August 25, 2013 in Features

Emphasis on lifesaving techniques helps more people

Residents such as Jake Desmirais, 14, living through cardiac arrest
By The Spokesman-Review
 
Tyler Tjomsland photoBuy this photo

JJ Dunn points out the scars his stepson, Jake Desmirais, has from various heart procedures. Dunn performed CPR on Jake last September as the teenager was in cardiac arrest. The family later discovered part of Jake’s heart had enlarged since a procedure he underwent as an infant.
(Full-size photo)

Shock to the system

While it buys time and “primes the pump” for electric shock, CPR alone won’t save a cardiac arrest victim. They need someone to apply a defibrillator, too, to shock their hearts back into rhythm – and the sooner the better

While emergency medical responders carry the devices, “we’re looking at every nuance of trying to zap people faster who need it,” said Dr. James Nania, of Spokane County Emergency Medical Services.

Nania’s office tracks the locations of automated external defibrillators in public and commercial buildings in Spokane County. As of April, about 155 locations were on the list, with some spots keeping multiple devices on hand.

The office has explored the idea of getting them into mobile fleets beyond fire trucks and ambulances, such as police cars.

Lt. Lydia Taylor, a spokeswoman for the Spokane Police Department, said the department has 19 AEDs, including six in corporals’ cars and two in SWAT vehicles. The rest are in facilities such as the downtown precinct and the police academy.

On average, the department puts six AEDs on the street daily. Putting AEDs in all the cars “has been discussed,” Taylor said. “Right now it’s a money issue.”

Resources

• For information about a support group for survivors of cardiac arrest, call AMR’s Cathy St. Amand at (509) 323-8829.

• To find in-person or online CPR courses, go to the American Heart Association’s website at www.heart.org.

• To request a CPR class through Spokane Heart Rescue, a collaborative effort to improve bystander CPR response to cardiac arrests, go to spokaneheartrescue.com.

The sound was tiny and muffled as it came through a vent in JJ Dunn’s bedroom and he teetered on the edge of sleep. He was dog tired, only awake an hour later than usual to adjust his fantasy football teams.

Maybe the sound was a little moan.

Dunn got out of bed to look around, finding no sign of trouble until he reached his 13-year-old stepson’s dark bedroom in the basement. The boy, Jake Desmirais, was on the floor, next to his twin bed.

Jake didn’t respond to Dunn’s call or when he tried to lift him. Dunn switched on a light. His stepson was gray.

“His color was gone, and he looked dead,” Dunn said. “And the most amazing feeling washed over me, kind of like, ‘This is what I’m built for.’ ”

Dunn flipped Jake onto his back and started doing chest compressions, pumping hard and fast, and blowing air into his lungs. He yelled and yelled for his wife, asleep upstairs, to call 911. He’d had no training in CPR, only seen it on TV. In describing what happened last September, Dunn used words such as “clarity” and “peace” and “hyperawareness.” There was nowhere he would rather have been, Dunn said, than on the basement floor.

“I remember thinking, ‘I don’t know if he’s alive or has a chance to be alive again, but that doesn’t matter. Totally irrelevant,’ ” Dunn said. “It was this peace in that I’m doing everything that I can.”

A growing club

As a survivor of cardiac arrest in Spokane County, Jake Desmirais – now 14 and set to begin his freshman year at Central Valley High School – is part of a group that’s suddenly bigger.

A countywide effort among emergency medical responders, doctors and others to improve the survival rate among cardiac arrest victims has resulted in a dramatic increase, officials say – from an estimated 20 percent in 2010 to 51.2 percent in 2012, among victims considered savable.

That’s partly because of efforts like Dunn’s.

In the cardiac arrest “chain of survival,” only two links have been proven to make a real difference: good CPR and the use of defibrillators, the devices that can shock an irregular heart back into rhythm, said Dr. James Nania, medical director for Spokane County Emergency Medical Services. So after leaders in the county’s emergency response system looked at the survival rate and decided it could be better, they put their energy into strengthening those links.

It seems to be working. Firefighters who’ve relearned CPR – adopting a “pit crew” approach and hands-only CPR – are seeing their patients come back to life. Thousands of residents are learning the streamlined procedure, too, recruited into an army of resuscitators officials – realizing that the majority of cardiac arrests happen in homes – hope will step forward for duty as needed. High school students are learning how to run defibrillators. Emergency dispatchers are moving faster to instruct callers to perform CPR – minus the airway-clearing and rescue-breath parts – and talking them through it until rescuers arrive.

