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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 | 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

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 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 Thomas Giberson | April 08, 2011 12:56 PM EDT

As an Emergency medicine physician I have been involved at cardiac arrests and at MVC sites. EMS personnel are in charge of the scene and my role is to assist where and when they allow. If they choose to use my resuscitative expertise I provide it. They are employed by the county or by a hospital and have protocols to follow. They know their equipment and their rules.

I am not insulted when told not to intubate (even when they are unable to do so), because I know the pt can be bag-valve ventilated to the hospital or have a King airway placed. In my ED I do not want a less skilled physician, or someone I do not know to be involved as the leader of a resuscitation. Being a physician does not mean that one has better expertise than a paramedic. In fact, most physicians cannot properly resuscitate a patient, and most cannot even do correct CPR. I don't want to argue with people about what they can or cannot do, so I simply would tell them that I do not require their assistance.

In trauma care at the scene of trauma I can do a wide variety of things the EMT's cannot and if there is a critical situation that I can resolve and they cannot and it requires instant intervention, then I will intervene with or without the concurrence of the EMT's. But that is essentially never.

So, in the final analysis, these are skilled people doing their job at the direction of their medical director. Offer assistance if you wish, but they are focused on their job, they are frequently scared and adrenaline surged, they will undergo monday morning quarterbacking of everything they do (frequently very critical and disrespectful), and they are in charge of the scene, not you. The ego that each of us possess needs to take a back seat to the responsibility that is placed on the EMT's. I personally marvel at what these guys do in the field

Tom Giberson

by gregory rutecki | March 17, 2011 3:14 PM EDT

Thanks I agree with your thoughtful comments. Eugene, I really appreciate your suggestions. Greg

Article Comment Pages: 1 2 3 4 Next

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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