'We need to take resuscitation seriously'

This article was originally published on 22 January 2013.

Australian Doctor follows one emergency doctor's campaign to tackle the country's 'appalling' record on resuscitation.

Hear Professor Paul Middleton speaking about paediatric emergencies at our Rural Doctor Live Seminar in Sydney on 14-15 November. Register here.

It's been 23 years since Kerry Packer famously ‘returned from the dead'.

The six minutes he spent pulseless on a Sydney polo field in 1990, following a cardiac arrest, became a defining moment in the media mogul's life after paramedics resuscitated him using a defibrillator — a rarity in ambulances at the time.

Packer later told journalist Ray Martin he had seen the other side and there was "nothing" there — no heaven and no hell. The experience moved him to donate thousands of dollars to fit out every NSW ambulance with defibrillators, so other lives could be saved.

Eight years after his death in 2005, Packer's legacy lives on, with defibrillators still fondly known by many as ‘Packer-whackers'.

But it's become clear that his near-death experience represented the high point of Australia's interest in defibrillation and resuscitation. National dialogue has dwindled ever since, with precious little government funding or leadership.

One man who hopes to reverse that decline is Paul Middleton (pictuerd below), an emergency physician at Sydney's Manly Hospital who chairs the NSW branch of the Australian Resuscitation Council.

Hear Professor Middleton speaking about paediatric emergencies at our Rural Doctor Live Seminar in Sydney on 14-15 November. Register here.


"People need to push things for them to be on the radar. And cardiac arrest is something that gets lost, really," says Associate Professor Middleton.

"Notionally, people know it's something that can happen to almost anybody. They all watch ER and those programs about the RPA [Royal Prince Alfred Hospital] and The Alfred in Melbourne, and they think ‘It's never going to be me'. But the problem is it is going to be you, or somebody like you, or somebody next to you."

Black Hole
Roughly 30,000 Australians are thought to experience a cardiac arrest each year, 8% of whom survive.

About 30-35% of cardiac arrests are due to ventricular fibrillation, and therefore shockable when first encountered by medical staff. Survival rates are better in this group, at 20-25%, but still far short of what can be achieved when CPR and defibrillation are given rapidly.

Have a VF arrest in the Melbourne Cricket Ground, for example, and you have a 71% chance of surviving. Airports and casinos are also good places to arrest: Chicago O'Hare has reported 75% survival from VF arrests, and Las Vegas casinos 53%.

Professor Middleton says these successes could be replicated on a bigger scale, with the appropriate funding, implementation and leadership.

He describes Australia's survival rate as "appalling", particularly since more than half of cardiac arrests occur in front of other people. CPR is only attempted in one-third of cases.

Hear Professor Middleton speaking about paediatric emergencies at our Rural Doctor Live Seminar in Sydney on 14-15 November. Register here.

NSW in particular has become a "black hole" for cardiac arrest, he says; there is no directory of automated external defibrillators, no statewide CPR training program and no centralised collection of data to inform practice.

The only proper estimate to date of Sydney's survival rates, published in 2006, found just 14% of patients survived a week after cardiac arrest and 11.5% survived a year. Professor Middleton is working on a new study that suggests overall survival has declined since then, although the reasons for this are unclear.

Having attended some 500 out-of-hospital cardiac arrests in his 20-year career, arriving "almost always too late", he believes a concerted, system-wide drive is needed to ensure effective CPR and defibrillation are given quicker in the community.

He estimates 90% of the arrests he has attended were fatal, with the window for intervention often missed as family members or bystanders watched on, helpless.

"We can improve all we want in hospitals, but we'll still have 10% survival and 90% death rates until we realise that it's not in my hands — it's in the hands of the bloke's wife standing next to him," Professor Middleton says.

"I've been to endless scenes where there's so much that could have been done with minimal amounts of training. People often say they thought about doing CPR but didn't, because they thought they would be causing harm. Okay, occasionally you can break a rib, but isn't it better to have a broken rib and be alive than have an intact chest and be dead?"

CPR is now easier than ever to perform, he adds, with mouth-to-mouth no longer considered mandatory. Guidelines still recommend it where possible, but have acknowledged since 2010 that continuous, compression-only CPR is a viable alternative to traditional CPR. Indeed some studies have suggested it might even be superior.

Chain of survival
It's a different mood over in Victoria, which continues to lead the way for cardiac arrest care in Australia. Statewide, 30% of people survive to hospital discharge after an out-of-hospital ventricular tachycardia/ventricular fibrillation arrest and 11% after any cardiac arrest.

Associate Professor Tony Walker, a paramedic and Ambulance Victoria's general manager of regional services, says these outcomes are the best in the country and in the top 5% worldwide. This success reflects a concerted effort to shape the entire emergency response system around the "chain of survival", ensuring that every link is as fast and effective as possible, he says.

"The ambulance service across the country is fantastic but the difference is that we've really focused on cardiac arrest, and we do a lot of clinical research to inform improvement. We measure it, and we're all held accountable for those measures."

