Having been teaching CPR for at least 25 years, I have seen several changes in the CPR guidelines and the content of my training has changed on quite a regular basis in line with the guidelines at the time. Incredibly, however, I have to admit that the method by which I have taught CPR had changed very little until about 18 months ago! I suspect that is true also of the majority of trainers.

Of course, presentation technology has changed and I have used flip charts, film projectors, video, powerpoint presentations and an array of visual aids to place emphasis on certain aspects or to provide variety. Essentially however, I still explained demonstrated and then let the student's have a go. Yet here am I, an experienced professional trainer, teaching a skill to the same old trusted pattern yet I had never really explored alternative ways of teaching. Now, I used to run popular first aid instructor courses during which I frequently hammered home the message, time and time again: "What they do - they remember!"

No wonder I felt embarrassed then, when Lars Wik of the Norwegian Resuscitation Council told the congress audience in Florence a couple of years ago that the average time each student spent actually using a mannequin, on a 3 hour CPR course, was just 2 minutes! This was based on his observation of numerous CPR courses. I felt embarrassed because (like many other CPR trainers in the audience that lovely sunny afternoon) I knew that my own students spent little more practical time, on just such a typical three hours course, than the two minutes Lars quoted.

It was with this in mind that I finally started to explore ways of improving the amount of practical time that each student received on CPR courses. It has been shown in several studies that a significant decay occurs, in CPR skill, within as little as six months.(1) Is this why perhaps?

I recalled a report in Resuscitation (2) of a different way of teaching CPR - in blocks - it was referred to as staged teaching and it was found that students taught to do blocks of 50 chest compressions repeated several times, reached a higher standard and maintained it for longer.

With this in mind, I looked at how to break up the process of CPR. I also recall, that when I was learning to fly aeroplanes, we used a number of drills. Learning to take off and land involved what is commonly known as 'circuits and bumps' which meant repetitive taking off, flying around to the runway again, landing and then taking off again without stopping. This is a difficult skill to acquire (and is the most demanding part of flight) yet it is done in a relatively short time. I decided then that simple learning blocks and repetition in the form of a 'drill' would form the basis of my new teaching method.

I came up with the idea of teaching students the initial action up to and including the first two breaths of mouth to mouth. By using low cost mannequins (I use Ambu Multiman) each student is easily able to have their own mannequin, as one can purchase 12 mannequins for the cost of just one typical full sized more elaborate mannequin. They Approach checking safety, attempt to wake up the patient (response) then shout for help. They then say aloud (as they do it): "Head tilt, mouth open, chin lift!" and proceed to check for any breathing effort for 10 seconds. They then say aloud: "this person is not breathing, call an ambulance!" and deliver the first two breaths of mouth-to-mouth. Then, they re-position the head to the normal position, step back and repeat the sequence again. This is repeated at least six times (or as many times as there are students). By so doing, I am able to personally assess and correct, where necessary, each student as they perform this first stage. When all have completed this, I demonstrate stage 2.

Stage 2 consists of the action following the two breaths to the end of the first fifteen compressions. They start with the head in the 'open airway' position and listen for a response to the two breaths (that would have preceded this check) - ie; signs of life. They state aloud: "there are no breathing attempts, coughing or movement - it is a cardiac arrest!" Now they land mark the chest, position their hands correctly and deliver fifteen correct inflations. After that, they step back and repeat the sequence again for the same number of times as they did stage 1. Again I am able to assess and confirm competence for each student, during these repetitions.

Stage 3 is the combination of stages 1 & 2 after which they continue CPR for a full 5 minutes starting from delivery of the first compression. During this, there is ample time again to re-check the competence of each student and the 5 minutes continuous practice seems to demonstrate a continuous improvement in skill.

By the time that a typical class of say, eight students have completed this, they have each undertaken around 20 - 30 minutes of 'hands on' mannequin practise time. My impression is that they achieve a higher standard of competence at the end of training, and they appear to be remaining competent for longer than those taught by previous methods. It is certainly well received by students.

I have not carried out a controlled randomised trial of this system yet, due to lack of resources, although have worked out the methodology for such a trial. I do hope to do so in the near future though, but in the meantime, I would thoroughly recommend that any first aid or CPR instructors reading this, should give it a try!

David Pulman david@dpulman.fslife.co.uk