How EMS Can Overcome SCA Obstacles

Brandon Oto, BA, NREMT-B, is editor of and a field EMT and clinical educator who works with rescuers in numerous settings to promote best practices for resuscitation and streamline systems of care. He discussed sudden cardiac arrest (SCA) outcomes with JEMS in advance of September’s biannual Emergency Cardiovascular Care Update Conference. In this question-and-answer session, Brandon offers his perspective on the current challenges of SCA and how folks in the trenches are confronting them.

Q: Why should we change the way we do things?
Sudden cardiac arrest (SCA) continues to needlessly kill too many people. If you collapse tomorrow without a pulse in downtown Seattle, you have about a 50/50 chance of walking out of the hospital with a functioning brain. But if you were to collapse in Detroit instead, your chances of survival would be less than 1%. That’s a difference of over 40 times, and we’d never accept such a survival disparity for other diseases. In fact, if anything else caused that many preventable deaths in our community, there would be an uproar.

Granted, some people simply aren’t going to survive after sudden out-of-hospital cardiac arrest. But when we compare numbers, we’re usually looking at witnessed arrests with a primarily cardiac etiology and a shockable initial rhythm. In other words, these are patients who could survive if we give them a fighting chance.

It is possible to fix the gap? Consider that Wake County, N.C., which saw around 14% of its shockable arrests survive in 2004, improved its survival to more than 40% after an aggressive initiative to strengthen their resuscitation infrastructure. That could be you.

Q: I want numbers like that in my community. What’s the secret?
Unfortunately, if we’ve learned anything yet after 60-plus years of resuscitation research, it’s that there’s no secret. The old model of a “cardiac chain of survival” keeps proving true. Good outcomes depend on an interlocking sequence of events happening rapidly and effectively. If even one link is weak or missing, you can’t make up for it elsewhere. There are no silver bullets or quick fixes; a comprehensive system built on a solid foundation is essential.

Q: This doesn’t sound new at all. What has changed?
It’s not new. If anything is new, it’s our understanding of what’s truly necessary and what can be deemphasized. It’s clear that early and high-quality chest compressions save lives, as does early defibrillation, and post-arrest hypothermia. Beyond those three interventions, anything else is experimental at best and a distraction at worst, so the goal is now to create systems that streamline delivery of the basics.

In most cases, the weakest link in the chain–and hence the lowest-hanging fruit–is layperson intervention. Many arrests still don’t get bystander compressions; even fewer get pre-EMS defibrillation. The consequences are grim. Thus, the challenges of resuscitation have shifted from the clinical, such as finding the ideal antiarrhythmic medication, and toward the psychological: determining how to market CPR so people will learn it, teach it so they’ll remember it, and contextualize it so they’ll be willing to do it.

That’s why the American Heart Association (AHA) CPR recommendations have been getting simpler every five years. If streamlining the methodology means that more patients get compressions instead of nothing, that’s a definite win.

We’re realizing that when EMS providers walk in and nobody’s doing CPR–even bystanders who have been certified–it’s because they were afraid of doing it wrong and being liable, concerned about catching a disease, or not confident they could correctly recognize the need. We can fix those problems with smart and pointed public education, such as public safety announcements and simplified 20-minute CPR Anytime courses. In short, we need to mobilize the population.

On the other hand, we’re also learning that chest compressions and defibrillation aren’t “all or nothing.” You can execute them well or poorly, and the quality of that execution makes a difference.

As a result, today’s ideal resuscitation is much closer to a golf swing than a math test. It’s become a physical rather than a cognitive skill. But it’s still not an easy skill, and practice is needed to succeed. EMS systems that are yielding the best survival are taking the time to drill through the fundamentals until all responders are performing compressions deep and fast, with full recoil, minimal interruptions, no hyperventilation and seamless integration with defibrillation.

That’s the reason for the “pit crew” model many successful services have adopted, where the role of every provider is explicitly assigned and choreographed ahead of time. It’s all just another way to ensure the fundamentals are done right.

Q: This sounds like a big undertaking. Where do I start?
To address any problem with so many different facets, numerous parties must be involved. This includes government, public safety, EMS and healthcare agencies, as well as the public itself. Rarely will a system be successful without widespread buy-in.

These parties won’t come together without an active effort to recruit them. Since most victims of SCA don’t survive, it isn’t a high-visibility problem and public awareness is poor. Motivation for change requires champions to advocate for it. EMS is well positioned to shoulder that burden, along with other public safety and healthcare services. We can also benefit from the testimony of successfully resuscitated victims, whose good outcomes and compelling stories help bring the message to life.

Most of all, it’s clear lip service isn’t enough. Everyone believes in these ideas and wants survival. But you need to put in real work and make real changes. And although it’s often difficult to get traction when most people don’t realize the problem exists, things can snowball once they develop momentum.

