Detangle by Kinjal
Detangle is a podcast created by health psychologist and writer, Dr Kinjal Goyal. Each episode is a conversation with an expert in their field, as they dive deep into their journerys and experiences. The conversations are full of insight and a great way to hear, first hand, how the mind plays a pivotal role in almost everything that we do. The guests range from doctors, to writers, to those in entertainment and of course, those from mental health fields.
Detangle by Kinjal
Detangle with Dr. Yash Lokhandwala and Dr. Manju Sinha
What exactly happens during a heart attack? How does it differ from a cardiac arrest? Join us for a compelling discussion with two of the brightest minds in cardiology and anesthesiology, Dr. Yash Lokhandwala and Dr. Manju Sinha. They break down these critical conditions, detailing that heart attacks result from blocked blood supply causing damage to the heart muscle, whereas cardiac arrests involve the heart coming to a complete stop. You'll learn about the evolution of CPR, which now places greater emphasis on chest compressions for maximum efficacy.
Discover the far-reaching impact of the Revive Heart Foundation, co-founded by our esteemed guests. This foundation has trained hundreds of thousands of people across India, from police officers to railway personnel and students, to effectively respond to cardiac arrests. Dr. Manju and Dr Kinjal share heartwarming stories of success and emphasize the importance of immediate action, moving away from outdated methods like checking the pulse. Dr. Yash addresses the increasing prevalence of cardiac arrests, linking it to diabetes, high blood pressure, urban pollution, and the lingering effects of the COVID pandemic.
We also delve into the psychological aftermath of cardiac arrest, underscoring the intense trauma both survivors and bystanders can experience. Our conversation highlights the urgent need for integrating CPR and AED training into educational curricula and everyday life. By debunking the myth that only medical professionals can perform CPR, we aim to empower listeners with the knowledge and confidence to act in emergencies. Through the tireless efforts of experts like Dr. Yash and Dr. Manju, we move closer to making India a cardiac-safe country.
Welcome to Detangle, where we untangle the complexities of life one conversation at a time. I'm your host, dr Kinjal Goel, a psychologist and a writer. This episode is a special one, releasing ahead of Season 3, for a very, very special reason. Our guests today are Dr Yash Lokhanwala, an eminent cardiologist and heart rhythm specialist, and Dr Manju Sinha, a senior anesthesiologist. They are the co-founders of Revive Heart Foundation and have been working tirelessly to spread awareness about cardiac arrests and CPR. I have been closely associated with RHF and I'm hoping that through this episode, we can bring more awareness and get one step closer to our goal of making India a cardiac safe country. Welcome, dr Yash and Dr Manju. It's so wonderful to have you with me on this podcast today.
Speaker 2:Hello, Hello.
Speaker 3:Kinkar. Thank you, dr Kinzer, good to be here.
Speaker 1:Well, let's start with our basic questions and let's see where they take us. So let's start with the basics, shall we? Dr Yash, we've been seeing these terms heart attack, cardiac arrest being used interchangeably in the media since forever. Can you tell us how they are different, please?
Speaker 2:A heart attack in the classical sense means medically a myocardial infarction. To put it in lay terms, a heart attack means when a part of the heart which undergoes an acute damage because of sudden blockage of its blood supply. The heart muscle is essentially supplied by three large blood vessels, which we call arteries, and if one of these arteries or one of its branches suddenly blocks off, that area of the heart doesn't receive blood and within a few minutes starts dying. That gives chest pain, choking sensation, shortness of breath, sweating and even can result in loss of life. So when it causes a sudden collapse, that's a cardiac arrest. That means there are many heart attacks, but only a small proportion of them will cause cardiac arrest. Overall it's estimated that one out of four heart attacks causes a cardiac arrest, so it's actually not that small a proportion. There are, however, other causes of cardiac arrest. Also. There are other diseases of the heart, like diseases of the heart muscle, where the muscle is very thick or very weak there are diseases of the heart valves.