The effort follows research finding that cardiac arrest can be more treatable than many people previously believed.

“Dead isn’t always dead,” said Cathy St. Amand, a clinical and educational services specialist at American Medical Response, the ambulance company that serves most of Spokane County. St. Amand’s goal for the year: to train 10,000 people in Spokane County to perform CPR. She’s halfway there.

“I kind of go back to ‘The Princess Bride,’ where the wizard is saying, ‘Well, you just think he’s dead. He’s just mostly dead,’ ” said St. Amand, a paramedic. “Maybe they’re mostly dead, and their heart still has a little bit of electrical activity. That’s something that we can fix. … When you change your thinking about that, it really changes the whole big picture.”

An electrical problem

Cardiac arrest is the sudden loss of heart function that stops blood flow. Victims also stop breathing and lose consciousness. It results from an electrical problem in the heart that disrupts its rhythm and pumping action. A heart attack and cardiac arrest aren’t the same thing, although heart attacks – more of a plumbing problem, as a blood clot blocks blood flow through a coronary artery – are a major cause of cardiac arrest.

Not everyone in cardiac arrest can be resuscitated. While some victims have bad heart rhythms that can be corrected by an electric shock from a defibrillator, some arrhythmias can’t be corrected.

Victims considered savable – those considered in that countywide survival rate of 51.2 percent – are those whose cardiac arrests were witnessed by other people who tried to help and whose heart rhythms turned out to be correctable by electric shock. Counting all victims, Spokane County’s survival rate was 17 percent in 2012, compared with 10 percent in the U.S.

When a victim goes down, there’s no way for bystanders to know whether his or her rhythm is correctable. But when a victim can be saved, good and timely CPR is key.

And good CPR isn’t what it used to be.

Formally endorsed by the American Heart Association in 1963, CPR has historically meant alternating chest compressions with rescue breaths.

But with the rise of AIDS and concerns about other blood-borne pathogens, would-be rescuers grew afraid to deliver it, said Dr. Scott Edminster, medical director for the Spokane Fire Department, which responds to medical emergency calls in Spokane.

Meanwhile, researchers started to measure the effectiveness of hands-only CPR – resuscitation without mouth-to-mouth breaths, consisting basically of two steps: calling 911, then pushing hard and fast in the center of the victim’s chest.

It turned out, in most cases, that hands-only CPR worked better, Edminster said (exceptions include children and drowning victims). That’s not only because more people are willing and able to do it, but because most cardiac arrest victims don’t really need someone to blow oxygen into their bodies, at least not for several minutes.

When you keel over in cardiac arrest, your problem isn’t that you need oxygen, Edminster said. There’s already oxygen in your blood. Your problem is that your blood isn’t circulating.

Using chest compressions to re-establish “perfusion” – blood flow to the heart and brain – buys time until doctors can perform more complicated procedures. So does defibrillation.

“The reality is, if you don’t have either one in 10 minutes, your survivability drops to about zero,” said Dr. Joel Edminster, an emergency room doctor at Providence Sacred Heart Medical Center (and Scott Edminster’s son) who’s helped lead an effort to teach CPR to freshmen at three county high schools. “Specifically, you have about a 7 to 10 percent drop in survival rate for every minute that nothing is done. So you get this pretty steep death curve.”

New results in the field

Firefighters and other emergency medical responders are seeing CPR work. They haven’t always.

AMR’s St. Amand has been an emergency responder for 25 years.

“When I first started,” she said, “the attitude about someone in cardiac arrest was, ‘They’re dead, and there’s not really a lot we’re going to do to save them. We’re going to just kind of go through the motions.’ ”

For firefighters who worked to save cardiac arrest victims and rarely could, it got depressing, said Brian Schaeffer, assistant chief at the Spokane Fire Department.

“We threw medication after medication after procedure – everything you can do in the emergency department, we’d do out in the field,” Schaeffer said. “And when you have that untoward outcome, it eats you up emotionally, because we’re trained to see good things happen. That’s what we expect. And now we’re starting to see that.”

Spokane firefighters now employ a high-efficiency “pit crew” approach to CPR, Scott Edminster said.

Under the new approach, chest ventilations aren’t so important anymore, and chest compressions are sacrosanct. Rescuers trade off doing compressions every two minutes, when studies show most people tire and their compressions diminish in quality.

“Everything is choreographed,” Scott Edminster said. “It’s like a dance. Everybody knows what role they’re supposed to play. They know exactly when they’re supposed to check the pulse, exactly when they’re supposed to deliver medication, exactly when they’re supposed to shock. And they never stop doing compressions, except when they’re going to shock.”

