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Out of hospital cardiac arrest in Saskatoon : an assessment of the emergency medical system Medd, Lorna May 1984

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OUT OF HOSPITAL CARDIAC ARREST IN SASKATOON: AN ASSESSMENT OF THE EMERGENCY MEDICAL SYSTEM By LORNA MAY MEDD BA (1966) B S c . Med. (1970) MD (1970), U n i v e r s i t y o f M a n i t o b a  A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE MASTER OF SCIENCE  in THE FACULTY OF GRADUATE STUDIES  (DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY)  We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d standard  THE UNIVERSITY OF BRITISH COLUMBIA October  1984  © Lorna May Medd, 1984  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree at the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make it  f r e e l y a v a i l a b l e f o r reference  and  study.  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may department or by h i s or her  be granted by the head o f representatives.  my  It i s  understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain  s h a l l not be  allowed without my  permission.  Department of I  The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date  Cur  iv  written  Abstract  The  question  addressed i n t h i s t h e s i s i s should  the  C i t y of Saskatoon, Saskatchewan develop an emergency m e d i c a l system cardiac  (EMS)  arrest?  In order questions 1.  s p e c i f i c a l l y designed to d e a l w i t h o u t - o f - h o s p i t a l  to answer t h i s q u e s t i o n ,  must be d e a l t with, Can  an EMS  decreased m o r b i d i t y 2.  provide  as  r e a l h e a l t h gains  and m o r t a l i t y from c a r d i a c  What are the components of an EMS  Is the community i n q u e s t i o n  and  i n terms o f arrest?  t h a t are  typical  for cardiac and  p a t t e r n s , or s u f f i c i e n t l y d i f f e r e n t from p o p u l a t i o n l i t e r a t u r e t h a t the EMS  accommodate the 4.  How  required  mortality?  a r r e s t i n terms o f sociodemographic, m o r b i d i t y ,  the p u b l i s h e d  subsidiary  follows:  to achieve t h i s decrease i n m o r b i d i t y 3.  a s e r i e s of  mortality data i n  w i l l be r e q u i r e d  to  differences?  important a cause of m o r b i d i t y  i s c a r d i a c a r r e s t , and w i l l  and  mortality  i t become a g r e a t e r o r a l e s s e r  problem i n the next decade? 5. way  Is the e s t a b l i s h m e n t  of reducing  morbidity  and  of such a s e r v i c e an e f f e c t i v e m o r t a l i t y from c a r d i a c a r r e s t ,  or are there ways of d e a l i n g w i t h c a r d i a c a r r e s t t h a t have more impact?  will  The p r o v i n c e o f Saskatchewan and the C i t y o f Saskatoon are attempting t o d e a l w i t h these i s s u e s i n o r d e r t o develop l o n g range p l a n s f o r an e f f e c t i v e and a f f o r d a b l e ambulance s e r v i c e f o r both the p r o v i n c e and the l a r g e r  cities.  The causes and e x t e n t o f sudden c a r d i a c death i n Canada and i n Saskatoon are d e s c r i b e d from r e p o r t s i n the e x i s t i n g s c i e n t i f i c l i t e r a t u r e and l o c a l death r e g i s t r y d a t a . epidemiology o f coronary h e a r t d i s e a s e (CHD) on m o r t a l i t y from CHD  The  and the impact  by an a r r a y o f primary, secondary and  t e r t i a r y p r e v e n t i v e i n t e r v e n t i o n s are p r e s e n t e d i n o r d e r to p r o v i d e a c o n t e x t from which the most a p p r o p r i a t e approach f o r Saskatoon may  be chosen.  