There was a better way to care for cardiac arrest, and it was sitting at our doorsteps. All we had to do was pick it up and put it to work.
We knew what we wished to deliver—continuous quality CPR with clearly defined roles for all rescuers involved, plus delivery of therapeutic hypothermia (TH) to improve neurologic recovery after return of spontaneous circulation—could enhance cardiac arrest survival. The science that drives our care at North Carolina’s New Hanover Regional EMS demonstrates that. But implementing it required instilling a new principle—staying put with cardiac arrest patients—among providers who had practiced “load and go” for decades, and ultimately retooling a system that had provided treatment in the same fashion for 20 years.
After observing the successes that came from making these changes to our countywide EMS system, we hope they can be mirrored around the country.
Living, Breathing Proof
Racing is popular in North Carolina, so we labeled our new approach the “pit crew cardiac arrest process.” It took a year of creating protocols and policies before our team was ready to introduce these new concepts to our system. Buy-in was crucial for them to work, so effective communication was essential. To provide our clinicians the evidence they demanded for the medicine we’d ask them to apply, we developed a daylong “cardiac arrest academy.”
Step one was to form a committee, which met at least once a month until the big day. Specific topics for the academy were assigned to key field training officers. We settled on a morning of lectures followed by an afternoon of breakout sessions. Our local college provided a large auditorium and several classrooms for the 200 providers we expected to attend.
It was important that our lecture topics matched our mission of better cardiac arrest care. We began by sharing our vision and demonstrating a simulated cardiac arrest treated with the pit crew process. The first lecture was based on the history of cardiopulmonary resuscitation and how it has evolved. While CPR has only been around in its true form for about 50 years, attempts at resuscitation date as far back as 1768, when the Dutch Humane Society was formed in an effort to improve resuscitation in drowning victims. Their first formal attempt at CPR included instruction on clearing the airway via rolling the victim over a barrel and hanging them upside down for several minutes. In 1960, Dr. Peter Safar brought his concepts of ventilation together with the chest-compression concepts of Drs. William Bennett Kouwenhoven and Guy Knickerbocker. Several years and many forgotten pioneers later, the organized technique of cardiopulmonary resuscitation was born.
Most healthcare providers believed we were doing CPR correctly over our careers. Then in 2005 the American Heart Association updated us all in one of the biggest moments in CPR since 1960. The upshot was that compressions were more important than airway for the first several minutes in cardiac arrest. Dramatic adjustments were needed in how we executed CPR, not only in the prehospital setting but everywhere.
Sharing the history of CPR was an effective way to lay the ideological background that the medicine of resuscitation is dynamic and its practice is constantly evolving. Our goal was to convince providers that their patients’ best chance at positive neurological outcome revolves on each provider’s ability to work a cardiac arrest where the patient is found, whether that’s in the mall with an audience or in a living room as a family looks on.
After selling that the CPR process evolves, we needed to show the changes we proposed would work. For us that meant more than just numbers. We wanted living, breathing proof that these huge efforts would not be wasted. Bringing in a cardiac arrest survivor who’d been treated with extended on-scene care (and his grateful spouse) was more powerful than any graphs and numbers we could show in a PowerPoint (see sidebar). Having Dan and Sue speak helped validate that we were telling our people worked and allowed us to recognize another EMS system for its outstanding performance.
After the emotion of the morning, the day’s next lecture topic was neurology and the science behind cardiac arrest. We are fortunate in our area to have access to many physicians who are willing to present to EMS. One system neurologist is a big supporter of our program and an advocate for improving neurological outcomes from sudden cardiac events. He also consulted as we created our protocol and procedure for inducing TH. He was therefore the perfect presenter to explain the science behind post-cardiac arrest syndrome and how proper care can salvage brain ganglia and neurons both during an arrest and following ROSC. In simple terms and with advanced slides, our neurologist explained the theory of slowing metabolism in a suboptimal environment of high lactic acid. He discussed the potential damage fevers and seizures can bring to the brain in this chilled state during the rewarming process. This lecture was important because it explained what happens in the intensive care unit after EMS hands off the patient.
Improving cardiac arrest survival takes coordination with at least one tertiary cardiac care center. To address the continuum of care inside the hospital, we recruited the manager of our STEMI and stroke system. Her lecture covered management of the Arctic Sun temperature management system from the emergency room into the catheterization lab. Since roughly 25% of cardiac arrests are STEMI in origin, this was a good time to emphasize the importance of early recognition in the ROSC patient. She also covered how the Arctic Sun stays in place even during the catheterization process. This supported the importance of EMS beginning hypothermia in the field.
In the spirit of being a part of a grander mission in North Carolina, we invited the state RACE CARS manager to present. RACE CARS stands for Regional Approach to Cardiovascular Emergencies Cardiac Arrest Regional System. RACE CARS is an effort to organize better systems of STEMI care, and it has produced dramatic results. This speaker shared cardiac arrest data from across the state. A key take-away was that the more EMS systems that reported their data, the greater the evidence base to support best practices, and the more they could be embraced to improve outcomes. The data we compiled from our charting clearly had meaning. And, by entering it into the CARES (Cardiac Arrest Registry to Enhance Survival) platform, we could be part of the same thing on a national scale. This topic showed our providers how important our documentation and review of cardiac arrest is and that better patient outcomes could come from evidence-based practice.