Fire Capt. Kevin McCollum remembers one recent call. A man in his late 20s or early 30s had gone into cardiac arrest at a North Side bowling alley.

“He came outside, he was with his family, and all of a sudden, boom – he went nose-first into the ground,” McCollum said.

Firefighters found out later the man had an undiagnosed congenital heart defect. It took two shocks for them to get his heartbeat back, but he survived.

“For a guy like that who’s still got his life ahead of him – that’s really cool,” McCollum said. “That felt good.”

A volunteer army

Before firefighters or paramedics arrive at a scene, though, a cardiac arrest victim’s survival depends on who else is around. If every minute matters between the time of the arrest and professionals’ arrival, the ability of bystanders to intervene is crucial.

“For so many years, resuscitation has been viewed as the task of the doctors and nurses or the paramedics and the firefighters or the lifeguards,” Joel Edminster said. “It’s a specific role and you have to have the card. … The reality is, if we are going to be successful, then the community has to take a responsibility for resuscitation.”

That’s why medical leaders are working to train, or retrain, so many civilians to do CPR.

Joel Edminster also serves as medical director for Fire District 4, which launched a pilot program about two years ago to teach CPR to freshmen at the three high schools in its coverage area: Riverside, Mt. Spokane and Deer Park.

The program inserted a two-day curriculum into required health classes that includes chest compression and defibrillator practice on mannequins. Gov. Jay Inslee has since signed a law requiring all high school students in Washington to learn CPR.

AMR’s St. Amand said she teaches CPR to anyone willing to learn wherever she can find them: church groups, veterans groups, trade shows.

Perhaps easier than teaching CPR to 10,000 people was revamping way the 20 or so emergency dispatchers at the Combined Communications Center guide people through CPR when they call 911 about a cardiac arrest.

As officials started to look for ways to boost the survival rate, the Spokane Fire Department’s Scott Edminster started listening to all the 911 tapes from cardiac arrest calls.

“I found out that the dispatchers were not having people do CPR a lot of the time, and when they did they were kind of slow getting started,” he said.

Now, as soon as dispatchers recognize a cardiac arrest case, they direct the caller to get the victim flat on their back on the floor and to start performing chest compressions, 2 inches deep, at the rate of 100 compressions a minute.

Some people will get CPR who don’t need it, Scott Edminster said. “We figure it’s worth it,” he said. “The worst thing that’s going to happen is they’re going to get a few broken ribs, and that’s not terrible.”

‘Hard to comprehend’

Partnering with Providence Sacred Heart Medical Center, AMR held the area’s first cardiac survivor “reunion” in 2012, bringing together people who’d lived through cardiac arrest and the emergency workers who’d helped them.

St. Amand said some survivors break down in tears as they relate their experiences, still struggling with some aspect of their survival. At first, St. Amand said, she wondered why: To survive is a great thing.

Then she started to understand.

“They live in a lot of fear, almost like post-traumatic stress disorder,” she said. “Is it going to happen again? If it does, where am I going to be? Am I going to be alone? Am I going to be in public? Is that going to be worse? And when they leave the hospital, they’re given a ton of information. … They’re overwhelmed with the amount of it, with what just happened to them.”

St. Amand helped organize a survivors support group that meets monthly.

Jake Desmirais said he doesn’t worry much about suffering another cardiac arrest.

But once a month in his parents’ bedroom, he holds a device up to his chest that reads data from his ICD, or implantable cardioverter-defibrillator, that regulates his heart’s rhythms. The device sends the data over the phone to a doctor’s office.

After Jake’s cardiac arrest, doctors determined that the right side of his heart had enlarged, forcing it to work harder, after surgeons removed his faulty pulmonary valve when he was an infant.

The cardiac arrest wasn’t his first medical emergency. At age 6, Jake suffered a stroke during another heart procedure. That’s when his stepdad became a stay-at-home parent, ferrying him to physical, occupational and speech therapists’ offices as well as his cardiology and neurology appointments.

When he grows up, Jake wants to launch a line of clothing, donating a portion of each sale to charity. He has a name for his brand: LTR, for Long-Term Recovery.

Compared with his stroke, cardiac arrest was easier to recover from physically, but not mentally, he said: “I was pretty much dead for a couple minutes, and that was hard to comprehend.”

Now, Jake said, he feels better about the idea of death than he did before his cardiac arrest.

“I’m not as scared, because I know it’s going to be a lot more peaceful than I thought it was going to be,” he said. “It’s not going to be as scary as I always worried it would be.”

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