For example, one of the great achievements in Seattle wasn’t just developing strong tools for resuscitation, it was creating a culture of survival. Now, the community is proud of what they have. They believe in it. And if someone collapses, there’s an expectation that someone else will intervene.

You don’t need to reinvent the wheel. Some great templates already exist, such as Medtronic Foundation’s HeartRescue program and the AHA’s HEARTSafe Communities. In the HEARTSafe model, a region (usually a state) establishes criteria supporting the chain of survival. When a community in that region meets the requirements, they can apply to their home office and receive “HEARTSafe” designation, earning the right to post a sign proclaiming that status. It’s an odd motivator and a grass-roots approach. Although the AHA supports the concept, nobody owns it, no central administration exists, and it costs nothing to implement. But it’s proven internationally successful, and if your state doesn’t already have a program, many good criteria exist that can be readily adopted.

Q: That covers bystanders. what should EMS agencies be doing?
The first step is data collection. You need a reliable scorecard. If you don’t know how well you’re doing, you can’t do much to improve. (Nor would you even realize if you had.) The more data, the better.

With hospital input, basic figures can be compiled directly from electronic patient care report systems. Or you can use a purpose-built, Utstein-type registry, such as the Cardiac Arrest Registry to Enhance Survival (CARES) database.

To drill down further, all major manufacturers offer software suites allowing review of data, such as compression fraction (i.e., the total time spent on vs. off the chest), depth and ventilatory rate. This is invaluable for pinpointing where you need to focus your efforts, both as a system and as individual providers. As you implement changes, you can track the results and watch your numbers climb.

Ironically, one of the challenges can come from the veterans in your system. Many paramedics with 10—20 years’ experience have visited so many arrests and seen so few positive outcomes that they’ve come to view working a code as mere ritual, an opportunity to go through the motions and perhaps practice some little-used skills, rather than a fight for survival. Highlighting the statistics and offering testimonies from survivors can help convince them that out-of-hospital SCA is now a treatable, survivable condition. Once they’re believers, they can become your best advocates.

Work with your fellow rescuers to establish a standard flow of care, if not an actual “pit crew” model, for every arrest. This will not only ensure that everybody understands their role and what the goals are on scene, it also gets all parties on-board so that the police officer who shows up first is just as passionate about compressions and defibrillation as the paramedics who arrive later.

In addition, remember that your receiving hospitals are a key part of the puzzle. Post-arrest hypothermia is truly lifesaving, yet has still not been consistently adopted in many EDs.

EMS may help move this forward by working directly with hospital administrators. However, if financial constraints or general institutional inertia stand in the way, we can also apply friendly but effective pressure by instituting field hypothermia protocols (most EDs are more likely to continue ongoing cooling measures than to initiate them), or even modifying destination plans to prohibit post-arrest patients from being transported to hospitals that won’t provide therapeutic hypothermia.

Another conversation worth having involves hospital willingness to perform percutaneous coronary intervention (PCI) on post-arrest patients, or even intra-arrest patients (perhaps using a mechanical compression device) who have not achieved return of spontaneous circulation (ROSC). Although potentially lifesaving, many centers are reluctant to catheterize these patients due to their risk–treating such a high-mortality cohort can bring down outcome figures. Try to work out indications and contraindications with the interventionalists ahead of time.

Q: What’s on the horizon?
Intriguing possibilities for future interventions include the administration of such IV female sex hormones as estrogen, which has shown promise for mitigating tissue damage. “Ischemic conditioning,” possibly using low-tech devices like blood pressure cuffs, may also prove to be beneficial.

Double defibrillation for refractory ventricular fibrillation (v fib), lipid infusions for overdoses and high-dose nitrates all might have a role for specific patient groups. And more studies are needed to refine best practices for hypothermia, including the role of field induction and specific endpoints for duration, temperature and supportive care.

We may even eventually find that effective hypothermia helps “bridge the gap” to neurologically intact discharge for the many therapies, such as epinephrine, that have shown early improvements in ROSC but no long-term benefits.

Better still are innovations that improve our ability to deliver BLS, such as real-time CPR feedback and metronome tools, active decompression devices or smartphone apps that direct bystanders to available AEDs.

And there’s some evidence that “hands-on CPR,” or defibrillation without taking gloved hands off the chest, may be safe and allow us to remove yet another interruption to continuous compressions. (Some clinicians are already practicing this routinely, with no negative incidents reported thus far.)

In the end, however, the basic picture remains the same. Improving survival from out-of-hospital cardiac arrest requires widespread improvements to the entire chain of survival. And that means making a commitment and doing the work. We can have it everywhere, but it won’t happen on its own.


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