Scientists love rigor - controlled environments, carefully defined processes and known variables (is that an oxymoron?). Much of the research relating to the resuscitation of cardiac arrest patients in the out-of-hospital setting is focused on therapies delivered by healthcare professionals beginning with Paramedics and then moving through the system to the ER and the CCU. Patients that receive effective therapies – quality chest compressions and defibrillation – prior to EMS arrival are at least six times more likely to survive (31.7% vs. 5.2%) than EMS attended patients and yet this group remains very small representing less than 6% of all cardiac arrest victims. Common sense dictates that it is time for a resource re-allocation that shifts the focus from what happens to the patient after EMS makes contact to what happens to the patient prior to EMS contact.
The pre-EMS world is a little messy and unpredictable. Although we know that there will be a next
event it is impossible to know when and where it will occur. It involves the
great unwashed masses and there is no way to control or predict how any
individual or group will respond when faced with a friend or family member in
cardiac arrest (or is there?). It can be nearly impossible to collect reliable data about how the event unfolded prior to EMS arrival. In consecutive post event
investigations responders to the first incident told me with confidence that they
shocked the patient three times - the ECG download showed no shocks, in the
second event bystanders said with conviction “No, we didn’t shock him at all” -
the download indicated two shocks. Scientists
are not happy working in this chaos and as a result little research is focused on
this most critical stage of resuscitation.
Out-of-hospital cardiac arrest is one of the most studied
medical phenomenons in the world and researchers have access to high horsepower
data sets that often include more than 10,000 SCA events. Every time large data sets are analyzed the pure
gold, survival to hospital discharge, is always found in the Bystander
Initiated Response cohort. Therefore it almost defies logic that that
preponderance of research dollars is spent on studies that are seeking to find
out such things as which pharmacological therapy or which cooling strategy initiated
by Paramedics is the most effective.
More research dollars should be dedicated to finding ways to
build communities that have high rates of Bystander CPR and high rates of
Bystander Delivered Defibrillation. The critical question has to be, how can we
increase the percentage of patients that have ROSC prior to EMS contact? How can we take what is proven to be the most
effective therapy, bystander response, and ensure that it happens significantly
more often? I will share some ideas in upcoming blogs.
In addition to research,
scientists and the organizations that fund them also need to come out of their offices and laboratories to meet with politicians, senior
bureaucrats, leaders in education and sport and explain to them the simple
truth - Improving the historically dismal survival rates for out-of-hospital
cardiac arrest is entirely dependent on the community’s willingness to take
ownership of the issue. Mandatory placement of AED’s in broad spectrum of
venues and mandatory CPR training for broad spectrum of citizens is the simple
and inexpensive solution to an enormous
problem that isn’t nearly as vexing as scientists would have us believe.
Why is simple, inexpensive and effective not the pathway of choice ?
