Defibrillation : The Trend in Lifesaving Is Shocking
Reflecting on it, emergency medical technician Stephen King recalls March 18 as “a wild night.” It was, state emergency services officials agree, likely to have a major effect on the way heart attack victims are treated--and how many of them survive.
In the bedroom of a house near here, King administered an electric shock to a heart attack victim--the first time in California that it is known to have been done legally by an ambulance worker. Until seven days before, the same shock could only have been given by a doctor or nurse, paramedic or other medical professional working under supervision of a physician.
The patient here died--he doubtless would have anyway, doctors agreed, no matter who treated him--but King had become part of the front line in a growing national movement to increase the availability of defibrillation, as the shock technique is called. The trend is occurring against a backdrop of growing disaffection with the ability of conventional cardiopulmonary resuscitation (CPR) programs to save meaningful numbers of lives.
Political Considerations
Depending, doctors agree, more on political than medical considerations, automated defibrillators could soon find their way into police cars, fire engines, office buildings, factories, hotels, health clubs and airliners.
“I think we have made a mistake by putting all our our eggs in one basket of public awareness, and that basket is CPR training,” said Kenneth Stults, a University of Iowa researcher generally identified as one of the nation’s leading experts in emergency care. “It should come as no surprise (today) to anyone working in this field that the chief determinant of survival (in heart attack cases) is the total (elapsed) time from collapse (from the heart seizure) to defibrillation.”
CPR Not Effective
A study recently completed by Stults and other researchers has concluded that, after a close look at influences on survival after heart attack, the chest compressions and breathing assistance of CPR make little difference in ultimate outcome.
“CPR will never return (a heart in seizure) to a beating status. The only thing that will do that is an electrical shock,” said Dr. Bruce Haynes, director of the state Emergency Medical Services Authority. “The key is that CPR only delays death (unless other life-saving measures are taken quickly) while the machine can remove . . . the rhythm that’s causing the death.”
Emergency technician King and a partner were on duty at 11:20 p.m. that day last month, King said matter of factly, when “we got the call . . . a possible heart attack.”
It took King 12 minutes to get to the house outside of town where an overweight, 56-year-old man with a history of heart attacks had been found unconscious in bed. Panic-stricken family members had initiated CPR, but without moving the victim from his bed to the floor. Any benefit of the CPR chest compressions had been lost because the mattress had neutralized the force of the chest thrusts.
King and his partner grabbed all of their usual gear, but they also pulled out a 28-pound beige box. The box contained a new type of defibrillator that analyzes electrical signals from the heart and determines if an electrical shock is appropriate. If it is, the box selects the correct electrical energy level. Until equipment of this type was developed, an electrocardiogram had to be interpreted by a physician--or someone working under a doctor’s direct supervision--before a conventional defibrillator could be used.
King rolled the victim off the bed and onto the floor, quickly positioning two large stick-on patches on his chest. He connected the patches to the machine and turned it on, watching as the device analyzed the heartbeat. Its conclusion: the man was in ventricular fibrillation, the random sort of twitching in which the heart does not truly beat and its pumping action is lost. It is the most common problem in severe heart attacks and the one most amenable to shock treatment.
A recorded voice warned everyone to stand back and told King to press a button to deliver the electric pulse. He did, but there was no response. Twice more, the machine directed King to push the button. Still nothing. With CPR in progress, King and his partner loaded their patient into the ambulance for what they recognized was to be a futile ride to the hospital.
Pronounced Dead
Hospital personnel pronounced him dead after about 15 minutes and state emergency services officials agreed that the delay of several minutes as the family frantically tried to revive the victim--coupled with the 12-minute response time of the ambulance to the rural location--inevitably meant that he would have succumbed, no matter what.
Although the attempt failed, officials here and elsewhere agreed that the advent of new defibrillation technology may make it possible to save many lives that now are lost. Among developments either under consideration or already in place are these:
- Automated defibrillators could be placed on fire engines and in police cars, in any location where response times for fully trained paramedics are likely to be four to six minutes longer than for less-trained medical personnel. Fire departments in Denver and Dallas already have concluded extensive tests of automated defibrillators mounted on fire engines and operated by medically untrained fire fighters.
In Dallas, firemen from 10 stations using defibrillators doubled apparent heart attack survival rates in attacks in which the victim’s heart stops--from about 5% to about 10%--contrasted with areas where victims had to wait for paramedics to arrive before shocks could be administered. Nine of 93 victims were saved. The Dallas department is preparing to buy units for 32 fire stations and hopes eventually to install a defibrillator on every pumper in the city.
Test Not as Successful
In Denver, a test in 16 fire houses--ending in January--was not as successful. Officials found little difference in survival rates and concluded that, for cities with extremely effective emergency systems, characterized by good response times and skilled paramedics, the new equipment may not add enough to survival rates to justify its cost--units likely to be used by fire departments are priced at just under $10,000 each, although reductions are seen as inevitable.
