A Free Paper Presentation in the 16th International Symposium in Critical Care and Emergency Medicine, Grand Hyatt, Bali, Indonesia (30th July - 1st August 2009). Won one of the best paper awards.

1. Translating Knowledge To Attitude:
A Survey On the Perception Towards
Bystander Cardiopulmonary
Resuscitation Among Dental Students
and School Teachers In Kota Bharu,
Kelantan, Malaysia
KS Chew, MNA Yazid
Emergency Medicine Department
School of Medical Sciences
Universiti Sains Malaysia

2. Bystander CPR
• Bystander CPR is CPR performed by any person who
is not responding as part of an organized
emergency response system approach to a cardiac
arrest
• Therefore, doctors and paramedics may be
described as performing bystander CPR if they are
not part of the patient’s resuscitation team.
• (Jacobs et al. 2004)

3. Early bystander CPR greatly improves (double
or triple) the chance of survival of out-of-
hospital cardiac arrest victims
(Eisenberg MS, Horwood BT, Cummins RO et al., 1990)(American Heart Association, 2005)

4. Research Question
How much does what one learn during the practical
skill of basic life support actually translate into a more
positive and willing attitudes towards performing CPR
in real situations?

5. Methods
• We conducted a voluntary and anonymous
questionnaire survey involving final year dental
students for the academic year 2007-2008 in
Universiti Sains Malaysia (USM) to look at their
attitude towards performing bystander CPR.
• There are a total of 60 dental students, in 3 groups
of 20 students each, went through a 2-week clinical
rotation in emergency medicine
• Each student is given a survey form at the end of
their rotation to assess their willingness to perform
bystander CPR under different hypothetical
scenarios.

6. Methods
• Realizing the potential vulnerability of the students
as study subjects, we emphasized to them that this
is an anonymous as well as voluntary survey
• Students are told that they can return the form
blank into the provided envelopes if they do not
want to fill. Also told not to reveal their names.
• They complete the survey in an unmonitored
environment because we do not want them to feel
that they are doing it under duress

7. Methods
• We chose to obtain the opinions of the final year medical and
dental students because they represent the immediate fresh
batch of future doctors and dentists in Malaysia.
• If our healthcare providers are not willing to perform
bystander CPR when they witness one, how much then can
we expect our public perform bystander CPR?
• This survey was repeated to a group of 120 school teachers
after a three-day first aid and basic life support workshop
training.
• During the workshop, the participants were exposed to
lectures as well as practical sessions on performing
cardiopulmonary resuscitation.

8. General Question
In general, what would you do if you witness someone
having cardiopulmonary arrest?
A. Pretend you do not see it and walk away
B. Offer to call ambulance, but afraid to offer CPR
(while you silently hope that someone else would do
the CPR or the ambulance would have arrived quickly)
C. Tell the crowd that you have the skills and offer to do
CPR

9. Question Scenarios
• You are walking alone. You witnessed victim A having
cardiopulmonary arrest (no breathing, no pulse) right in front
of you. You have no pocket mask with you. Assuming no
scene danger and help has already been summoned, would
you perform CPR (both mouth-to-mouth and chest
compression) if victim A were
1. your own family member?
2. your close friend?
3. of different gender from you?

10. Question Scenario
1. involved in a motor vehicle accident with some amount of
blood on the face?
2. is a child (unknown to you)?
3. is an elderly man/woman from old folks home?
4. Stranger appeared unkempt (probably a beggar/street
wanderer/drug addict)?
5. in personal dispute with you or someone whom you don’t
like?

11. Methods
• For each scenario, the respondents are asked to rate their
willingness to perform bystander CPR from a four-point Likert
Scale
• ‘definitely yes’
• ‘probably yes’
• ‘probably no’
• ‘definitely no’

12. Methods
• For selected analysis, re-coding of responses done with:
• ‘Definitely yes’ and ‘probably yes’ is defined as a positive
response
• Whereas a negative response means either ‘probably no’ or
‘definitely no’.
• Forms returned blank or inappropriately filled are excluded
from the analysis
• Comparison between the students’ response of willingness
under different scenarios is done using McNemar Test, Chi-
square or Fisher-Exact where appropriate, computed with
SPSS® version 12.0.1

13. RESULTS

14. In general, what would you do if you
witness someone having
cardiopulmonary arrest?
2%
69%

15. Number of Positive Responses When The
Victim is a Stranger of Different Gender

16. Results
If Victim A is Dental Students School Teachers
A family member 54 (98.2%) 71 (97.3%)
A close friend 51 (92.7%) 69 (94.5%)
Stranger of a different gender 21 (38.2%) 25 (34.3%)
Involved in MVA 9 (16.4%) 13 (17.8%)
An unknown child 39 (70.9%) 54 (74.0%)
An unknown elderly 28 (50.9%) 38 (52.1%)
An unkempt stranger 1 (1.8%) 6 (8.2%)
In Personal Dispute with you 30 (54.5%) 31 (42.4%)
Note: “Positive Response” is a recoded variable of both “Definitely yes” and “Probably yes”

17. Discussion
• Knowing how to do does not necessarily
translate into willing to do
• Except for the categories of victim who is a
family member and victim who is a close
friend, the positive response rate among both
dental students and school teachers is less
than 90%.

18. Discussion
• What is not frequently mentioned in other
published articles elsewhere, but is likely a
significant factor in our Malaysian culture, is
when the victim is of a different gender from
the potential responder (in our case,
especially in the school teachers group).

20. Compression-Only CPR
Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only)
cardiopulmonary resuscitation: a call to action for bystander response to adults who
experience out-of-hospital sudden cardiac arrest: a science advisory for the public from
the American Heart Association Emergency Cardiovascular Care Committee. Circulation.
2008 Apr 22;117(16):2162-7.

21. Why Compression-Only CPR is
preferred in Bystander CPR?
• Advantages to the rescuer
• Simplify technique
• More willing to perform
• Advantages to the patients
• Less interruptions of essential chest compression
• Mouth-to-mouth may actually increase intrathoracic pressure
and reduce venous return
• Ventilation maybe unnecessary especially during initial stage
when the oxygen tension is still adequate

22. Conclusion
• In the case of performing bystander CPR,
knowing how to do it does not necessarily
mean more willing to do it.
• The challenge is ultimately to get more people
to perform bystander CPR
• Compression-only CPR is, predictably
becoming more important in the future

23. Limitations
• Responses in hypothetical situations may not
necessarily translate into actual behavior should
our students encounter one cardiac arrest.
• Emotional make up at that spur of moment, the
perceived ability and confidence of the student as
well as the ability to speedily recognize a cardiac
arrest are some of the confounding factors
• The fact that the students completed the form in an
unmonitored environment may actually encourage
them to discuss with one another rather than
revealing their own true intentions.

24. References
• Hallstrom A, Cobb L, Johnson E et al. Cardiopulmonary
resuscitation by chest compression alone or with mouth-to-mouth
ventilation. N Engl J Med 2000; 342 (21):1546-53.
• Waalewijn RA, Tijssen JG, Koster RW. Bystander initiated actions in
out-of-hospital cardiopulmonary resuscitation: results from the
Amsterdam Resuscitation Study (ARRESUST). Resuscitation 2001;
50 (3):273-9.
• Cardiopulmonary resuscitation by bystanders with chest
compression only (SOS-KANTO): an observational study. Lancet
2007; 369 (9565):920-6.
• Iwami T, Kawamura T, Hiraide A et al. Effectiveness of bystander-
initiated cardiac-only resuscitation for patients with out-of-
hospital cardiac arrest. Circulation 2007; 116 (25):2900-7.