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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 gregory rutecki | March 02, 2011 10:51 AM EST

Wow, I guess I struck a chord! To Karen Hughes, when I asked for a BP reading the patient did have QRS complexes. CPR was stopped at that time without a blood pressure reading. I apologize for being harsh. However, this was my second experience in ashort period of time. The previous one, I was with an electrophysiologists and when we asked if we could help, the EMT responded "No, we are very good at what we do." Connie, thanks we are on the same page. Thansk for insightful comments, Michael, Peter, and Jin. Greg

by Karen Hughes | March 01, 2011 5:18 PM EST

If I understand your recap of the situation, the unfortunate gentleman had no pulse except for with compressions, and remained for the most part in a Vfib rhythm. Your suggestion on obtaining a blood pressure, while well intended, indicated to the EMT's that you were not familiar with handling codes. You cannot get a blood pressure in someone without a pulse. While being a physician means we know more about the process going on with the heart itself, the EMT's are more adept at being first responders. Don't judge them so harshly. They have many a tale to tell of physicians who try to take over when they are not qualified and delay proper care. Ego needs to be set aside by all in the patient's interest.

by Connie Carmany | March 01, 2011 2:31 PM EST

Kudos to you for trying to assist, Dr. Rutecki! And kudos to the people who rushed to do CPR. I applaud you for stating so clearly the necessity of having AEDs available in public places. I have been working on achieving that in our communities since 2001. You are so right that they are saving many more lives than with CPR alone. I have teamed up with the SCAA (Sudden Cardiac Arrest Association) in efforts to raise public awareness about this issue. Thank you. Connie Carmany Northeast Ohio

by Michael Cater | March 01, 2011 2:04 PM EST

I can identify with your story. My 88 y/o father had a cardiac arrest standing next to me in my garage. As my wife called 911 I initiated CPR. When my wife returned we did two person CPR until the EMTs arrived. Just before they arrived my father became conscious. However, when the EMTs came in they bluntly asked me to step aside despite the fact that we had been doing CPR for 5 minutes and my father was now conscious; this took place despite the fact that I told them I was a physician. Then they wanted to transfer him to the nearest hospital, which in my opinion, was a substandard institution. I instructed them to take the extra 5 minutes and go to the nearest quality hospital nearby which they did reluctantly. Despite breaking four of my father's ribs, three days later he had a aortic pig valve placed and lived an additional productive 13 years. I agree, EMTs need to be a little more receptive to physician help when it is available. The flip side, however, is that physician's should step aside if they do not know how to assess and handle a cardiac emergency.

Michael W. Cater, MD

by Peter Berge | March 01, 2011 11:37 AM EST

EMS systems have varying protocols regarding interaction between advanced pre-hospital care providers (e.g., paramedics) and on scene physicians. While there is no excuse for rudeness, some protocols do not allow for bystander physician participation, and rather require the paramedics to consult with their base-hospital physician if there is a doubt.

Having worked as a paramedic years ago, I can say with certainty that an on-scene physician presents a quandary at best, notwithsanding protocols. Is this really a physician? Do I take time to ask for and verify identification? Does this physician have current advanced life support knowledge and experience? Other than asking, how do I verify claims that s/he does?

Example: call to restaurant. Patient, who is light headed, is seated on a chair with physician/friend attending. Physician says she is diabetic and we should give glucose. I palpate her pulse, determine that she is in a bradycardia, place her supine (light headedness resolves) and determine that she is in a 2nd degree heart block. Physician thereafter limits himself to assisting the paramedic team.

PB, JD, RPA

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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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