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Bystander Cardiac Arrest in a Restaurant: Some Physician Reflections

By Gregory W. Rutecki, MD
University of South Alabama | February 23, 2011

Recently, my wife and I received a gift certificate for one of our favorite restaurants, and we wasted no time in using it. The food and conversation were delightful, and the meal turned out to be exciting and enlightening on many levels. A patron of the restaurant, who was celebrating his 55th wedding anniversary, sustained a witnessed, public cardiac arrest. The experience led to an analysis of my involvement in the resuscitation.

The unfortunate man's arrest summoned at least 5 trained persons to institute aggressive and timely cardiopulmonary resuscitation (CPR). We were told that the restaurant had a defibrillator, but until the emergency medicine personnel (EMP) arrived 20 minutes later, no such machine materialized. A pulse was generated by the compressions; however, there was no circulation or respiration without our efforts. Timely electrical shock by the EMP was unsuccessful in converting the man's ventricular fibrillation to anything more than short-lived QRS complexes. Despite the fact that I was the only physician present, when I identified myself, defined the electrical activity, and politely suggested a blood pressure reading, I was rebuffed rudely by the EMP and told "to move."

WOULD BYSTANDER DEFIBRILLATION HAVE MADE A DIFFERENCE?
A recent study¹ may serve as a critique of the initial efforts expended on this elderly man, who unfortunately was pronounced dead shortly thereafter. The paper evaluated 12,930 out-of-hospital arrests (2042 occurring in public as my experience did and 9564 at home). An interesting and therapeutically critical difference was uncovered. Public cardiac arrests were characterized by a 38% incidence of ventricular tachycardia (VT) or pulseless electrical activity (PEA) when the events were witnessed by EMP (the home arrest incidence of these 2 rhythms was 25% under the same circumstances). VT or PEA occurred 60% of the time when a public arrest was witnessed by a bystander (compared with 35% for home arrests). Finally, the numbers for VT and PEA were 79% public versus 36% home when arrests were not only witnessed by bystanders, but they were able to apply an automated external defibrillator (AED).
My personal quality debriefing led to an inescapable fact: the presence of an AED may have led to a better outcome. In fact, the editorialist for this paper observed that improvements in resuscitation have been driven more by the prompt availability of AEDs than by CPR.²

PATIENT SAFETY REQUIRES TEAMWORK
The other unsettling aspect of my experience was the lack of civility demonstrated by the EMP. A review of the literature reveals a paucity of data regarding collegial physician-EMP interactions recently, but the issue should be revisited. Patient safety requires teamwork rather than insulated silos that ignore a variety of talents each healthcare profession brings to the table (sorry for the pun). Recent evidence has documented that bystander-initiated CPR outside the hospital specifically directed by physicians had the best outcomes, including recovery of cerebral function.³

by Kimberly Spering | March 10, 2011 6:26 AM EST

I agree that rudeness is unacceptable. However, from the EMS perspective, it was perhaps due to other factors, such as (1) abruptness due to the lack of patient response to the therapy, and (2) prior interactions with medical personnel who actually did impede EMS actions.

I have worked with many EMS personnel in an outpatient setting...some at my office, some at accidents. Once they arrive, I step back and let them work. I let them know the situation that I assessed, but I stay out of their way. From what I've observed, they work best alone. JMHO. (smile)

by gregory rutecki | March 07, 2011 8:55 AM EST

Thanks for your additional comments Karen. To be fair, some of teh tension may have been my fault, in this instance, you agree with my wife (that's a good thing), Greg

by eugene saltzberg | March 05, 2011 2:01 PM EST

Discuss the situation with the local EMS Coordinator (call receiving hospital to ID that person).No reason for rudeness. Plus, they should have politely asked you if you are an ER, Critical Care doc or are you ACLS certified, and finally IF you are going to manage the arrest at the restaurant WILL YOU BE WILLING TO RIDE THE AMBULANCE TO HOSPITAL which they must require when they relinquish the responsibility to you.

by Karen Hughes | March 02, 2011 3:04 PM EST

Another short recap, and I am going to go and hide! I agree whole-heartedly (no pun intended) with several things said by others. First, there is never a need to start out an interaction being rude or disrespectful, and I apologize if I came across that way in trying to be brief. Second, broader availability of AED's would be of great benefit and hooray for those who are working for this. Third, I definitely agree with the kudos for being willing to step up and provide CPR to a stranger, which as we know is not a universal response. And fourth and final, every situation is different and I apologize again if I came across as judgemental. Things look different from each side of a situation. I am sure the person's family was grateful for your help.

by susan osborn | March 02, 2011 2:27 PM EST

Understanding that EMS has their own protocols for on-the-scene care, there is NEVER any excuse for rudeness and unprofessionalism. Having worked in a clinic for the homeless and many times having to call EMS for cardiac and respiratory arrests, I found some (not all) EMS were abrupt and did not take the time to get the facts before jumping in. Let's not label all EMS as erogant and disresoectful.

SO, FNP-C

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REFERENCES:
1. Weisfeldt ML, Everson-Stewart S, Sitlani C, et al. Ventricular Tachyarrhythmias after cardiac arrest in public versus at home. N Engl J Med. 2011;364:313-321.
2. Bardy GH. A critic’s assessment of our approach to cardiac arrest. N Engl J Med. 2011;364:374-375.
3. Yasunaga H, Horiguchi YH, Tanabe S, et al. Collaborative effects of bystander-initiated cardiopulmonary resuscitation and prehospital advanced cardiac life support by physicians on survival of out-of-hospital cardiac arrest: a nationwide population-based observational study. Crit Care. 2020;14:R199 (e pub ahead of print).

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Bystander Cardiac Arrest in a Restaurant: Some Physician Reflections

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