CHARLES LINDBERGH’S HISTORIC FLIGHT across the Atlantic Ocean was triggered in part by a bet. New York hotelier Raymond Orteig offered $25,000 to the first person who could fly between New York and Paris, and several pilots lined up to take the risk. While Lindbergh’s successful transatlantic flight in the Spirit of St. Louis in May 1927 has been well chronicled, it is little known that four of his competitors died. Two were killed in a test flight in Virginia, and two others attempting the journey from France disappeared after crossing over Greenland. Clearly, such a journey in a plane made of wood strips held together with wire and linen was fraught with peril.
Domestic commercial air travel at that time was nearly as dangerous. Though the planes were sturdier, there was still not a comprehensive system in place to enable flights to take place safely. For example, there wasn’t the same level of integration between pilots and crews on the ground, airports were primitive (often not much more than a large field), and communication was limited, as was the understanding of how to handle safety issues on board. For instance, if the seal on the door were to become compromised, the pilot would likely continue the journey rather than going through a checklist and then making adjustments in altitude, cabin pressure, and flying speed to prepare for an emergency landing. Consequently, passengers boarding a plane were almost literally taking their lives into their own hands. In the United States from 1926 to 1927, there were twenty-four fatal commercial airline crashes. Things got worse in the following two years as commercial airlines logged sixty-seven deadly crashes. The fatality rate was one passenger death for every three thousand flying—which would translate to seven thousand deaths per year in today’s numbers. This is staggering given that from 2000 to 2010, even with the deaths on 9/11, the fatality rate was just one in eight million.
The aviation industry in its infancy was roughly where cardiac arrest care and resuscitation are today in terms of the implementation of optimized system management, as well as, of course, safety measures. Despite the fact that planes were becoming more reliable throughout the 1920s, there was a lack of overall system management in place, so fatalities remained high. Likewise, nascent resuscitation techniques discovered in the mid-1960s, such as closed chest compressions and artificial breathing through mouth to mouth, were being done in isolation and not as part of a comprehensive and integrated system of care with attention being paid to every vital link of what we have termed the “chain of survival.” But once aviation married better equipment with a comprehensive and systematic program that included better aircraft design, materials, aerodynamics, landing gear, on-the-ground inspection teams, specialized airports (instead of fields), radar, crew management and teamwork, and a checklist safety system, fatality rates dropped rapidly—to 1 in 450,000 in the 1960s and then to 1 in 2 million by the 1980s.
Aviation and resuscitation science share many similarities. Both are new discoveries that have enabled human beings to overcome something that had forever seemed impossible—a flight of fantasy or a dream that would never be within the realm of possibility. What aviation and resuscitation science share most of all is that they both require a highly complex, sophisticated, and integrated system of management, which if it fails inevitably leads to fatalities or devastating disabilities—even if the failure was due to just one error.*
Today we take flight for granted. It doesn’t seem so novel anymore. When we sit on a modern aircraft and fly tens of thousands of feet above the ground and thousands of miles across the earth, we are most likely not even aware of the human toil, sacrifice, perseverance, and dedication that eventually led to this truly incredible achievement. But in 1903, after many attempts, the human dream of flying using a machine heavier than the air was finally realized on a remote, windswept beach in North Carolina. In truth, even that event itself was far from earth shattering. A “flying machine” built by two brothers managed to overcome gravity and fly a little above ground for only twelve seconds—a far cry from what we have achieved today but nonetheless incredibly significant. From this small event, now we overcome the force of gravity using a machine that is far heavier than air and fly anywhere we want, including into deep space. Anyone who has seen the sketches of Leonardo da Vinci’s flying machine will get a feel of what a real fantasy this idea must have been to our forefathers. But in just over sixty years after the Wright brothers’ first flight using their primitive plane, we developed aircraft and engines that could not only safely fly thousands of feet above the ground, but could also fly supersonically and even hypersonically reaching the highest points of the stratosphere and even on to the moon. The challenges were incredible, but what was achieved in this time period simply attests to the incredible human resolve in overcoming any challenge, no matter how seemingly impossible.
By contrast, in the almost sixty years that followed the discovery of modern resuscitation by pioneers such as Safar, Jude, Knickerbocker, and Kouwenhoven, we have not witnessed anywhere near the same level of progress in this field. In fact, despite the fact that we have made enormous progress in the fields of science and medicine, and we now have cardiac catheterization laboratories, modern ventilators, and powerful blood pressure drugs to keep people alive, our long-term survival rates from cardiac arrest have not particularly improved in this time frame. It’s really amazing but absolutely true. When I first came across this statistic, I frankly didn’t believe it. I thought it was impossible. I actually searched the original studies from the 1950s and 1960s up to the present day but found that it was indeed sadly true.* Interestingly, when I now bring this up at conferences or lectures, it has the same jaw-dropping effect on others too. In many ways, resuscitation science reflects the opposite to aviation. That is, although resuscitation after cardiac arrest is an incredibly innovative scientific discovery and the field has progressed scientifically in the past sixty years, it has lacked a sophisticated and coordinated system of management. Resuscitation science reflects the story of at best limited and often failed universal implementation and adoption of the highest standards combined with a lack of external regulation. It also reflects what happens to a medical condition that cuts across all boundaries and is thus not “owned” by any one group of medical specialists such as cardiologists, neurologists, or emergency medicine doctors. Consequently, no one group drives the highest standards of care in our hospitals and in the communities.
