Consultant.

BLOG
PRIMARY CARE MATTERS

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 Pamela Cleveland | April 12, 2011 2:24 PM EDT

As a nurse, and now a nurse practitioner, I have received the same rudeness from EMTs every time I have interacted with them. They don't want to hear what happened or what has been done so far. They treat other health care providers as if we don't know anything. I'm sure this is not true of all EMTs, but in general they seem to be trained with this mindset.

by Todd Berends | April 22, 2011 11:52 AM EDT

As a person who has progressed from First Responder - EMT - Paramedic - RN - NP I have seen health care and interactions of providers from many levels. First, while I believe Dr. Rutecki comments that he was 'polite' with/to the paramedics, this is a would be a rare occurrence - from first hand experience. Also, it must be understood that paramedic obtain their 'authority' to practice based on guidelines and the Medical Director. An on scene physician can assume patient care with the permission from the Medical Director - but that also means the physician would need to transport with the patient. Where you willing and did you make that willingness known? I truly wish there was better interactions and respect between ALL providers. Todd

by gregory rutecki | April 26, 2011 1:40 PM EDT

Thanks to all who have joined our conversation. You bring up some very intersting and practical points. Michael Carter thanks for our agreement about the value physicnas can bring to critical events outside the hospital. Peter Berge, I agree that it is hard to know whether bystanders are physicans as they say.
Greg Rutecki

Article Comment Pages: 1 2 3 4 Previous

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).

BLOG FOR CONSULTANTLIVE

Send us your blogs! Contact us for more information if you are interested in writing a post or becoming a blogger.

TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

ABOUT OUR BLOGGERS

	On Health and Mental Health Erik R. Vanderlip, MD, is a senior fellow and acting instructor in the University of Washington Department of Psychiatry. As a dually-trained family physician and psychiatrist, Dr Vanderlip is active in national health system redesign efforts with a particular interest in newer models of the medical home. He practices family medicine in a hybrid primary care clinic within a mental health center in Seattle.
	The HIV-AIDS Observer Rodger D. MacArthur, MD, is Professor of Medicine, Wayne State University, Department of Internal Medicine, Division of Infectious Diseases and Director and Site Principal Investigator, Wayne State University HIV/AIDS Clinical Research Unit.
	Speaking of Pain Steven A. King, MD, MS, is in the private practice of pain medicine in New York, and he is Clinical Professor of Psychiatry at the New York University School of Medicine, New York.
	Tales Doctors Tell David T Nash, MD, is Clinical Professor of Medicine at Upstate Medical Center in Syracuse, New York. The author of more than 250 peer-reviewed clinical articles, Dr Nash has practiced cardiology in Syracuse for over 50 years. He is a Fellow of the National Lipid Association.
	Primary Care Matters Gregory W. Rutecki, MD, is Professor of Medicine at the University of South Alabama College of Medicine in Mobile. He is section editor of the hypertension topic center on this web site.
	Practice Makes Perfect Pamela Wible, MD, pioneered the first community-designed ideal medical clinic in America. An expert in patient-centered care, Dr Wible helps citizens design cutting-edge clinics and hospitals nationwide. Her model is taught in medical schools and featured in Harvard School of Public Health's newest edition of Renegotiating Health Care. Dr. Wible is a medical reporter for the Oregonian, has been interviewed by CNN, ABC, CBS, and is a frequent guest on NPR.

FROM PHYSICIANS PRACTICE

Primary Care Can't Thrive Without Nurse Practitioners
Courtney H. Lyder, ND, May 17, 2013
With a projected shortfall of primary-care physicians, it's time for alternate solutions to patient care. Nurse practitioners are one logical remedy.

VWhat Physicians Can Learn from the Allscripts EHR Lawsuit
Marisa Torrieri, May 16, 2013
Lawsuit prompts question: What should physicians do to ensure they end up with a great EHR instead of buyer’s remorse?

Eight Ways ICD-9 Will Still Matter to Medical Practices
Brenda Edwards, CPC, May 15, 2013
What should your medical practice do with your ICD-9-CM book after October 1, 2014? Keep it.

Seven Ways Technology Can Speed Up Patient Collections
Cheyenne Brinson, May 15, 2013
Failing to adopt widely available billing and collections technology can cost medical practices big. Here's how to do it right.

Four Reasons Private Medical Practice is Becoming Extinct
Carol Stryker, May 15, 2013
It’s becoming increasingly difficult for private medical practices to thrive. Here’s what’s driving the trend toward consolidation.

Bystander Cardiac Arrest in a Restaurant: Some Physician Reflections

Join the Conversation