Speaker 2:There are diseases of the heart since birth, what we call congenital heart disease. There are some electrical diseases of the heart valves. There are diseases of the heart since birth, what we call congenital heart disease. There are some electrical diseases of the heart. The heart muscle is normal, but the electrical signals are horribly abnormal. And all of these can also lead to cardiac arrest. Cardiac arrest means a person collapses, the heart stops beating and the person stops breathing also, and if not revived immediately, the person dies. So that's the difference between a heart attack and a cardiac arrest.
Speaker 1:All right, so for the rest of this conversation, we'll be focusing only on cardiac arrests, for simplicity of understanding, and about CPR, which is done during a cardiac arrest. So, doc, we have been talking about CPR loud and clear since such a long time now. However, most people that I meet still ask the same question what is CPR? Can you tell us a little more about it?
Speaker 2:The full form of CPR is cardiopulmonary resuscitation. That means revival of the heart and pulmonary means the lungs. Conventionally, this was thought to be by giving cardiac or chest massage and mouth-to-mouth breathing. However, in the last decade, this has shifted, for purposes of efficacy as well as safety, to pure chest compressions. So, though we call it CPR, it's essentially cardiac massage or chest massage.
Speaker 1:OK, so talking about the campaign that is going on with Revive Heart Foundation now, can you tell us how did this come about? I mean, how did the foundation of RHF actually take place Since?
Speaker 2:the time I can remember having joined medicine and I'm sure my seniors will remember even more We've had it was very common that a cardiac arrest in India would not get revived, and India is one of the largest incidences of cardiac arrest for the simple reason that heart disease is the maximum in the Indian subcontinent, especially the blockages of the arteries and even other types of heart disease like valve disease. The problem is that there was almost zero awareness amongst the lay public as to what to do if, faced with a cardiac arrest. Someone has a cardiac arrest or someone collapses. People wouldn't even know why they have collapsed, would make them do things like you know smell a shoe or sprinkle water on their face, or sprinkle water on their face or, in the best case scenario, try to put them into a vehicle and take them to the closest hospital. In contrast with that, several countries in the last four-five decades did two great strides in the response to a cardiac arrest. One must understand that almost 80% of cardiac arrests occur outside a hospital and therefore the lay public must know how to recognize and act on it.
Speaker 2:In India, cardiac arrest was equal to death and there was nothing in the horizon, and we used to be frustrated year in and year out hearing about people dying suddenly. We know that in India the heart disease and cardiac arrest occurs 10 years younger than in the some of the developed countries. Now that means an average age of 50 is cardiac arrest in India. We lost several people and no one seemed to be really doing anything in a meaningful way. There were some of our colleagues who were individually trying to conduct these workshops, but we realized that on an individual basis you really can't do much. So a few years ago, with the help of the Holy Family Hospital, we thought let us start a proper training program hospital. We thought let us start a proper training program which will be there for the long run and it will be sustained and run by full-time employees also, so it doesn't depend on the voluntary efforts of doctors who may not be able to always take time out from their busy schedule. And that's how the ReviveArt Foundation took shape.
Speaker 2:Initially it was called iCare cardiac arrest resuscitation for everyone, but in the last few years has been renamed for official reasons as the Revive Heart Foundation, and we are fortunate enough that it has not only sustained but grown over the years, and colleagues all over the country have also got encouraged and started similar initiatives.
Speaker 1:So, Dr Manju, can you tell us more about the organization and how many people has RHF trained so far?
Speaker 3:Kinjal. We've had more than 950 workshops to train people. Training has been at residential societies, police stations, bus stations, in schools, colleges, as well as in various corporations. Around 3 lakh people have been trained in person and about 5 lakh people when you consider the online sessions which started during the COVID pandemic. During the COVID pandemic, 73 police stations in Mumbai have been covered. All zones of Mumbai police stations have been covered. Lucknow police stations have been covered. Lucknow police, indore police and a lot of railway personnel have been covered during the training.
Speaker 1:How fantastic. So we are targeting different segments of society so that we can actually push this right into the population and someone, somewhere, can help when the need arises.
Speaker 3:Absolutely that's right. So during what over the years, we realized that we also need to take this pan India and started targeting at various segments. So in 2022, we targeted the railways, 2023, we targeted the police personnel and this year we plan to target the schools, colleges and all educational institutes. So during the targeted sessions, that is, the sudden cardiac arrest awareness week, we target various sections Right.