Asthma has a home in pulmonary medicine. Cancer is the domain of oncology. Parkinson’s belongs to the neurologist. But cardiac arrest is an orphan by virtue of the fact that it cuts across many specialties because it is death, and death happens in all specialties of medicine but is parented by no one. This comes as a surprise to most nonmedical professionals, who assume cardiac arrest and a heart attack are one and the same, but as we have demonstrated, they are not. Cardiologists specialize in the heart attack, which occurs when a blocked blood vessel stops blood flow to the heart, but they are generally not trained in the full spectrum of resuscitation because this requires expertise in a whole lot more than just the heart. It includes many delicate noncardiac facets involved in restarting the heart combined with excellent postresuscitation treatments, which should be the area of responsibility of the intensive care physician, as well as brain management, which should be the province of specialized neurological intensive care physicians. A cardiologist is not an expert in critical care medicine, including the management of complex lung and ventilation disorders, while the intensive care physician is not trained in the nuances of cardiac care, and neither of the two is usually fully versed in the intricacies of brain management. Of course, the neurological intensive care physician who is an expert in this area is also not an expert with the heart and lungs.
This in itself leads to variations in treatment. For this reason, even in the same institution, the same patient will not infrequently receive different care depending on who is in charge and which ward the person is taken to, such as the medical intensive care unit, coronary care unit, surgical intensive care unit, or neurological intensive care unit. This applies to the large institutions with multiple intensive care units, while in smaller community hospitals with fewer resources the care can also vary. Furthermore, inadvertently people may manage cardiac arrest without clearly following all the latest recommendations, discoveries, or guidelines because they may not be fully aware of their existence, or even how to implement them, which also contributes to the enormous variations in the standard of care. It is seeing this variation that drives me to push on and work hard in this field, and it is this that motivates me to write this book and highlight some of the areas that need to be improved in order for us to save many more lives and brains.
Today, when it comes to safety, there has been a reversal in aviation, and most of us feel completely safe on an airplane. Modern-day commercial air travel is statistically the safest mode of mass transportation—even flying across the Atlantic Ocean by way of Greenland. Airline crashes garner major national news coverage because of the sheer number of people involved, whereas even the worst automobile crashes are typically limited to a segment on the local news. But the fact is that flying is overwhelmingly safer than traveling by car. Consider that in 2008 the National Transportation Safety Board in the United States reported 1.27 deaths for every 100 million miles driven in an automobile. By contrast, there were no commercial airline deaths that year in twenty accidents reported; therefore, there were zero airplane deaths per 100 million miles flown. According to the National Safety Council, the odds of dying in a motor vehicle accident over an average lifetime are 1 in 85, or 1 in 6,584 per year, whereas the odds of dying in an airline crash are 1 in 5,862 over a lifetime, or 1 in 455,516 per year.
Flying is far safer than it was in Lindbergh’s day because numerous advancements have taken place in aircraft design, navigational instruments, and safety procedures on the ground and in the air. But the main reason that flying is the safest mode of transportation is the development of step-by-step protocols for servicing and operating airplanes that include many people working together seamlessly in concert in all stages of a flight. Through these detailed procedures, mistakes can be found and corrected before they endanger lives both on the ground and in flight. The many perils of everyday air travel, such as foreign object debris, lightning, ice, engine failure, bird strikes, volcanic ash, misleading information, criminal acts, and human error, can be mitigated through a system of checklists and procedures that have been implemented by the airlines and are enforced by bodies such as the Federal Aviation Administration in the United States, the Civil Aviation Authority in the United Kingdom, and other similar organizations across the world.
These procedures involve a “chain” with many links, and if one or two links are missing, the results can be disastrous. Consider the deadly Air France Concorde crash in 2000 that ultimately resulted in the grounding of the Concorde altogether. Investigators found that several steps in the safety chain had broken down. The plane was loaded up as much as one ton over its maximum weight, and its center of gravity was tilted toward the rear rather than being centered. Further, fuel distribution was incorrect and fuel shifted during taxi and overfilled the number five fuel tank. Minutes before the Concorde took off, another plane in its path lost a small strip of alloy on the runway, but this debris remained because a mandatory tarmac inspection was not completed. As the Concorde was taking off, it ran over the debris, which was then slingshot into the number five fuel tank, causing a shock wave that resulted in the fuel tank rupturing. The fuel that spewed out was ignited and the fire damaged one of the wings, rendering the aircraft unstable in flight and ultimately causing it to crash.
To better describe the state of resuscitation, imagine if today the risk of flying had always remained as high as in the 1920s and everyone simply took this fact for granted because “well, it has always been risky to fly.” Furthermore, the standards of pilots and the various crews needed to provide the requirements for flight varied greatly not only from airline to airline but even within the same airline. However, no external regulation and monitoring ensured standards. Also in this operational climate, when new scientific discoveries took place that could help improve flight and make it safer, they would either just not be adopted or adopted piecemeal during some flights but not others. For instance, imagine if following the discovery of radar, some airports or airlines continued to work without it, or it was only used on some flights while on others it wasn’t, because some people “believed” in radar while others didn’t even though its benefits had been acknowledged scientifically and its use recommended by the various national and international aviation bodies.
Imagine further if external organizations did exist that could make recommendations, but there was no organization to enforce the highest standards whether it be the incorporation of radar, or the level of training for the staff involved in flight. So ultimately the decision to train staff or use radar or any other factor was left to individuals such as pilots, airline managers, or local airports, and their decision to adopt these or not would of course reflect a variety of issues such as knowledge, experience, expertise, financial constraints, and so on.
Although the preceding is thankfully largely unthinkable in the airline industry, this is the situation we face with resuscitation science. Without doubt, the majority of our doctors are remarkable and exemplary, as are our pilots. The expectation that as well as knowing how to fly, a pilot or any one individual should also know all there is to know about radar, aircraft design, materials, running an airport, creating landing systems, and so on, and have the final say about all these vital components involved in successful aviation would seem absurd. Medicine too has become so sophisticated that it would be impossible to ask a physician or any hospital manager to know all there is to know. This is why, even though I may meet a remarkable physician, it would be impossible to expect him or her to know how to manage all the nuances of resuscitation science, because in the same way that flight is much more than taking off from the ground for a short time using a simple aircraft made of wood, resuscitation is also far more than chest compressions, breathing, shocking the heart, and giving drugs.
