Legislating the entire "Chain of Survival"

The potential to improve outcomes for patients suffering cardiac arrest, heart attack and stroke is enormous. Survival rates and outcomes in communities that are amongst the leaders in implementing the latest evidence based practices in pre-hospital cardiovascular emergency management can be three hundred to four hundred per cent better than in communities that are stuck in the 20th century.

Since the 1990 conference at the Utstein Abbey in Norway an avalanche of excellent scientific research has created a strong evidence base that provides clear direction for implementing best practice in community cardiac response. The evidence indicates that there is not one but several pillars on which a community cardiac response program must be built.

• AED's. Everybody loves to advocate for AED's. Not one life has ever been saved by an AED. Someone had to take the device off the wall, place the pads and deliver the shock (and then perform effective CPR). Of course we need them, but to begin and end with a law that promotes more AED's in the community will not produce the hoped for results
• CPR. I find it bizarre when the AED lobby is distinct and seperate from the CPR lobby. Different people and organizations approaching different legislators with different proposals, both groups claiming that their way is the true path to improved survival rates. The two therapies are inseperable. I am also very concerned about the love affair many advocates have with teaching CPR to teenagers, with little or no thought given to the importance of teaching CPR to adults including educators, coaches, trainers, youth leaders, adult athletes, in fact just about everybody.
• Early Recognition. Raising community wide awareness of the warning signs of heart attack, stroke and arrhythmia and how to respond to them is the most undervalued link in the chain. It is also the link with the greatest potential to deliver significant and measurable economic return. Rehabilitating survivors whose MI and Stroke symptoms evolve over several hours is expensive.  If everyone made it the hospital within and hour of the onset of symptoms imagine the cost savings, billions.
• 9-1-1 and Dispatch. Investing in the best dispatch technologies to reduce EMS response times will always have benefits. Dispatcher coached CPR is proving to be a very simple and cost effective way to improve survival rates. The abilty for all dispatch centres to perform instant GPS locate on cell phones is critical and long overdue in many Canadian communities.
• Early Advanced Care including Induced Hypothermia. If all qualifying patients are not cooled half of the money invested in acheiving ROSC in the pre-hospital setting is wasted, along with the corresponding number of lives.

Ontario where I live, work and play is far from a leader in legislating policies that strengthen the cardiac chain of survival. However there are a number of individuals and organizations lobbying both the provincial and municipal governments to enact laws that promote their "pet" link in the chain. Legislators are busy and the number of issues that they must contemplate is immense. Presenting them with a tidy, gift wrapped, inclusive policy package makes their life easier and is the best way to earn their respect and their ear. I hope that advocates and law makers in Ontario and in all jurisdictions work together with all stakeholders that have an interest in pre-hospital cardiac emergency response to develop a comprehensive strategy for improving survival rates and outcomes. The links in the Chain of Survival are co-dependant and the whole will always be greater than the sum of the parts.

When a child is diagnosed with an Arrhythmia

I wanted to throw out some thoughts on looking for and finding heritable heart arrhythmia in children. The spectrum of opinions on whether we should even be looking for heritable disease and what to do once we find it is broad. When I began my journey into the world of Inherited Heart Rhythm Disorders (IHRD's) I thought the answers to all of these questions were self-evident but I now recognize that there are valid opinions on all sides. This blog is a random unstructured list of questions and concerns that have no right and/or wrong answer. These are immensely complex medico-legal, moral, ethical, philosophical, religious, societal, familial issues and a 500 word blog does not even make the tiniest scratch on the tip of the iceberg.

