You could call Dr. Mickey Eisenberg’s book, Resuscitate! How Your Community Can Improve Survival from Sudden Cardiac Arrest, a labor of love. But that wouldn’t fully encompass his passion—or mission—for saving people who have suffered cardiac arrest.
“The book is a culmination of 35 years of experience in EMS research, a culmination of everything I have been taught by others, and everything I have learned over the years,” says Eisenberg, who is medical director for Seattle’s King County Emergency Medical Services and professor of medicine at the University of Washington and long considered one of the pioneers of cardiac arrest resuscitation. “I’ve lived this for 35 years. It’s a passion and a career. It’s the way I was taught to practice medicine.”
An Unexplained Gap
Eisenberg wrote the book because of the large disparity of cardiac arrest survival rates across the nation.
“The catalyst was the fact that cardiac arrest survival has a disparity like nothing else I can think of in terms of its outcome—namely survival,” he says. “Why do some communities, particularly large urban cities, have zero, three percent, five percent, seven percent survival rates from ventricular fibrillation and other communities have 46 percent survival? There’s got to be an explanation for that.”
Resuscitate! is an attempt to answer why some communities have excellent cardiac survival rates while others don’t, and to suggest areas systems that can focus on to increase their resuscitation rates. Eisenberg presents 25 suggestions for improving cardiac survival rates in our communities.
He also outlines 50 factors his experience has shown him affect survival and breaks them into four groups: patient, event, system, and therapy. He then details the characteristics of each factor, the research underscoring their importance, and their link to higher rates of survival.
“A lot of factors determine whether someone lives or dies, and of those 50 factors, some are strongly associated with survival. Others are more speculative, or we don’t have enough information,” he says. “For example, there are likely to be genetic factors that explain why some people are more resuscitatable than others. But we don’t yet have the science to understand that.”
Eisenberg believes a large percentage of the factors fall into the patient and event groupings, which can’t be changed. “There is nothing you can do to alter that situation; it’s fate or circumstance,” he says. “Whether the cardiac arrest is witnessed or unwitnessed has nothing to do with the quality of an EMS system, but it has everything to do with the circumstances. Those things can’t be changed, and you just have to accept that.”
The Links to Understanding
Eisenberg is quick to point out that the system and therapy factors can be altered for the better because they’re under the control of a medical director or EMS administrator. “How you set up your dispatch system, how you set up your response system, how you perform CPR, and how it interacts with defibrillation are all system factors,” Eisenberg says. “Those are the ones that can be changed, and that’s what the book describes in great detail.”
Eisenberg admits that even though the groupings drawn together can shed light on the best ways to improve cardiac arrest survivability, they still only provide a partial understanding of the overall factors influencing the survivability disparity between communities.
“The links in the chain of survival are quantifiable factors. They have to do with [people] calling 9-1-1 early, the actions of the dispatcher, early CPR, early defibrillation, early advanced care and early post-resuscitative care,” he says. “But I don’t think that explains all of the disparity. Surrounding those links is a qualitative frame, which I think is difficult to measure, and that has to do with medical leadership, a culture of excellence, and the training and quality of EMS providers.”
He thinks if both the qualitative and quantitative factors could be reliably measured, a true picture would emerge of why survivability rates vary between communities. “If you could measure them, you would begin to truly understand why some systems are so much different than others,” he says. “And that really is the message that summarizes why the disparity exists.”
At its heart, Eisenberg feels that successful cardiac arrest survivability rests in every aspect of a community. This is why he says there are no quick fixes—and why he wrote the book.
“You first have to intensely study the community you are in and tear apart everything you can measure,” he says. By doing this, EMS agencies may begin to discover that they’re taking longer to arrive at a scene than they think. “For example, paramedics may think they’re getting somewhere in six minutes. But when we really started measuring every piece of that response [from call to dispatch center to arrival at the patient’s side] it turns out to be 12 minutes. No wonder we weren’t saving anybody,” Eisenberg says. “Unless you take a hard, honest look, you’ll never get to the root of the problem.”
Eisenberg would also like EMS agencies to take a closer look at critical cases, especially cardiac patients with witnessed V-fib who die. “I think every community should be looking at every person who dies from ventricular fibrillation and asking why the patient died. What could we have done to prevent that death?” he says. “If you take the mindset that says, ‘This patient should have lived. What could we have done differently?’ then I think you’re starting to get at quality improvement.”
This work isn’t hard, Eisenberg emphasizes. It simply requires the right people to look at the data and be accountable. Without making sense of the data and then making the right decisions based on the data, the answers will remain elusive. “It requires somebody to tear the data apart and make sense of it,” he says.
He adds, “I suppose the bottom line is, are you there just to answer calls, or are you there to say how can we do better?” Resuscitate! aims to help readers work with the data and notice other variables that can impact the percentages of survivability.
The book has been warmly received, especially by those in the EMS community, a response Eisenberg finds satisfying.
“People have told me that they’ve bought the book for their entire crews or shifts, or asked everyone in their department to read it,” he says. “I think that when you get that kind of response, it is indeed gratifying. There are some serious messages here, and if they start percolating through an organization, it will begin to create that culture of excellence, so I’m thrilled.”
As a testament to Eisenberg’s devotion to his mission, all proceeds from the book go to fund cardiac arrest resuscitation research. “We have ongoing projects trying to look at new ways of providing care, and new ways of looking at the information we get,” Eisenberg says. “In ventricular fibrillation, we can learn from the signal coming from the heart that may help guide the resuscitation, so there is a lot to learn.”
Pay Attention to the Signs
Eisenberg stresses that measuring and considering all data concerning the cardiac arrest event will help systems find the gems that may reveal transformative solutions.
“Step one is to look at what you’re doing. If you can’t answer the question of ‘How are we doing right now, what is our true response time from the moment the 9-1-1 call comes in until the moment we arrive at the patient’s side?’ and if you are not measuring every key aspect of that resuscitation, you can’t begin to improve,” he says. “So that has to be the first step.”
He also encourages sharing information with national reporting systems, such as the Cardiac Arrest Registry to Enhance Survival site at mycares.net. “Much of it is automated,” he says. “With 10 or 15 minutes per case, you get back an incredible wealth of information that allows you to look at your own system’s performance as well as make peer comparisons.”
Although Eisenberg wrote Resuscitate! on his own, he credits the many people who have influenced and supported him throughout his career. “Over those 35 years, there’s been an incredible number of people I’ve had the great joy of working with, and they have taught me a great deal,” he says. “People in the EMS community have a kind of mission-driven purpose in their work. There are an awful lot of people out there who have that same drive to succeed in what they do, so I’ve had some great role models—in particular Dr. Leonard Cobb and Dr. Michael Copass.”
Even so, Eisenberg stresses that all the experience and training in the world won’t necessarily make a difference in cardiac arrest survival rates unless attention is paid to the myriad factors that go into quickly arriving at a scene and providing state-of-the-art care throughout the whole process.
He asks simply: “How can you begin to improve unless you know how you are performing right now?”
It’s a thought-provoking question to keep in mind.