CLINICAL INNOVATORS
In the United States we
have had one person die
of Ebola in the last 100
years as far as I know. By
contrast, with cardiac
arrest, we have 1,000
people/day arrest [...]
Think about the public
outcry with the Ebola
crises. [...] And here we
have something that is
a leading cause of death
for which we know there
are things we can do,
that won’t take as many
resources.
starts in people’s homes. It’s in grocery stores, in
churches, in synagogues, parks, recreation centers,
malls—anywhere that people are. This is where
people have cardiac arrests.
What do you think it will take for this shift in
consciousness to take place, to address factors
that exist beyond hospital walls?
Well, I’ll be honest. I think what people need to
realize is that some communities have it down. Some
communities are doing really well. But those are not
the communities that most Americans live i n. For
example, the state of Arizona has almost tripled its
survivor rate in the last 5 years. This did not happen
by accident. They looked at a state-wide level at their
whole system. To me what it’s going to take is for
citizens to realize that there are safe and unsafe areas
to have a cardiac arrest. Right here in our country,
across every state, there are unsafe places. And until
we have the data, we won’t even know where those
places are. The very first recommendation in the
IOM report is that we have good national data, and I
think it’s the data that will drive improvements.
It sounds like this is more than a resources
issue. What makes some communities better at
improving survival after cardiac arrest?
Some resources are necessary, but these are not
extraordinary resources. It’s more about leadership, having the data, and having a system where
there is someone who is accountable. The thing
about cardiac arrest is that there is no one who is
38 CardioSource WorldNews
really responsible for it. There needs to be a coming
together of public health officials to address this.
In the United States we have had one person die
of Ebola in the last 100 years as far as I know. By
contrast, with cardiac arrest, we have, give or take,
1,000 people/day arrest. And we know that we
could triple or quadruple the survival rate for a city
like New York. Think about the public outcry with
the Ebola crisis. Public health officials got together,
hospitals spent millions of dollars because we were
afraid of Ebola and what it might do. And here we
have something that is a leading cause of death for
which we know there are things we can do, that
won’t take as many resources. But what we do need
is a reorganization and a commitment to gather
truthful data. We need to find places doing poorly
and make them better, and we need to find places
doing great and make them better, too.
What are some of the key things that
communities need to do better?
The first thing is reliable data. We need a national
cardiac arrest registry, like what Japan and other
places have. Second, we need to educate the public
so that they know what to do when a cardiac arrest
takes place. We need to develop dispatcher CPR so
that when a person calls 911, the dispatcher can
get them started. That is how Arizona tripled their
survival rate. Third, we need a more team-oriented
approach in the way that EMS handles cardiac arrest. It’s called “high performance CPR” and we are
now teaching it across the country, and EMS organizations are getting better and better at acting like
fast- functioning pit crews when it comes to doing
CPR. But not all agencies have adopted that.
We know there are things that can be done in
almost every emergency department in the country,
like measuring CPR quality, debriefing as a team
after a cardiac arrest, ensuring they are looking at
the right parameters while going through a code.
These things are sometimes, but not always, done.
Another thing is quickly getting patients to the
cath lab in the event that they had a heart attack.
These are all things that are feasible, and places that
routinely try to do these things have better survival
rates than the places that don’t. Those are all things
that we know right now.
What does the future of resuscitation science
look like?
Let me tell you about the near future. And by the
near future I mean that these are things being done
internationally, but not in the United States. There
was a recent study from Australia called the CHEER
trial, and it is remarkable. It uses a technology available in most hospitals—cardiopulmonary bypass.
Essentially any hospital with cardiology patients
has one or twenty of these machines, typically in
the operating room. The catch is that using these
bypass machines is technically difficult. I’ve done
it. It’s hard—particularly to start it in a patient who
is in cardiac arrest. But let me tell you about the
study. They took 26 patients who were in refractory
cardiac arrest, who failed 30 minutes of CPR and
advanced cardiac life support. And then they did four
things as quickly as they could. The first thing was
they put them on a mechanical chest compressor
that does automatic CPR. Second, they infused two
liters of ice old saline to produce intra-arrest cooling
(the typical cooling that we do in America is after
patients’ hearts have restarted). Third, they put them
on a cardiopulmonary bypass machine. And fourth,
they then took them to the cath lab for percutaneous
intervention. That’s their protocol. What they found
was that of the 26 patients they tried this on, 14 of
them (54%) were alive and neurologically intact 7
days later. These were patients that could have been
declared dead! This was a hard study to do. It took a
lot of team work. And that was one of the major lessons—it took a whole team to be able to provide this
kind of care. But they went from 0% survival to 54%
survival. That is pretty dramatic.
The use of cardiopulmonary bypass in cardiac
arrest patients is being pioneered in Japan. It’s being
routinely practiced in more than 30 of its major hospitals, and it is dramatically improving the survival
rate. Right now they are doing it on patients with
nearly 0% chance of survival and they get anywhere
from 15% to 25% survival using this, which is pretty
amazing. This technique started in the U.S., but it is
being developed in Japan to a high degree. I travel
there to learn from them.
Tell me about your work at Penn’s Center for
Resuscitation Science.
The reason that CHEER study was so successful is
that they had a whole bundle of treatment. They
didn’t depend on just one thing—they had the automatic CPR machine, they did cooling to protect the
brain, they did bypass to get the blood flowing, and
then they went to cath lab to fix the heart. It makes
sense. We are also trying to put together a bundle of
treatment—with drugs that could be neuroprotective in combination with cardiopulmonary bypass.
We’re studying this in animals. We know that we
can improve survival with cardiopulmonary bypass,
but many of these animals are neurologically damaged. We are trying to develop a special “cocktail”
to go together with bypass that will provide both
circulation and neuroprotection. And that’s the focus
of our basic science laboratory. We’re trying to work
out the biochemistry, the science of why the cells are
injured, and put powerful new drugs into the bypass
machine that will allow patients’ hearts and brains
to survive an arrest.
The latest evidence is telling us that cardiac arrest
patients are not hopeless. We need more research,
but the whole paradigm is shifting. ■
Katlyn Nemani, MD, is a physician
at New York University.
August 2015