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How to care for lay responders who perform CPR

Diffusing and debriefing lay responders can mitigate traumatic stress and reduce the risk of post-traumatic injury from the experience of performing CPR


Paul Snobelen, specialist, Community Safety Programs for Peel Regional Paramedic Services, presented his research findings to EMTs and paramedics attending EMS World Expo 2019.


NEW ORLEANS — The Lay Responder Support Model (LRSM) is a framework to capture first-hand information from the lay responders’ perspectives about their experience of providing CPR and using an AED. Paul Snobelen, specialist, Community Safety Programs for Peel Regional Paramedic Services, presented his research findings to EMTs and paramedics attending EMS World Expo 2019.

Snobelen became curious about the bystanders who witness cardiac arrest in public places through repeated scene observation of lay responders’ experience with cardiac arrest response before paramedics arrive. During the presentation, he discussed the need to understand the psychological impact on lay responders and developing a systematic approach to support those individuals.

Peel Regional Paramedic Services, the second largest municipal service in Canada, serves 2.1 million people during the day, as well as Canada’s busiest airport. Peel paramedics respond to 133,000 calls annually with 1,400 cardiac arrests per year. Lay responders in Peel perform CPR on 45.1% of sudden cardiac arrest patients, with an overall survival rate of 16.9%. Survival from VF is 37%.

Memorable quotes on lay responder follow-up, research and care

Here are five memorable quotes from Snobelen’s presentation:

“We created a culture for medics to help everyone involved. They know if they collect information, someone will follow up with the bystanders.”

“At each incident, there are usually three to four lay responders involved.”

“Only two people have declined a post-incident debriefing invitation. There have been some no-shows – 78% of people have attended a debrief.”

“Paramedics; the most important thing you can do to help bystanders is two words, ‘thank you.’”

“The biggest piece of all of this is we recognize the action, not the outcome.”

Top takeaways on the impact of acting to save a life on lay rescuers

Here are the top takeaways from Snobelen’s presentation.

1. Acknowledge the impact of CPR on bystanders

Snobelen’s journey began with recognizing that the people who witness cardiac arrest and take action to save a coworker, customer or stranger are impacted by witnessing death and acting to save the patient. The framework Peel has developed is available for other EMS agencies to implement for their cardiac arrest lay responders.

2. Formalize a post-incident response model

Peel developed a first of its kind post-incident response model for cardiac arrest to bridge the clinical review and the psychological impact of being a lay responder. The first stage of the model is to identify and engage lay responders. Snobelen offers post-event diffusing and invites people to a debriefing.

Stage two of the model, 12- to 24- hours post incident, is data collection about the lay responder’s role, the initiation of CPR and the application of the AED. Snobelen noted that 56% of the time a lay responder reported an issue with the functionality or use of an AED, including issues with lid removal, button colors and volume.

The third stage of the model is follow-up with lay rescuers and – as needed – referral for professional support. Types of support include non-professional care, professional care and self-care. Peel has developed a Bystander Resource Guide to assist lay rescuers with support. Additional follow-up is used to determine if lay rescuers’ needs have been addressed. This final follow-up step is either recognition of action or – in rare cases – referral to professional mental health services.

3. Post-incident mitigation prevents traumatic stress

Exploration of a responder’s thoughts and perceptions, in the third stage, followed by a technical review of CPR performance and AED use, is the critical component of the post-incident debrief. Snobelen described the importance of identifying and mitigating cognitive distortions; essentially bystander misunderstandings about the impact of care, such as breaking a rib. If those cognitive distortions go unaddressed, acute stress can develop and potentially worsen to post-traumatic stress injury.

Snobelen listed the 11 most common bystander questions he answers in post-incident debriefs. Those questions are:

  1. Why was there blood coming from the mouth?

  2. Why was their stomach moving so much during compressions?

  3. Why were their eyes open?

  4. Why did they make sounds? (gasping, gurgling)

  5. Why were they drooling/frothy?

  6. Why did they soil themselves?

  7. Why were they twitching/making a fist?

  8. Why did their color change? Why so fast?

  9. Am I supposed to break ribs to do proper CPR?

  10. Were they actually dead?

  11. Was it my fault?

Those questions are helpful insights for other EMS leaders, as well as CPR instructors.

4. Better inform bystanders about what cardiac arrest looks like

Snobelen’s research has identified that what people are taught about recognizing cardiac arrest (I.e., unconsciousness and no normal breathing signs) doesn’t match the signs noticed by lay rescuers. In reality, lay rescuers tell Snobelen they see significant discoloration, abnormal twitching, snoring, gurgling sounds and incontinence.

5. Engage lay responders in sharing, connecting

The Bystander Network is a virtual resource for bystanders and survivors to support future research. Since its 2017 launch, 72 people have asked to join the bystander network and 22 people have submitted their rescue story.

Learn more about lay responder CPR

To learn more about lay responder CPR check out these Circulation articles and EMS1 articles:

This article, originally published in October 2019, has been updated.

Greg Friese, MS, NRP, is the Lexipol Editorial Director, leading the efforts of the editorial team on Police1, FireRescue1, Corrections1 and EMS1. Greg served as the EMS1 editor-in-chief for five years. He has a bachelor’s degree from the University of Wisconsin-Madison and a master’s degree from the University of Idaho. He is an educator, author, national registry paramedic since 2005, and a long-distance runner. Greg was a 2010 recipient of the EMS 10 Award for innovation. He is also a three-time Jesse H. Neal award winner, the most prestigious award in specialized journalism, and the 2018 and 2020 Eddie Award winner for best Column/Blog. Connect with Greg on LinkedIn.