COLS - How Indian Anaesthesiologists are Educating Citizens to 'Restart a Heart'

Dr Roshan Radhakrishnan
For decades, doctors across the world have been creating and regularly updating step-by-step algorithms on how to save a life of someone who has collapsed. This matters because providing cardiopulmonary resuscitation (CPR) in the early stages of a cardiac arrest can actually save the life of a person who has no apparent heartbeat.

We doctors study these guidelines diligently and become certified providers of Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) by passing exams.

But these international guidelines are not enough for India. And the truth is, we have known it for awhile.

Which is why, the Indian Society of Anaesthesiologists (who formed a special branch called the Indian Resuscitation Council have formulated guidelines specific to the Indian subcontinent to help make every citizen a lifesaver.

These guidelines are called Compression Only Life Support (COLS)

How Indian Anaesthesiologists are Educating Citizens to 'Restart a Heart'

Why is there a need for modifying internationally established guidelines of BLS and ACLS?

  • Doctors and paramedics cannot be everywhere or reach the victim in time, especially in a country like India. When a person collapses on the streets or at home, it is the immediate people in the vicinity who should be aware of how provide CPR and keep the person's heart active till help arrives.
  • The guidelines for BLS and ACLS tends to be complicated with multiple steps. With COLS, the aim is to keep the steps so simple, even an uneducated layperson can understand and perform it easily.
  • Look at the room you are sitting in. Now tell me where the nearest Automated Defibrillator is. You don't know (where/what it is)? Neither do 99% of the Indian population. And a defibrillator is a key part of the international BLS guidelines meant to save the collapsed person. In India where we don't have easy access to these defibrillators, we need to modify the guidelines appropriately to save a life.
  • Cultural issues arise wherein the majority of the public maybe reluctant to provide mouth-to-mouth resuscitation.
  • BLS and ACLS are expensive certified courses that the general public may not be interested in spending time, requiring learning from two voluminous textbooks and attending courses with written and practical exams. 

Compression Only Life Support (COLS)

Keeping the above problems in mind, the Indian Society of Anaesthesiologists held multiple brainstorming sessions and came out with a series of guidelines based on the skill level of the target people - the general public, doctors and paramedics outside hospitals and doctors/ paramedics inside hospitals.

For you, as the general public in India, the guideline to focus on is Compression Only Life Support (COLS) and as part of the concept of spreading the word to help every house in India have a lifesaver, I will explain COLS to you here.

The 3 key steps of COLS are:
  1. Early Recognition and Activation
  2. Early Chest Compression
  3. Early Transfer

What you should do when you come across a victim who is unresponsive.

The three key steps of COLS to follow are:    Early Recognition and Activation Early Chest Compression Early Transfer


1.1 Ensure A Safe Place
If there is an imminent danger of fire or the victim is in the middle of a traffic-laden road, your first goal is to move him away to a safe location.

COLS - If there is an imminent danger of fire or the victim is in the middle of a traffic-laden road, your first goal is to move him away to a safe location.

1.2 Check Response
Tap the person on the shoulder and ask loudly 'Hello! Are You Okay?'

You are looking for a verbal response or maybe a purposeful movement to your query or signs that the person is breathing normally.

COLS - Tap the person on the shoulder and ask loudly 'Hello! Are You Okay?'

1.2.a. If the victim is responsive, observe the victim to ensure he is not deteriorating, call for help and arrange to shift to the nearest facility.

1.2.b. What happens when the victim is not responsive?

This is when your knowledge of COLS can turn you literally into a lifesaver.
  1. Shout for Help.
  2. Call 108 or the local emergency number.
  3. In your call, you must specify -
  • Who You are.
  • Your location.
  • The number of victims - details regarding their age, sex, the incident and condition.

Hang up the phone only when asked to do so after receiving instructions.

COLS - What happens when the victim is not responsive?


The algorithms taught in BLS and ACLS are complicated, involving multiple steps.
In COLS, you focus on one thing alone - 30 CHEST COMPRESSIONS.

In COLS, you focus on one thing alone - 30 CHEST COMPRESSIONS.

