AMR aims to standardize new cardiac arrest approach
The message now to medical personnel – and the public – is to stay on the scene and focus on high-quality CPR
By Henry L. Davis
The Buffalo News
BUFFALO, N.Y. — As Edward Bush walked out of New Era Field after a Buffalo Bills game, he felt dizzy and dropped unconscious to the ground.
Within moments, an alert stadium worker radioed for help and started CPR. Speed is everything in cardiac arrest before lack of oxygen-rich blood leads to brain damage and death. Physicians and paramedics rushed to his aid.
"I'm the luckiest guy that it happened there," recalled Bush, now 57. "It was the perfect situation to have your heart go out."
Bush, who had a pacemaker implanted after the 2016 incident, is among the few who live to talk about a cardiac arrest. More than 90 percent of people who suffer from the condition outside of a hospital die.
Outcomes are so bad that, in recent years, physicians and emergency medical personnel have rethought how to respond.
In Western New York, the region's largest emergency medical service provider, AMR, is trying to standardize a new approach, bucking old habits and conventional wisdom. The message now to medical personnel – and the public – is to stay on the scene and focus on high-quality CPR. The early results are promising.
But getting public buy-in isn't easy. Movies and television portray CPR as simple and successful. In popular culture, patients collapse, clutching their chests for effect, and ambulances race them to hospitals where they are miraculously saved from near death. Reality is different.
"That image of a gurney being wheeled into an emergency room, the doctor doing some magic, and the patient sitting upright and going on to live their life – it just doesn’t happen," said Dr. Brian Clemency, medical director at AMR.
To improve cardiac arrest survival, doctors and emergency workers around the world are collecting better data, measuring performance and examining ways to expand the use of CPR by bystanders. They also are questioning established ways, such as whether ambulances doing a "scoop and run" – getting someone to the nearest hospital as soon as possible – is really best in most cases. That's a major change.
"For the majority of patients, we're now either going to bring them back at the scene or not. Going to the hospital isn't going to add anything," said Clemency. "If anything, it only creates false hope."
Survival has been 'abysmal'
This is no small matter.
Cardiac arrest ranks as the third-leading cause of death in the nation behind cancer and heart disease. It strikes about 400,000 Americans each year in the home or in public. In contrast, about 209,000 cardiac arrests occur annually in hospitals, and 24 percent survive.
"Cardiac arrest survival has always been abysmal. If you are going to save someone, if has to be within the first few minutes," said Dr. Anne Curtis, chairwoman of the department of medicine in the University at Buffalo Jacobs School of Medicine and Biomedical Sciences.
The reality, Clemency and others said, is that the medical community has figured out that you can't do effective CPR while also trying to insert a breathing tube and inject medication in an ambulance as it bumpily darts down city streets.
"For the last 30 years, we have been taking people down flights of stairs, throwing them in an ambulance and speeding to the hospital. People are dead by then," said Clemency. "We've got maybe 10 minutes. Let's use it in a way that makes more sense."
AMR serves Buffalo, Cheektowaga, Hamburg, West Seneca, East Aurora, Evans and Lackawanna, as well as Niagara County. In 154 cardiac arrest resuscitation attempts from Jan. 1 to March 31 last year in cases that did not involve trauma, such as a car accident, overall survival was 4.5 percent. In 393 resuscitation attempts from April 1 through Dec. 31, with a vigorous push to standardize a new practice that emphasizes high-quality CPR on site, the proportion of patients who survived increased to 8.9 percent.
Surviving cardiac arrest is not enough. Even if efforts get a heart beating again, it's often too late to prevent brain damage. Success is really about how many patients recover with neurological functions intact.
In the period before AMR initiated the change, 2.6 percent of cardiac arrest patients went home in a "neurologically favorable" condition. That improved to 7.1 percent. Here's another way to look at it: On average, the number of survivors with good brain function increased from 1.3 a month to more than three a month. As modest as this sounds, it's a big victory for those in a field where even incremental change is tough to achieve.
"That's awesome. There are three people who would have been dead who are alive in a month. They are living their lives again, and back with their families, and doing the things they used to do," said Clemency, also an associate professor of emergency medicine at UB.
Cardiac arrest vs. a heart attack
A cardiac arrest is often confused with a heart attack, but they are different.
