HeartTalk with Dr. Karl Kern
HeartTalk is WorldPoint’s web video interview series where we ask important questions to leading experts in the CPR and healthcare industry to learn about the topics that affect people today. Exciting, informative, and educational, HeartTalk will provide you with never-before-heard stories, real life industry experiences, and actionable takeaways. Watch HeartTalk to gain fresh and valuable insights into how we can all work together to improve patient outcomes!
We welcomed Dr. Karl Kern, winner of the Hans Dahll Award, to our set at the 2023 Cardiac Arrest Survival Summit, to chat with the influential researcher about his role in the field of resuscitation. Dr. Kern detailed his research and results around hands-only CPR and how it has affected the American Heart Association's guidelines for bystander rescue.
Read the transcript below or watch the video!
Shelly
Dr. Karl Kern, welcome to HeartTalk! We have Dr. Karl Kern with us here today, who is the 2023 Hans Dahll Award winner for the Citizen CPR Foundation Cardiac Arrest Survival Summit. Congratulations, sir.
(Dr. Kern) Thank you.
Shelly
You are considered one of the giants in the industry, CPR resuscitation. And you have an incredibly long and distinguished career. So the Hans Dahll Award recognizes incredible and significant contributions to the industry from science and research, and just incredible contributions. Can you talk a little bit out of your long, distinguished career, some of the most notable moments for which you were recognized for this award?
Dr. Kern
So I think the American Heart Association really deserves a big thank you from me. My group there at the University of Arizona was active in helping with writing the guidelines and so it was kind of an automatic path—they got me invited. But I remember I was asked to be the National ACLS Chair in 2000, so when we rewrote the guidelines in that era and that literally opened up international doors for me. That's a visible enough position in the American Heart Association that it really just kind of kickstarted my whole career in that regard.
One example was an individual came up to me during that time—from Brazil—and he said, “We'd really like you to come down and help establish a national program of CPR in Brazil.” And I was pretty naïve then. I thought, “Brazil, a third world country. Okay, I should go help.” And it turned out to be so helpful to me. And I made the best of friends. Experience I'll never forget.
Shelly
So you are known for your work in resuscitation, specifically around hands-only CPR. Let's talk a little bit about challenging the status quo. Right? Hands-only CPR is relatively new to our industry, and you've been a critical stakeholder, researcher, implementer. How did you become interested in hands only CPR and what can you share about that path?
Dr. Kern
Yeah, well, really, I've got to give credit to a medical student. A second year, inexperienced medical student spending some time in our lab with us said to me, “Well, why do we do mouth to mouth anyway?” And I thought, “Oh! Because it's part of CPR. Been that way for 30 years. We've gotta make sure that they're getting the oxygen they need as well as circulating the blood." And then we all went home that night and began to think about it ourselves.
And and we simply then asked, “Well, what's the most important aspect?” In the very first few minutes, when somebody collapses and no longer has circulation, is it circulating in the blood cells then, or is it making sure that they have oxygen? And it depends. It depends on the circumstances of the arrest. And sometimes the age of the patients is the easiest way to think about that. If it's a child, their scenario is usually they've got a bad respiratory problem and they're actually getting quite hypoxic while they're still awake and alert. And then they progress to where they have so little oxygen that their heart stops. That individual clearly needs, from the very start, mouth to mouth or some kind of ventilation and oxygenation.
But that's not the case for the witnessed adult arrest who is doing fairly well, collapses in front of you. They've got plenty of oxygen in their body at the moment. It's just not moving around because there's no flow. Right. And so it's really at that point, most important to get those red cells to the brain and to the heart with the oxygen they have.
And it turns out that with compressions and CPR, you get some flow, but you don't get normal flow. But it's enough flow to maintain cell viability and you've got enough oxygen on those cells already for the first five, six, eight, even 10 minutes before you really have to worry about replenishing the oxygen. And so that's where we begin to start really investigating the influence of compression only without mouth to mouth or ventilation.
Shelly
So speaking of consequences that was pretty contrarian, right, at the time. Can you talk about how that went and how you were received?
