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Links in the Chain


It’s 9 a.m. on a warm March morning. You and your partner just finished breakfast at the beginning of a 24-hour tour of duty. All things considered, you’re expecting a typical shift, and the citizens in the district you protect are expecting a typical day at work. Soon after breakfast, things drastically change for you, your partner and several employees of a local business.

The Call
The tones drop, and you’re dispatched for a patient having seizures in an office building located in the northeast corner of your district. You’re familiar with this building because you’ve been there for a few other calls. At this time of day, you expect a seven- or eight-minute response, depending on traffic.

En route, county dispatch advises you that your patient is a 58-year-old male, now reported to be in cardiac arrest. The patient is located in an elevator, which is currently stopped on the third floor of the office building. An engine is added to the response for assistance.

On your arrival to the third-floor elevator lobby, you find a hectic scene. Approximately 30 employees have congregated around the entrance to the elevator. As you and your partner make your way through the crowd of onlookers, you’re surprised at what you find: a middle-age, unconscious man with an AED applied.

A female employee who’s kneeling at the head of the patient anxiously says, “We shocked him, and we think he has a pulse.” You confirm this with a pulse check. The patient’s situation is still dire, because he’s unresponsive with agonal respirations. You and your partner take over patient care and initiate transport to the closest facility.

En route, your patient’s status slowly improves. His vitals are relatively stable, and, although intubated, his respiratory rate increases and becomes more regular. During transport, a 12-lead ECG is acquired following patient reassessment. The ECG is transmitted to the receiving facility emergency department (ED) via your monitor’s recently installed Bluetooth device. You arrive at the hospital, transfer patient care to a waiting ED team (who has your prehospital 12-lead in hand) and return to the station.

You and the team are pleased that your advanced training, technology and the “chain of survival” changed a patient outcome today. During a follow-up, you discover that the patient received post-resuscitation cooling and was transferred to a hospital that continued the connected care approach. A later follow-up indicates that the patient was discharged neurologically intact—more proof that teamwork and connected care made a difference in this patient’s post-arrest quality of life.

The Chain of Survival
Although we often hear it only once every two years when we take a CPR refresher course, the chain of survival is a critical part of any cardiac arrest response.

It starts with a witnessed event and is followed by bystander CPR and AED use, ALS intervention with a prehospital 12-lead transmitted to the ED while the ambulance is en route, ED review of the 12-lead and patient care report prior to ambulance arrival, and diagnosis and hospital interventions, including therapeutic hypothermia when appropriate. It ends with the hospital discharge of a neurologically intact person.

From the first CPR class we take, the chain of survival is committed to our memories. Unfortunately, it’s not often that we get to see this chain work to its full ability. When EMS arrives on scene at a cardiac arrest, far too often the only care being provided is CPR, despite the fact that the American Hospital Association (AHA) recommends that CPR with defibrillation should take place within three to five minutes after a patient collapses from sudden V-fib cardiac arrest.(1)

But this isn’t always possible with an EMS-only response. Factor in 9-1-1 dispatch times and response times, and it’s hard to imagine many EMS systems arriving on location within three to five minutes after patient collapse. According to NFPA 1710, fire departments should have, at minimum, a first responder with AED capabilities on location within five minutes of the dispatch (four minutes of response time plus one-minute turnout time) at least 90% of the time.(2) Because the call must be processed and dispatched by the 9-1-1 center, adding extra time on the front end of the call’s dispatch, EMS response within the three- to five-minute standard may be unrealistic.

In addition, in many EMS systems, NFPA response times aren’t currently possible due to staffing and funding issues. NFPA 1710 is geared toward response standards in career fire departments. Many systems in the U.S. rely on combination career/volunteer response, and others rely solely on volunteer response for EMS. In volunteer systems that do not have on-duty, at-station crews, response times can be longer.

This is where the public can play the biggest role in the chain of survival for cardiac arrest victims. Although it’s not feasible to put a paramedic or EMS unit on every corner, it is possible to saturate your response district with AEDs located throughout the community and citizens trained in CPR. EMS and fire agencies must give more attention to educating communities and businesses to the importance of Public Access Defibrillation (PAD) programs and AED and CPR training in the community. These two elements can be the key to increasing the number of lives saved in your community.

The Chain in Action
The incident mentioned at the beginning of this article represents an excellent example of how the chain of survival is supposed to work in the workplace. The patient’s co-workers initially called 9-1-1 to report that the patient had collapsed and was seizing. The co-workers had recently completed a CPR/AED class at their workplace and mimicked the video they watched as they split up to complete the tasks they had just learned. As two co-workers started CPR, one went to grab the AED and another called 9-1-1.

Because the patient collapsed in front of co-workers who had just completed workplace CPR/AED training, CPR was initiated almost immediately after patient collapse. Too often, CPR isn’t started until after someone contacts the 9-1-1 center and receives instructions on how to do it. In cases of cardiac arrest, these extra seconds lost can mean the difference between life and death for the patient.

