When does the timer start?

The timer starts when the victim arrests. Period. It doesn't start when you call 911, it doesn't start when the ambulance gets there. I starts when the victim dies.

Please don't ever wait for the ambulance to get there. The result is overwhelmingly going to be bad if you wait.

I'm not talking about your seeing some random, sketchy stranger go down. The far more likely scenario is that when you see an out-of-hospital sudden cardiac arrest, it will be a family member, a friend, or an acquaintance. Learn what to do. Better yet, learn what to do and get a personal use AED because two thirds of all cardiac arrests happen in the home, and immediate CPR + prompt defibrillation can change the average home survival rate from 2% to 75%..

If you cannot take an AHA or an ARC course right away, go to www.slicc,org, click on the For Past Trainees link in the left column, and download the class video and watch it. - and then take the AHA or ARC course when you can.

Do it now, PLEASE!

London top as cardiac arrest survival rates compared

Fabrice Muamba survived a cardiac arrest on the pitch - he later retired from football

Continue reading the main story

(From the BBC)

London has the best cardiac arrest survival rate in the country, newly-released figures suggest.

During 2011-12, the out-of-hospital cardiac arrest survival rate in London was 31.7% - a figure that includes footballer Fabrice Muamba's case.

That compares with second placed East of England with 24.4% and a low of 10.8% in the South Central region.

It is the first time all ambulance services in England have measured the survival rate.

The figures were submitted to the Department of Health for collation.

Continue reading the main story

CARDIAC SURVIVAL RATES BY AMBULANCE SERVICE

• London - 31.7%
• East of England - 24.7%
• North East - 24%
• South East Coast - 23.6%
• North West - 22.6%
• Yorkshire - 20.5%
• East Midlands - 20.4%
• South Western - 18.7%
• West Midlands - 18.3%
• Isle of Wight - 17.4%
• Great Western - 15.1%
• South Central - 10.8%

Source: Ambulance Clinical Quality Indicators

Erica Payet, 25, was one of those who survived cardiac arrest in London.

She was jogging along Bermondsey Street, Southwark, with her boyfriend on a Sunday afternoon in March when she collapsed and stopped breathing.

A passer-by called 999 and motorcycle paramedics were on the scene within five minutes to find bystanders already performing basic life support.

Ambulance staff attached defibrillator pads to Ms Payet and shocked her heart to restart it.

An ambulance crew took Ms Payet to St Thomas' Hospital for further treatment.

She regained consciousness after a week and spent a further two weeks in hospital before being discharged home with an implantable cardioverter defibrillator fitted.

Ms Payet, who is taking a masters degree at King's College University, had no previous history of heart problems and no family history.

She said: "I was really lucky to be in a busy street with medical people around.

The cause of Erica Payet's cardiac arrest remains unknown

"Otherwise I might not be here. They brought me back."

The hospital ran tests, but the cause of her cardiac arrest is unknown.

London Ambulance Service medical director Fiona Moore said: "We are delighted with these figures.

"We've been tracking these figures since 1998 - and when we started the figure was about 4%.

"We've seen a year-on-year improvement, which is fantastic."

South Central Ambulance Service is yet to comment.

HELP, PLEASE...

Please alert everyone you know who has survived a sudden cardiac arrest: there will be a very helpful workshop in Orlando in mid-September.

This will be very helpful for survivors, spouses, and rescuers.

Details are at http://www.slicc.org/ECCU_Survivor.pdf

Bob

bobt@slicc.org

YOU do the math...

[If you have an AED at home, you can skip this.]

The monthly total cost of ownership for an AED is on the range of $20-$30 over ten years, depending upon the model and how well you shop.

Two thirds of all cardiac arrests in the U.S.A. occur in the home.

Your odds of seeing a family member, friend, or acquaintance die of an out-of-hospital sudden cardiac arrest is 10% during your lifetime.

Your spouse has the same odds of seeing an arrest as you do. (That wasn't meant to be subtle.)

If you arrest and someone calls 911, starts CPR, and defibrillates you, your odds of getting out of the hospital with major brain function intact go way up. (The Phoenix airport averages 75% saves. The national average is less than 10%.)

And you can't find a dollar a day to greatly reduce your odds of a premature death or a terrible disability?

Just what ARE the odds?

Well, it depends...

Was your arrest witnessed?
If there's nobody else around when you have your cardiac arrest - or if there is someone else around and they don't notice that you have died - you have a 3.9% chance of getting out of the hospital with your major brain functions intact. How often does this happen? More than half of all out-of-hospital ("OOH") arrests are unwitnessed.