Dr. Kern
Yeah, not well, to be frank! We were pretty astounded ourselves when we found absolutely no real difference in outcome when we were doing 15 to 2 or just compressions—15 to 2 compression-ventilation cycle. We did a total of six experiments of varying the different intervals of no CPR, basic life support and advanced life support, comparing all those combinations to just compression only and found that indeed it was very, very consistent. Over 100 preclinical experiments showed really very similar results, and so we were convinced, but the world was not. I remember very distinctly in some of the national meetings when we first presented that, I felt like we were booed off the stage.
Those who were very strong proponents and who had really put together mouth-to-mouth and compressions were still alive and many of their trainees were very influential at the time. And our idea in the beginning was we don't really have to show that it's better, just equal, because more people will do it. And so if it's as effective as compression and ventilation and twice as many people will do it, we're going to end up with more saves that way. It turned out, at least by our data, that it's not just equally effective, it's more effective in the first 10 minutes. So it's been remarkable.
Shelly
That's incredible work.
Dr. Kern
So we know that if you get bystander help CPR attempts, you're going to double survival in almost every study that's been done. And the real question we had was, well, is that true? If you just if they just do compressions only? And it was very clear that that was preferable to them. And so we began the study that we actually did surveys. We then did actually before and after observational studies in different communities throughout Arizona. And to be totally honest, every community who got on board doubled their survival.
Shelly
You mentioned the—kind of the standards that were in place—and that you were then your research and evidence were kind of calling into question. Can you share a little bit about your role on the ECC, your involvement with the American Heart Association, ECC and just guidelines and how all of that works for somebody who may not understand or know how guidelines are released in the science associated with it? And of course what happened with your science.
Dr. Kern
Yeah. So, so that the American Heart has these committees that looks at the science behind basic life support, advanced life support, and now even education, for example, and systems of care. And they review the literature, they get experts in the field and and then they actually have a model where they then get a consensus conference together and they discuss all of it. And occasionally they will change things.
Example is—after our work where we showed that interruptions really can have tremendous consequences on hemodynamic support and thereby survival, they went from their standard 15 compressions to two breaths to 30 compressions and two breaths. We wanted them go all the way and just do compression only. That took a little longer. And there's still that's now the American Heart Association's suggestion for bystanders, for sure.
But they still also want professionals to be able to do the breaths. But they have realized that, for example, yeah, 15 compressions. If you do interrupt for any period of time, the detrimental effect can be mitigated by extending the period that you're compressing for the two breaths. And so you do half the time or the penalty of that interruption by going from 15 to 30.
Shelly
Wonderful. Wow. So, Dr. Kern, you have been at this for over 40 years.
Dr. Kern
Yes.
Shelly
You have had incredible progress and contributions. You've seen a lot. What's next for the field of resuscitation? What are the opportunities? What are the challenges that you see in front of us?
Dr. Kern
Well, I think, first of all, we have made progress. And I think that's really important to note. You know, a lot of times people still have this idea that this is a hopeless situation and it can be if nothing’s done early. We want people who arrest to come back and be themselves again. The key to that is immediate intervention.
In the examples we've seen of even some famous individuals—it took a minute or even a minute and a half where they didn't start compressions until the AED got there. We got there early, but there's no reason that you have to wait and assign everybody—somebody should start right away, within 10 seconds, push on the chest. If they're not really arrested, they'll tell you, “Get off my chest!” Right? And we have learned that you do not mortally hurt people by pushing on their chest. It's not a good idea if they're alive, but it doesn't kill them. What kills them is no intervention.
So my dream is we still have a ways to go to convince people—start right now. Y’know, it's become apparent in these high profile sports events where we've seen sudden death this year that we're getting better and better. And some of these outcomes are really fabulous. But still, one guy can start pushing on the chest right away while somebody else is organizing—you get the AED, you call 9-1-1. All right. And all the other little steps that have to occur. So that would be my biggest hope is we can continue to convince people—the sin here or the mistake here is not to do compressions. Not, I did them and they weren't needed. Right. Because that's not the that's not the problem we used to believe it was.
