By AMERICAN HEART ASSOCIATION NEWS
When Russ Goedde woke up in the hospital in March, he checked for bruises because he thought he might have fallen down the stairs. But it was his heart that had caused the commotion in the gym that morning. It had stopped beating shortly after he stepped off an elliptical at Seattle University.
Goedde’s cardiologist told the 65-year-old if it was going to happen to him, he was very lucky to be in the right place.
That’s because someone who has a cardiac arrest in Seattle and any of the other 38 cities in Washington’s King County might have a greater chance of survival than anywhere else in the world, according to Mickey Eisenberg, M.D., professor of emergency medicine and King County emergency medical services medical director.
In 2013, the county’s survival rate reached an all-time high of 62 percent for bystander-witnessed cardiac arrest caused by ventricular fibrillation.
Cardiac arrest is the abrupt loss of heart function, and the most common cause is ventricular fibrillation, or VF. In this rhythm the heart’s electrical impulses suddenly become chaotic and ineffective, like an orchestra out of sync, and the heart can’t pump blood to the brain and other organs.
By comparison, the VF cardiac arrest survival rates in many other urban areas are in the single digits. Nationally the VF survival rate for bystander-witnessed cardiac arrest is 31 percent. When you look at all forms of cardiac arrest, the outcomes are more dismal: only 10 percent survive.
“There’s no doubt that the disparity in survival from cardiac arrest is a great, unappreciated tragedy because many, many people dying could be snatched from the jaws of death with the appropriate emergency medical services,” Eisenberg said.
Many health experts say that Seattle and King County laid the foundation for how EMS should operate. It didn’t happen overnight. Back in 1970, Seattle’s sudden cardiac arrest survival rate was less than 20 percent. Although higher than many other communities, the city wanted to do better. Officials started pouring over its cardiac arrest outcomes — the good and the bad.
“I wish I could share some magic pixie dust,” Eisenberg said. “It has taken a lot of hard work and iterative changes over the decades. It was studying what we did, chipping away and making it better and better.”
More than 326,000 Americans have a cardiac arrest outside the hospital each year. Although bystander CPR can increase the chance of survival by two- to three-fold, fewer than half receive it, according to the American Heart Association.
Experts agree that cardiac arrest is an urgent public health need, given the wide disparities in how it’s treated and the lack of trained bystanders in many communities, yet many cities are woefully behind.
In Seattle, emergency dispatchers give CPR instructions over the phone to bystanders who call 911. Most Seattle and King County residents — about 75 percent — are already CPR-trained, Eisenberg said.
“Bystander CPR slows the dying process,” he said. “It buys a few critical minutes of time for other interventions to kick in.”
In King County, there are more than 3,000 automated external defibrillators, or AEDs, registered with EMS and dispatch centers, and most law enforcement vehicles have them as well. Plus, King County paramedics get 2,500 hours of training — twice the national average, Eisenberg said.
“They say, ‘Everybody in VF survives.’ It’s a cultural mindset here,” he said.
Seattle also uses a registry to track and improve its response to sudden cardiac arrests.
“You’ve got to keep score,” said Michael Sayre, M.D., professor of emergency medicine and EMS fellowship director at the University of Washington and medical director of the Seattle Fire Department. “That takes some bravery, and you might find out you’re not doing as well as you thought.”
Some communities, he said, think that if they had a new drug or a better CPR method they’d have better survival rates. But that’s not the case. Rather, many communities would be better off taking a fire truck off the road and reallocating the money for quality measurement and more training, said Sayre, who is also a former chair of the AHA’s Emergency Cardiovascular Care Committee.
Training and awareness of bystanders were key in Goedde’s survival.
Jason Morin, a 29-year-old engineering student and former athletic trainer, was working out next to Goedde. Morin and others sprang into action, calling 911, performing CPR right away and shocking Goedde with an AED.
“Somehow, despite not practicing, I was able to recall the skills and steps needed to keep the patient alive without conscious thought,” Morin said. Fire officials told Morin that if he and others had not acted, Goedde likely would not have survived long enough to make it to the hospital.
The hospital was just a block away. Within an hour Goedde got his first set of stents, tiny mesh tubes that prop open blocked heart arteries.
Communities elsewhere in the nation have learned from Seattle’s successes. In Arizona, for instance, a statewide network for responding to out-of-hospital cardiac arrests was set up about a decade ago.
“One of the things that King County showed us is that sudden cardiac arrest doesn’t have to be a death sentence,” said Ben Bobrow, M.D., medical director of the Bureau of EMS and Trauma System and professor of emergency medicine at the University of Arizona College of Medicine in Phoenix.
Northern Arizona got serious about sudden cardiac arrest in 2004, when its VF survival rate was 7 percent. “That is very consistent with other areas of the country, but really, really dismal,” said Bobrow, who helped write the AHA’s resuscitation guidelines. “Our entire EMS system looked at this as a tragedy and an opportunity to improve.”
Today, Arizona’s overall VF survival rate is 35 percent thanks to a statewide response network. Some areas, like Flagstaff and Mesa, have achieved survival rates of well over 50 percent, Bobrow said. More than 2,500 Arizonans have survived cardiac arrest over the past decade.
Sudden cardiac arrest victims are taken to the closest Arizona Cardiac Receiving Center. The state also tracks 6,000 AEDs that are registered with the Department of Health to increase their use when a cardiac arrest happens.
But just as important, Bobrow said, are CPR television ads and PSAs that have helped people understand they are not helpless when they see someone in cardiac arrest.
None of it is a quick fix. But experts say the communities with systems of care are saving more lives.
“CPR — good, solid care and measurement — isn’t sexy, and frankly it takes a lot of work and time and coordination,” said Bobrow, who also practices at Arizona Emergency Medicine Research Center. “But the reality is, that’s what saves the most lives at the end of the day. If systems are really implemented, survival will go up.”
In Rochester, Minnesota, anesthesiologist Roger White, M.D., of the Mayo Clinic, helped pave the way for putting AEDs in public places, improving CPR practices and education, and speeding up emergency response times.
“If you’re in a shockable heart rhythm in Rochester and somebody sees you collapse, we’ll get you back home about 50 percent of the time,” said White, who also helped write the AHA’s resuscitation guidelines. That’s a big boost since the 1980s, when the survival rate was about 31 percent.
One of the things White did was to make sure Rochester police vehicles had AEDs. Police, he said, often arrive at the scene of a 911 call before paramedics, making them a patient’s best chance for survival.
“It had never been done before,” White said. “But it worked.”
Back in Seattle, Goedde said that resuscitating someone in cardiac arrest requires more than just resources and training — it takes confidence and bravery, he said. And he said it was “the perfect place” to have his cardiac event, considering all those who came to his aid.
“I was dead and now I live, solely because strangers nearby had the mental framework and training to act quickly, and the confidence to engage as best they could,” Goedde said. “Someday it’d be nice if CPR was no longer seen as a heroic act, just one of collective compassion.”
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Photo courtesy of Russ Goedde