The Art and Science of Improving Resuscitation

Mickey Eisenberg, MD, PhD
Mickey Eisenberg, MD, PhD

For over 40 years as a physician, researcher, author and EMS medical director, Mickey Eisenberg has led the charge for increasing sudden cardiac arrest survival rates and is one reason for the success that Seattle and King County, Washington, have demonstrated in saving people’s lives.

Eisenberg first came to Seattle and the King County EMS system, known as Medic One, in the 1970s. Under the guidance of Drs. Leonard Cobb and Michael Copass, Eisenberg helped take the Medic One system that had started in Seattle and implement it throughout the entire county. At the same time, he combined his public health education and his passion for improving resuscitation to conduct groundbreaking research. As early as 1979, Eisenberg and his colleagues published research outlining the key factors in successful resuscitation. Four decades later, those findings remain the key tenets of resuscitation: early CPR, including bystander CPR, and rapid defibrillation are critical.

Eisenberg, who currently serves as director of medical quality improvement for King County Medic One and a professor of emergency medicine at the University of Washington, was one of several experts recently tapped by the National Highway Traffic Safety Administration’s Office of Emergency Medical Services (OEMS) to create CPR LifeLinks, a toolkit to help communities improve cardiac arrest care through implementation of telecommunicator CPR and high-performance CPR.

In this interview, Eisenberg discusses the challenges of implementing these programs, the importance of teamwork and collaboration and what it’s like to see communities around the world committing themselves to improving resuscitation.

 

JEMS: Some of the changes taking root now across the country are ones your team implemented years or even decades ago. Why has improving cardiac arrest proven to be so difficult for some communities?

Eisenberg: It’s an excellent question because there’s a large gap between the discovery of an intervention that really improves survival and widespread adoption as the standard of care. All technologies go through various phases: the technology is developed, there are early adopters, and finally a larger mass of people follow—and that often takes a while to play out. I think the same phenomenon is happening with the adoption of EMS programs that improve survival.

The typical vehicle to announce and promote these kinds of developments is the scientific literature, and the most vigorous way in proving utility is with randomized controlled trials. It takes a while. If the findings are confirmed, it adds momentum, and eventually you get a shift in the adoption curve—so instead of slowly going up, it really accelerates. And I think that’s where we are right now for telecommunicator CPR, at that acceleration phase. The American Heart Association and National Highway Traffic Safety Administration (NHTSA) have endorsed it, and NHTSA has come out with a toolkit to help people implement both telephone CPR and high-performance CPR. These are wonderful developments that are going to make a big difference.

 

JEMS: That toolkit, CPR LifeLinks, was the result of a project that brought together some of the leading experts in high-performance and telephone CPR. What were some of the lessons learned by bringing everyone together in the same room?

Eisenberg: The expert panel that was put together, led by Dr. Ben Bobrow, included people who not only were experts in the science of resuscitation, but had experience implementing telephone CPR or high-performance CPR in their own community. They had first-hand experience in training and quality improvement and collection of data to demonstrate that it actually worked. And that was the group that helped write the CPR LifeLinks. CPR LifeLinks is really a wonderful marriage of telecommunicator CPR with the benefit that EMTs provide in the field. You put those together, the telecommunicator and the EMS personnel, and you’ve really got a powerful team that works. It really does save lives.

 

JEMS: It seems that for communities to successfully increase cardiac arrest survival rates they have to undergo a shift in mindset first, in addition to adopting evidence-based practices?

Eisenberg: It’s the mindset that everyone in VF survives—we’ll never give up; we’ll do everything we can. As we become more and more aware of the reasons that some communities achieve higher survival rates than others, it invariably comes down not only to the time but the quality of the interventions; the time to the first CPR (achieved with telecommunicator CPR) and the quality of that CPR (achieved with high-performance CPR). All these things truly make it possible that more people in VF can survive.

It’s not just that the telecommunication centers say they’re committed to telecommunicator CPR. They have to bring high fidelity to the intervention, the telecommunicators are all trained and have ongoing training, and they have continuous quality improvement for every cardiac arrest call, that telecommunicators get feedback on how the call went, all with the purpose of trying to make it even better for the next call. Cardiac arrest is not something that happens all the time with every telecommunicator. It represents maybe one or two % of the calls. For something that infrequent, not only do you have to be ready to act, but you need to learn from every time you deliver that message. So it’s both the training and the quality improvement that are critical to making this successful.

 

JEMS: You’ve been an advocate and researcher focused on cardiac arrest for your entire career and seen the evolution of resuscitation to where it is now. What’s next—what innovations or developments will lead to the next big breakthroughs?

Eisenberg: I think in the short-term we’ll see more and more communities that truly start to embrace telecommunicator CPR and high-performance CPR. And that is going to lead to some dramatic improvements in outcomes. Right now, the national survival rate from witnessed cases of VF is hovering around 30%, essentially unchanged for the last 10 years. Overall survival for all rhythms has been hovering at around 10%. So, survival is low, and it has been flat for the past decade. Once communities start to embrace TCPR and HP-CPR, I think you’re going to really see an inflection in that curve and it’s going to start to rise. We’re going to get to 35%, 40%, and I think it’s not unrealistic for a community that really embraces these two vital steps to hit 50% survival for witnessed cases of ventricular fibrillation.

Now the question is, can we go higher than that. And I think we can. I have a feeling it’s going to take some thinking outside the box to create a fundamental change in the way care is delivered to patients. I can conceive one day there being consumer defibrillators as ubiquitous as a smoke alarm in people’s homes (75% of cardiac arrests occur in the home). Let your imagination run wild a little here and try to envision a consumer defibrillator. It would be a very small device that runs on AA batteries with a shelf life of 10 years and is used one time—and costs $100 or less. If such devices were disseminated throughout society you can envision a dramatic improvement in survival from VF.

Even though it’s fun to dream about such a day where consumer defibrillators are widely adopted, let’s face current reality: There’s going be someone at the scene who calls 911, and those early actions by that individual either because they’ve been trained or they call an emergency telecommunication center that provides telecommunicator CPR by a highly trained staff—that really is the crucial step. We can do a heck of a lot now to improve survival. We can dream about some futuristic thing, but we can act now.

 

JEMS: What is it like for you, personally, to see these concepts finally taking root across the country, and the world?

Eisenberg: It’s extremely gratifying. I’ve had two mentors that provided tremendous beacons of how to be engaged in this, and those were Drs. Leonard Cobb and Michael Copass—without their mentorship, none of my involvement would have happened. But I’ve been doubly fortunate because the people I’ve worked with for decades have been remarkable individuals who have been a part of what I consider to be a team effort. Just like a phrase we have in the Resuscitation Academy that it takes a system to save a victim, it also takes a team to study cardiac arrest—the goal being improvement in resuscitation. I also live in an amazing community that’s committed to quality resuscitation.

It’s not just a science, it’s also the art of trying to achieve high fidelity implementation in the community. Too often we just focus on the science, there’s this discovery and we’ve got to do that, and we forget about the art: the challenge of implementation, including quality improvement and education—all these things that are what I term the art of resuscitation. And that’s where the challenge is: it’s not only learning how to do it, it’s as much how to implement it.

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