If a bystander saw you arrest, you have 15.2% chance of survival with brain intact - that's nearly four-times better odds. The moral of this factoid is that you need to always have someone around, and that person needs to know how to tell if you've just arrested. More than one-third of all OOH arrests are witnessed by a bystander.

If a 911 responder got there in time to see you arrest - maybe someone called 911 because you weren't looking all that good a few minutes ago - you have an 18.6% chance of survival with major brain functions intact.  A little more than 10% of the time, a 911 responder sees the arrest happen.

Many of you are asking yourselves, "Why is it that my odds of survival only improve by 22% when it's the professionals see the arrest, as opposed to an ordinary bystander?" Good question. Read on.

Who started performing CPR on you?
In one third of the cases a bystander initiated CPR, and in two thirds of the cases a 911 responder initiated CPR. When the 911 responder initiated CPR, 8.7% survived. When the bystander initiated CPR, 11.3% survived - a 41% improvement.

Who first applied the AED or Monitor to your right upper chest and left side chest wall?
An overwhelming 96.3% of the arrest victims had an AED / Monitor applied by the 911 responder, and only 3.7% had one applied by a bystander. When the 911 responder applied the monitor, 9.1% survived. When the bystander applied the AED, 23.5% survived.

Why did so few AEDs get applied by bystanders? First of all, there aren't enough AED's nearby in most locations. Second, fewer than one-third of the bystanders will perform CPR, so why would we think that all bystanders would apply the AED, even if AED's were everywhere?

Why did the bystanders get such better results? An AED promptly applied works far, far better than one applied after the 911 responder gets there.

How representative are these numbers?
Mileage does vary. If you arrest on a farm, your chances of surviving are near zero. If you are in the passenger concourse in the Pheonix, AZ airport your chances of surviving are 75% - an average value for the past ten years. The Phoenix airport gets such good results because there are lots of trained people and AED's nearby, and they practice.

Interestingly enough, the existence of such a wide range of outcome probabilities tells us that most places can do far better than they do.

What does all this mean?

1. You do not want to have a cardiac arrest, and you really don't want to have an unwitnessed one.
2. If you get immediate, high-quality CPR (chest compressions of two inches or more, 100-120 times a minute with almost no interruptions and with no interruption longer than five seconds) and if you get defibrillated promptly - say, within three minutes of the arrest - you can expect your survival odds to be far, far higher than otherwise.
3. Get a personal AED, unless you live alone.

How long will a bystander / 911 responder have to do CPR?

Somewhere in the five-to-fifteen minute range - sometimes longer. It's going to take the person who witnesses the arrest a few moments to figure out what is going on, it's going to take a few moments to get a phone and call 911, it's going to take a few moments to tell the 911 operator where you are / what's wrong / what you are doing / what you need, it's going to take a few moments for the operator to decide which ambulance is going to respond and to contact them, and so forth. The ambulance probably won't be rolling until somewhere between two and four minutes after the arrest. 

How long can a bystander perform adequate CPR?

Extremely few bystanders can perform adequate CPR compressions for three minutes. Ouch!

If the bystander who came to your aid isn't alone, the bystanders will need to alternate, switching every few minutes. Otherwise the chest compressions will become too shallow and too slow.

If the bystander at your side is alone, he or she will have to perform chest compressions adequately until the ambulance crew arrives and takes over the compressions. Unfortunately, this is not possible using the chest compression method that we learn in all certificated CPR courses (AHA, ARC, etc.) The lone bystander needs to stand by your side (you're flat on your back on a hard, flat surface with your head tilted back slightly), facing the direction your legs are pointing, has to take off his or her shoes, and has to place the heel of the foot at the CPR point so that he / she can compress your chest at an adequate rate and depth until the ambulance crew takes over. The bystander needs to be very careful to not put pressure on that thingy at the bottom of the breastbone. (the Xiphoid process)

Will the ambulance crew know how to do this?

Probably not, but there will be multiple people arriving with the ambulance and they can take turns. (Many ambulance services dispatch two ambulances to cardiac arrest calls, and each ambulance has at least two crew members.) And even if they do know, the odds of their being able to use this technique are slim - it's not part of the healthcare provider Basic Life Support CPR certification course that they have to pass, and absent a directive from that ambulance service's Medical Director, they will have to use the hands method. Unfortunately, there are too many situations where an EMTs or Paramedic has to work on the patient alone while his partner drives. There are also a few who haven't embraced the importance of deep, rapid, and uninterrupted chest compressions.