H i g h l y developed EMS s i n North America are d e s c r i b e d 1  from p u b l i s h e d r e p o r t s .  T h e i r impact on m o r t a l i t y i s  analysed, with p a r t i c u l a r a t t e n t i o n paid to recent which appear most p r o m i s i n g f o r Saskatoon and a r e a .  developments Features  o f the system which i s c u r r e n t l y o p e r a t i n g i n Saskatoon are drawn from data i n the annual r e p o r t s o f the Saskatoon Area Ambulance Board from 1980  to  and  1983.  Recommendations based on the compiled data are s p e c i f i c t o Saskatoon and a r e a and are r e l a t e d t o the needs,  existing  s e r v i c e s and s t r u c t u r e s , and a v a i l a b l e r e s o u r c e s i n t h a t community.  iv  TABLE OF CONTENTS  Chapter I II  Page No, Statement o f the Problem and Background  1  Methodology  6  1. 2. III-  The Epidemiology o f C a r d i a c A r r e s t 1. 2.  IV-  4. VI  36  Components o f the System Recent M o d i f i c a t i o n s Impact o f the System  Emergency 1. 2. 3.  11  Coronary Heart Disease Sudden C a r d i a c Death  The System o f Emergency M e d i c a l S e r v i c e s 1. 2. 3.  V  Sources o f Data Plan of Analysis  M e d i c a l S e r v i c e s i n Saskatoon  56  The P r o v i n c i a l Context The System i n Saskatoon Epidemiology o f C a r d i a c A r r e s t i n Saskatoon A P r o p o s a l with A l t e r n a t i v e s  Summary and Recommendations  77  Bibliography  81  Appendix A  85  Appendix B  86  V  LIST OF FIGURES  Figure 1  Age-Adjusted Death Rates f o r Ischemic Heart D i s e a s e , By C o l o r and Sex. U n i t e d S t a t e s 1950-76  12  Figure 2  Age-Adjusted Death Rates from CHD Among Men Aged 35-74.  15  F i g u r e 3 a-d  F a c t o r s Causing the Coronary M o r t a l i t y D e c l i n e and the Measure o f t h e i r C o n t r i b u t i o n  17  Figure 4  The Role o f P r e v e n t i v e S t r a t e g i e s i n CHD  29  vi LIST OF TABLES  C o u n t r i e s w i t h a Decrease o r Increase i n Rate o f M o r t a l i t y Due t o Coronary Heart Disease (men aged 35 t o 74 years, 1969 to 1977) Rates o f S u r v i v a l (%) f o r Paramedic-Treated o r EMTT r e a t e d Cases o f C a r d i a c Arrest Rates o f S u r v i v a l (%) F o l l o w i n g BystanderI n i t i a t e d CPR Age-Standardized M o r t a l i t y Rates f o r CHD 1 9 7 3 - 1 9 7 9 i n S e l e c t e d Canadian Cities Deaths from Acute M y o c a r d i a l I n f a r c t i o n (ICDA Code 4 1 0 ) Saskatoon 1 9 8 0 - 1 9 8 3  vit  Acknowledgements  I am very p l e a s e d t o be able to express my thanks t o the members of my t h e s i s committee f o r t h e i r and  encouragement  advice. Dr. C o r t Mackenzie has p r o v i d e d i n v a l u a b l e a s s i s t a n c e  a t a l l stages o f my program and h i s guidance has been c r u c i a l t o the completion  o f the study.  I am indebted t o Dr. Anne C r i c h t o n f o r her p e r c e p t i v e a n a l y s e s o f the approach and her c r i t i c a l  i n s i g h t s i n t o the  arguments h e r e i n . Dr. Morton Warner has been a constant  source o f  support,  and h i s ideas have i n f l u e n c e d me g r e a t l y . My a s s o c i a t i o n w i t h these a d v i s o r s has r a d i c a l l y changed my understanding  o f h e a l t h and h e a l t h c a r e , and I owe them a  g r e a t debt o f g r a t i t u d e . Any e r r o r s , and the l i m i t a t i o n s o f t h i s study are s o l e l y my  responsibility.  