So while we figured out long ago that success with aviation would only come about through the establishment of a universal system that puts together all the important components into preflight, in-flight, and postflight stages and thus made aviation the safest form of mass transportation around the world, we have not implemented the necessary complex systems of care needed to overcome the issues of precardiac arrest, intracardiac arrest, and postcardiac arrest complexity and ensure acceptable outcomes with this condition. This applies to our hospitals, our ambulance services, and our health-care establishments. This is the big challenge we face today. It’s like saying we know how to make better aircraft and we have great pilots, but we still have the same overall fatality rate associated with flight—the problem is not with the pilots or planes, it’s just that we haven’t incorporated all the other vital components, such as good airport landing systems, radar, crew management, and so on, into an efficient system.
Resuscitation science could learn from the airline industry. Pilots spend countless hours in simulators before they fly each aircraft. They practice crisis management in concert with flight attendants and emergency personnel, so when a disaster occurs, they have a detailed procedure to follow that eliminates much of the guesswork. In contrast, in resuscitation science, only a relatively basic training program, called Advanced Cardiac Life Support (ACLS), is in place for doctors. As mentioned earlier, it teaches basic teamwork and cooperation skills, as well as how to perform chest compressions, assist breathing, provide shocks, and give drugs correctly.
These courses have many limitations. For starters, the overall level of the course corresponds more or less with the core discoveries made in the 1960s and 1970s, and it doesn’t put together all the other various complex treatments that are involved and needed for greater success with this condition. It teaches medical, nursing, and ambulance personnel how to deliver the basic core components that, while undoubtedly very important, reflect only a fraction of the level of knowledge needed. Although great as an introductory course to resuscitation science that teaches the basic skills required to restart the heart, which is vital, the course is too basic.
The other major problem is that these courses are not even always mandatory for medical professionals who could end up dealing with a cardiac arrest case. Some assume that by virtue of having trained in cardiology, intensive care, or emergency medicine a physician would simply know and should be able to deliver all the nuances of resuscitation. Patients who have suffered a cardiac arrest are by definition the sickest patients in any hospital, and many have multiorgan failure resulting from a lack of oxygen being delivered to their organs and are in a state of medical shock. They often have brain failure, heart failure, kidney failure, liver failure, lung failure, infections, and much more.
Training in any one field of medicine does not provide expertise with all the nuances of cardiac arrest cases, since the nuances cross many different specialties; the knowledge required is real hands-on practical knowledge and not theoretical knowledge. While we can’t expect such a high level of knowledge from our ambulance crews, nurses, or junior doctors who may be the first to the scene of a cardiac arrest, they all need to be able to perform the basics very effectively and deliver patients to specialized units with a comprehensive system that can deal with all nuances. Currently these systems and hospitals do not exist in a formal systematic fashion. It is very easy to save a life in theory but very hard in practice. The courses are also designed to cater to all levels and thus often contain people of different abilities. For example, a nurse working in an outpatient skin clinic who has never dealt with a critically ill patient will do the same ACLS course as a senior cardiologist, a medical director of an emergency department, or a senior intensive care physician who deals with life and death every day. This simply highlights that the level of knowledge taught in these courses, while vitally important, is too basic and only touches part of the problem.
The ACLS course contains some simple role-play and simulation cases, but they are not extensive or detailed enough. In addition, for those who take the course, it is usually repeated every two or three years, depending on which country the person lives in, but realistically speaking it is not possible to expect people to remember all the details of any course, let alone an important lifesaving course with two- or three-year blocks of time in between attendance. Many studies have confirmed that significant skills decay within just a few weeks to months after taking the course. We had firsthand experience of this at my own hospital after we put together a training course for our emergency doctors last year and found that when we retested them a month later, they had forgotten much of it. As a result, we have now put together a monthly detailed resuscitation course called Resuscitation Plus. This is why pilots train and train for long periods in simulators before gradually working their way into actual passenger flights. Unfortunately, we don’t have such an organized system in medicine. Some individuals assume that just having a medical degree or a particular qualification is sufficient, which it is not. It is just the beginning.
An analysis of a major U.S. academic medical center in 2011 showed that of all patients who had had a cardiac arrest and who should have received hypothermia treatment (based on the institution’s own criteria), 40 percent had not been given this treatment, and the overall survival figures were lower for this group. When asked why they hadn’t provided the care, many physicians simply either didn’t know about the recommendation or were not aware of the weight of evidence behind it and thus stated they weren’t sure if they believed in it, or simply felt they didn’t have the experience or comfort level to deal with it. These physicians included cardiologists, emergency physicians, intensive care physicians, general surgeons, and cardiothoracic surgeons—a wide array of doctors—many of them highly accomplished and all at the same institution. Although the institution had an approved “hypothermia protocol” with clear recommendations regarding who should receive this treatment (as with many other places), it did not enforce the protocol’s implementation. This returns to one of the main challenges: neither this institution nor any other is mandated to provide this care because no governmental regulatory body exists to enforce it. Ultimately it is left to individual physicians with different areas of expertise, different levels of knowledge, and different comfort levels. Managers also can’t be expected to enforce a protocol, because they don’t have the knowledge or expertise and they are not being asked to do so by regulatory bodies. In this case, receiving hypothermia seemed to relate to the location where a patient with cardiac arrest was cared for in the hospital, indicating a lack of universal understanding; the American Heart Association (AHA) and other world bodies give hypothermia their highest recommendation. Consider that this randomness does not occur in heart attack patients. The standard of care in heart attacks is to have the blocked blood vessel supplying the heart opened as soon as possible (ideally within sixty minutes to prevent long-term damage). Therefore, hospitals have door-to-needle and now door-to-balloon times (i.e., opening the clot by powerful clot-busting medication or through a cardiac catheterization with a balloon). This is because a heart attack has a medical parent (cardiology) and because it has been pushed onto the agenda by regulatory bodies that collect statistics regarding door-to-balloon or door-to-needle times and severely penalize hospitals if they fail to deliver. Imagine the uproar if 40 percent of heart attack patients in our hospitals were not taken to the catheterization laboratory or given the powerful clot-busting medication simply because some physicians didn’t know about the recommendation or were not aware of the weight of evidence behind it and thus weren’t sure if they believed in it or simply because they felt they didn’t have the experience or comfort level to deal with it!
