Many advancements have been made in the treatment of heart attacks and sudden cardiac arrest over the past 40 years. Early acquisition and transmission of 12-lead ECGs from the field, angioplasty with stent placement and the surprising realization that early administration of aspirin has a survival rate rivaling that of tPA, according to the Thrombolysis in Myocardial Infarction (TIMI) study. Yet, according to the American Heart Association, despite all these advances, one-third—or about half a million—of the 1.6 million patients who suffer a heart attack every year die prior to reaching the hospital. And that statistic has not changed since it was first reported over a decade ago.
So what can EMS do to save those half a million lives? Well, as far as conventional EMS goes, nothing! Only a dramatic change in the scope of EMS can solve this problem and save those lives.
Waiting for EMS to arrive on the scene to influence those most critical of cardiac patients will no longer do. EMS must take the lead in becoming more proactive in fighting sudden cardiac arrest. The best way to do this is through community outreach programs where CPR/AED training is offered to the public. These classes can be held monthly or quarterly at EMS headquarters, at sponsoring locations throughout the community or at specifically targeted organizations, such as senior centers, retirement communities, churches etc.
Sudden cardiac arrest is the most time sensitive of all medical emergencies. Nothing can make up for time lost between patient collapse from cardiac arrest, the initiation of CPR, which stops the clock, and the ultimate lifesaving treatment of a defibrillation to convert the fibrillating heart back into a perfusing rhythm. Therefore, the most important person in a cardiac arrest is not the greatest paramedic or cardiologist in the world, but whoever happens to be nearby when the patient collapses.
If a bystander, co-worker or family member starts CPR, and either utilizes a nearby AED or summons one by calling 9-1-1, there is up to a 50% chance the patient can be successfully resuscitated. The chance of survival decreases by about 10% every minute without CPR. If nothing is done until EMS arrives, the patient will likely die despite the most heroic, but belated, efforts.
Most cardiac arrests are the terminal result of a cascade of events that cannot be reversed, such as the case with chronically and terminally ill patients. But, those otherwise healthy individuals— including athletes who collapse suddenly without warning, as well as those who develop sudden cardiac symptoms prior to collapsing—are the patients who can be resuscitated and returned to a high quality of life if resuscitative efforts are initiated quickly.
Community CPR and AED training has been recognized as the cornerstone of resuscitative efforts. But one concept that has the potential to save far more lives than bystander CPR is early identification of the seriously ill patient and early activation of 9-1-1 to get those patients to the hospital, where they can be treated before they arrest.
Notice I mention “seriously ill” and not just “heart attack” in the above paragraph. Being too specific here might be self-defeating. There are many other things besides a heart attack that can kill a person if activation of EMS is delayed. Ideally we should want to save as many critically ill patients as possible, regardless of whether they’re suffering a heart attack, asthma attack, aortic dissection or a status seizure.
At this point in time pretty much everyone is tuned in to the potential seriousness of chest pain. If a 14-year-old child mentions they have chest pain a call is quickly placed to 9-1-1; this despite the fact that chest pains in pediatrics and even young adults is rarely an acute myocardial infarction (AMI). In EMS, we know not everyone having an MI will present with the classic symptom of chest pain. According to the American Heart Association, up to one third of all AMIs will present with more ambiguous symptoms such as sudden weakness; shortness of breath; dyspnea on exertion; breaking out in a sweat for no apparent reason; or back, arm or jaw pain. Women, the elderly and diabetics are more likely to have these non-chest pain symptoms. Many women complain of a general feeling of illness, fatigue or even flu-like symptoms. Developing an index of suspicion cannot be over-emphasized.
Whenever I instruct a community CPR class I discuss the importance of calling 9-1-1 for anything that looks, feels or smells like it could be a medical emergency. I tell my students to play devil’s advocate and resist the temptation of buying into the patient’s denial. No one wants to believe they could be seriously ill or dying. Consequently many patients suffering a serious medical emergency will try to explain away their symptoms up to the very moment they arrest. I wish I had a dollar for every critically ill patient who blamed his crushing chest pain, shortness of breath and impending feeling of doom on the hot dog they just ate. Cemeteries are also filled with people who died of "indigestion," which in actuality turned out to be an AMI.
I tell my students if the patient looks sick, assume they’re sick until proven otherwise. The more symptoms the patient has, or the more serious the symptoms appear, the more likely it is that EMS needs to be activated without delay. Likewise, the older the patient, the more medical problems or risk factors they have, and the more likely that new or sudden onset of symptoms may be serious.
I also tell my students that even if the patient is totally resistant to allowing 9-1-1 to be called, leave the room and call 9-1-1. If it ends up being nothing, EMS will allow the patient to refuse. If there’s any question, EMS has more diagnostics and an online medical command physician they can consult, and they’re also much more experienced at dealing with sick patients in denial. I assure my students no one will get into trouble for calling 9-1-1 if they’re legitimately concerned. Finally I tell my students if there is any doubt, call 9-1-1 and call as soon as possible. EMS can easily return if there is no problem, but you cannot make up for lost time.
The two statistics from the American Heart Association cited in this column—that one third of heart attack patients die prior to reaching the hospital—and one third of heart attack patients present without classic chest pain have always intrigued me. While it’s probably not an exact one-to-one relationship, it’s hard to imagine there’s not a strong correlation between these two ‘one-third’ statistics. It makes sense that we start emphasizing to the public at every opportunity the importance of early recognition of medical emergencies and early activation of EMS in an effort to save those half a million heart attack patients and many others.
Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years' experience in EMS. Contact Joe at email@example.com.