Cardiac Response Lags in D.C.
EMS Chief Doctor Says Training, Funds Needed

By Elissa Silverman
Washington Post Staff Writer
Thursday, May 29, 2008

Only one in eight cardiac arrest patients transported by District ambulances make it to an emergency room with a pulse. Across the river in Arlington County and Alexandria, the rate is twice as high.

Patients in cardiac arrest, a condition usually triggered by an electrical disorder that disrupts the heart's blood-pumping, make up less than 1 percent of the District's 911 calls. That was 585 patients in 2005, the last year for which statistics are available. But experts say success in keeping those patients alive is one of the most telling indicators of the overall quality of an emergency medical system.

The number of cardiac arrest patients who are discharged and are able to resume their old lives is unknown because the hospitals do not provide that patient data to the District.

The District, at 61 square miles, would seem to have an advantage over more sprawling suburban counties in response time for patients in cardiac arrest. But its rate matches that of Prince George's County, which is 485 square miles and is growing so fast that officials are scrambling to provide more ambulance services. Arlington and Alexandria, jurisdictions similar to the District in density, lead the area in getting the patients to the hospital alive. Montgomery and Fairfax counties had rates of about one in six. Chances of survival increase in all jurisdictions when cardiac arrest is witnessed.

Although officials say the District is meeting a national standard of getting advanced life support units to critical cases within eight minutes 90 percent of the time, that's often too long. The likelihood of survival falls each minute patients in cardiac arrest go without treatment.

In 2005, only 12 percent, or 69, of the cardiac arrest patients treated by D.C. emergency medical personnel reached the hospital with a pulse, or in technical terms, a "return of spontaneous circulation." The numbers do not include those in cardiac arrest because of trauma.

"It's a clear indicator that the system in the District is not performing up to the [de facto national] standard of care," said Gregg C. Lord, associate director of the National Emergency Medical Services Preparedness Initiative at George Washington University. "If you improve cardiac arrest survival rates," then the EMS system will have been improved.

There is no national average for cardiac arrest survival, and not all jurisdictions calculate rates using the same method, Lord said. But no matter how you do the math, the District's percentage is low, he said.

In addition to response time, boosting rates depends on factors such as public access to defibrillators and people's willingness to help a stranger in distress, according to experts.

Michael Williams, chief medical officer for D.C. Fire and Emergency Medical Services, said that the District's rate is "too low" and that he has plans to boost the numbers, including training all D.C. government workers in CPR. But he said those plans are contingent on his department receiving supplemental funding. That money, which was approved by the D.C. Council this month but has not been disbursed, is also needed to address other shortcomings in the District's approach to emergency care.

Some are long-standing problems, despite efforts to remedy them.

For example, morphine and Valium, drugs commonly given to patients experiencing symptoms of a heart attack or seizure, respectively, are not stocked on District ambulances though they were approved for such use in 2002. Williams said he wants to use part of the designated $3.7 million to purchase the drugs.

Both drugs have significant street value, and there are concerns about theft, but Williams said the department has a plan to meet security requirements, which include a double-locking system that makes medics accountable for the drugs.

"The current situation we have is not optimal. We have no interventions to break seizures except for supportive care," Williams said. "Many of our paramedics have complained that they would like to use the tools available to other jurisdictions, and I agree with them completely."

EMS experts said the lack of these drugs is unusual. "I am not aware of any other system with advanced life-support ambulances that do not carry morphine and Valium," said Jerry Johnston, president of the National Association of Emergency Medical Technicians.

City leaders have vowed to improve the EMS system for years, and the death of retired New York Times journalist David E. Rosenbaum in January 2006 spurred additional changes. Gross missteps occurred at almost every point in the care of Rosenbaum, who was hit in the head with a lead pipe during an evening stroll but was assessed as drunk by firefighters and medics at the scene.

In the arena of cardiac arrest survival, Seattle is the national leader. Two of every three, or 67 percent, of cardiac arrest patients make it to the emergency room alive, according to data compiled by the Abaris Group, a consulting firm that worked with the city's EMS task force last year.

Arriving in the emergency room with a pulse is important, but experts said the true rate of cardiac arrest survival is how many people are discharged from the hospital. In Seattle, that's 45 percent of cardiac arrest patients, according to Abaris.

The District's discharge rate is unknown because the city doesn't track those figures; neither do surrounding jurisdictions.

Officials in Alexandria said the number of cardiac arrest patients arriving at the hospital with a pulse has risen to almost 50 percent after medics started using a ResQPOD. The device, which is disposable and retails for $100 online, helps increase blood flow and is recommended by national health organizations.

Training people to use defibrillators and making the devices available have had a clear impact on boosting rates, experts said.

A recent effort to put defibrillators in Montgomery fitness centers has had dramatic results.

"We've had eight saves in health clubs in 21 months. That is phenomenal," said Asst. Chief Mike McAdams of the county's fire and rescue department.

"Cities don't achieve higher survival rates by chance or circumstance," said Jocelyn Rogers, a spokeswoman with the mid-Atlantic affiliate of the American Heart Association. "They do so by increasing access to automatic external defibrillators, training more lay rescuers to use them and perform CPR, and ensuring that EMS and hospital protocols give cardiac arrest patients the fastest and best treatment possible."

The District has improved response times and is meeting its target of advanced life support units reaching patients in less than eight minutes 90 percent of the time, Ken Riddle of Abaris said.

But cardiac arrest patients need a faster response time.

Williams has launched initiatives in two critical areas that have proved successful in other cities. The first is CPR training for 24,000 D.C. government workers, using a new DVD from the heart association. A pilot program began with civilian members of his department last month.

Bystander CPR has been key in cities with high survival rates, experts said.

"If you collapse on a sidewalk in downtown Seattle, the next three to five people who come upon you are likely to know CPR," said Johnston, of the EMTs association.

And Williams wants to start calculating the city's true survival rate: How many cardiac arrest victims are able to return to their former lives?

The city is joining a program run by Emory University and the Centers for Disease Control and Prevention that helps track patients from the 911 call through the hospital. Letters were recently mailed to area hospitals to encourage them to release patient data to the program, known as the Cardiac Arrest Registry to Enhance Survival.

EMS directors across the region said sharing patient information between emergency medical agencies and hospitals would help increase accountability and improve pre-hospital care.

"It's like pulling teeth to get patient information from the hospital," said Brian Hricik, EMS operations manager for Alexandria's fire department. "Just because we bring a patient to the hospital with a pulse doesn't mean they survive to discharge. We'd love to know how our medicine in the field translates to survival rates in the hospital."

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