• Why would we want to know that our child has an Inherited Heart Rhythm Disorder? Because there are effective therapies for most IHRD's and because left untreated IHRD's may result in sudden death would be the obvious answer. That said there are people that choose to play the hand life has dealt them without taking action to change what they believe fate may have in store for them.
• Will a positive diagnosis disqualify my child from buying life insurance? Almost assuredly. However, will a cheque from an insurance company bring back your child or truly compensate for your loss? There are numerous ways to invest on your child's behalf that will pay equal or greater future dividends. The term "life insurance" is an oxymoron. I'm blown away when people give this as a reason for not testing their at-risk children.
• Will a positive diagnosis limit my child's career choices? Absolutely. Of course we all have limited career choices ... despite my desire to play professional hockey I was born with a serious talent deficit.  If your brother tests positive for an IHRD should you get tested or simply carry on with your plan to become a commercial airline pilot? Who will be responsible if you die at the controls and the plane crashes killing everyone on board?
• What if a false positive wrongly curtails my child's participation in athletics? The first question I ask in response to this concern is "When is a diagnosis considered positive?" If an initial ECG results in further tests being ordered is that a positive diagnosis or is it simply an ECG that suggests further testing is required? If follow-up testing takes two months and the Doctor recommends no competitive athletics until she has made a definitive diagnosis what has been lost ? Will missing a few game and practices while you wait for the right diagnosis change your child's career path, especially if they are truly gifted? Will you be able to live with yourself if your child dies because you chose not to miss the "big" tournament?  Everyone with skin in this game knows a family that made the wrong decision.
• What if a true positive ends my child's athletic career? Very few of the truly great or even  good people on this earth are elite athletes. Of the elite athletes that are good or great people it is not their athleticism that makes them that way. If a child has special attributes that allow them to be a great athlete they will be able to apply those attributes to other areas of life which may include coaching or officiating in sport. Most people accomplish very little after their death.
• What if my child refuses to give up sport? You are the parent, you must decide what is best for your child. Prior to a child attaining the age of majority it is up to parents and guardians to act in the child's best interest.
• What if I test positive and my sister refuses to have herself or her children tested? This is almost too scary to contemplate, but it happens. I guess the best starting point is communication, and lots of it. Talk to everyone that might be able to help and exhaust all of the possibilities while keeping in mind that you do not have the final say.
• What happens when Personal Health Information Privacy Laws come into conflict with the best interest of a minor child? This is a very thorny issue and people with many letters behind their names could debate this one for days. These often poorly formed laws were never intended to place a Doctor in the position of choosing between his career and the life of a child. 

Above are eight questions out of the hundreds of questions that can and should be asked when contempalting heritable disease. Over the past decade I have been exposed to many sides of these issues. With each passing year I am less astounded by the positions that people take on these matters and hopefully more accepting of views different than my own. Always I hope and pray that where children are involved preserving life is the foremost priority.

Buying and Selling the "Other Half" of CPR

CPR courses break down into two components, management of the unresponsive patient and management of the conscious patient. When CPR training is being bought and sold the emphasis always seems to be on the value of the unresponsive patient portion of the training; performing chest compressions and applying an AED to cardiac arrest victims. The value proposition that both buyers and sellers tend to focus on is how many people are likely to go into cardiac arrest at a location that we are responsible for and how can we insure that the organization is prepared to respond to that event with the minimum investment in training and equipment?

People that buy CPR for, or are selling CPR to; a corporation, a municipal, provincial, state or federal government, a school board or a private, provincial or state health care delivery system should apply equal or greater weight to the value of  having as many people as possible properly trained to recognize and manage the conscious MI or Stroke patient. Recognizing and responding to MI and Stroke in a timely manner in the pre-hospital setting is the singular way to achieve the best possible outcome for these potentially devastating events.

Advancements in the treatment of  MI and Stroke, when therapy is initiated within 90 minutes of the onset of symptoms, are producing amazing, life changing results.  Patients who previously would have been left completely debilitated for months or even longer are now leaving hospital in days and returning to a quality life which often includes a return to work within a few weeks. Anecdotally we hear of construction workers and firefighters returning to work six to eight weeks after a STEMI.  More importantly the published data is unequivocal in pointing to "time" as a leading contributor to good outcomes.

