By Erin Mathews
The Salina Journal, Kan.
SALINA, Kan. — If there is such a thing as a good place to have a heart attack, Salina is becoming that place.
Since Jan. 1, when Salina emergency responders implemented a new “pit crew” approach to handling cardiac arrests, more patients are arriving at Salina Regional Health Center with a pulse, said Shane Pearson, emergency medical services division chief for the Salina Fire Department.
“Last year we had 44 cardiac arrest patients who we attempted to resuscitate with advanced life support and medications,” Pearson said.
Of that number, 14 had “a return of circulation and had a pulse when they got to the hospital.”
“So far this year, we’ve had 27 patients, and 12 have been delivered to the hospital with a pulse,” he said. “Two of them have walked back into the fire station to tell us thank you.”
You’re not a car, but ...
Pearson, other fire department personnel and Dr. Sean Herrington, EMS medical director for the Salina Fire Department and co-director of the hospital’s emergency department, learned about the “pit crew” last summer at a professional conference. As the name implies, it’s is inspired by the well-choreographed crews who get race cars back on the track, and in a hurry.
“It made so much sense, it was pretty hard to argue why we shouldn’t do it,” said Joshua Rogers, firefighter/paramedic. Rogers and Allen Grant, engineer/EMT, were put in charge of developing recommendations for how the approach should be implemented in Salina.
Rogers said they started with the procedures utilized by the King County EMS in Seattle, which claims the highest save rate in the world — 62 percent in 2013 — and modified them slightly to account for variability in staffing levels.
Salina EMTs and paramedics used a mannequin to train between July and December 2014, before attempting the new protocol on a real patient. Grant said emergency responders have embraced the change.
“They had a way that they did it, and it worked, and when something new comes along change is hard, but everybody’s taken this seriously and taking their role seriously,” Herrington said. “I’ve been so proud of these guys. They’ve been working hard. It’s your tax dollars at work.”
You start at the chest
The pit crew method emphasizes starting chest compressions as soon as possible. The first person to arrive initiates chest compressions from a position to the right of the patient’s chest. After a minute, that person is relieved by the second emergency responder positioned on the left of the patient’s chest.
Those two alternate compressions as a third responder stands at the patient’s head and establishes the airway and straps on an oxygen mask, allowing the patient to receive oxygen passively during chest compressions. Those three positions, which are all jobs that can be performed by an EMT, constitute the basic life support “triangle of trust,” Grant said.
“The big difference is there are no interruptions in chest compressions,” Pearson said. “With traditional CPR, you start doing compressions, and then you stop to breathe or you stop to put in a breathing tube. When you start compressions up again, it takes anywhere from 15 to 30 compressions to even get back to where you were at.”
Push, and push down hard
Herrington said EMTs switch off doing the compressions so that no one gets too tired to give “really good, two-inch-deep” compressions. Compressions should be performed at the rate of about 100 to 110 a minute, or to the beat of the chorus of the BeeGee’s classic “Stayin’ Alive.”
“If you’re barely pushing in the sternum, you’re not doing anything,” he said. “I know I’ve broken ribs doing it. I’d rather break a rib and have somebody live than not push hard enough and not get the heart started. Most people don’t realize how hard you have to push. We learn to put our entire weight into it. You lock your elbows and push as hard as you can.”
A paramedic at the patient’s left leg looks for a heart rhythm that could be organized into a heart beat by the electrical shock from a defibrillator. After two minutes of compressions, a break of 10 seconds or less is taken to read the monitor and administer an electric shock to the heart if one is warranted, and then compressions continue.
A paramedic at the right leg uses an intraosseous needle, which acts like a small drill, to administer adrenaline and other medications directly into the bone marrow. The intraosseous needle is quicker than establishing an IV and provides nearly equal access to the blood stream, Pearson said.
If compressions, shocking and medications fail to restart a patient’s heart, EMTs strap on a machine called an AutoPulse that continues compressions while the patient is loaded onto a cot for transport to the hospital.
Success, and right away
Results of the pit crew approach became apparent right away. The 2014 rate of 32 percent return to spontaneous circulation for cardiac arrest patients has jumped to 44 percent this year, and Pearson said there’s no reason it can’t continue to improve.
Two years ago, he said, the percent of patients who made it to the hospital with a pulse restored was in the teens.
“Ten years ago when I started, we’d have 40 patients we’d start resuscitation on and maybe one or two a year would get successfully resuscitated,” he said.
Currently, the national average for cardiac arrest patients recovering a palpable pulse or blood pressure and starting to breathe again is hovering around 10 percent, Pearson said.
”Across the country, the survivability of a heart attack varies greatly depending on where you are when you have it,” Herrington said. “People in Seattle have a more than 50 percent chance of surviving, while people in Detroit have an 18 percent chance.”
Herrington said that the pit crew method originated at the University of Arizona’s Sarver Heart Center with a small trial group in 2004.
Know what your job is
“The No. 1 difference (in the new method) is efficiency,” Grant said. “That’s the reason they call it pit crew. Everybody knows when they walk through the door what their assignment is, based on when you walk through the door.
“It all depends on who’s the first to the patient. There’s a lot less verbal communication. It’s like a puzzle, and everybody just falls in place.”
And because brain damage, on average, begins to occur at between four and six minutes after the heart stops pumping, the efficient use of each second can make a life-saving difference.
“Time is brain cells. Time is heart muscle cells,” Herrington said. “You really don’t have time to waste on patients when their heart stops.”
The public has a role, too
Pearson said that when people call in about a heart attack victim, 911 dispatchers talk people through the correct way to perform compressions. Although a public class this past year to teach the new techniques was canceled for lack of participation, other cities have had success teaching the new techniques during flash mob events at halftimes of sporting events. He hopes Salina firefighters can do the same.
”The hospital can’t save everybody; we can’t save everybody, but if we can do things that are evidence-based procedures that are proven to increase survivability or the chance of survivability, that’s what we’re going to do,” Pearson said. “Our job is to give them the best fighting chance. We want to give everybody as much of a chance to survive, recuperate and recover as we can.”
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©2015 The Salina Journal (Salina, Kan.)