Shelly
Right. There's a behavioral portion when we talk about bystander CPR and willingness to engage, particularly around women and/or situations that are just unknown. Can you talk a little bit about what we can do—recommendations that you would have for us—to increase bystander CPR and improve those behaviors and engagements and likelihood of giving bystander CPR?
Dr. Kern
Well, there is a difference by gender. If you look at outcomes, women receive less CPR and certainly less defibrillation and less and have consequences of not getting that treatment where they are more likely to die. How do you take that on? You gotta realize, well, what...what holds people back? And some of it is they're...they're just a little bit afraid that, number one, they might hurt somebody. Number two, they might put themselves in an embarrassing situation and they're not so sure.
First thing I'd say is that you can push on anybody's chest with their clothes on, and it helps so that when it comes time for the AED it has to be on skin. There's no question about that. And that's a that's a hurdle we need to overcome. You know, I actually gave some talks in Saudi Arabia, and you can imagine how this topic goes there. But eventually, it's got to be understood that you have to have contact skin to paddle—and it's okay, you're going to save a life—as opposed to let that life get away.
Shelly
Right. Because that’s somebody’s mom, daughter, sister...
Dr. Kern
Right. But I think one of the ways we've kind of looked at this is, well, how do we convince people it's okay? And we did a very interesting project in a retirement community south of Tucson, a little place called Green Valley. And in this community of 2,000 homeowners, we actually formed a neighborhood CPR watch program, if you will, where they were—they volunteered to be on call and they then were taught how to do CPR. We put an AED in the middle of the community—wasn't very far from anybody—and we did this all mock to see if this would work.
And we worked with the fire department there and we said, “We want you to notify these volunteers on your 9-1-1 calls for cardiac arrest and they will respond just like you respond.” The fire department was three miles away, not far, but and but these guys were neighbors. They beat the firefighters by minutes, you know, 5 minutes. And they were always there before the firefighters arrived, suggesting that they could have started CPR and even defibrillated.
Then we did one where we were not so kind and they we said, “We're going to do this over a whole week. We're not going to tell you when.” And but they still did a great job. But what we saw was the potential to harvest neighborhood and familiarity. And I think if it's...if it's not a total stranger, it's—maybe you don't know them well, but, you know, they live around the corner.
Shelly
Sure.
Dr. Kern
I found that they were much more willing...
Shelly
Okay.
Dr. Kern ...to make the effort to be on call, to be woken up, to be inconvenienced. What we don't know yet is how long will that enthusiasm continue? And I'm a little worried about that. I think there's a fatigue factor that comes in when this is a rare event. You haven't been called, but you're always on call.
And so there's some things to work out yet. But what I clearly saw was it overcomes the reluctance that “I don't know that woman. I'm not taking her...opening her blouse to put this defibrillator on.” I just think it's simple things like that, that if we can convince neighbors to help neighbors, we'll make progress.
Shelly
That's a great start. So that's wonderful. So before we sign off, this has been incredible time with you. What advice would you have for anybody entering this industry? This field of resuscitation, going to work around CPR and resuscitation and improving outcomes? Any advice to somebody new starting out?
Dr. Kern
Well, I guess I would simply point out to them there's two ways to approach this and both are legit. One is to look at what's the simple things that would make a profound influence? And that's what I'm still very interested in convincing people start immediately. I mean, literally within seconds. Don't wait a minute, don't wait ‘til somebody else is there.
What we have seen is what's really effective in retirement communities is to form a little circle. So one person starts—and this is fatiguing, particularly compression only—so they do it for a minute. The next person jumps in, they just go to the back of the line and just get this wonderful, unending line of support. But that magic first 60 seconds, I think there's a lot to be gained and how we do that I think is still not answered.
The other side is there are some really exciting technologies, but these are complex and expensive. But ECPR—extracorporeal membrane oxygenation CPR—where we put people on bypass machines and take over their circulation because they're not responding and we either have a choice to stop and let them die or to go really further.
Shelly
Wonderful. Well, thank you so much for much of your time today.
Dr. Kern
My pleasure. You're very welcome.
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