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Before I tell you what this pocket-sized problem is, let’s back up a bit.

To get an open airway in an unconscious, non-breathing casualty one of your best bets is the good old head tilt, chin lift method. Head tilt gets the tongue off the back of the throat and chin lift… exactly what does chin lift do?

In your throat, down past your tongue you have a little flappy valve thing made of cartilage called your epiglottis. Right now, you’re breathing, and your epiglottis is in the vertical, open position allowing air to enter and leave your lungs via your ‘wind pipe’.

During lunch however, when you swallowed that mouth full, your epiglottis did this neat trick where it lays down and closes the wind pipe so that the food parcel will travel to your stomach and not your lungs.

The problem is that if you’re unconscious, not breathing and laying on your back, your epiglottis relaxes into the ‘close the airway’ position. This means that if you tilt their head back, pinch their nose, make a seal with your mouth over theirs and blow… you’ll get noisy, obstructed respiration and probably just inflate their stomach.

Apart from not doing anything to help the casualty it also means more pressure in the stomach. The more the stomach expands, the more it forces other organs up into the diaphragm area, making it harder for the lungs to work. Give the stomach enough pressure and their lunch is going to revisit you too. As if CPR was difficult enough, now it’s becoming really gross, yucky, smelly and that chunky material can block the airway.

So how do we avoid all this hassle? Chin lift.

Lifting the chin, lifts the epiglottis off the wind pipe. To see it in action here’s a video provide from our good buddy Dr Justin. They are using the jaw thrust method but it produces the same effect.

If you don’t know who Dr Justin is, you should watch some of his presentations here. Highly recommended watching. Even if you know the topic he’s speaking on your understanding will improve every time you listen to him. He is one of only two Doctors I know who speaks fluent ‘lifeguardian’, probably because he’s a lifeguard as well.

So now we’re up to date on why head tilt AND chin lift, are really important.

The pocket-sized problem is pocket cpr masks. If you’re doing one-person CPR from the standard position beside the casualty, how do you do chin lift if you’re pushing the mask down to get a seal on the face?

If you’re doing CPR like this and you aren’t seeing chest rise, I think you have three options;

  1. Keep doing what your doing and watch the person die.
  2. Throw away your pocket mask and do mouth to mouth.
  3. Move to the head end of the casualty and do CPR from there. Now you can use the jaw thrust method to open the epiglottis and pull the person’s jaw up into the mask to get a seal. A couple of effective breathes and then you can lean over, across their head, and do compressions from there.

I had not heard of ‘Overhead CPR’ before but there are a number of organisations who use it e.g. the Royal Australian Navy and the New Zealand Ambulance Service (St John’s). Both of these organisations use the method when other factors mean there is no room to get to the side of the casualty such as a narrow gangway on a ship.

Lifeguards, and all first responders for that matter, need less procedures and more options. When the way we fight becomes blocked, we need another way. Otherwise we keep doing, what we’re doing and the result doesn’t change. We need to be able alter our response to match the emergency unfolding in front of us.

Laerdal has a video on their YouTube channel of how to use a pocket mask. You’ll notice that it’s not used from the side of the casualty;

Incidentally when in New Zealand training lifeguards recently I noticed a few using face shields not pocket masks. A plastic shield still allows the chin lift method but it’s still not as easy as mouth to mouth. The ones I saw used had a small plastic insert that located the shield correctly over the casualties face and helped it stay in position.

Whatever you use, practice with it. If you don’t, first time you’re required to use one, be that training or the real thing, it becomes plainly obvious if you haven’t.