Speaker 1:So, coming back to the cause of cardiac arrest Now, Dr Yashu, you explained the difference between heart attack and cardiac arrest, but nowadays everybody has this similar feeling that there's an increase in the number of cardiac arrests and resulting deaths. But what do you think is the reason behind this?
Speaker 2:See, we don't have exact population counts in India, but we can extrapolate from pockets to the rest of the country and we can extrapolate from data of heart disease in general and from those estimates there are approximately one and a half to two million. That means up to 20 lakh cardiac sudden deaths in India in a year, which is a big number. It's certainly increasing, not only in terms of numbers but also versus it's occurring at a younger age. The reasons are several. India has the maximum number of diabetes. High blood pressure is rampant. Urban pollution is a major factor which was under-recognized for the heart. Everyone thought pollution is only bad for the lungs, but now there's increasing evidence that it causes also more heart disease. And the COVID pandemic and to some extent the increased blood clotting effects during the COVID pandemic for various reasons we have seen also. So all these have combined to have an increasing number of cardiac arrests. That too at a younger age in our country.
Speaker 1:Right, so let's break this down into simpler segments, because my audience is varied. Everybody's listening. Everybody wants to understand. What do we do about this increase in cardiac arrests? Now, there are some basic steps to follow. The first is, of course, identifying a collapse as a cardiac arrest. Most people are absolutely clueless that a person has collapsed due to cardiac arrest, and hence they don't reach the next step of CPR at all. How can someone who is not trained as a medical professional identify a cardiac arrest?
Speaker 2:It's very easy. Previously there was an emphasis on checking the pulse rate. Now we know that checking the pulse is fallacious If a person may have a pulse and you may not feel it or may not have a pulse, and you may feel your own pulse and think that the person has a pulse. So therefore that is given up In a cardiac arrest. You not only as I said at the outset, you not only collapse and fall unconscious, but the victim stops breathing.
Speaker 2:There are several reasons why a person can become unconscious.
Speaker 2:For example, a sudden drop in blood pressure, a low blood sugar, a brain stroke, an epileptic attack, etc. Will continue to breathe, maybe for a few seconds it may stop, but will continue to breathe after that. Cardiac arrest is the only condition where you not only fall unconscious but you stop breathing. So therefore, to check whether a person is breathing or not is very easy. First of all, you see if the person is unresponsive by tapping the shoulders and calling out to the person, and then you look at the movement of the chest. In a male person, you should remove the shirt, and in a woman, if for reasons of modesty you can't do that, you can look at the abdomen and see if it's moving up and down, or sometimes even put your hand in front of the nose and see if there is air hitting your, not the palm, but the other surface we call the dorsum of the hand, but it's more sensitive and if the person is not breathing for 15-20 seconds and is still unconscious, there can be no other reason but a cardiac arrest.
Speaker 1:Right. So once an arrest has been identified, after calling for medical help, a person needs to start CPR immediately. So, Dr Manju, can you explain this process of CPR? I know a video would be ideal at this point. I will be adding a link with the episode, but just to begin, do explain.
Speaker 3:Once you have established that the person has had a cardiac arrest, it is important that the person is laid down supine. That is, placed on the chest of the person. Intermingle your other hand fingers with the other hand and start with pressure right from your shoulders, keeping your elbows straight, and start with compressing at 100 to 120 beats per minute and you should achieve a compression that is a depth of at least two to two and a half inches of the chest. That would give effective compressions. You don't wait in between at all. Continue the compressions and till that time you're hoping that somebody else would have got called for cardiac ambulance or an AED would have arrived, call for cardiac ambulance or an AED would have arrived and in case there isn't an AED which hasn't, or medical help not arrived as yet, please tell whoever else is observing you to see what you are doing, because this can be very fatiguing and you will get very tired very soon. So after two minutes it's a good test to ask somebody else to take over and continue with the cardiac massage.