October  1984  Lorna Medd  1  Chapter  The  I  Statement o f the Problem and Background  q u e s t i o n d e a l t w i t h i n t h i s t h e s i s i s should the  C i t y o f Saskatoon, Saskatchewan develop s e r v i c e system  (EMS) designed  an emergency  medical  s p e c i f i c a l l y to deal with out-  of-hospital cardiac arrest? The  q u e s t i o n cannot be answered u n t i l a s e r i e s o f  s u b s i d i a r y but necessary q u e s t i o n s are f i r s t 1.  Can an EMS be expected  i n terms o f decreased  addressed.  t o p r o v i d e r e a l h e a l t h gains  m o r b i d i t y and m o r t a l i t y from c a r d i a c  arrest? 2.  What are the components o f an EMS t h a t are r e q u i r e d  to achieve t h i s decrease 3.  Can a c i t y w i t h a p o p u l a t i o n o f 170,000 support a  service that f u l f i l l s 4.  i n m o r b i d i t y and m o r t a l i t y ?  these  How important  requirements?  a cause o f m o r b i d i t y and m o r t a l i t y  i s c a r d i a c a r r e s t , and w i l l  i t become a g r e a t e r o r a l e s s e r  problem i n the next decade? 5.  Is the e s t a b l i s h m e n t o f such a s e r v i c e an e f f e c t i v e  way o f r e d u c i n g m o r b i d i t y and m o r t a l i t y from c a r d i a c a r r e s t , o r are t h e r e ways o f d e a l i n g w i t h c a r d i a c a r r e s t t h a t w i l l more impact?  have  2  E f f o r t s t o r e s u s c i t a t e the dead are as o l d as h i s t o r y itself,  and the r e s u s c i t a t i o n t e c h n i q u e s o f many c u l t u r e s  and e r a s have been documented.  Sudden c a r d i a c death has been  d e p i c t e d i n E g y p t i a n r e l i e f s c u l p t u r e from the tomb o f a noble o f the S i x t h Dynasty,  approximately 4500 years ago."*"  t o mouth r e s u s c i t a t i o n i s d e s c r i b e d i n the B i b l e  Mouth  (II Kings 4  2  (34) King James V e r s i o n )  and t h e r e have been h i s t o r i c a l  attempts t o r e v i v e an i n d i v i d u a l  electrically.  The i n s t i t u t i o n a l i z a t i o n o f r e s u s c i t a t i o n i n  contemporary  terms began i n the I960's w i t h the advent of coronary care 3 units  (CCU).  In 1967  P a n t r i d g e and Geddes  published a  landmark paper d e s c r i b i n g mobile coronary care u n i t s ( " f l y i n g squads") o p e r a t i n g i n the s t r e e t s of B e l f a s t . r a p i d and widespread  A  e v o l u t i o n o f s i m i l a r emergency m e d i c a l  response systems f o l l o w e d immediately.  These systems were  d i r e c t e d toward p r e v e n t i n g deaths from coronary h e a r t disease  (CHD)  which a t t h a t time had reached the peak o f i t s  epidemic curve.  The modern o r i g i n s of o u t - o f - h o s p i t a l  emergency medical s e r v i c e s  (EMS)  are thus i n e x t r i c a b l y  linked  to sudden death from c a r d i a c d i s e a s e . EMS  has come t o be d e f i n e d as programs t h a t  d e f i n i t i v e care f o r cardiopulmonary  arrest  (CPA)  Although there are o t h e r a p p l i c a t i o n s f o r EMS, p a t i e n t s remain the s i n g l e l a r g e s t user group.  deliver i n the  cardiac Non-cardiac  a r r e s t uses of emergency m e d i c a l s e r v i c e s w i l l not be addressed i n the paper.  field.  3  A f u l l y developed EMS complex and  costly.  system i s l a r g e ,  technologically  I t s components i n c l u d e  a mechanism f o r  r a p i d access to the  system, u s u a l l y a u n i v e r s a l emergency  number such as 911;  c i t i z e n s t r a i n e d to d e l i v e r CPR;  response u n i t s s t a f f e d with personnel t r a i n e d and in  d e l i v e r i n g basic l i f e  support  first  effective  (BLS); paramedic u n i t s w i t h  more h i g h l y t r a i n e d s t a f f able t o d e l i v e r the wider range o f services  (many o f them p h y s i c i a n - d e l e g a t e d ) t h a t  advanced c a r d i a c  life  techniques include  support  (ACLS).  