Because cardiac arrest occurs across specialties, combined with the long-standing perception that it is essentially the end and that not much can be done since outcomes have always been poor (like saying flight has always been risky), together with the fact that it does not belong to any particular medical group (such as cardiology), it means that patients sometimes do not receive all that may be available when considered within the full requirements set out by international guidelines. We have a real opportunity to learn from the airline system, because although cardiac arrest is complex, a workable system can be implemented if we break down all the stages and create a comprehensive system that incorporates all the details and nuances relating to precardiac arrest, intracardiac arrest, and postcardiac arrest care. With adequate resources and continued educational programs, as well as a detailed checklist system like that which the airlines use for preflight, in-flight, and landing, a comprehensive system could integrate these disciplines and have an external agency mandate things be done in a certain way in much the same way the governmental agencies oversee the airline industry. Clearly, there is a need for this, and although some action has been taken by certain groups within the medical community, little will be achieved without proper and dedicated resources as well as external regulation and enforcement that ensure implementation of the highest levels of care for all.
MEDICAL SHOWS HAVE BECOME very popular on television, and in shows such as E.R. and Grey’s Anatomy, most of the time that doctors perform CPR they are successful. In one study, called “Cardiopulmonary Resuscitation on Television—Miracles and Misinformation,” by Susan Diem at the Durham Veterans Affairs Medical Center in Durham, North Carolina, and her colleagues, published in the New England Journal of Medicine, it was found that the success rate of CPR on TV is far higher than in real life. While this might be expected for dramatic purposes, the fact is that TV shows have to bend reality because the real-life success rate of CPR is less than 20 percent in hospitals and a lot less out of hospitals—on TV the success rate was found to be almost 70 percent. What’s even more staggering is that as mentioned already, this success rate has actually not really improved since the 1950s—an outrageous statistic given all the advances in medicine over the past six decades. So how could this be?
What exactly are those things that enable people to survive that need to be implemented? The American Heart Association has a “chain of survival” that can be analogized to a bridge. In the same way that a bridge must have every section in place for a person to get across safely, the same is true of resuscitation. Imagine trying to cross the Golden Gate Bridge in San Francisco with just one or two segments missing! The consequences would be devastating. In resuscitation, we often miss many sections, yet each section must be followed or the outcome will be compromised, and the chain works as successive studies described in international guidelines published by the American Heart Association, European Resuscitation Council, and other world bodies have detailed. In 2005, the overall rate of survival from out-of-hospital cardiac arrest in Arizona was 4 percent (11 percent for witnessed ventricular fibrillation—this is the type that responds well to shock treatment using a defibrillator and is usually the easiest to treat). Survival increased with the continued implementation of each link in the chain of survival, and in 2009, overall survival reached 10 percent (30 percent for witnessed ventricular fibrillation).
The chain of survival begins when help arrives. This is a factor no matter where the patient has the cardiac arrest, but in a hospital, doctors should be able to arrive within five minutes. Out of the hospital, it depends on the ambulance service, but again we should aim to arrive within a few minutes from a person making a call. Even though doctors should be able to arrive quickly in a hospital (or paramedics in the community), the results are still only going to be as good as the care. This starts with the quality of the chest compressions. Perfect chest compressions can only deliver between 25 and 30 percent of the circulation that takes place before the heart stops, hence at best, oxygen delivery may be only one-third of what it is in a person whose heart is beating. From the perspective of the cells in the body, this is not enough to prevent progression from a state of potentially reversible to irreversible cell death in the organs, but it is better than nothing and can slow the speed by which cells die down.
CPR is a terrible grind. Administering steady compressions in two-minute shifts is difficult even for those who are trained and in the best of shape. In practice, during the frantic minutes of a resuscitation effort, medical personnel take turns conducting chest compressions on the patient. Some people are more effective and better trained than others. The primary issue is that people giving CPR become fatigued, resulting in the consistency being thrown off. No one can generally deliver effective chest compressions for more than a minute or two. Numerous studies have shown that doctors, nurses, and ambulance crews alike cannot deliver the optimal quality of chest compressions even if trained.
In one study, it was found that when people highly trained in the delivery of chest compressions—in fact, instructors who teach the courses—were put in an ambulance, they were able to deliver effective chest compressions less than 40 percent of the time. In this study only the use of an automated machine enabled the delivery of greater than 90 percent effective chest compressions. So clearly if someone is doing inferior chest compressions, then the patient is much more likely to either just not survive or suffer brain damage because not enough oxygen is being delivered. If the quality isn’t perfect, then by definition oxygen delivery will be less. While chest compressions should be continuous with no more than ten-second pauses every few minutes, studies have shown that very often the pauses are very long, or the depth or rate of chest compressions is not adequate. This is assuming the person delivering chest compressions is physically strong enough to do so. If somebody is five feet tall and weighs one hundred pounds and is trying to deliver chest compressions, it is almost impossible to sustain the proper level even for a minute. People believe that they are doing proper chest compressions and they are going through all the right motions, but they are not delivering them effectively; and since there is no standardized system to check the quality, doctors can be executing chest compressions without knowing how effective they are. This is one major segment that is almost universally missing.
Although we now have the technology to give us feedback regarding the quality of CPR—which we did not have in the 1960s, 1970s, or 1980s—there is no requirement for hospitals or ambulance crews to use it. This is like a pilot flying without an altimeter. If the pilot is flying in the dark and doesn’t know how high his plane is, then he might fly into a mountain. No pilot would take such a risk. So now that feedback systems for CPR quality have been developed, they should be standard issue for everyone performing CPR, whether in hospitals or ambulances. Currently, they are only used to a limited extent by very few individuals or hospitals and often as part of research studies. But as Dr. Dana Edelson’s study at the University of Chicago showed, outcomes can be improved if feedback machines are used.