The San Francisco Fire Department hopes to conduct its own test of the new equipment at two engine companies that cover areas of the city where ambulances are notoriously slow to arrive. Still more change in state regulations will be necessary before the San Francisco test can begin, however, since California firefighters--as opposed to emergency medical technicians, like King--may not yet legally use the new equipment. Changes in state law itself may also be necessary. State officials hope to interest the Los Angeles city and county fire departments in testing the equipment but neither agency has agreed. UCLA Medical Center has scheduled a conference this summer to try to interest local public safety agencies in tests.
- Defibrillators could be sold, leased or loaned to the families and friends of many recovered heart attack victims whose conditions leave them prone to additional seizures. A pilot program in Seattle, where seven victims have received shocks administered by equipment operated by relatives, has not produced any survivors. But doctors there say the equipment worked flawlessly and other factors influenced the outcomes--two of the heart attacks occurred when no relative was immediately at hand and two others involved heart rhythm disturbances no defibrillator can correct. Physicians in Seattle said that the program shows promise for increasing survival rates in many heart attack victims who now die.
Training Relatives
Doctors at Cedars-Sinai Medical Center in Los Angeles have begun training victims’ relatives in a similar program. The Cedars-Sinai program has been stalled temporarily because of uncertainty over whether private and government health insurance programs will pay for the home devices, which are less elaborate and cost between $2,500 and $5,000. New home models weigh as little as six pounds. Despite the cost, making defibrillators available in home settings for heart patients is thought to be the most promising application for the new equipment since an estimated 70% of cardiac arrests outside of hospitals occur in the home, according to a variety of studies. The smaller models are not rugged enough for firefighter or police use.
- Several large corporations--including General Electric Co., General Motors Corp. and McKesson Corp.--have begun purchasing automated defibrillators to be stationed strategically around offices and plants. At a McKesson office complex in San Francisco, health officials have taught 10 employees with no previous medical training to act as emergency defibrillation workers in the event of a heart attack. While experts in the new technology are divided on how widely the machines should be distributed, doctors agree that many factories, office buildings, health clubs, restaurants, senior citizen centers and hotels could benefit from having defibrillators available for quick use by minimally trained employees or even bystanders.
In California at the moment, however, such practices are thought by state officials to exist in a legal vacuum--one that the state Emergency Medical Services Authority hopes to resolve soon. It is not clear, said Haynes and officials of the state Board of Medical Quality Assurance, whether lay people using defibrillators in emergency settings are operating completely within the letter of the law. The problem, said a medical board attorney, is that state law prohibits anyone but a doctor from making diagnoses and authorizing treatment, although there is an exception that permits almost anything to be done in a bona fide emergency. Haynes said his agency may soon ask for a legal opinion from Atty. Gen. John K. Van de Kamp clarifying the legal status of employees and bystanders who use automatic defibrillators. A spokesman for Van de Kamp said the emergency care exemptions would probably apply but acknowledged that there are no court decisions clarifying the situation.
- At least one international airline--British Caledonia--has begun an experimental program in which 14 defibrillators have been installed on wide-body transatlantic aircraft. None of the units has yet been used in an actual emergency, but flight attendants have been trained in certain aspects of heart attack treatment. The program is supervised by a team from the University of Washington School of Medicine in Seattle, which has pioneered a variety of advances in emergency care. American flag carriers have declined to participate, according to program officials.
Disquieting Reality
The objective in all of these applications is to address the disquieting reality of an attack in which the heart stops beating: the seizure may begin with the heart going into ventricular fibrillation, but that rhythm very quickly deteriorates into a total absence of heart muscle activity--what laymen sometimes call “flat-line,” since an electrocardiogram screen displays only an unmoving straight line, indicating that the heart has stopped functioning. Defibrillation cannot reverse or cure “flat-line” and, in the average case, if more than four to 12 minutes go by between the time the patient collapses and when an electric shock can be administered, further treatment is futile.
Having ambulance workers administer electric shocks is not a new concept. It was first described in medical literature in 1972 when researchers described a defibrillation program established by an Oregon ambulance company that saved seven of 14 people on whom the rescue technique was attempted. One of them was the ambulance company’s 80-year-old founder. In California, researchers first proposed that the technique be tested in the state more than three years ago, but reluctance to permit untrained medical workers to participate scuttled the evaluation.
The careful studies that will be necessary to evaluate the life-saving potential of automated defibrillation have not yet been done, but initial results suggest that the new equipment represents a potentially major advance. In a recently completed Iowa study, researchers found that if the time between collapse and defibrillation can be held to six minutes or less, more than one-quarter of patients survive to be discharged from the hospital--a greater proportion than under existing out-of-hospital systems. Last year, Iowa researchers reported that defibrillation of 111 victims by non-paramedics produced 11 people whose hearts were returned to working beating patterns.
