Guest Post by Professor Paul Middleton
, emergency physician and founder of Take Heart Australia
I have spent the last 20 years practicing emergency medicine on the ground and in the air. I have attended countless cardiac arrests both in hospital and the pre-hospital setting; performed compressions on hundreds of chests; sent countless joules of energy through wobbling hearts, and squirted buckets of adrenaline into cannulae, IO needles and ET tubes…but I still have an empty feeling inside – I know we can do better.
We hear about cardiac arrest all the time, and as clinicians working in emergency medicine and critical care we spend a larger part of our time dealing with the prevention, treatment, and outcomes of cardiac arrest than any other group.
For the in-hospital cardiac arrest we are often incredibly well informed about the diagnostic synergies of gestalt and troponin, we may know about the predictive power of a lactate above 4 even in the presence of normal physiology, we can see the dysfunctional ventricle and the valvular regurgitation on our bedside echo, and we can avoid complications of intubation by our practiced use of NODESAT and bimanual laryngoscopy….
…but, the simple fact remains, that we are just not going to be there for the 30,000 Australians and 350,000 Americans who suffer cardiac arrest outside of the hospital setting.
Communities in the US, such as Seattle and King County, WA, have a cardiac arrest survival rate of over 60% for patients with shockable rhythms such as ventricular fibrillation or ventricular tachycardia. This is in sharp contrast to Australia, which has VF/VT survival rate of between 10 and 20%. This level of mortality would be unacceptable in any other pathology, so what makes it OK to just accept it here; and what can be so different about Seattle, King County, Arizona, Minnesota and Tokyo, that gives them survival rates 2-3 times that which we have in Australia?
What’s the secret?
Unfortunately, if we’ve learned anything from the last 60 years of resuscitation research…it’s that there is no secret. The venerable model of a “cardiac chain of survival” keeps proving to be true, and good outcomes for any cardiac arrest patient depend on an interlocking series of events occurring rapidly and effectively. When even one link is weak or missing, it can’t be compensated for elsewhere.
Although the establishment of cardiac arrest centres, helicopter cardiac arrest retrieval, ECMO on arrival and even during transport are significant and valuable additions to care, none of them are any use if they are applied to a patient who has been in cardiac arrest without basic life support for more than ten minutes or so. We already know that for every one minute without BLS before defibrillation means almost 10% decrease in survival, and intense focus on technological and infrastructure-heavy additions to the far end of the chain or survival often miss the point that much more bang for our buck is achieved, much more cheaply, with focus on the first two or three links in the chain.
In most cases of cardiac arrest the weak, or more often non-existent, link is layperson intervention. Most cardiac arrests do not get bystander chest compressions; either they are afraid of doing it wrongly, afraid of causing harm, afraid of being found liable for some later problem, worried about catching some disease, or just not being confident that they could recognise the need. If high-quality bystander CPR is started, however, the decrease in survival slows to 3-4% each minute to defibrillation.
Similarly, the success of Automated External Defibrillators used by bystanders has been shown to be hugely beneficial, with twice the number of victims surviving in one trial where AEDs were added to standardised CPR training, compared to CPR alone. If you insist on having a cardiac arrest, have it at the Melbourne Cricket Ground, where bystander CPR rates are over 90%, 85% of victims are resuscitated at scene, and 70% leave hospital. OHCA survival can be between 40 -70% in airports, casinos and aircraft, but most success is seen where there are AED placement programs, or PAD programs, with lay rescuers trained as first responders and the AEDs linked to the ambulance service.
The first five minutes holds the key to survival. We need more people of all ages who are trained and willing to provide immediate CPR, more and easily accessible defibrillators and we need a coordinated healthcare system.
Thus, the challenges of cardiac arrest resuscitation have shifted from the clinical, such as finding the ideal antiarrhythmic medication, and toward the psychological – determining how to market CPR so people will learn it, teach it so they’ll remember it, and contextualise it so they’ll be willing to do it. It is no coincidence that the ILCOR and ARC guidelines have become exponentially simple and straightforward over the last few years; what we now realise very clearly is that we need to perform the most basic of interventions, but do them really, really well.
What are the possible models?
To illustrate what is possible, we should think about what happens in Seattle. Emergency physicians and senior emergency medicine technicians from Medic One, the venerable and highly effective ambulance service in Seattle City and King County, run the Resuscitation Academy. This teaches the core message that communities need to work as single systems to ensure the best survival from cardiac arrest, and that this system starts with the bystander. Not content with just making CPR training available, there are impassioned and active campaigns to inform, persuade and educate the entire community of the necessity of immediate recognition of the problem, instant CPR and AED use as quickly as possible. As a result, the population as a whole is responsive and primed to take responsibility to save the life of the victim who was standing next to them only a few moments previously. They joke that you can’t fall asleep in a Seattle park in the summer sun, as someone will immediately start pushing on your chest!