What does the "only 22% improvement" question from the first point tell us?

It tells us that the average bystander can perform CPR at a level that yields a result that's only about 80% of what the average, trained, certified, do-it-all-the-time professional can achieve. That's pretty impressive.

How big a deal is this? It only comes into play when there's a lone bystander helping.

Right you are. There is 'only' up to a thirty-six percent chance that your cardiac will be treated using a method that cannot do the job.

Omitting the "heel CPR" method from the AHA, ARC, etc. curricula is the same as telling someone whose foot is under the tire of a car that just ran over his foot, "Pick up the car, move your foot, and set the car down gently."

Where did all this data come from?

Its all in Table 3 in the CDC publication of the CARES data. You can find it at

www.cdc.gov/mmwr/preview/mmwrhtml/ss6008a1.htm

Where can I learn more about the heel method?

Go to www.slicc.org and click on the "for past trainees" link in the left-hand column. You can download the class video. It's not slick and polished, but it contains the information. The video runs about 35 minutes, and you'll learn Bystander CPR, AED use, dealing with choking, and stroke recognition.

Improving the odds

My family all know what to do when they witness a sudden cardiac arrest: if the victim is non-responsive and not breathing normally, they call 911, they get the victim on a hard, flat surface with the head tilted back, and they begin compressing the chest at least two inches deep at a rate between 100 and 120 compressions per minute, and they defibrillate the victim promptly if there is an AED available and immediately resume compressions. If there is no AED available, they don't stop compressions until someone else takes over.

But there's a problem with this: if they perform chest compressions the way they would be taught in an AHA or ARC or just about any other course, they won't be able to sustain the target compression rate and depth until the ambulance gets there. Most people cannot provide adequate chest compressions for three minutes. The longest I've seen is an Army Ranger Medic who lasted a little more than nine minutes.

So how long do you have to perform chest compressions in a real-world situation? and how can you overcome the three minute wall?

It all depends upon where you have the arrest and how many people are able to share the chest compression task. If you have your arrest on a farm, your chance of surviving are close to zero, probably because a long period of time elapses between the time of the arrest and the arrival of the ambulance.

In a suburban or metropolitan setting, the shortest time between the time of the arrest and the arrival of the ambulance crew at the victim's side is likely to be ten to twelve minutes. Remember that when you see the arrest, you have to figure out what's happening; you have to call 911; you have to tell the 911 operator where you are, what's wrong, what you're doing about it, and what you need; the 911 operator needs to either relay the information to the ambulance dispatcher or has to figure out which ambulance will be dispatched and contact them; and the crew on the ambulance has to get in route to the scene. By the time the wheels are rolling, two to four minutes are likely to have elapsed since the time of the arrest. It is not unusual for five to eight minutes to elapse from the time the ambulance is rolling to the time of patient contact. Do the math. Act out all the steps. it's likely that if you are alone with the victim, the victim's odds of getting out of the hospital with major brain function intact will hinge or your ability to perform adequate chest compressions for ten to twelve minutes.

My wife can perform adequate chest compressions for more than ten minutes.(That's when we stopped timing - she was still going strong at the ten minute mark.) She was using the heel of her foot at the "CPR point", standing alongside the victim, facing the manikin's feet.

Unfortunately, that's not what you learn in most CPR classes.

SLICC's current class video teaches the traditional method but also teaches the "with your heel" method. It can be downloaded from www.slicc.org - just click on "for past trainees" in the left-hand column. It's a large file. Clicking on it multiple times will simply lengthen the time it takes to download it. SLICC's next class video will feature the "heel" method, with a small segment covering the traditional method.

Bob

It is time to re-think how we're trying to deal with SCA's.

I believe that if the BLS curriculum were changed to teach what current resuscitation science teaches, many tens of thousand more people in North America would survive cardiac arrests than currently do. ("Survive" means "Get discharged from the hospital with major brain functions intact - i.e., with a CPC score of 1 or 2.")

Very few people perform CPR properly: the rate is too slow, the interruptions are too frequent and too long, and the compression depth is too shallow.

The imposition of a limit on compression interruptions didn't do much more than promote the documentation of five- and ten-second intubations and intubations without interruptions.

The CARES data shows us that two-thirds of all out-of-hospital sudden cardiac arrests occur in the home. Survival data shows that two percent of OOHSCA's occurring in the home have a survival outcome.

The Pheonix, AZ Airport has averaged a 75% survival rate for ten years.

Perhaps it's time to re-think what we take on faith as being the solution to the problem.

Bob