Examples o f ACLS  d e f i b r i l l a t i o n , establishment  i n t r a v e n o u s l i n e s , EKG  i n t e r p r e t a t i o n and  drug  Because time i s so c r u c i a l a f a c t o r i n a response and  because of the t e c h n o l o g i c a l l y  support systems r e q u i r e d , o l i t a n areas. appropriate  comprise  EMS  of administration.  successful  sophisticated  works best i n l a r g e metrop-  R u r a l communities have r a r e l y been c o n s i d e r e d  s i t e s f o r paramedic u n i t s , although the  o f e s t a b l i s h i n g an EMS  f o r a c i t y but not  communities i s an important  inequity  f o r nearby  smaller  issue.  When s p e c i f i c q u e s t i o n s about d e v e l o p i n g an EMS posed, t h e r e are two  major o b s t a c l e s  development of complete answers. o f r e l i a b l e s u p p o r t i n g data.  and  quantity  a basis  first  the  i s the  Research i n t o and  emergency medical s e r v i c e s as one c a r e system has  The  t h a t prevent  are  scarcity  evaluation  component of the  i n t e n s i f i e d , but u n t i l r e c e n t l y the  health quality  o f the data have not been adequate to p r o v i d e  f o r making informed judgments on the u t i l i t y  of  the  of  4  system. The  second o b s t a c l e i s the sheer f o r c e o f the  emotional  component i n v o l v e d i n the p r o v i s i o n of emergency ambulance services.  P o l i c y planners  a b s t r a c t with numbers and competing systems, but one  may  be able to d e a l i n the  q u a l i t y of l i v e s saved  by  t e l e v i s i o n c l i p o f an  ambulance  a t the scene o f a c o l l a p s e , l i g h t s f l a s h i n g , with r e s u s c i t a t i n g an i n d i v i d u a l on the pavement can reasoned judgment i n the minds of taxpayers. r a t i o n a l arguments i n f a v o r o f p r e v e n t i n g  paramedics  overpower  The  such a  most scenario  i n s t e a d o f d e a l i n g w i t h i t a f t e r - t h e - f a c t go by the  board.  T h i s study arose from the e f f o r t s of the Saskatoon Area Ambulance D i s t r i c t Board  (SAADB) to p l a n and  and  direct  the e v a l u a t i o n of ambulance s e r v i c e s i n the C i t y of Saskatoon and  surrounding  rural districts.  The  Board i s  developing  a p l a n i n c o n c e r t with e f f o r t s by the p r o v i n c i a l p l a n n i n g u n i t , the Ambulance S e r v i c e s U n i t , to e s t a b l i s h a adequate EMS  a c r o s s the p r o v i n c e  o f Saskatchewan.  near f u t u r e the Board w i l l be d e a l i n g with of access  f o r r u r a l and  uniformly In  issues of  urban c o n s t i t u e n t s , the c o s t s  b e n e f i t s of e s t a b l i s h i n g a 911  the equity and  system, the optimum l e v e l  t r a i n i n g f o r ambulance p e r s o n n e l ,  sources of funding  of  for  s a l a r i e s i f personnel  are r e q u i r e d to take a d d i t i o n a l  t r a i n i n g , and optimal  deployment o f ambulance u n i t s w i t h i n  the D i s t r i c t . t h a t may  T h i s paper attempts to p r o v i d e  information  a s s i s t the Board i n i t s d e l i b e r a t i o n s .  5  Chapter I  Notes  1.  Lown, B. "Sudden C a r d i a c Death: The Major C h a l l e n g e F a c i n g Contemporary C a r d i o l o g y . " Amer. J . C a r d i o l . 