AEDs are positioned in multiple public locations and the Seattle AED Register not only plots the position of the majority on a mapping tool, but also allows immediate identification location by 911 operators to allow them to direct rescuers to devices. Seattle EMTs respond with at least three vehicles to each arrest, giving a minimum of seven EMTs at each scene, allowing a highly organised ‘pit crew’ model, where the role of each and every provider is explicitly planned, assigned and choreographed. This means that the fundamentals of performing deep and fast compressions with full recoil, minimal interruptions, no hyperventilation and seamless integration with defibrillation are comprehensively drilled well ahead of time.
Destination hospitals are well organised and clearly defined in terms of their capabilities and capacity, meaning that patients are rapidly transported to hospitals that are set up to provide immediate access to angiography and angioplasty, ECMO, targeted temperature control and intensive care.
To construct a system like this, which actually works to provide the desired result, numerous parties must be involved, including government, ambulance, hospitals and healthcare agencies, as well as, crucially, clinicians and the public themselves. This disparate and inertia-ridden bunch won’t come together without active efforts to recruit, enthuse, motivate and coordinate them, so champions are needed to advocate for a new system. Since most victims of cardiac arrest don’t survive, the problem remains one of low visibility and poor public awareness, but emergency and critical care clinicians, including paramedics, nurses and doctors, are well positioned to shoulder this burden, and utilise their motivation and energy to drive the changes needed. We even need the benefit of hearing the stories of survivors, as these are some of the most powerful motivators to do the job well, bringing the issue to life, particularly when knowledge of the problem is limited.
Everyone believes in the ideas and wants survival to improve, but we know we need to put in real work to make real changes, and although it’s often difficult to gain traction when most people don’t realise the problem even exists, transformation can snowball once momentum is developed. One of the great achievements in Seattle wasn’t just developing the tools for resuscitation, but was creating a culture of survival. Not only is the community proud of what they have, and believe in it strongly, but so also are the clinicians of all backgrounds. When someone collapses in the street there is an expectation that someone will intervene and that if they do so, the patient is likely to survive!
What can we do in Australia?
Take Heart Australia launched on 28th May 2014. This is a public advocacy organisation and a charity, and its aims are to increase survival from cardiac arrest in Australia. It is modelled after some great templates that already exist, such as the HeartRescue program, HEARTSafe communities, Take Heart America and, of course, the Resuscitation Academy.
Take Heart Australia plans to drive system change to construct a real chain of survival, where if someone collapses outside hospital, rescuers will be trained and willing to immediately intervene, call for help and start high-quality CPR; where there is a Public Access Defibrillation program in place that allows a bystander to quickly appear with an AED and use it, because the PAD program is coordinated with the 000 dispatchers who instruct the bystanders; where there are widely used smartphone programs that alert potential trained rescuers to the collapse; where the ambulance services arrive quickly and perform seamless and coordinated pit-crew BLS and ALS; and where the destination hospitals have the capacity and the training to implement recognised evidence-based solutions in peri- and post-arrest care to improve outcomes.
Supporting organisations include Surf Life Saving Australia, the Royal Life Saving Society, St John’s Ambulance, Careflight, the Royal Flying Doctor Service, Ambulance NSW, Fire and Rescue NSW, Police Rescue, the Royal Australian Navy Submarine and Underwater Medicine Unit, Laerdal, Zoll and Physio Control.
We are developing a THA badged HQ-CPR course, producing a documentary and talking to schools, RSLs, sports clubs and others about AED placement and training, and trying to come up with innovative schemes to allow areas to band together to provide AED coverage. We are talking to our colleagues in the ambulance, fire and police services to try to move forward an agenda of actually working together to actually make this all work, as well as lobbying politicians not only to bring it to their attention, but to keep it there!
What we need, though, is two more things to give Take Heart Australia the credibility, drive and energy it needs to start to take cardiac arrest survival towards Seattle levels. It needs data, and it needs you!
If we don’t know what we are doing then we can’t improve it, and if we don’t collect good data we cannot know whether all these interventions will incrementally improve survival. Take Heart Australia is working with our embryonic emergency medicine epidemiology and research network, the DREAM Collaboration, to put emergency medicine clinician researchers together across NSW and Australia, entering small amounts of granular clinical data into linked, routinely collected administrative data sets. We plan to actively work with ambulance services and other researchers to build up a clear picture of the outcomes of cardiac arrest and related problems. We are also working with some hospital colleagues to plan trials of in-hospital cardiac arrest registries and analysis.
We also need advocates, champions and campaigners across Australia, willing to drive change in their communities, nag bureaucrats and politicians, speak at meetings, assist with training, and a host of other tasks. Join us on Twitter (@TakeHeartAust), Facebook and the website and together we can make a difference…