Collapse at a Summer Health Camp
At 11:20 on a May afternoon a health camp is running in a village hall where the indoor temperature is 41 °C. A 62-year-old man who complained of chest tightness an hour earlier suddenly slumps off his chair. You are the only person at the camp with first-aid training; about 40 villagers are watching. He does not respond when you shout and shake his shoulders. He is not breathing normally - you hear an occasional noisy gasp roughly every 10 seconds. You check the carotid pulse for 10 seconds and feel nothing. There is no AED at the camp and the nearest ambulance is 25 minutes away on a rough road. One bystander runs for a glass of water, another tries to lift the man into a chair, and a third begins pressing on his abdomen.
1. State your working diagnosis and list, in order, the first four actions you take within the next 60 seconds, giving the reason for each.
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Working diagnosis: cardiac arrest. Agonal gasps mean he is not breathing effectively, and an absent carotid pulse after 10 seconds of palpation means there is no circulation. Time from collapse to compressions is the single biggest determinant of survival.
- Shout for help and send a named person to call 108, stating the location and 'adult, unconscious, not breathing'. Reason: the ambulance is the only route to defibrillation and advanced care.
- Lay him flat on his back on the floor, clearing the space around him. A chair or a bed is too soft; compressions on a soft surface lose depth.
- Begin chest compressions at once - heel of the hand on the lower half of the sternum, 30 compressions at 100–120 per minute, 5–6 cm deep, allowing full recoil, minimal interruption.
- Give 2 rescue breaths after each cycle of 30 compressions because I am trained and have a barrier device; each breath over 1 second with visible chest rise, then straight back to compressions.
Heat and onlookers are secondary; nothing delays the first compression.
2. Explain to the two bystanders why water must not be given and why the man must not be seated. Then describe exactly how you position your hands and body for compressions.
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No water: he has no gag or cough reflex. Fluid poured into the mouth runs into the trachea, obstructs the airway and causes aspiration; water cannot restart a stopped heart and the attempt costs the minutes that matter. I would say this clearly and take the glass away rather than argue.
Not seated: sitting up lowers venous return to the heart, worsens cerebral blood flow and makes effective compressions physically impossible. A collapsed patient lifted into a chair may also be dropped.
Hand and body position: kneel at his side with my shoulder directly above his sternum. Heel of the lower hand on the centre of the chest at nipple level (lower half of the sternum), fingers lifted off the ribs; second hand on top, fingers interlocked. Elbows locked, arms vertical, so my body weight rather than arm strength produces the compression. Push 5–6 cm, about one-third of chest depth, at 100–120 per minute, let the chest recoil completely, and keep my hands on the chest between cycles. I avoid the xiphisternum and the upper abdomen.
3. After 8 minutes of CPR you are alone and exhausted; the ambulance is still 15 minutes away. What do you do, and what events would justify stopping resuscitation?
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I continue. Elapsed time or my tiredness is not a criterion for stopping; the patient's response is.
Practical steps: if I can no longer sustain 30:2, I switch to continuous compression-only CPR - good compressions alone are far better than stopping or than poor-quality cycles. I call a bystander over, kneel them beside me, place their hands correctly and let them compress for 2-minute cycles while I rest and coach; handover should take under 10 seconds. I take over again, and repeat. I keep the compressor rotating every 2 minutes even when I feel able, because depth and rate fall silently with fatigue.
Stop only if: spontaneous breathing and a pulse return (then recovery position and monitor), the ambulance team takes over, the scene becomes unsafe, or I am physically incapable of continuing. In a witnessed collapse with immediate bystander CPR and no signs of irreversible death, stopping because 'it has been long enough' is not justified.