Speaker 1:Right. So I think one of the main things that we see, even when we are conducting sessions, is that people always say oh, we took so-and-so to the nearest hospital, but they did not make it even till there. So what you're saying is don't put the person in an ambulance, in a car or a vehicle. Wait for the ambulance, stay where you are and start CPR. That's right. Let's talk about AEDs now. These are crucial, but seem like complicated medical equipment meant only for trained doctors. I'm sure most people have seen an AED at airports, malls etc. But haven't really registered their importance. Dr Yash, can you tell us about AEDs and their role in saving a victim of cardiac arrest?
Speaker 2:AED stands for automated external defibrillator. In simple terms, it's a shock machine, but it's portable. In more simple terms, it's made for out-of-hospital use. By by and large, though, it is present in hospitals also, and most important is, it is idiot proof. So it is made for people who have no knowledge previously, who have never seen it before yet, will be able to use it. For example, today everyone knows how to put a sim card in a mobile and how to start a mobile and download an app. So it is even more simple. You open the box and there's a voice prompt. It tells you press this button. There's a diagram there. It also tells you stick the pad here and there, and then it tells you look at what is coming and the machine says if it detects the cardiac arrest, it tells that, okay, this is really a cardiac arrest. And then it tells you there's a button here, press that, and that button is flashing. It's that simple. It's that easy. The problem is it looks like a medical equipment.
Speaker 2:It has to be demystified it has to be made widely known that AED is for anyone to use and you cannot. Because some people have this thing that what if I give a shock wrongly? No, the AED also tells Suppose it's a common faint, the person will recover before you can even deliver a shock. Suppose it's a brain hemorrhage, where you won't recover, you're still unconscious. The AED will say no, the patient is having a heart rhythm. You don't have to give a shock. And suppose, worst case scenario, you deliver some.
Speaker 2:We have these defibrillators which are implanted inside the body which sometimes give a shock which is not necessary. That will not happen 99.9% of the time with the AED, but even if it does happen, it will not do great harm. Not giving a shock and losing life is the worst thing you can do. With an AED available close by, you can save up to if you start CPR immediately immediately means within a couple of minutes or maximum three, four minutes you can save up to 10% of people. If you have an AED at hand and use it along with CPR, you can save up to 30 to 40% of people.
Speaker 2:Then imagine the number of lives saved. In fact, there are some cities of the world, like Seattle and some of the Scandinavian cities where they save up to 60% of people with cardiac arrest out of hospital. So let's not aim for the sky. Let's at least say, in India, from a near zero, point, a near zero, maybe we save a few lives here and there of cardiac arrest in the community. But from that state, if we can go even to 5% survival, it will be a huge step. We'll save lakhs of lives.
Speaker 1:Right, okay, so we've had some really large scale awareness programs. I mean, in the last few years we've had celebrities, politicians, some fairly senior people backing up this campaign, and yet we haven't reached this critical mass. What do you think is the main hindrance here?
Speaker 3:I think the awareness is, by and large, the main hindrance, as well as not only your awareness, the public awareness, because invariably somebody from the crowd will tell you that please take to the hospital immediately. In fact, they will not even allow you to start CPR because they'll say you need to take the patient to the hospital immediately. So what we need is to bring this awareness right at the grassroots level as well, as make not only just the politicians. So this campaign has to start and teaching awareness from the schools. Once you have taken over and this is included in the curriculum of the schools, that is when large scale awareness will occur.
Speaker 1:Right. So that's the only step, according to you, which will help us train maximum people, and sustainably so. So everybody coming out of school will be trained in CPR and then can kind of be the growing population.
Speaker 3:Absolutely. It is only then that we will be able to attain a critical mass of people being trained in CPR.
Speaker 1:Okay, so let me ask you something a little different here. When a cardiac arrest victim collapses, the scene is quite chaotic, like you said. The crowd will ask you to take the person immediately, not allow you to start CPR, even if you are trained. Also, there is this bystander effect which comes into play and people are scared. People are scared of making a mistake, taking the first step. How can we overcome these issues?
Speaker 3:So there is a good Samaritan law which was introduced in 2016, and the good Samaritan laws actually does not hold you responsible and you're going to take over and help somebody in the time of an emergency.