In view of these findings, we managed to convince administrators at my hospital to purchase a number of automated chest compression devices so that we could deliver the optimal quality of chest compressions combined with systems to provide feedback regarding our quality. Although there are three main automated chest compression devices, called the Lucas, the LifeStat, and the AutoPulse, on the market, few people actually use them. We brought in the LifeStat because in addition to chest compressions, the LifeStat also regulates breathing. Part of the problem is that not enough research has been done to convince hospitals to use CPR feedback machines or automated chest compression devices. The AHA guidelines published (but not enforced) for resuscitating a patient are neither for nor against the machines. This has left hospitals in limbo. We found that we were able to restart the heart 75 percent of the time using our machine compared to 45 percent when chest compressions were done by hand, and this improvement seemed to be directly related to the ability of the machine to provide higher oxygen delivery and blood flow to the brain, heart, and other organs. We are now trying to get the system in place everywhere in the hospital.
In CPR, the rate at which breaths are supplied is just as important as the chest compressions—too many breaths actually themselves can kill people due to the phenomenon called breath stacking that I referred to earlier. This is why some researchers have called it death by hyperventilation. In many cases, people frequently provide too many breaths, a fact illustrated in Dr. Dana Edelson’s study in which she found that though the recommendation is eight to ten breaths per minute, in reality patients were often receiving thirty-five to forty breaths per minute. Therefore, without a system to regulate the number of breaths being delivered, some lives may not be saved and people will simply assume it was because the person had suffered a cardiac arrest. In resuscitation, attention to detail really counts. However, excessive ventilation is another almost universally missing section on the bridge to recovery. The LifeStat machine has the advantage of being able to deliver the exact quantity and quality of chest compressions and breaths needed and thus take the delivery of breaths out of the hands of humans.
During resuscitation, the other factor in the patient that may need to be addressed is an abnormality in the heart. This can only be treated if the heart is shocked. For every minute of delay in identifying those rhythms, mortality increases by about 5 to 10 percent. If this issue is not identified and treated, those irregular rhythms will eventually become a flatline, and a flatline is clearly much harder to treat than abnormal rhythms. Modern defibrillator machines are available, such as the R series made by ZOLL, which allow doctors to see the exact heart rhythm even when chest compressions are ongoing (called see-through technology); they thus provide shock treatment immediately and without delay when it is needed. Again, these systems have generally not been adopted so far, and so in reality there is usually at least a few minutes of delay even at the best of times. At our hospital we are trying to incorporate these technologies in order to provide a seamless and completely automated system of care. We have also tried to reach out to our community ambulance services to implement some of the lessons we have learned in the hospital, so that we can all work together to create a streamlined service and system that focuses on quality from the moment the heart stops until a patient arrives at the hospital and then through to discharge from the intensive care unit.
In the United States, ambulances can be a bigger issue than many people realize. Suffolk County, New York, where I work, is one of the most affluent counties in the United States, yet it has one of the worst out-of-hospital cardiac arrest survival rates at 2 to 3 percent. Part of the problem is that literally a hundred different ambulance companies are providing service, much of which is provided by highly dedicated yet volunteer crews who get paid from other jobs. Learning about this was an eye-opener for me because I originally grew up in London and then lived in New York City before moving to Suffolk County. Neither city runs a volunteer service. In fact, I had never heard of or even considered that an emergency service dealing with life-threatening situations such as cardiac arrest, where every minute counts, could be manned by volunteers, but this is what happens in our region. In fact, the county has recruitment billboards for fire and ambulance emergency personnel that boldly states “work for pride not a paycheck.”
The question is this: How do we regulate personnel who, although amazing and remarkable individuals by virtue of the fact that they have selflessly given up their time to work for “pride,” have to integrate this critical volunteer position with their real jobs, which pay the bills and the mortgage on their homes, as well as provide for their family’s other needs? One of them recently told me that in practice when an emergency call is received, he often has to leave his family at home, drive to the ambulance center where the ambulances are stationed, and then drive his ambulance to the scene of the emergency. Furthermore, it is not infrequent that one ambulance crew in a particular geographical location may not be manned at a certain time or cannot take the call, so if the emergency call that has been dispatched to a particular station by the call center is not answered within a certain period of time, the telephone dispatch office will automatically send it to the next ambulance service in another geographical location and so on until it is finally answered, all the time creating many minutes of delay. Yet in terms of response times, the statistic that is recorded is the time taken for the ambulance service that actually received and took the call from the dispatch center to arrive at the scene of the emergency, not the time taken for the ambulance to arrive after a distress call was first made to the Suffolk County telephone center.
Not to slight any of the companies, but it is clearly more difficult to have a uniform system for dealing with cardiac arrests with so many ambulance services operating in one county and on a voluntary basis. In the United States there are more than three thousand counties spread across the different states, and most of them (like Suffolk County) rely on volunteers working through different ambulance companies to provide a large component of their emergency responses. It is hard to believe that, in the most affluent country in the world, we can’t establish a unified service where we pay all our emergency responders. We wouldn’t expect our doctors or nurses to work on a volunteer basis, nor would we do so for the people working in an airport control tower. Yet we do with our emergency responders.
The FDNY in New York City, which has seven times as many residents as Suffolk County and is only about forty miles away, has demonstrated that a centralized, nonvolunteer system works better. In New York City, for example, ambulance crews now cool patients immediately to slow down cell damage, and as Dr. John Freese, who pioneered this system, reported, this has improved patient outcomes. The FDNY is constantly working to set new standards for lifesaving measures. It also insists on certain protocols from hospitals so the crews’ work is not for naught once they bring the patient to the emergency department. London also has an efficient single system, as does Paris, where in my mind the system is even better because ambulance crews attending cardiac arrests also have an emergency doctor with them, thus giving a higher level of immediate care and expertise to patients.
