I've struggled with trying to find a study that accurately captures reasons why bystanders avoid CPR. The best one I've found, from Tasuku Matsuyama of the Kyoto Prefectural University of Medicine in Japan is in the December 2020 edition of Resusictation Plus. Much of what I would expect is found there. Factors influencing willingness to perform CPR included:
- Having to undress of apply an AED pad for a female in public
- Low confidence or exposure to training or unsure of benefit
- Social-economic status
- Existence of vomit, blood, drugs, alcohol, or other disagreeable characteristics
As part of this research, the team looked at 18 eligible studies addressing willingness to perform CPR. 14 of them were personal factor, 3 CPR knowledge, and 2 procedural. One of the authors conclusions immediately jumped out to me.
In a study of actual bystanders interviewed after an emergency call and the emergency medical service (EMS) dispatcher instruction of performance of CPR, the most frequently cited reason why non-responders were unable to perform CPR was “panic” (37.5%). According to one study, emotional factors such as panic and hysteria were reported in 20% of the emergency calls and were dominant barriers against dispatcher-assisted CPR among bystander-witnessed cardiac arrests.
In people willing to respond to these questionnaires, panic stopped them from doing so. Unfortunately, the people who didn't intervene could also opt to avoid engaging in the survey too, and even more meaningful data may be lost.
Avoiding the Trauma in the First Place
I have an anecdote that is nonscientific, but something I experienced and the mental vision I return to when I discuss this problem. In that vision, I'm back at a rural home on a call as a supervisor. My crew has arrived concurrently to a report of a cardiac arrest. A woman is outside, the caller, the bystander, the only one who could engage in meaningful help for the patient. She is screaming. There is no bystander CPR taking place. The patient does not have a good outcome despite our best efforts.
When I review the call and talk to the woman, she advises she saw the patient in need of CPR, but stepped outside because she "didn't want to see that."
That bystander was practicing an avoidance behavior. And I have a suspicion it's not the only time that has happened.
Psychology is well aware of avoidance behavior. Dr. Michael G Wetter from Los Angeles suggests that "the function of avoidance is to protect us from what we perceive to be a threat."
“Sometimes, these fears are based on experiences, e.g., ‘I was bit by a dog, so now I’m afraid to approach dogs.’ Other times they are simply cognitive, e.g., ‘I imagine being bit by a dog would be horrible, so I will avoid dogs,’” says Wetter.
In the scenario above, the bystander was engaging in classic situational avoidance. She was staying away from something that felt triggering to her, which is a symptom of PTSD. She had likely never seen a loved one in cardiac arrest, so how could she have already experienced that traumatic event?
We unfortunately think that someone has to be a direct witness to a trauma, but the Royal College of Psychiatrists has a great resource spelling out all the ways that we can be exposed to traumatic events.
- Directly experiencing it
- Witnessing it happens to someone else
- Learning about it happening to someone close to them
- Repeated exposure through media, TV, pictures, or even sharing from others.
Yes, trauma by proxy is a thing, and some of us in the education realm may unknowingly be creating an environment that triggers avoidance or CPR when it's needed the most.
Becoming Comfortable with the Uncomfortable
I hope I speak for the majority when I say no one wants to be exposed to death and trauma daily. The reason I keep at this job is to try to reduce pain and suffering among others, and I'd hazard to guess others in the CPR advocacy realm are doing the same.
The challenge is, as more people get exposed to cardiac arrest (such as through Damar Hamlin or Christian Erikson's televised codes) that trauma exposure can potentially become triggers for overall avoidance. Instead of stopping to see what's wrong with an unconscious patient, they may opt to only call 911 and stay at a distance away, unable to provide the dispatcher with more specific information. They may pass a car on the road where an occupant is slumped over the wheel without giving it a second thought. They may look around in a crowd, spot someone on a phone, and assume they're calling 911, so no action on their part is needed.
While some people might think mindfulness is just an annoying pop up on their Apple Watch, it actually can play a role in preparing someone to respond in these situations. While I'll have to dedicate a post in the future to all the changes I've suggested we implement to community and formal CPR training in order to address relatability in particular, imagine adding into training a 5-minute breathing meditation, a guided vision through what a scene may look like (instead of a training video where Bob from accounting suddenly falls over at the reception desk). Ask the class to express their thoughts and emotions on the situation. Help them to respond to bring order to chaos, instead of bringing their chaos to the response.
Of course, this only looks at how we can try to prevent avoidance responses in people who aren't already exposed to SCA. For those survivors, co-survivors, and bystanders who experience it directly, much more is needed after the call... a topic for yet another day!
Tasuku Matsuyama, Andrea Scapigliati, Tommaso Pellis, Robert Greif, Taku Iwami, Willingness to perform bystander cardiopulmonary resuscitation: A scoping review, Resuscitation Plus, Volume 4, 2020,
100043, ISSN 2666-5204, https://doi.org/10.1016/j.resplu.2020.100043.