Community recognition of cardiac arrest has been raised in Victoria through the 4 Steps for Life program, which has taught about one million people to recognise cardiac arrest, call triple-0 and perform CPR. The program has just launched iPhone and iPad apps to guide bystanders through the process.

Ambulance Victoria has meanwhile reshuffled its dispatch systems to ensure suspected cardiac arrests are assigned the highest priority. It also harnesses other emergency services; in Melbourne, firefighters carry defibrillators and oxygen, are fully trained in CPR and can be dispatched to calls if they are closer than an ambulance. This program is being piloted across the state.

In rural areas, survival rates from VT/VF arrest have risen dramatically since 2008 when the Metropolitan Ambulance Service, Rural Ambulance Victoria and the Alexandra District Ambulance Service merged into a single provider, enabling them to harmonise their systems. Forty-two per cent of rural patients now survive to hospital and 17% to discharge, up from 23% and 7%, respectively, in 2007.

Crucially, Victoria is also home to Australia's largest cardiac arrest registry, which has now captured data on 60,000 cases, Professor Walker says.

Community pride
Internationally, Australia's survival rates from cardiac arrest are "middle of the road". "We're not lagging behind but we've got capacity to improve substantially," says Ian Jacobs, professor of resuscitation and pre-hospital care at the University of WA and chair of the national Australian Resuscitation Council.

The global benchmark is Seattle, with survival rates from VF cardiac arrest as high as 40%.

"They have a wide community education program, and there's a lot of pride in being the world's best place to have a cardiac arrest. They also have very sophisticated response systems ... and a very aggressive approach to resuscitation care."

The whole-of-commun­ity approach is also being ramped up in WA, where a St John Ambulance-led program has provided automated external defibrillators, community education and first aid courses to about 150 small towns across the state, says Professor Jacobs, who is also clinical services director at St John Ambulance, WA.

The program has also trained up about 300 ‘first responders' — designated members of the public who are dispatched to nearby cardiac arrests.

"The community is the ultimate coronary care unit. If you've got a trained community that can do CPR and shock, that's [as good as] a first responder program."

A new direction to take
Similar community-focused projects exist in other Australian states, to varying degrees, he adds.

As well as raising public awareness, Australia will need to address its lack of automated external defibrillator directories if it is to boost cardiac arrest survival.

The devices are thought to be commonplace, particularly in shopping centres and sports clubs, but they're as good as useless if they can't be found and used within minutes.

Ambulance Victoria runs a directory that allows triple-0 operators to tell callers if there is a defibrillator on site they can use. It has around 1000 defibrillators registered but even this is incomplete, since the system depends on owners to be proactive and log their defibrillators.

Outside Victoria, Professor Jacobs says he has "no clue whatsoever" how many devices are in Australia, or where to find them. He has, however, been freshly inspired by a recent ‘crowdsourcing' project in Philadelphia, which made a public competition out of finding and photographing automated external defibrillators.

"I don't see why we couldn't do that here," says Professor Jacobs. "It's an excellent way of getting the information."

Winning hearts and minds
Back in Sydney, Professor Middleton is gearing up for a publicity offensive to finally get resuscitation back on the agenda.

The Australian Resuscitation Council NSW, a voluntary, not-for-profit group that has traditionally focused on training health professionals, is now financially and structurally ready to step up its public profile and attempt to influence policy, he says.

Several organisations, including St John Ambulance and the Red Cross, run basic life support and CPR training courses, but what's truly needed is a statewide, government-sponsored program, Professor Middleton says.


He also wants serious financial commitment to public-access defibrillation programs in regional towns and cities as well as Sydney. There has recently been some good news on this front, with the Red Cross launching a new national initiative called Project Defib, to subsidise defibrillators in sports clubs.

Nationally, there is also fresh optimism in the form of a recent $2.5 million, five-year NHMRC grant — the first serious injection of federal funds into out-of-hospital cardiac arrest research for years. The money has been used to establish Aus-ROC, the Australian Resuscitation Outcomes Consortium, which has brought together several experts to conduct multicentre clinical trials, examine existing systems and build capacity.

Aus-ROC also plans to join existing cardiac arrest registries in Victoria, SA and WA into one super-registry, which could turn Australia into a world leader for resuscitation research.

"It's getting some momentum. This is the first real effort to get out-of-hospital cardiac arrest onto the research agenda and to be able to inform policy and practice," says Professor Jacobs, an Aus-ROC chief investigator.

Professor Middleton says he is "under no illusions" that it will be quick or easy to get Australians fully engaged with resuscitation.

"All we've ever had is that single, high-profile event," he says of Packer's cardiac arrest. "But it needs to be a whole public health campaign. We've got 23 million people in Australia — a big chunk of them will die of a cardiac arrest, and at government level there's very little being done."

Hear Professor Middleton speaking about paediatric emergencies at our Rural Doctor Live Seminar in Sydney on 14-15 November. Register here.

This article was originally published in January 2013.