MI and Stroke rehab is often a long and costly process. The cost burden falls to employers and to the health care system. In a jurisdiction such as Ontario (pop. 12 mill.) the price tag for cardiac and stroke rehab runs into the hundreds of millions each year. That does not even begin to consider the hidden costs that the healing process takes on individuals, families and employers. It would require relatively few instances of an early 9-1-1 call resulting in a best possible outcome to produce a positive return on money invested in quality CPR training.

Excellent recognition and mangement of MI and Stroke symptoms by witnesses in a pre-hospital setting has the potential to produce significant overall cost savings for all stakeholders. If your job places you under pressure to reduce the skyrocketing cost of healthcare delivery you need to be considering an investment in broad based CPR training with a strong emphasis on MI and Stroke recognition and management

Hospitals, Ambulance Services and CPR Training Agencies need to work together to develop MI and Stroke messaging for the community. Adult learners take great comfort and assurance in knowing that local Physicians have contributed to the curriculum. It helps older adults to understand why they or their spouse will not be taken to "their" hospital, but rather to the regional MI or Stroke Centre. Buyers need to insist that all CPR training features a strong MI and Stroke management component that includes an up to date review of local protocols. Sellers need to be promoting the benefits to both the client and the community of improved MI and Stroke pre-hospital response.

As you are reading this blog an individual, couple or group within close proximity to you are observing a family member, colleague or friend experiencing MI or Stroke symptoms. None of them want to pick up the phone because they are all unsure of what should be done. When the Paramedics arrive and ask the question "When is the last time you saw the patient in a normal state of health?" and the answer is "Oh she's been like this for about three hours now" it will be too late....and the funds for a long and expensive rehab program will need to be found.

Resuscitation (bringing dead people back to life) is dead sexy, but use your money to buy some steak along with the sizzle.

The Importance of "Meet and Greet" in CPR

"As soon as you determine that the patient is unresponsive send someone too call 9-1-1 and send one or two people outside of the building to meet professional responders (EMS/Fire/Police) and guide them to the patient."

I've taught CPR to thousands of students and of course many of them have taken CPR training previously.  To many of my students tell me that I am the first instructor that has ever mentioned this concept.  Meet and Greet is an important, and I believe undervalued, step in the management of out-of-hospital cardiovascular emergencies.

Whether Bystanders have achieved Return of Spontaneous Circulation (ROSC) prior to EMS arrival or are still working to do so, reducing the time to patient contact for professional responders will contribute significantly to improved outcomes.  In the "Cardiac Chain of Survival" the link immediately after "Early Defibrillation" is "Early Advanced Care".  Advanced Care begins when Paramedics start working the patient, not when the ambulance pulls up in front of the building.

If this were a 5,000 word essay I would regale you with stories of how excellent Meet and Greet contributed to lives saved and how the absence of Meet and Greet was a contributing factor to lives lost. Every Paramedic I know has at least one story of being locked out of a secure building or parking on the wrong side of a building or searching a property to find the patient.

CPR Instructors need to be teaching all of their students that whenever 9-1-1 is called and there is manpower available, get people outside, as far away from the building as is necessary to help professional responders make time saving decisions.  In the absence of Meet and Greet responders will usually park their vehicle at the front or main entrance to a building. In many cases (I always think of High Schools) the patient may be lying close to an entrance that is a few hundred yards from the front door. If there are multiple driveways onto the property get the greeters right out to the main road and direct EMS to the best access road (I always think of  Golf Courses).

Encourage organizations to have pre-determined Meet and Greet protocols and practice and review them during all CPR related exercises. In communities where Fire is tiered for medical response it is important to insure that there are people outside to bring members of both services to the patient.

Achieving the best possible survival rates for out-of-hospital cardiac arrest in your community requires that the big issues such as more and better Bystander CPR and more AED's be addressed. At the same time the sum of all the little things make a huge contribution and cannot be ignored.

