If you're walking down the street and your heart stops, the chance you'll see another day is about the same as it was thirty years ago. But the proven systematic and cultural changes that could drastically increase survival after cardiac arrest are very much within reach.
If you're going to have a cardiac arrest, the best place to do it is in Seattle. That's because King County, Washington, boasts the highest out-of-hospital cardiac arrest survival rates in the country, at 49 percent.
While that might sound like a bad bet -- basically flipping a coin on your chance of living -- compared to the rest of the country, it is astonishingly high. The national average for out-of-hospital cardiac arrest survival quivers at around 10 percent, depending on location. In some cities, like Detroit, your chance of survival is near zero.
According to a 2005-2010 survey by the Centers for Disease Control and Prevention, 300,000 people suffer cardiac arrest outside of a hospital every year, and 92 percent of those people die. But that statistic isn't even the most frustrating aspect about the state of survival. It's this: "Despite advances in technology and resuscitation science, these rates have remained virtually unchanged for more than three decades," the CDC reported in the survey.
We have the medical tools to save peoples' lives, but we're not using them to their most effective outcomes. Raising the national survival rate by just one percent would have a significant impact on the lives and families of many, many people. But raising them by a factor of five or more? That would be a breakthrough.
The issue is timing. In the absence of an intervention, the moment a heart goes into cardiac arrest, a doom clock of biological events begins, starting and ending with a loss of oxygen to the brain. And the window for intervention is just several minutes long. That's where quick CPR comes in: Compressions on the chest maintains blood pressure, which keeps blood and oxygen circulating around the body and to the brain.
"90 percent of the time, we'll arrive in seven minutes. But at seven minutes, you're on the edge of survivability."
"If somebody can start chest compression in four to five, maybe as much as six minutes, you then extend the opportunity by which the shock [defibrillation] can succeed," Dr. Mickey Eisenberg, medical director of the King County EMS system told me. "Good CPR suspends death for 10 to 12 minutes."
This is why your chances of surviving a cardiac arrest in Seattle are so much greater than the rest of the country. King County has a system that operates with a mechanical efficiency. Eisenberg says nearly 75 percent of the population is trained in CPR, which means, if you collapse in public, chances are someone around you will know the basics to help. But also, the county has an aggressive dispatcher-assisted CPR program, wherein 911 operators give callers prompt and detailed instructions on resuscitation. Fire departments arrive on scene in four to five minutes. The county also keeps reliable statistics on every patient, assessing which parts of the chain of survival can become more efficient.
"Every cardiac arrest is studied to the nth degree," Einsenberg says, "and all of the medical leadership have academic appointments to the University of Washington. All of those factors, you put them in the soup, and you have a very tasty gumbo that is very successful."
But not all fire departments are so quick to the scene as Seattle's. That's why witnesses to cardiac arrests are a crucial factor in increasing survival.
"Any bystander CPR, not even good-quality bystander CPR, more than doubles and in some studies triples survival from cardiac arrest," said Dr. Ben Bobrow, medical director for the state of Arizona. "The question is how to get more people to do bystander CPR."
Perhaps one part of the answer lies in communications technology. For the past year, the city of San Ramon California has been experimenting with a smart phone app called Pulse Point, a push-notification response system for lay citizens.
Here's how it works. When the fireboard receives a call about a cardiac arrest , it activates Pulse Point, sending a ping to every person trained in CPR in the vicinity of the patient. The app directs the would-be responders to the victim, and alerts them to the location of nearby defibrillators. These app responders can then start CPR during those crucial first few moments before paramedics arrive.
"We activate the app now almost every day, sometimes three or four times in a single day," says Richard Price, chief of the San Ramon fire department and president of Pulse Point.
This technology engages the community to act in those crucial moments before advanced medical help can arrive, and pinpoints the people around the victim who have a demonstrated willingness to perform CPR. Price says several people typically respond to each posted emergency, and the app will occasionally summon a dozen or more.
"Even in San Ramon, we have a very good paramedic response system here, a very good EMS system," Price said, but "90 percent of the time, we'll arrive in seven minutes. But at seven minutes, you're on the edge of survivability."
If victims can just survive to the hospital, they'll have the opportunity to have all the life-saving advances of the 21st century. "The goal of the app, sort of the promise of the app, is delivering more patients that are alive to the hospital," Price said.
Pulse Point currently has 4,900 users in San Ramon (a city of 72,000) and its API is open for any community's fire department to use for free. Next year, a three-year clinical trial will take place in Toronto, Canada, evaluating the app's effectiveness.
Software like Pulse Point is only viable for cardiac arrests that occur in public. But most cardiac events happen in the home. Another way to increase survivability, Eisenberg suggested, is to put more defibrillators in the home.
"I see the biggest opportunity for a breakthrough is a consumer defibrillator, a defibrillator that would cost less than $500, be virtually disposable, and it would be viewed as a consumer safety-net item, not unlike a smoke detector or an airbag in the car," he says. "That has got to be the next horizon of resuscitation."
Currently, there is an at-home AED that is sold over the counter, but its cost is prohibitive at $1,200. However, a 2008 clinical trial of at-home AEDs showed unclear results as to whether they are a benefit to cardiac arrest survivability in the home.
But technology is only piece of the puzzle -- increasing cardiac survival also depends on good public education on CPR and the public's willingness to perform it.
In 2012, the American Heart Association updated its protocols for bystander CPR, making them much simpler. Lay responders are no longer are told to perform mouth-to-mouth rescue breathing. Instead, they are instructed to solely focus on pumping the chest at a rate of 100 compressions per minute. That's because, once a rescuer takes his or her hands off the victim's chest to turn to breathing, the blood pressure drops to zero, and the heart drains of blood. "It takes another 10 to 15 compressions to refill the heart," Einsenberg said. Also, most people have an aversion to putting their mouth on a dying body. "I think it's resulted in a higher willingness to perform CPR."
And the new protocols appear to be working. According to a study by the AHA, the likelihood of surviving a non-shockable cardiac arrest to discharge from the hospital improved from 4.6 percent to 6.8 percent after the new guidelines were put in place.
But one of the best lines of defense, Bobrow said, is to have well-trained 911 dispatchers who can quickly teach bystanders CPR and have them begin pumping the chest within one minute. "You can train thousands and thousands and thousands of people in the community to do bystander CPR, but most of them are not ever likely to see someone in cardiac arrest," he says. Meanwhile 911 dispatchers may give CPR instructions every week.
While Seattle does a good job with training dispatchers, across the country, there is no standard for what those instructions should be.
"We did a national survey of 911 dispatch centers across the country," Bobrow said. "What we found was, overwhelmingly, most dispatch centers say, 'Yes, we give pre-arrival CPR instructions.'" But when you ask the dispatchers about their protocols, and how they measure those protocols, the answers are completely varied. "Most of them don't measure this, and if they do give pre-arrival CPR instructions, sometimes it can be in minute seven or eight into the call. If you give CPR instructions in minute seven or eight, it is another world different than if you give CPR instructions in one minute."
It takes a system to save a life, a swift, seamless interaction among individuals, municipalities, and the medical community. Eisenberg believes the most important component of increasing cardiac arrest survival rates is strengthening the links between these entities . "How do you measure quality, how do you measure culture, how do you measure leadership?" said Eisenberg. "And yet they are as important -- if not more important -- in terms of the total package to make a program succeed."