Speaker 1:So even if the CPR is not effective and the patient has not been revived, the person who has tried CPR is not liable to any legal proceedings, absolutely. Okay. So what if, Dr Yash, if there's a road accident, the victim is bleeding but is also in cardiac arrest, can CPR still be given?
Speaker 2:If there is cardiac arrest, cpr has to be given, whatever be the reason for cardiac arrest. Usually a road accident will not cause a direct cardiac arrest but it can sometimes earthquakes in earthquakes, a lot of the victims are not because of the rubble falling on them but because of cardiac arrest. So any cause of cardiac arrest, if you don't give cpr, your anyway the person is dead. So you have to institute chest compressions.
Speaker 3:Say that both the things need to be done simultaneously.
Speaker 1:Right, so you have to control the bleeding if it is to severe and start CPR also. Yes, there's another question which keeps coming up. I'm sure you've answered this a million times already, but it's a question most people have in their minds what if you break a person's ribs while doing CPR? Is that acceptable?
Speaker 3:If you have saved the person, breaking the rib is not a major issue, but it does happen. If you do not give CPR, the person is already dead. So if you have saved the person's life, the rib can be taken care of. The rib fracture can be taken care of.
Speaker 1:Right. So, like we were talking just before, these questions is that if we can bring CPR training into the school curriculum, let's say for standard 9, 10 and above, it will bring us closer to the countries that have a better survival rate. But something in our country is still not clicking. What do you think Dr Yash is stopping the authorities from bringing this into the curriculum already?
Speaker 2:I think, unfortunately, you know, health has never been a major issue. For example, at the time of elections, it's a huge issue in many countries, like if you start the, you try to do anything. Tinker with the national health service in uk, it's a, it's a. It's a huge thing. Similarly, in in the usa, you know, the funding or the insurance is a huge issue. Health insurance in india, it's somehow never a big issue at the time of elections.
Speaker 2:The allocation for health also has never been more than a few small percent of the GDP, much, much less than many of the countries which have much better health indices. So that is but for CPR. What we are trying to impress upon is that it doesn't cost. There is hardly any cost in training people for CPR and therefore I feel that, for example, if you make it compulsory in schools for persons to learn CPR before they pass out of school, it doesn't cost. It costs hardly anything. So it's going to be the right person in the charge of affairs who's convinced about this and to implement this policy. Once it's implemented as a policy, things will fall into place.
Speaker 1:Right, so is there a message or appeal that you have which you would like to make directly to the authorities?
Speaker 2:Yes, see, just asking schools to train them, students in CPR won't work beyond a small percent, whether they're really motivated school principals or people in charge, the trustees who understand.
Speaker 2:But if it becomes, for example, a part of the curriculum with, let's say, five marks, a five mark question in the final exam of class 10, class 12, then automatically, automatically, the students will learn and in college we call it as credit. If it's given one credit, for example, it becomes a part where the students will have to learn and they will attend and the college will arrange some teaching for CPR. So this is crucial getting it into the syllabus, getting into the curriculum, having a question in the exam on some aspect of cardiac arrest and having one credit for it. In colleges and universities. This exists in many countries and this is the way we will get people trained when they are 15, 20 and 30 and they will carry forward with them this knowledge and this ability for 40, 50, 60 years and surely, surely, most of them will get a chance to try and save some people, at least one, two, three or more people's lives in their lifetime.
Speaker 3:Dr Kinchil, Scandinavian countries have been able to achieve it by not only including it in the school curriculum, but also making it compulsory for obtaining a driving license. Oh super, that is how they have managed to increase a large number of their population being CPR trained. I think that is another policy which can be looked into and can be adapted in our country.
Speaker 2:It can also be done at various other levels. As we were discussing the other day, India apparently has several thousand marathons a year, Several thousand More than the rest of the world probably put together. If it's compulsory, anybody who wants to run a marathon. You can't run unless you are CPR trained, Because in a marathon we find a maximum number of deaths per number of people running marathons in India probably and the one who will help you is the one running next to you, not a medical personnel who will take time to come. So there are several ways in which this can be done.