Focus on giving 5 cycles of 30 chest compressions, keeping in mind:

  • Push at least 5 cm downwards but more than 6 cms.
  • Compress the chest at the rate of around 120 per minute. 
  • Allow the chest to recoil back to normal between each compression.
  • Do not stop chest compression unnecessarily.

Where do I place my hands during chest compression

  • You want to find the xiphoid process, the lowest end of the bony chest cage situated at the depression in the centre.  

COLS - identifying the point where you give chest compressions is very important

  • You will place the heel of your hand two fingers above that xiphoid process (on the bony cage). Now keep the heel of your other hand above the first and interlock your fingers. Your hands are now firmly in place above the heart. 

COLS - identifying the point where you give chest compressions is very important

  • Compress downwards with your shoulders directly above the victim's chest and without bending your elbows. 
COLS - Compress downwards with your shoulders directly above the victim's chest and without bending your elbows.

How do I do COLS?

  • Do 30 compressions in a cycle, counting loudly. 
  • Do it for 5 cycles without stopping.
  • Compressions can be very exhausting so if more than one person is around, interchange after every 5 cycles.

What do I do after 5 cycles?

You check quickly for a response - is the victim moving, coughing or vocalizing?

What do I do after 5 cycles of Chest compression?

If yes, you have successfully restarted his heart and now need to observe (the patient may get worse again) and shift him to a medical center for advanced care. Take care to place the victim gently on to his side now as it helps keep his airway open in some cases.

If not, we start a new cycle of 5 sets of 30 compressions and reassess once more after that.

The Compression Only Life Support Algorithm meant for the Indian subcontinent to save lives
The complete COLS algorithm looks like this

How Long Can I Continue Doing CPR?

  • Till medical help or a trained rescuer arrives.
  • Till victim is revived (showing signs of life)
  • Till you (the rescuer) is exhausted and cannot do any more compressions.
  • If the place you are in becomes unsafe.

When do I not do CPR at all?

  • If the place is unsafe.
  • If the patient is responsive (awake, talking, breathing normally)
  • If the body has become stiff (suggesting signs of irreversible death)


The key goal of performing COLS is to keep the blood flow pumping to the vital organs (through your compressions) until the patient recovers or else medical help arrives. The earlier he can be transferred to a medical centre for advanced care, the better.

World Restart a Heart Day

In general, anaesthesiologists are notoriously infamous for being inside the operation theater all day. Yet, this - educating the public - matters. On October 23, 2018 all across India, Anaesthesiologists worked together, aiming to personally train over a lakh Indians to perform COLS with visual aids, mannequins and live demonstrations.

As a man who walks two worlds - the medical as well as the blogosphere - this is the best way I can help - by educating you online.

How Indian anaesthesiologists have formulated guidelines specific to India to make every citizen a lifesaver.
Pin this article and save it for later

Please save this page (online or as a printout) and keep it with you. These guidelines have been made just for you by the Anaesthesiologists of India, with the idea of making every Indian capable of saving a life.

And believe me, following COLS can make you a life saver when it matters most. It can literally help you RESTART A HEART.

Authors note:

Got some doubts or an experience to share? Type them in the comment section below.

Want to know more about anaesthesia?

I have written articles on:
1. The Magical Origins of Anaesthesia (Featured in Huffington Post)

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Let me know what you think.

  1. Spread the awareness in all the groups that I'm a part of. You are doing a commendable job Doc.

    1. Thank you so much for sharing. It is meant for everyone of the general public

  2. This is such helpful information, Roshan! Sharing it as much as possible!


  3. A very informative and detailed post on saving someone's life, approach step-by-step and made simple. Thanks for sharing and we need to be educated about the entire process. Public spaces must be equipped with such guidelines.

  4. It's very informative.all should be scientifically learn COLS .
    For almost 25 years i as anaesthesiologist am teaching lay persons .
    I am proud to say mr sachin bhosale 25 yrs male was saved with COLS on 9/11/2013.he,when shifted to hospital ,was diagnosed as massive pulmoray embolism.
    Now he is working as a driver on 108 ambulance...(he is from rich farmer family,but wants to spend some time to save some bodies life.

    From 2013 till today our ISA KOLHAPUR br have record of 17 victims who are saved by lay people and paramedics....
    Long live ISA.

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