Screening Teens for Heart Arrhythmia

In Ontario, Canada the billing price for an ECG is $14.00.  The cost of accessing health care services is different in every country as is the ability of each system to deliver services.  However the real cost of ECG is minuscule relative to the information it provides and the ease with which  that information can be acquired.  Virtually everyone in the health care system from Paramedics to RN's to GP's to Cardiologists are trained (and often equipped) to acquire an ECG.  Reading and interpreting ECG's requires special skills and training however many health care professionals are very good at spotting suspicious ECG's that should be referred to a specialist.  The current generation of ECG monitors are programmed with excellent algorithms that are more accurate than many people at spotting trouble.

When people set out to do a repetitive task they design efficiencies into the system and continually refine their methods while monitoring for quality assurance and quality improvement.  I submit that within two years a digital system that acquires an ECG for every Grade 9 student in Ontario and attaches it to their permanent health record could be in operation and the cost per child would be less than $7.00.

This long preamble is my way of saying we should acquire an ECG for every teenager in Canada or your Country here.  My personal interest in ECG Screening is that I advocate for individuals and families living with an Inherited Heart Rhythm Disorder;  those that have a diagnosis and more importantly those that are unaware that they are living with a potentially lethal disease.  A complete patient and family history along with an ECG provides an excellent starting point for identifying at-risk individuals and families. Papers published on various screening programs that have been piloted around the world suggest that somewhere between 1 in 120/150 young people screened will be recommended for follow-up with a cardiologist. I have seen no published articles that follow these individuals however given that most heart rhythm disorders are genetic the yield for individuals with a definitive diagnosis as result of screening will be multiplied as affected family members are identified.  In addition to screening for arrhythmia an even greater benefit to the patient and the health care system will come from having a baseline ECG attached to every patients permanent file, which Doctors can and will refer to throughout that patients life.

All children should be screened. So much of the conversation around screening speaks to athletes. Genetic disease does not recognize athletic ability. Only one third of young people killed by an Inherited Heart Rhythm Disorder were engaged in physical activity preceding sudden death. Intense physical activity is one known trigger for cardiac arrest in patients with an inherited heart rhythm disorder, as is auditory startle, from an alarm clock perhaps, as is emotional distress, such as a pending Math exam. When a young athlete dies in a filled to capacity sporting venue there is going to be  a media storm. For every athlete that dies during a game there are two or more children that die outside of the media spotlight, many, perhaps most, are non-athletes. The prevalence of genetic heart disease is spread equally across children of all different abilities and capabilities. Every child deserves equal attention.

All medical screening program generates a small percentage of false positives. An ECG that requires follow-up is not a positive test it is an ECG that requires follow-up. There is no diagnosis until the Cardiologist has completed their work and made a determination. An ECG that does not require follow-up is not a negative test, it is simply an ECG that is not suggestive of heart disease or defect.

In the world of "Do No Harm" the harm is done by not screening.

STEMI/PPCI Awareness: Part 2

Time is Muscle

Since the turn of the century I have had the privelege of discussing heart attack and stroke recognition and management with hundreds of older adults. What I've learned from these discussions is that when it comes to heart attack seniors are burdened with some very realistic fears and a very scary lack of knowledge.

I've also found that filling the knowledge void goes a long way toward reducing the fear. Adult learners want to know the hows and whys and once they do they will buy into the message and be better prepared to act in a way that insures the best possible outcome.

In the vast and evolving universe of Myocardial Infarction (MI) there is one constant that all Cardiologists agree on - "Time is Muscle".

Blood carries oxygen, all human tissue needs oxygen, in the absence of oxygen all human tissue dies. When a person is having a Heart Attack part of their heart muscle is not getting any blood, is therefore not getting any oxygen and is therefore dying. If blood flow is not restored to the affected part of the heart within 90 minutes heart muscle will be dead. The longer it takes to restore blood flow the more heart muscle that dies. The more heart muscle that dies the greater the likelihood of permanent disability or death.

In every community where I teach there is a hospital with a team of interventional cardiologists, working in a cardiac catheterization lab, that specializes in restoring blood flow to the affected part of the heart within 90 minutes thereby minimizing damage and insuring the best possible outcomes for Heart Attack patients. Virtually none of my students know this.

