The Collapsed Runner in a Crowded Park
You are a PHECC EMT on a single crew responding to a call at a public park. A 58-year-old man collapsed while jogging. Bystanders report he went down suddenly with no warning and has not moved since. On arrival, he is unresponsive, lying supine on grass. You cannot feel a carotid pulse within 10 seconds and you observe no normal breathing, only occasional gasping sounds. A bystander has already started chest compressions but with hands placed low on the abdomen. Your partner is a first responder on scene with you. An AED is in the ambulance roughly 40 metres away. A crowd of onlookers is gathering and a relative is shouting at you to 'do something now'.
1. List, in priority order, the immediate actions you and your partner take in the first 60 seconds, and justify the order.
Read the worked answer
- Confirm unresponsiveness and abnormal/absent breathing (the gasping is agonal, not normal breathing) - this is the trigger for CPR, not a reason to wait.
- Correct the bystander's hand position immediately and take over compressions, or coach the bystander with clear verbal feedback. Compressions on the abdomen deliver no cardiac output and risk gastric insufflation/aspiration. High-quality compressions (centre of chest, adequate depth and rate, full recoil, minimal interruption) are the single highest-value intervention.
- Direct your partner to retrieve the AED from the ambulance and apply it as soon as possible, while you continue compressions. The 40 m distance is a task-allocation problem, not a reason to delay compressions.
- Assign a bystander to call for additional resources/backup and to manage the crowd and the distressed relative - this is delegation of non-clinical tasks so the clinical team is not diverted.
The order is driven by the principle that interventions which most change survival (early, effective compressions and early defibrillation) come first, and everything that can be delegated should be delegated.
2. The AED arrives and is applied. It advises a shock. Describe how you manage the shock, the immediate post-shock period, and the competing priorities at that moment.
Read the worked answer
- Ensure nobody is touching the patient (verbal 'clear' plus visual check), deliver the shock, then immediately resume compressions without pausing to reassess a pulse or rhythm. Post-shock rhythm checks are not done until the AED prompts a reanalysis (typically after a 2-minute cycle).
- Minimise the hands-off time: the pause for the shock should be the only interruption, and compressions resume within seconds.
- Continue cycles of 30:2 (or continuous compressions if a second trained provider is available to ventilate) until the AED prompts reanalysis, the patient shows signs of life, or you hand over to a higher level of care.
- Competing priorities: the relative demanding immediate action and the crowd are distractions that must be managed by a delegated person, not by the compressor. Do not stop compressions to explain or reassure.
- Note the time of collapse, time of first compression, time of AED application and each shock, because this information is needed for handover and for the receiving team's decisions.
3. The patient achieves return of spontaneous circulation after the second shock. He remains unresponsive but now has a palpable pulse and spontaneous, though shallow, breathing. What are your priorities during transport, and what judgement calls must you make?
Read the worked answer
- Post-ROSC care focuses on preventing a second arrest: support oxygenation and ventilation without hyperventilation (target normal oxygenation, avoid excessive rate/volume), monitor the rhythm continuously, and be ready to resume CPR immediately if he re-arrests.
- Position and airway: he is unresponsive with shallow breathing, so airway protection is the priority. Use airway adjuncts as appropriate and be prepared to assist ventilation; do not assume spontaneous breathing is adequate just because it exists.
- Judgement calls: (a) recognise that 'shallow breathing with a pulse' is a borderline state that can deteriorate quickly, so you do not relax monitoring; (b) the relative may want to travel with you - decide based on clinical need and safety, and explain calmly; (c) decide the receiving destination and pre-alert early, because post-arrest patients need definitive care and pre-alerting changes the receiving team's readiness.
- Document and hand over: downtime, shocks delivered, rhythm, times, and the patient's response, because this drives post-arrest care decisions.