Even with CPR in progress, the heart muscle itself may deteriorate to the point where the heart cannot be restarted, whether blood flow to the brain is maintained by CPR or not, experts agreed. “We’ve got about six minutes,” Stults said. “Whoever can get to the patient in that six minutes--police, fire or bystanders--should have a defibrillator. There’s no alternative to a good cardiac care program in the community.”
Sees Start of Trend
To Dr. Richard Cummins, a University of Washington expert on a variety of emergency cardiac care issues, the new developments in making defibrillation more widely available signal the start of a trend. But Cummins, Haynes and Stults agree that while electric shock is the most important bystander treatment for heart attack, expansion of defibrillation should not supplant existing CPR programs and what they have come to represent.
Rather, the three experts said, CPR training can become a useful adjunct. CPR guidelines revised last year by the American Heart Assn., American Red Cross and American Medical Assn. set the stage for changes in such procedures by recommending that--contrary to previous procedures in which a person finding an unconscious patient immediately began CPR--rescuers first telephone for paramedic assistance and, if defibrillation capability is immediately available, attempt electric shocks before actually beginning CPR.
Cummins said CPR training programs can be useful in acquainting lay people with techniques to recognize when a heart attack has occurred--and, just as important, when one has not . Most advocates of expanded defibrillation agree that basic CPR skills are necessary so that time is not wasted in attempting to defibrillate if the patient’s problem is not a heart attack.
“I think this really has to be considered as a package deal,” said Cummins of the mix of traditional CPR and defibrillation. “CPR is a prerequisite to learning how to use one of these machines and the benefits of CPR are almost independent of the controversy about whether (CPR itself actually succeeds in maintaining even minimal blood circulation). CPR teaches people to recognize a cardiac arrest. And it teaches people to respond very quickly. But the important principle here is to get the (defibrillation) shock in as fast as possible.”
Cummins and Haynes emphasized that, while automatic defibrillation machines may represent an appealing alternative to existing systems, the precise degree to which the new technology may influence survival remains undetermined. Haynes said state officials hope to stave off a rush to purchase such machines without thorough planning by both public agencies and private companies.
Competitive Field
“There are a couple of types of future for this equipment and one of them is the marketing future,” said Cummins, who noted that three manufacturers already sell automated defibrillators and a variety of new models are in the planning stages, which could make the field intensely competitive. “I think the real future is for the high-risk patient,” Cummins said. “In that, (an) older person, there will be saves.”
But Cummins said he has been encouraged, too, by corporations that have shown interest in the new technology even though the average factory or office building is only rarely the site of cardiac arrest cases. Occupational medicine specialists questioned by The Times agreed that large companies--those with 10,000 employees or more--may experience only one or two arrests in their facilities each decade. Experts said places such as health clubs and senior citizen centers probably have a far greater chance of being the site of a heart failure than do offices and factories.
Haynes said state officials are concerned that communities may rush to purchase automated defibrillators without investing in planning for improved emergency medical services of other types--especially techniques that can assure the quality of training for lay people who will use the new machines and monitor victims. Haynes said training in use of the machines may take only four to 12 hours and could be coupled with existing CPR courses. What is undetermined so far, he said, is how much periodic retraining would be necessary to make certain that lay defibrillator operators could quickly locate and connect the equipment.
At Cedars-Sinai, Dr. George Diamond said initial reaction among families of heart patients has been encouraging. “We are teaching people, basically, that CPR is what you do until the defibrillator arrives,” he said. “The idea here is to get that machine to the patient’s side quickly.”
But, he said, programs for patients’ families--as well as community heart attack response programs, in general--must emphasize the unfortunate reality that, even with the best and fastest care, a majority of victims of sudden-death-type heart attacks will die, no matter what. For that reason, Diamond said, training programs have to emphasize the possibility that a bystander CPR rescue attempt or defibrillation may fail. “We have to tell them, ‘There is the possibility you are not going to resuscitate your husband,’ ” Diamond said. “ ‘There is at least a 50-50 chance you are going to fail.’ ”
Some Made Nervous
Haynes and other sources familiar with the trend toward use of automated defibrillation agreed that public acceptance of the technology may face more potential obstacles of a political nature than of a medical nature. Paramedic program sources in Los Angeles said some paramedics have already indicated that they were nervous about the prospect of ambulance attendants and bystanders administering defibrillation. But Haynes, who said he has heard similar expressions of discontent, said he is confident that if defibrillation programs are intelligently and carefully set up, any opposition that materializes can be overcome.
UCLA officials said they scheduled the July conference at least in part to blunt political opposition among emergency medical services workers.
“I think people have learned from (what has happened with) paramedic programs that paramedical personnel can do an effective job at saving lives,” Haynes said. “It took a long time to convince the (medical community that paramedics were) a good idea. I think they’ll be able to see that this, too, is a good idea.”
