious, non-breathing person is laid on their back, their epiglottis relaxes down into the ‘airway closed’ position. This means that if you tilt their head back, pinch their nose, make a seal with your mouth over theirs and blow… you’ll get noisy, obstructed respiration and probably just inflate their stomach.
Apart from not helping the person it also means more pressure in the stomach. The more the stomach expands the more it forces other organs up into the diaphragm area, making it harder for the lungs to expand when they need to. Give the stomach enough pressure and their lunch is going to revisit you too. As if CPR was difficult enough, now it’s become really gross, yucky, smelly and that chunky material can block the airway.
So how do we avoid all this hassle? Chin lift.
Lifting the chin, lifts the epiglottis off the windpipe. To see it in action here’s a video provide by our good buddy Dr Justin. They are using the jaw thrust method but it produces the same effect as chin lift; https://www.lifeguardsloveyoutube.com/single-post/2017/02/05/Jaw-Thrust-Maneuver
If you don’t know who Dr Justin is you should watch some of his presentations here; https://www.lifeguardsloveyoutube.com/lifeguardswithoutboarders He is one of only two Doctors I know who also speaks fluent ‘lifeguardese’.
If you’ve got a spare 15 minutes and want to see how simple mouth to mouth can be explained watch this video. It’s from the Royal Prince Alfred Hospital in Australia way back in 1960. It’s a fabulous watch. You’ll learn a heap; https://www.youtube.com/watch?v=tJEXFBCayFM
So now we’re all up to date on why head tilt AND chin lift, is important. Back to the pocket-sized problem.
The pocket-sized problem is pocket cpr masks. If you’re doing one-person CPR positioned beside the casualty, how do you do chin lift if you’re trying to push a mask down and get a seal on the face?
If you’re doing CPR like this and you aren’t seeing chest rise, you probably only have three options;
1. Keep doing what your doing and watch the person die.
2. Throw away your pocket mask and do mouth to mouth.
3. Move to the head end of the casualty and do CPR from there. Now you can use the jaw thrust method to lift the chin and open the epiglottis. Effectively pulling the person’s jaw up into the mask to get a seal. A couple of effective breathes and then you can lean over, across their head, and do compressions from there.
I had not heard of, what is called, overhead CR before but there are a number of organisations who use it. Mainly those who find themselves doing cpr in a narrow space that doesn’t allow for cpr to be delivered from the side. Think of a narrow gangway in a naval ship.
Lifeguards, and all first responders for that matter, need fewer procedures and more options and guidelines. When the way we fight becomes blocked by something, we need to have other ways, other tools that allow us to alter our response to the emergency unfolding in front of us.
Laerdal has a video on their YouTube channel of how to use a pocket mask. You’ll notice it isn’t used from the side of the casualty; https://www.youtube.com/watch?v=OTtDiY0P8Uw
Incidentally when recently in New Zealand training lifeguards I noticed a few people using face shields not pocket masks. A plastic shield still allows the chin lift method but it’s still not as easy as mouth to mouth.
If you’re going to use a mask, practice with it. Practice with it a lot. If the first time you use it is during the real thing… you’re in for trouble.