A heart attack is a plumbing problem. Fat and cholesterol build up in an artery and block blood flow, damaging heart muscle. Such symptoms as chest discomfort typically offer an early sign of trouble.
A cardiac arrest is an electrical problem. The wiring around the heart malfunctions, and the heart stops abruptly and usually without warning.
Electricity in the heart? Yes. The heart's electrical system controls the timing of your heartbeat and heart rhythm, the coordinated pumping action in the heart's chambers. If the heart can't pump blood, a person loses consciousness and collapses. Most sudden cardiac deaths result from abnormal heart rhythms called arrhythmias.
About 70 percent of cardiac arrests occur in the home and 20 percent in public places. If you want to significantly increase your chance of surviving, collapse in front of a bystander who knows CPR or how to use an automated external defibrillator, if a device is handy.
A bystander responds about 45 percent of the time in communities with a good track record of training people in CPR, but the rate varies widely across the country, according to the American Heart Association. The average for cardiac arrest bystander responses for AMR in the Buffalo area is 25 percent.
All of which is why every moment counts. The likelihood of survival decreases by about 10 percent with every passing minute between collapse and return of blood flow.
"The quicker you have hands on a patient's chest the more likely he or she is to make it," said Dr. Michael Kurz, a University of Alabama physician leading an American Heart Association initiative to expand the use of telephone-assisted CPR by EMS dispatchers.
Pushing for changes in care
With more than 1,600 people suffering a cardiac arrest each day, and little change in survival over the years, physicians have been advocating for new thinking.
The Seattle-based Resuscitation Academy Foundation, formed in 2008, was a pioneer in benchmarking EMS performance and standardizing best practices. It's also part of a Global Resuscitation Alliance that came together in 2016 with an aim to increase survival rates by 50 percent.
The National Academy of Medicine in a 2015 report described the condition as "an immense and sustained public health problem." The independent academy, which advises government, called for a national data bank to track progress and identify problems, expanded CPR training to the public, and improved emergency medical systems.
The report led to the creation last year of a National Cardiac Arrest Collaborative that includes the American Heart Association, National Institutes of Health and Sudden Cardiac Arrest Foundation.
"We need systems of care and evidence-based guidelines," said Kurz.
Emergency medical systems can now grade themselves by looking at data collected by the Cardiac Arrest Registry to Enhance Survival, a collaboration of the federal Centers for Disease Control and Prevention and Emory University, with statistics from more than 1,400 EMS agencies in 18 states, including AMR in Buffalo. The registry shows an overall survival rate from cardiac arrest of 10.8 percent in 2016, but 8.9 percent for patients who left the hospital with good neurological function.
Those results include the best-performing areas of the country. The average survival rate overall in the Unites States is likely lower – around 6 percent – experts say.
Your chance of living after cardiac arrest depends on geography. Last year, researchers reported survival rates ranging from 4.2 percent to 19.8 percent at 106 different EMS agencies from 10 cities around the country in the Resuscitation Outcomes Consortium, a network of sites in North America that studied out-of-hospital cardiac arrest. The consortium includes about two dozen North American cities with well-functioning emergency care systems, including Pittsburgh, San Diego, Milwaukee, Vancouver and Toronto, but not Buffalo.
What separates one area from another? The top locations have highly coordinated emergency systems that respond quickly, more bystanders willing to provide CPR, greater availability of automated external defibrillators, and telephone assistance with CPR.
One other key factor: Studies show that CPR quality varies greatly even when performed by trained rescuers. The odds of survival increase when EMS personnel focus on high-quality CPR, making sure to maintain a consistent rate and depth of compression.
Confronting public expectations
AMR is not the first EMS provider to make the shift away from scoop and run, but it is part of an emerging practice. Evidence is starting to back it up. For example, research presented this year at a National Association of Emergency Medical Service Physicians conference found that EMS agencies that spend more time on the scene focused on compressions, defibrillation and ventilations have higher survival rates.
It's an approach to resuscitation that requires a change in culture in emergency medical services. It also can conflict with public expectations, creating a tense, uneasy atmosphere when EMS crews stay and work on a victim. Cardiac arrest reveals the limitations of medicine.
"It's difficult for paramedics to have a deep-level discussion with upset family members or bystanders when they're focusing on a million things while trying to resuscitate someone," said Clemency. "We have to educate people that with every minute, there are diminishing returns."