Sometimes it is who you know, but it also may be where you live, that determines whether you live or die. Despite huge advances in the treatment of cardiac arrest, survival to discharge from the hospital ranges from 8.1% in Seattle, WA to just 1.1% in Alabama and everything in between. In a recent book, Erasing Death by Dr. Samuel Parnia, describes the shocking science that changes the ways we address death. In fact, survival rates as high as 75% have been documented in a New York hospital when this particular physician is on duty.
Could it be dumb luck or could it be that the treatment protocols for emergency medical services are different in every state? And could it be that each and every physician can treat cardiac arrest according to his/her beliefs instead of a standardized protocol?
An example is a use of an ECMO which is widely used in Southeast Asia (especially South Korea and Japan) which has increased resuscitation rates to 70–90 percent vs 20–50 percent, in the best case scenario in the United States. Although the machine is widely available in the United States there is no standardized protocol for its use. Could it be expensive, or simply preference of practice? There is no standard not only from State to State but from hospital to hospital and physician to physician. Despite mounds of science and research, each and every physician has the right to ignore it, allow it to change their practice, adopt some but not all, or anything in between.
The first case in Erasing Death documents the case of a taxi driver who was resuscitated and discharged home after coding. Shockingly, he was neuro-intact after over 40 minutes of resuscitation. A few things lined up in his favor. The right physician was on duty (most would have stopped at the AHA recommended 30 minutes), he ended up at a hospital that utilizes automated compression devices (able to better maintain coronary perfusion pressure), and a hospital that aggressively utilizes hypothermia to maintain neurological function.
If any one of these had not been in place, statistics show that this patient would have died. Yet few hospitals have all, many have some, and still, many more have none of the above. And there are no requirements that they do have this technology available.
According to Dr. Parnia, many health care teams call a code at about 20 minutes following resuscitation efforts. To increase the odds of a successful resuscitation, the team should continue for 40 minutes. In fact, the National Model EMS Clinical Guidelines state that recent evidence has shown that to capture over 99% of potential survivors from cardiac arrest, resuscitation should continue for 40 minutes. Although, this same document states that this is not true in the face of asystolic rhythms.
What about the Hs & Ts? Or the specific medications to administer for each rhythm? Something as simple as how many compressions are done or how much electricity is used for defibrillation differ from state to state. Unfortunately, the emergency medical services protocols under which EMTs and paramedics function differ depending on your location.
Emergency medicine has been calling for consistent health services since the 1960s. Although training is being standardized via the National Registry of Emergency Medical Technicians (NREMT), practice is not even close behind. The practice is determined by protocol, geography, and the individual physician which may differ from shift to shift.
It seems that it doesn’t matter anyway because by the time most healthcare teams figure out the nuances of resuscitation with each patient, the AHA recommended 30 minutes of CPR is up and you can quit. Unless you have read the science lately to discover that people are walking out of the hospital after being in cardiac arrest much longer.
Something we’ve long known about healthcare is that time is not a luxury most of us have. Understand the problem?
Parnia, S. (2014). Erasing Death: The Science That Is Rewriting the Boundaries Between Life and Death. HarperCollins Publisher.