CPR, implicit bias training and lessons for the medical community
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The United States is in the throes of debate over police reform.
In a recent editorial, Cardiology Today Editorial Board Member Kim Allan Williams Sr., MD, MACC, FAHA, MASNC, FESC, James B. Herrick professor and chief of the division of cardiology at Rush University Medical Center and past president of the American College of Cardiology, said making CPR training and implicit bias training mandatory for police officers could help prevent deaths such as George Floyd’s, a Black man who died of asphyxia with hypoxic cardiac arrest after a police offer kneeled on his neck.
“While racism may have loaded the gun of police actions [that caused deaths such as Floyd’s], I would posit that ignorance actually pulled the trigger,” Williams wrote in the International Journal of Disease Reversal and Prevention, of which he is editor-in-chief. “To paraphrase Hanlon’s razor, we should not necessarily ‘attribute to malice that which is easily attributed to ignorance.’ In fact, I view this as an education failure, or rather a learning opportunity, of the deepest human and economic consequences of theft and property destruction, the latter fueled no doubt to some degree by pent-up COVID-driven frustration and unemployment. Prevention in this regard would therefore need to correct two educational failures for everyone who works in a public-facing profession: training in personal implicit bias and basic CPR — airway, breathing and circulation.”
Healio spoke with Williams about the potential societal benefits of requiring CPR training for public employees, how better understanding of human physiology could help reduce disparities in health and other areas, and how these lessons can be applied to the practice of medicine.
Question: Why do you think CPR training has been underused?
Williams: This is one of many facets of institutional racism in the U.S. One example where this was documented was in a study published in July 2019 (Naim MY, et al. J Am Heart Assoc. 2019;doi:10.1161/JAHA.119.012637), which found that race and neighborhood characteristics dramatically impact which children were able to receive bystander CPR. The more “nonwhite,” low education and low income a neighborhood was, the less likely a child there was to receive bystander CPR.
Beyond this, I and many others have theorized that knowledge of CPR — airway breathing circulation — by all responding and arresting police could have prevented respiratory obstructive deaths. I wrote in the International Journal of Disease Reversal and Prevention editorial that understanding CPR principles “might have led the arresting officers to consider the mortality rate associated with inability to breathe, changing the outcome for the victims, their families, law enforcement and, in [the Floyd] case, countless large and small businesses in urban areas and their workers.”
Q: What are the arguments for police not performing CPR training, and what are the counterarguments?
Williams: Some police officers feel that this would be job creep. They are required to learn many skills, and feel that this is the domain of emergency medical technicians. Concern for personal health and lawsuits are among the other factors for not getting CPR training.
The most powerful argument for them getting CPR training is that people are dying because of lack of community knowledge about CPR. That may not be entirely solved by training police to do CPR, but more people in the community understanding CPR principles can only help. The officer who killed George Floyd did not intend to crush his airway. If he had known just a little respiratory physiology from a CPR course, maybe he would have thought twice about what he was doing. Avoiding choking incidents will help greatly. Legislation has come up in various regions to bar chokeholds. This is somewhat controversial because it has been argued that a chokehold can prevent a shooting. I can understand that, but at least the police should know what they are doing in terms of maintaining an airway.
Q: What are the potential societal benefits of CPR training?
Williams: CPR saves lives and saves functioning lives. According to the CDC, “9 in 10 people who have cardiac arrest outside the hospital die. But CPR can help improve those odds. If it is performed in the first few minutes of cardiac arrest, CPR can double or triple a person's chance of survival.”
For example, Seattle has been a hotbed of CPR training, and has had better outcomes than the rest of the country because witnessed arrests would generally get CPR, which is not the case in other parts of the country.
Q: Are there other ways in which better education about human physiology can produce societal benefits?
Williams: For the entire community, not just the police department, better understanding of how the body works would be extremely helpful to many Americans, particularly those suffering from health care disparities, part of which is attributed to poor health literacy. This lack of understanding can lead to poor choices when it comes to diet, exercise and many other lifestyle choices.
Q: Why do you think implicit bias training has been underused?
Williams: Many are unfamiliar with implicit bias training. In fact, they are not aware that we all have inherent biases that need to be unroofed so that they can be addressed head on.
Implicit bias has existed for centuries, and the ability to correct it has been very slow. As Malcolm X said, “If you stick a knife in my back 9 inches and pull it out 6 inches, there's no progress. If you pull it all the way out, that’s not progress. Progress is healing the wound that the blow made. And they haven't even pulled the knife out, much less healed the wound. They won’t even admit the knife is there.” With the events of the past few weeks, everyone knows the knife is there.
How can we retrain everyone to recognize the biases they were brought up with? Almost all of them are based on experiences and learned behavior. The Black population has been looked down upon for centuries, and it is hard to disembed that from the experience of human life in the U.S. and elsewhere. I think progress is going to be made. I do not know if the knife is out of the back yet, but we have taken the first step, and everyone is admitting there is a knife now.
Q: What are the potential benefits of implicit bias training in the health care realm?
Williams: The medical literature on health care disparities is replete with implicit bias, resulting in poor outcomes, particularly for minorities and women. We may not be able to eliminate all of these all at once, but we can certainly make the practitioner aware of biases that can be corrected.
A well-known example of implicit bias in health care is that of Serena Williams, the Black tennis star. She had had foot surgery to reattach a tendon and flew across the country while in a cast. The cast, air travel and immobility gave her deep vein thrombosis and pulmonary embolism. Later, when she had a baby, she had a lot of hemorrhaging and told her doctors that she felt she was getting DVT again and they should do an ultrasound. They told her she was fine and did not need to worry. This is the kind of response men give to women, particularly Black women. After she almost died a second time from PE because they missed her warning about DVT, she gave interviews about how the concerns of Black women are ignored by a mostly male and white physician workforce.
Q: You are involved with the ACC Task Force on Diversity and Inclusion. What has it done to help counteract implicit bias?
Williams : The ACC task force has pushed recently for all members and leadership, including the board of trustees, board of governors and leaders on our ACC staff, to undergo implicit bias training. We are hoping to change the culture within cardiology toward more equanimity between ethnicity and gender. This will hopefully attract the next generation of women and underrepresented minorities into the field of cardiology.
This may seem burdensome and upsetting, but once you recognize your biases, you can do something about them. I was able to recognize my own bias of ignoring white male homeless people while giving to females and minorities who are homeless. I do not do that anymore. Maybe it was easy to change my behavior because I think about these issues all the time, and maybe it will not be as easy to change police behavior because every police killing I can think of has been motivated by fear, but it’s very important to try.
For more information:
Kim Allan Williams Sr., MD, MACC, FAHA, MASNC, FESC, can be reached at 1717 W. Congress Parkway, Suite 303 Kellogg, Chicago, IL 60612; email: kim_a_williams@rush.edu; Twitter: @cardio10s.
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