The course to improving out-of-hospital CPR rates is fairly straightforward. There must be an increased rate of bystander CPR (which is CPR given by ordinary citizens who witness a cardiac arrest prior to the arrival of EMS personnel), so that CPR can be started immediately rather than after the paramedics arrive. This requires more training within the community, like that which has been done in Seattle. Having defibrillators in the community is also important—yet another initiative that began in Seattle. Ambulances must arrive promptly, in less than five minutes, and the ambulances must have personnel who can deliver a high quality of chest compressions, whether done manually or through the use of portable chest compression machines, which can do the job more uniformly and consistently without the problems of human error or fatigue that have been highlighted by many research studies, such as those by Drs. Dana Edelson and Benjamin Abella. People can help their communities by becoming trained in basic life support. Finding a course locally in the United States is relatively easy and can be done by contacting the American Heart Association (www.heart.org) or the American Red Cross (www.redcross.org). Another excellent resource is the Citizen CPR Foundation (www.citizencpr.org), which holds regular conferences and has excellent links to other organizations involved with resuscitation.
Improving these basic areas can lead to survival rates increasing from 0 percent to as high as 21 percent in the community. In fact, as Dr. Graham Nichol at the University of Washington in Seattle concludes in one of his studies, if all communities in the United States used the Seattle model, we would have fifteen thousand more cardiac arrest survivors every year. That’s a staggeringly high number on an annual basis. Over ten years that would be 150,000 people. I actually believe we could save a lot more, since this only focuses on out-of-hospital cardiac arrests (i.e., where people died and attempts at resuscitation had been made only up to the point where a person is delivered to the hospital). There are also many more cases in hospitals. Optimizing and standardizing hospital care is one of the major areas where improvement is also needed urgently and where a huge impact can be made in survival and quality of life.
PROGRESS HAS BEEN MADE in some places. In New York City, knowing that cooling is now best practice, the FDNY concluded that it is not safe to take the patients to hospitals that did not offer that treatment. Consequently, the FDNY mandated that as of January 1, 2009, every hospital that receives cardiac arrest patients must have a designated hypothermia program. This action led to New York City hospitals finally uniformly adopting cooling (this is an example of how external factors can influence an organization). Prior to this, cooling was piecemeal—some hospitals had it and some didn’t—but even after this initiative, within individual hospitals some units cooled patients but others did not. This is because even some doctors familiar with the landmark 2002 studies remained skeptical of cooling patients in the hospital and nobody enforced it.
The studies clearly showed that for every six people treated by cooling, one more person had a benefit. This adds up to an enormous number of people. If you consider a sample of 350,000 people (which is estimated to be the total number of cardiac arrests occurring in the community in the United States each year), then you would potentially get up to fifty thousand more survivors.* However, many doctors decided not to provide the treatment to patients in the hospital because the actual studies were conducted on patients who had suffered a cardiac arrest out of the hospital. And, as a practical matter, it would now be unethical to design a study for in-hospital patients suffering with cardiac arrest and withhold cooling from half the participants, so there will never be such a study since the benefits are clear.
The same dilemma exists in pediatrics. Cooling studies have not been specifically conducted on children because it is generally tricky to perform research studies on underage children. As a consequence, some doctors will withhold cooling from children in cardiac arrest cases because they say there haven’t been studies specifically in children and thus they don’t have enough data to support this treatment for children. But again, to me and many of my colleagues, their refusal doesn’t make sense if one understands the rationale for the use of cooling. Even though specific studies haven’t been done in children, numerous studies have shown benefit in animals, neonates, and adults. The brain and other organs of neonates and pediatric patients are not significantly different. At my hospital, we had a case where two kids, one nineteen and the other sixteen, fell into a cesspool and were overcome by toxic gases. It took twenty minutes for paramedics to rescue them. When the boys arrived at the hospital, they were both in terrible shape, having had all the complications of a cardiac arrest. If we were to follow things didactically, then by definition the sixteen-year-old should not have received hypothermia, but the nineteen-year-old should have. Again, this is arbitrary and doesn’t make sense. As already pointed out, aside from hypothermia, many other important items need to be incorporated during the postresuscitation phase, including providing early cardiac catheterization; optimizing blood pressure regulation (these patients often require higher than usual blood pressure to get blood into the brain); preventing seizures, since it is estimated that around a quarter of patients develop seizures that lead to long-term brain damage; keeping oxygen levels on the relatively low side of normal, since excess oxygen itself is toxic to the brain; and ensuring the levels of carbon dioxide in the blood are normal (otherwise it affects brain blood flow, which if too little or too high causes more brain damage).
IN 2009, THE AMERICAN Heart Association sponsored a conference called the Cardiac Arrest Survival Summit and released consensus recommendations in a report titled “Implementation Strategies for Improving Survival After Out-of-Hospital Cardiac Arrest” to address the disparities and variation in care across the United States for people who suffer from cardiac arrest and the difficulties in implementing optimal standards of care for everyone. The goals were to take the latest discoveries and best practices discovered through research and “translate” them into common practice, to make sure they were understood, and to determine how to implement them. The conference featured many of the leaders in the field of resuscitation science, like conference chair Dr. Robert Neumar, and equally as important, it gathered representatives from multiple disciplines involved in all stages of cardiac arrest care. In addition to the physicians in critical care medicine and resuscitation science, the conference included insurance company representatives, officials from regulatory agencies, ambulance personnel, nurses, funding agencies, research scientists, and people from the general public. It was a concerted effort to involve everyone who has anything to do with cardiac arrest, because the only way to change outcomes is to bring together all those with a stake.