Virtually none of these adult learners know that every ambulance in their community is equipped with an ECG monitor and every paramedic is trained to identify the electronic signature (ST Elevation) of a heart attack that requires direct transport to the cath lab. None of them know that using a personal vehicle to transport a patient to the closest (and often wrong) hospital could result in the 90 minute window being closed and the worst possible outcome.

Governments and health care systems take billions of tax dollars from the people most at risk of morbidity and mortality resulting from Myocardial Infarction and use that money to build state of the art treatment programs; training and equipping paramedics and interventional cardiologists, so that blood flow can be restored to the affected part of the heart effectively solving the age old "Time is Muscle" dilemma. And then the entire system fails to invest one nickel in educating those same taxpayers on how and why to access the progams that they have paid for.

Teaching CPR to Adults versus Teens

I write this blog at my own peril. Whenever I promote this concept the push back is always intense, but I remain steadfast. That said I want to be clear right off the top I am not talking about a 90/10 deal but more of a 55/45 arrangement. I simply feel it would be beneficial to re-direct some of the universal enthusiasm for teaching CPR to teenagers toward teaching CPR to Adults. I don't believe teens should not be taught CPR, I just know that more adults should.

Adults hang with adults, teenagers hang with teenagers. I get it, it's not an absolute, but it is a fairly accurate generalization. There are not too many teenagers in a typical workplace. There are not too many teenagers at the gym at 11:00 pm when the senior men's league is playing basketball. There are not too many teenagers living in adult only condos and communities.

In the game of resuscitation the prize is increased survival to discharge for out-of-hospital cardiac arrest (OOHCA) and we need to build a team that can win now and win in the future. To win now we need adults to find a few hours in their busy schedule to learn CPR.

Adults experience the vast majority of cardiac arrest and they must take the majority of the responsibility for responding to cardiac arrest. Although teenagers are capable of performing appropriately during a cardiac emergency we cannot download the responsibility for saving our lives onto them. Think about all of the places where you spend significant blocks of time. Think of all the places where you are engaged in activity that may place you at increased risk for cardiac arrest. How often are there teenagers about?

In Ontario there is a well supported push to teach CPR to every grade nine student.  My thought is that yes we should teach CPR to every grade nine student - right after we teach CPR to every elementary and high school teacher, principal and support staff that work in our schools. If a student or a teacher collapses to the ground, VSA, in cardiac arrest, adults should not be watching helplessly and praying that a thirteen year old student steps up and saves the day. In Ontario cardiac arrest kills more than 9,000 people each year. I'm not sure that deferring improving that statistic until the current cohort of grade nine students comes of age is the best strategy. We need to be looking at much shorter term fixes.

Expecting young teens to perform CPR in a real life situation places an unfair emotional burden on them. I've listened to dozens of real life CPR stories: the storyteller speaks as if it happened yesterday even if it happened 15 years ago, their voice waivers and their eyes may fill with tears. Performing real life CPR is a traumatic experience that most people never forget. It seems a little weak and irresponsible to look to our children to fix the problem of historically dismal survival rates for out-of-hospital cardiac arrest.

Physically people weighing less than 120 lbs find it very challenging to perform effective chest compressions for more than a few seconds. I've evaluated CPR compressions performed by over 300 grade nine students on metered Laerdal manikins and the smaller kids are too fatigued to achieve an effective compression depth after only a few reps. Poor CPR is the equivalent of no CPR.  All of the research on improving survival to discharge rates for cardiac arrest  points to other solutions, none of the research suggests that teenagers are the answer.

The evidence is unequivocal, most cardiac arrest survivors benefit from an effective bystander intervention which includes quality CPR and/or the application of an AED. The communities with the highest survival rates for OOHCA are the communities with the highest rate of bystander intervention. Over the next ten years the communities that will enjoy the greatest improvement in survival rates for cardiac arrest are the communities that teach CPR to the greatest number of ADULTS.

Teaching CPR to thirteen year olds may pay dividends in 2025, in the meantime if you are over age twenty five recognize your civic responsibility and learn CPR this year.