Speaker 1:Fantastic. Yes, so, dr Manju, do we have any revival stories, any survivor stories directly from the CPR training that has been provided?
Speaker 3:Yes, Dr Kinjal, In fact that is very heartwarming and in fact that is very motivating and inspiring for us to continue with this. With this project, we have had six direct survivor stories and survivals because of the training and the availability of the AED and we have had about 10 stories which is indirect. There are how many which may have occurred, we don't know and in addition to the training, we also have inspired people to donate placement of AEDs in various locations.
Speaker 1:Well, that's a really heartwarming note to come to.
Speaker 2:In fact, in Mumbai, you know, the airport always had AEDs, In fact, many, many AEDs more than a hundred, but the railway stations had nil.
Speaker 2:One of our colleagues, dr Akshay Mepta, with the help of the Rotary Organization, has started installing AEDs in the suburban railway stations of Mumbai, which there are more than 60 railway stations. I think They've already placed in about 20 and also have undertaken training sessions at the railway station, either in the station master's office or sometimes on the platform. And look at the coincidence Marine Lines is one of the railway stations in Mumbai. They trained the Marine Line station three weeks ago and just one week after the training and placement of the ED, a railway personnel has saved a passenger who had a cardiac arrest at Marine Lines and he's revived, and this story has been carried by the press also. So imagine how many. If the railway personnel are trained all over the country, how many lives can be saved.
Speaker 1:Oh, absolutely so, Dr Yash. Dr Manju, before we come to a close of this interaction, is there any question you would like to ask me as a psychologist?
Speaker 2:Yes. What I would like to know is you know that after a cardiac arrest, we treat the medical aspect and then we discharge the patient, but I will not be surprised if they continue to have dreams, nightmares. Their family members are shaken up and the person never gets the confidence to get back again. So does something more need to be looked into? Have you come across such stories?
Speaker 1:Oh yes, and there are some fabulous organizations worldwide working only on the psychological aspect of cardiac arrest in various levels. Actually, if somebody loses a family member or a close friend to cardiac arrest, of course the grief is overwhelming. If there is a survival, then knowing that you were so close to death for the patient and for those people who were present is also very difficult. Sometimes bystanders who are experiencing CPR, being given that intense moment where you don't know whether the patient will live or not live, that can also have PTSD-like symptoms. So these patients, like you said, can have recurring nightmares, they can have night sweats, they can have increased anxiety, they can have palpitations. So they also need to be spoken to. We need to have a survivor's handbook, we need to have a family handbook for those who lost their family members to cardiac arrest, because the psychological ramifications are plenty and it is a very intense moment. I mean, like you said, it happens outside hospital. There may or may not be medical help available and suddenly a non-trained person has to take care of somebody's life. So it's quite intense. Well, this has been a very interesting conversation. I'm so glad we were able to put it together because the more we can circulate this as an audio note, as video notes, as training sessions. We can get more and more people to get aware about CPR, to learn CPR, to understand AEDs and to demystify the whole. You know this whole myth that we have that it's a very intense thing that only doctors can handle. This is a life or death situation, but you don't need to be a doctor or a trained nurse to give CPR at the right time.
Speaker 1:It's also very important, like Dr Manju mentioned, that sometimes awareness is key. So a lot of patients, a lot of people also ask that online sessions are they really effective? And for that we need to understand that the more people we train even if it is online that many people are now aware about CPR and AEDs and at least they will not hinder somebody's attempts at CPR. Also, we need to get the government to sit up and take notice that this is absolutely achievable. The goal of a cardiac safe country is not very difficult to achieve. We need to get CPR training into school curriculum, specifically for credit and for marks, so that everybody who exits the Indian school system knows CPR. We can also get it as part of licenses, so anybody wants to get a driving license has to know CPR Small steps, big results. But, Dr Yash, Dr Manju, it has been tremendous working with you in this campaign all these years and I hope that we can get more and more awareness through all the efforts that everybody's putting in across the country.
Speaker 3:Yes, Kendal, that is the goal.
Speaker 2:Yeah, definitely we shall overcome.