The conference focused on the central problem of why survival rates vary so much across the United States and around the world and why more people aren’t being revived, kept alive, and sent home without brain damage, like Joe Tiralosi. Participants zeroed in on many of the critical issues. “The differences in outcome after cardiac arrest do not appear to be fully explained by differences in patient characteristics,” the conference’s report stated. “Rather, the high rate of survival observed in some communities suggests that OHCA [out-of-hospital cardiac arrest] is a treatable condition and that outcomes may depend on the effectiveness of the system of care. Ongoing comprehensive surveillance of OHCA events and outcomes through hospital discharge is necessary to identify opportunities for improvement so that all communities can achieve higher rates of survival. The absence of a national surveillance system is a barrier to such an effort, and available resources are insufficient to support it on an ongoing basis.”
THE PROBLEM LIES NOT just with cardiac arrest but also with much of medicine. The issue is called knowledge translation, which is essentially putting research into action. The knowledge translation process is dependent on everyone, from those who fund research to doctors who treat patients to the general public. However, since the roles of those involved are not clearly defined, studies have shown that knowledge translation is often haphazard, slow, and unpredictable even in the best-funded fields of medicine—making it all the worse for an “orphan” like cardiac arrest.
Clearly, steps can be taken to raise survival rates if these can be implemented on a wide-scale basis. As difficult as this may be, it can be accomplished. Currently, there is a body called the International Liaison Committee on Resuscitation (ILCOR) that is composed of experts from around the world. ILCOR has more than two hundred doctors with expertise in cardiac arrest, who painstakingly review all the data that has been published in the research literature on cardiac arrest. They meet every five years and debate international guidelines for cardiac arrest. Once these guidelines are accepted by ILCOR, they are endorsed, published, and disseminated by numerous national and international bodies such as the American Heart Association in the United States, the European Resuscitation Council in Europe, as well as the Australian and New Zealand Council on Resuscitation, the Heart and Stroke Foundation of Canada, the InterAmerican Heart Foundation, the Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa. However, if doctors do not know where the guidelines are, then they obviously aren’t going to be very helpful. Either way, these are guidelines, not mandated requirements, and as such there is no enforcement body to ensure they are followed. In fact, few or maybe even no hospital that I know of fully incorporates all the recommendations and links in the precardiac arrest, intracardiac arrest, and postcardiac arrest (postresuscitation) phases at all times. As the AHA conference report stated: “The Institute of Medicine has recognized that emergency medicine lacks a standard set of measures to assess the performance of the full emergency and trauma care system in all communities, as well as the ability to benchmark that performance against statewide and national performance metrics. In this respect, cardiac arrest is similar to other acute life-threatening illnesses. You must have benchmarks so you know you are approaching the standard.”
IN THE UNITED STATES, an organization called the Joint Commission for Health sets quality standards for medical care in hospitals. The commission looks at certain conditions and declares them measureable entities, such as the rates of infections in intensive care units in hospitals, but unfortunately they don’t cover every important medical condition or complication. Cardiac arrest has traditionally not been covered by the Joint Commission as a measurable entity, so hospitals have not had a mandatory need to comply with any recommendations issued by the AHA or any other body. Thankfully, in 2010 the Joint Commission did finally set up an initiative to make core aspects of cardiac arrest performance in hospitals measurable entities. However, instead of simply working to adopt and, most important, implement all the recommendations set up by ILCOR, which have been endorsed and disseminated in the United States by the AHA in separate guidelines published in 2008 (focusing on postresuscitation treatment) and again through a new set of guidelines published in 2010 (regarding the whole spectrum of precardiac arrest, intracardiac arrest, and postcardiac arrest care), the commission worked on a small number of items. In fact, the Joint Commission started with nine items that members considered important, which included the use of hypothermia but sadly only mandated its use for adults who have suffered a cardiac arrest in the community and not in the hospital setting. It also excluded children and neonates.
So hypothetically speaking, based on this standard, if a thirty-five-year-old man’s heart stops inside a hospital building, there is no mandatory requirement for the hospital to provide hypothermia treatment, but if the same man’s heart stops in the street outside the hospital, there will be a requirement to do so. Or if a seventeen-year-old person’s heart stops, there is no requirement to provide hypothermia whether in the community or in the hospital, but if the same person’s heart stops on the streets outside the hospital a day after he or she has reached eighteen, then the hospital will be mandated to provide hypothermia—but not if the heart actually stopped when the person arrived in the hospital emergency room. The nine items also still missed some of the most important and fundamental recommendations, such as the time to the start of chest compressions and, importantly, the quality of chest compressions. As we have seen, there is no point giving compressions if they are not of a high quality, so if hospitals are not mandated to measure the quality, how will they know if they need to improve it or not? The commission also did not include the critical issue of overventilation (breathing) rate, which, as discussed, if in excess leads to death since it prevents the heart from restarting; instead the Joint Commission focused on the insertion of a breathing tube without focusing on how many breaths are given through the tube. Other important areas that are missing are competencies for staff regarding skills in delivering resuscitation care, the use of a specific quality parameter called “end tidal carbon dioxide,” which indicates the overall quality of the circulation and hence chest compressions, the time to patients receiving cardiac catheterization, blood pressure regulation, prevention of seizures, the levels of oxygen being administered, as well as the levels of carbon dioxide in the blood. Each and every one of these factors, if ignored, can lead to devastating consequences.
Unfortunately, since the original nine items were introduced, and following a system of discussion, the Joint Commission members have actually reduced the original nine items to four. Initially, actual survival figures were part of the nine items, but they have since been removed. So without a mandatory requirement for reporting of actual survival figures among institutions, how can we strive to improve care? If some institutions are achieving only 15 percent overall survival while others are achieving 30 to 40 percent, it would be difficult to identify areas that need to be rectified. The final four items that have been agreed on are the time to shock treatment of the heart, the insertion of a breathing tube, the initiation of cooling treatment for adults who have suffered cardiac arrest in the community only, and, finally, ensuring the right temperature is maintained for these people. After a pilot phase, the goal is to introduce these items in 2013. Although the fact that the Joint Commission has adopted a minimum protocol is commendable and better than not having one at all, since the protocol items are missing the major weaknesses in the system, it is very unlikely they will make a significant enough difference in outcomes. Unfortunately, policymakers will be left thinking that some external regulation actually exists, but clearly the regulation will at best be severely insufficient; the zip-code lottery of care will just continue. It’s like setting up an aviation standard that misses some of the most important safety issues raised by the world’s leading authorities and the results of published research studies. Since cardiac arrest is an orphan without an FAA-like monitoring body, many of the main issues that are related to outcomes have not been fully addressed. The bottom line is that there is no national or international standard.