Although initiating CPR quickly is extremely important, CPR alone will most likely not resuscitate a sudden cardiac arrest patient. Once the heart is subjected to a lethal rhythm (V-fib or V-tach), quick defibrillation is paramount. Studies have shown that for every minute that passes between sudden VF cardiac arrest and defibrillation, survival rates decrease dramatically.(3) A more recent study indicates that survival doesn’t decline at a constant rate. The study found that the change in survival rate over time is almost flat in the first four minutes following collapse, then declines steeply until about 10 minutes after collapse, at which point it becomes fairly flat again, because few patients survive when treated this late. Most notable is the fact that when EMS does not arrive between five and 10 minutes of arrest, survival declines by 5.2% per minute.(4)

In our example, the response time was approximately eight minutes. The time needed to recognize the problem, for co-workers to call 9-1-1 and county to dispatch the call isn’t included in those eight minutes. Once on scene, we also had to climb three flights of stairs to access the patient. If CPR hadn’t been initiated by the patient’s co-workers so quickly, those eight minutes represented a significant potential decrease in the patient’s possible chance of survival. An intact chain of survival can negate all of these delays.

After CPR is initiated, quick defibrillation must occur for the heart to have any chance of returning to a normal rhythm. If an AED isn’t readily available, the chain of survival can easily be broken. The Department of Health and Human Services (HHS) and the General Services Administration (GSA) recently collaborated to define guidelines for public access defibrillators in federal buildings. Their findings indicate that a defibrillator, if placed properly in a public building, should be within three minutes of any area within the building.(5) These agencies also recommend that as many employees as possible be trained in the use of the AEDs, and the location of AEDs must be easily accessible, well marked and within close proximity to a telephone in anticipation that 9-1-1 will be dialed immediately.

Hopefully, by the time the 9-1-1 call is made and EMS is dispatched to a sudden cardiac arrest, the first three links of the chain of survival have been well connected. Although circulation in the cardiac arrest patient is prolonged by effective CPR and an AED can convert the patient’s lethal, non-perfusing rhythm into a perfusing one, what if that’s where the chain ends?

The fact is that a quick response by ALS to provide post-resuscitation care will exponentially improve the victim’s survival rate. According to the AHA, only 33% (one in three) of EMS-treated sudden cardiac arrest victims actually experience symptoms within one hour of death.(6) This is why early ALS intervention is so important.

ALS can delve further into each patient’s medical event and investigate the potential causes. In addition to documenting the patient’s post-resuscitation rhythms, we should obtain as complete a medical history as possible from family members and bystanders, and search for medical alert tags and wallet cards that will help procure a differential diagnosis of the condition that preceded the cardiac arrest.

Also, take advantage of the latest EMS technology. In the case described above, EMS was able to obtain, interpret and transmit a 12-lead ECG to the receiving facility. The ED staff was able to read and make its own interpretations prior to EMS arriving at the facility. When the hospital was notified of the incoming patient via cell phone, the ED physician was able to discuss the patient’s condition with EMS, citing specific ECG abnormalities. In cases such as this, the ED physician and EMS crew become a team. This connects care between the street and the hospital.

Finally, therapeutic hypothermia should be considered, either en route or in the ED for comatose survivors of V-fib and V-tach (for more information on therapeutic hypothermia in the field, see p. 9).

These are all components of the ALS arsenal that can increase survival rates for the out-of-hospital sudden cardiac arrest victim.

A Final Word
The above case is an excellent example of a successful chain of survival. Although incidents such as this happen every day, countless other victims could be successfully resuscitated with stronger community involvement in the chain of survival. The most critical minutes for a victim of sudden cardiac arrest occur before EMS arrives. It’s impossible to station an EMT or paramedic with an AED at every corner, but it is possible to educate the community and strategically place AEDs through community PAD programs.

The bottom line: A little community effort today could save a significant number of lives tomorrow.

Disclosure: The authors have received no monetary support from Philips. Berwyn Fire Company utilizes Philips HeartStart MRx monitor/defibrilllators and AEDs.


1. American Heart Association: Cardiopulmonary Resuscitation (CPR) Statistics. www.americanheart.org/presenter.jhtml?identifier=4483. Retrieved May 31, 2010.
2. National Fire Protection Association: NFPA 1710: Standard for the Organization and Development of Fire Suppression Operations, Emergency Medical Services Operations, and Special Operations to the Public by Career Fire Departments, 2010 Edition.
3. Resuscitation Central: Early Defibrillation Programs. www.resuscitationcentral.com/defibrillation/early-defibrillation-sca-chain-of-survival. Retrieved June 1, 2010.
4. Gold LS, Fahrenbruch CE, Rea TD, et al. The relationship between time to arrival of emergency medical services (EMS) and survival from out-of-hospital ventricular fibrillation cardiac arrest. Resuscitation. 2010:81(622–625).
5. Federal Occupational Health. Public Access Defibrillation Guidelines. www.foh.dhhs.gov/public/whatwedo/AED/HHSAED.asp. Retrieved June 1, 2010.
6. American Heart Association: Out-of-Hospital Cardiac Arrest Statistics, 2009 Update. http://strokeassociation.org/downloadable/heart/1236978541670OUT_OF_HOSP.pdf. Retrieved June 1, 2010.

This article originally appeared in an editorial supplement to the September 2010 JEMS as “Links in the Chain: A success story in Berwyn, Pa., demonstrates the value of bystander CPR, AEDs in public buildings & early ALS care.”



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