The afternoon consisted of four breakout sessions designed to apply the morning’s information: Operational Questions, Inducing Therapeutic Hypothermia, The Pit Crew Process and Dealing With the Living. We rotated groups through each of the 30-minute sessions. Breaking into small groups left more time available to answer questions and let providers get hands-on training with the pit crew process.
The operational session, led by a senior battalion chief, was designed to address questions surrounding logistical demands of the new approach and the issues of conducting resuscitations in public. He discussed the increase in manpower the pit crew model required and how a busy system could have six medical personnel on a cardiac arrest scene for up to 30 minutes. But if you’re in a public place and a code doesn’t begin to improve, it may be time to head to the ambulance and hospital. No one expects us to leave a deceased body in Foot Locker for the coroner to collect. This station ultimately showed our personnel that they would have the support of the agency, its leaders and their medical director, even in tough grey areas.
The American Heart Association now classifies induction of mild hypothermia as a Class IIa intervention, and our session on inducing it was led by two FTOs who explained the clinical management of patients following ROSC. EMS begins the process based on a set protocol that prevents delays in definitive care. Because TH may be harmful if patients are allowed to rewarm prematurely, coordination with our tertiary care hospital is essential. After reviewing different options for initiating TH, our system chose to use a 4ºC saline fluid bolus (30mL/kg, max 2 liters) and application of cold packs to the groin and armpits.
Questions about the new protocol focused on when to initiate the saline and other care required following ROSC, including the rapid acquisition of a 12-lead ECG and aggressive airway management. Highlights from this session included a paper on therapeutic hypothermia written by an author in a neighboring EMS system that already uses it. This presenter was a well-seasoned supervisor, which helped generate buy-in from some of our senior staff.
The Pit Crew Process
For the session on the pit crew process, we introduced and broke down each position. Our process assigns roles to arriving providers as follows:
Arriving first would be ideally three EMTs on an engine. Position 1 is on the patient’s right side; this provider checks pulse and responsiveness, then begins compressions. Position 2 is on the patient’s left side and prepares the AED, including placement of pads around the compressor. Position 3 manages the airway, preparing a King LT (see sidebar) and inserting it without disturbing compressions. Positions change at two-minute intervals to keep the compressor fresh and check the AED rhythm.
Arriving second should be a dual-staffed paramedic unit with a paramedic-staffed quick-response vehicle as backup. Arrival of the third paramedic should allow for the role of position 4, the team leader. This position is responsible for explaining everything to the family or, if necessary, bystanders, who may wonder why we don’t move the patient to the ambulance. This provider also works with the team to get equipment and other needed items. This position need not be a paramedic-level person, but that’s helpful for medical interpretations for the family and public.
Position 5 obtains IO access and is the ACLS drug handler. We emphasize how important IO access is outside of the “triangle of CPR” formed by the first three positions. Position 6 is declared the code commander and directs ACLS measures based on the ECG rhythm checks occurring at two-minute intervals. Here we also instructed on the technique of precharging the defibrillator before the end of the two-minute cycle of CPR. This helps reduce cerebral perfusion loss, which we risk every time we cease compressions for more than 10 seconds.
We explained to our people why each position exists and how each role is designed to highlight the most important feature of patient care: continuous chest compressions. We presented the science behind the pit crew idea, including its variations in places like Seattle, Austin and Collier County, FL, as well as Wake County in our state. This station was led by FTOs who were well-versed in the process. Hands-on practice followed, allowing everyone to participate in each role at least once during a simulated cardiac arrest.
We explained that the role of team leader may become difficult due to the stress of informing the family in the home that efforts have been terminated. This will either prepare family members for the beginning stages of death or explain what happens once a pulse returns. We believe a member of the team with experience in death and dying situations may be best suited for this role.
The last breakout session covered that taboo topic of death and dying. We had our own EMS chaplain lead this session. In developing it, he worked with one of our senior leaders who has a background as an ordained minister. They produced a presentation titled “Dealing With the Living.” The AHA recommends explaining resuscitative efforts during the event to help survivors cope with the stages of death and dying. To be good at this, we needed to prepare our providers with support for the psychological and spiritual challenges they may encounter through these traumatic events. Our presenter covered spiritual and psychological aspects drawn both from scientific literature and riding several shifts with us. We provided access to him outside the session as well, in case anyone didn’t feel comfortable asking a question in front of their peers.
The results of our combination of traditional lecture and breakout sessions resulted in an outstanding and renewed passion for the treatment of cardiac arrest. We rolled out our new hypothermia protocol and pit crew process with 700 providers ready to perform. It was an amazing demonstration of how a good training initiative can work. The academy helped catapult our system into a new age of cardiac arrest care. Since our changes, our survival rate for cardiac arrest patients presenting in v-fib or v-tach is a resounding 73%.
Our system’s next goal is education of the public on hands-only CPR, so we can continue our great outcomes. We currently are in the beginning stages of training 200,000 citizens, free of charge. No cardiac arrest system of care will work in the long run without that first link of the chain of survival. If we forget who calls 9-1-1, we forget the importance of CPR. The person who calls 9-1-1 must know how to do chest compressions properly and surely, and can’t be afraid to perform when duty calls.