The whole world witnessed the devastation that happens as a result of a cardiac arrest and the potential difference in outcomes, as well as the impact on families, in two similar young people. The first, Fabrice Muamba, a twenty-three-year-old professional soccer player, was playing for Bolton against Tottenham in a live televised FA Cup game in England when in the middle of the game he collapsed. His heart had stopped. He died. The world witnessed the ensuing events in horror on live television. The paramedics attempted CPR on the soccer field. A cardiologist, Dr. Andrew Deaner from the London Chest Hospital, who happened to be watching the game, ran on to the field to help. After about ten minutes without a heartbeat from Muamba, the paramedics decided to transfer him to a local hospital. Dr. Deaner, however, insisted that Muamba be taken to his hospital and his intensive care unit and nowhere else, even though his hospital was farther away. I watched the events on television and was horrified like everyone else, although I wished I could have been on the field. I kept telling my wife, “I hope they do all the right things, and I hope they cool him.”
Muamba did not have a heartbeat for almost an hour and a half before it was restarted in Dr. Deaner’s hospital. Muamba was given hypothermia treatment, and to everyone’s astonishment he recovered and was able to leave the hospital neurologically intact a month later. I couldn’t help but wonder why Dr. Deaner insisted that Muamba be taken only to his hospital. He was probably uncertain of the care that Muamba would have received elsewhere, and at least he felt secure that he could help bring better care in his own unit. If Muamba had gone elsewhere or with a different group of doctors, they may have stopped trying to get his heart started well before the hour and a half that it took. Traditionally, people don’t go beyond ten or twenty minutes, and in the case of a young person, sixty minutes would be considered a long time. However, they did continue trying and with appropriate postresuscitation care delivered him back to his family and to the whole world.
Almost four weeks later, on April 14, 2012, just as Muamba was preparing to leave the hospital, the exact same thing happened in Italy. A twenty-five-year-old professional soccer player, Piermario Morosini, was playing for Livorno in a game against Pescara when in the thirty-first minute he collapsed. His heart, like Muamba’s, suddenly stopped beating, and he died in full view of the television cameras. The other players were devastated and were visibly crying while paramedics attempted CPR. There was a report that there may have been a delay getting an ambulance to the scene, as it had been blocked out from the entrance to the stadium by parked police cars. Nevertheless, Morosini received some CPR on the field before being taken to a local hospital once the ambulance arrived. However, he was declared dead soon after. Dr. Leonardo Paloscia, the cardiologist at the hospital where Morosini was taken, said, “Nothing could be done. It was all ineffective, after about an hour and a half of intensive care, his heart never made a beat.”
Listening, I found it hard to know what he meant by “nothing.” Had Morosini received the quality of CPR needed for an hour and a half? Studies have shown that most people cannot deliver the required quality. How about the breathing rate—had that been maintained? There are many more details that would make the difference, and clearly I don’t know all the details, but what was most obvious was that if this young man had been taken to the hospital in Japan where the young woman with an overdose had been taken, he would have been placed on an ECMO machine. This is a form of heart-lung bypass, and it can artificially provide the oxygen and circulation required to maintain his organs even when the heart doesn’t beat, while giving the doctors much more time to find the problem that had caused him to die and so fix the underlying problem. Then with good postresuscitation care, as with Muamba, he likely would have escaped brain damage and potentially would have even played again. Again, it is hard to know, but the reality is the team in Italy most likely did the best that they could under the circumstances, and this is why we need a system of care to be developed. If ECMO is helpful in Japan and South Korea, then it is helpful in Italy too—in the same way that if radar is helpful in Japan and South Korea, then it is helpful in Italy too. We don’t have these disparities in aviation, but we do with cardiac arrest resuscitation. This is the difference between one person coming back to life and another not.*
Unfortunately, the saddest part of the whole story was that Morosini had a disabled sister who had relied entirely on this young man for her financial and emotional support since their parents had died seven years earlier. They had one other brother and he too had died, so she had only Morosini to rely on. After he died, she had no one to care for her. It is therefore not just the story of Morosini’s death but also of the impact on his sister. This is why we need to develop the same standards of care for everyone, so that you and your mother, father, brother, sister, spouse, or children don’t end up receiving a type of zip-code lottery care, and this is why we need to continue to put aside old perceptions and implement the highest standards while continuing to study through science what happens when we die. Let’s not forget that cardiac arrest will happen to every one of us. It is inevitable.
Until hospitals implement reforms and create a uniform checklist to perform, survival outcomes will not increase. The AHA conference report concluded: “Organization of the system of care appears to have a larger effect on survival than patient factors. The creation and maintenance of an effective system for delivering optimal emergency medical care are complex. Examining either systems with historically good outcomes or systems in which change has improved outcomes provides an opportunity to identify best practices that can be broadly implemented.” In other words, the problem is not that the patients who have a cardiac arrest are very sick and probably won’t make it. If there is a system in place, survival rates will increase.
In spite of the need to improve our systems and implementation techniques across the board, the fact that we can now reverse death begs a fascinating question. Since we now know that cells, including brain cells, that are not functioning can still remain viable (in the sense that if supplied with oxygen and nutrients they can gain function again) for a period of hours after death, and that death itself, medically speaking, is a global stroke that affects the entire brain (also termed anoxic brain injury) and leads a person to go into a deep coma within a few seconds, what actually happens to our mind and consciousness (that entity the Greeks called the “psyche” or “soul”), or put more simply, our “real self”? Does it become annihilated immediately after death, or does it continue to exist for a period of time after death? And if so, for how long?