Why Don't Doctors Recognize Cardiac Arrest?

If your heart stops beating, you may be more likely to survive in a casino or on an airplane than in a hospital.

When people’s hearts stop beating, they lose consciousness in seconds. If standing, they fall. If sitting, they slump over. Their bodies jerk, and reflexively, they gasp.

Those breaths are deceptive. They can trick physicians and nurses into thinking a hospital patient is experiencing a seizure, not cardiac arrest. And that misinterpretation can delay a shot at resuscitation.

“Those are the two things we really want everyone to remember: the person becomes unconscious, and they’re not breathing normally,” says Clifton Callaway, a professor of Emergency Medicine at the University of Pittsburgh. “If anyone is unconscious and not breathing normally, think about cardiac arrest, and get on the chest and start chest compressions.”

It’s odd to think that doctors and nurses could be duped by such a common medical emergency; according to the American Heart Association, there were 209,000 in-hospital cardiac-arrest cases in 2013. But clinical researchers find that too many people in medicine are hesitant to believe a patient is in cardiac arrest. And not all are aware of the most effective methods of resuscitation. While critical-care physicians often have plenty of practice resuscitating patients, other doctors, like primary-care physicians, have relatively little.

“We know from clinical studies that health-care providers do an awful job of knowing,” says Jason Persoff, an assistant professor of Internal Medicine at the University of Colorado Hospital. He points to studies that have shown at best a 65 percent accuracy of providers knowing whether a patient has no pulse and is not breathing.

To be sure, hospitals are complex operations, and their patients can be equally complex. That’s because hospital patients often are the sickest of the sick, and those who are relatively healthy don’t merit round-the-clock monitoring or a bed in the intensive care unit. But according to Persoff, your chances of surviving cardiac arrest are higher in a casino or on an airplane than on a monitored ward or in an ICU. That’s because casino workers and flight attendants are trained to start resuscitation immediately, whereas doctors learn to be prudent to an extent that might be counterproductive.

“The biggest delay that occurs in doing resuscitative efforts is that people are afraid to do chest compressions unless the patient is clearly in cardiac arrest,” Persoff explains. He believes that clinicians can spend too much time looking for a pulse or at monitors, or thinking about what drugs could help with resuscitation. “But it’s one of the few times in medicine that it’s far more important to begin treatment and ask questions later,” he says.

For successful resuscitation, Persoff says it’s crucial to “start now, push hard, pump fast, have good recoil, and don’t stop.” And by fast, Persoff means 100 to 120 compressions per minute, roughly the same rhythm as the song “Staying Alive,” by the Bee Gees. And by hard, he means harder than you think. “Although there is an upper limit to how effective a chest compression may be or that there is harm to doing too-deep a chest compression, the reality is in human studies that almost never happens,” he says.

Dana Edelson, the Executive Medical Director for Inpatient Quality and Safety at the University of Chicago Medicine, says she sees prevention of cardiac arrest as key to improving patients’ odds of survival. “In hospitals, we tend to have signs of clinical deterioration hours, if not days, before it happens,” she says. “Our focus has to be on identifying the early signs of clinical deterioration and intervening on those rather than waiting for the arrest to happen and then rushing into action as if it happened out of nowhere.”

With that in mind, Edelson and her colleagues have developed eCART, or electronic Cardiac Arrest Risk Tool, an algorithm based on hospital patients’ vital signs that indicates who’s likely to have cardiac arrest in the next 24 hours.

“We are running that algorithm in real time, and we send automatic pages to our rapid response team who will go and see the patient and treat the underlying cause or move the patient to the ICU if they need a higher level of care than they are getting,” Edelson says.

Preventing cardiac arrest with the help of algorithms may well improve patients’ odds of survival, but so would training caregivers to give the most effective cardiac resuscitation possible. “I believe most physicians and nurses need only a small amount of training to correctly be able to resuscitate a patient,” says Persoff. “Once resuscitation goes on for more than 10 or 15 minutes, you need other levels of training that most people don’t have. But I believe if we can just focus on what really works, and what’s been proven to work, we can improve delivery of care and save lives.”