Agonal Breathing, a Pacemaker, and a Fearful Daughter
At 11:06 a 911 call comes from a grocery store at 1200 West Market Street. A 58-year-old man collapsed in aisle 7. His daughter reports he made “a funny snoring sound” twice, then stopped, and now “breathes every few seconds.” He has a pacemaker and prior heart attack. Bystanders moved him to the floor; no one is doing CPR. The daughter is crying: “I can’t do this - he has a pacemaker, I’ll hurt him.” An AED is mounted 40 feet away, and a staff member is getting it. The store’s main entrance is on the north side; aisle 7 is near the pharmacy. EMS ETA is 6 minutes; ALS ETA is 9 minutes. You are the only ETC handling the call.
1. Is this cardiac arrest, and which observations drive your decision?
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Treat it as cardiac arrest until proven otherwise. The key is not the word “breathing” but the pattern: two snoring sounds, then stopped, then breaths “every few seconds.” That is agonal respiration - ineffective, irregular gasping that often follows arrest. A pulse may still be present early, but agonal breathing is not adequate ventilation. The history of prior heart attack and pacemaker increases risk but does not rule in or out arrest. Ask the daughter: is he responsive? Can she wake him? Is he breathing normally? Can she feel a pulse? If she is unsure, do not spend minutes on a pulse check; start CPR per protocol. The pacemaker is irrelevant to the decision. The 6-minute EMS ETA is good, but brain injury risk begins in minutes, so dispatcher-assisted CPR should start now.
2. How do you address the pacemaker fear and coach compressions?
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Acknowledge the fear in one short sentence: “I understand - a pacemaker does not make CPR dangerous; it is under the collarbone, and you will compress the center of the chest.” Do not argue. Explain that without compressions, he has no blood flow. Ask her to kneel at his side, place the heel of one hand on the lower half of the sternum between the nipples, the other hand on top, lock elbows, and push hard and fast at 100-120 per minute, about 5-6 cm deep. Use a metronome or count aloud. Allow full chest recoil and minimize interruptions. If she is unwilling or unable to give ventilations, coach compression-only CPR - do not delay compressions to search for a barrier device. If she is trained and willing, follow protocol for 30:2. Stay on the line and give one instruction at a time. If she physically cannot, ask a bystander to take over.
3. What should you do about the AED and the handoff?
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Send the staff member for the AED immediately and tell the caller to continue compressions while it is retrieved. When it arrives, turn it on and follow the voice prompts; bare the chest, dry it if wet, and place pads as shown, avoiding the pacemaker site if it is visible - do not delay pad placement to hunt for it. Clear everyone before analysis and shock. If a shock is advised, deliver it and resume compressions immediately. If no shock is advised, resume CPR. Give EMS a concise handoff: whether arrest was witnessed, bystander CPR start time, AED applied, number of shocks, pacemaker, prior heart attack, and location at aisle 7 near the pharmacy. Do not stop CPR for the handoff; let the arriving crew take over. Document the times.