4_3 February 1979. pp. 313-28. p. 313.  2.  Warren, J.V. " D e l i v e r y System f o r Emergency C a r d i a c Care: The M e d i c a l Plan o f A c t i o n . " Amer. J . C a r d i o l . 50. August 1982. pp. 370-72. p. 370.  3.  P a n t r i d g e , J.F., J.S. Geddes. "A Mobile I n t e n s i v e Care U n i t i n the Management o f M y o c a r d i a l I n f a r c t i o n . " Lancet 2. 1967. pp. 271-73.  6  Chapter I I  1.  Methodology  Sources o f Data  The e p i d e m i o l o g i c f e a t u r e s of the group who  most need  emergency ambulance s e r v i c e s are d e s c r i b e d i n Chapter I I I , The Epidemiology o f C a r d i a c A r r e s t .  T h i s chapter a l s o  s i t u a t e s ambulance s e r v i c e s w i t h i n the c o n t e x t o f the c l a s s i c a l model o f l e v e l s o f p r e v e n t i o n (primary, secondary, t e r t i a r y ) as a p p l i e d to d i s e a s e s c a u s i n g c a r d i a c  arrest.  I t d i s c u s s e s evidence f o r the primary and secondary p r e v e n t i o n o f those d i s e a s e s , i n c l u d i n g maximum numbers o f people i n c a r d i a c a r r e s t a f f e c t e d by emergency m e d i c a l s e r v i c e s ideal situations.  under  Data f o r t h i s d i s c u s s i o n are drawn from  the p u b l i s h e d l i t e r a t u r e . Chapter IV d e s c r i b e s the development  o f emergency m e d i c a l  s e r v i c e s i n g e n e r a l terms from the mid-1960's t o the p r e s e n t . The h i s t o r y o f the s e r v i c e , the f u l l y developed model as i t e x i s t s i n a few urban c e n t r e s i n the U n i t e d S t a t e s , and the impact i n terms o f l e n g t h o f s u r v i v a l are taken from a n a l y s e s p u b l i s h e d i n the c u r r e n t l i t e r a t u r e . o f t h r e e Canadian c i t y  systems  The comparative  i s d e r i v e d from c o n s u l t a n t s '  s t u d i e s c a r r i e d out on b e h a l f o f those c i t i e s and d i s c u s s i o n s w i t h i n d i v i d u a l s who firsthand.  analysis  from  have observed those  systems  7  Chapter V, Emergency M e d i c a l S e r v i c e s i n Saskatoon, has been developed from documentary data a v a i l a b l e from p r o v i n c i a l and  m u n i c i p a l sources.  Sociodemographic data has been taken  from Neighborhood Profiles"*", a document p u b l i s h e d by the C i t y o f Saskatoon P l a n n i n g Department u s i n g 1981 Census data and of  1983 p r o v i n c i a l p o p u l a t i o n f i g u r e s .  The epidemiology  c a r d i a c a r r e s t i n Saskatoon i s d e r i v e d from l o c a l  vital  s t a t i s t i c s i n f o r m a t i o n a v a i l a b l e from the Saskatoon Community H e a l t h U n i t and the U n i v e r s i t y o f Saskatchewan Department of  S o c i a l and P r e v e n t i v e Medicine. The a n a l y s i s o f the o p e r a t i o n o f the SAADB ambulance  system was developed from the Annual Reports 1980-83 o f the ambulance d i s t r i c t o p e r a t i o n .  The primary data t h a t form the  b a s i s f o r the r e p o r t s c o n s i s t o f the i n d i v i d u a l ambulance run r e p o r t s , formatted f o r and analyzed by a computer program developed by Joan Feather o f the U n i v e r s i t y o f Saskatchewan Department o f S o c i a l and P r e v e n t i v e M e d i c i n e . i s run by the H o s p i t a l Systems Study Group  The program  (HSSG) and  data p r o c e s s i n g was c a r r i e d out by HSSG p e r s o n n e l .  2.  Plan o f A n a l y s i s  The a n a l y s i s o f the data has been s t r u c t u r e d by 2 Chambers' need/demand-supply i s d e f i n e d as:  model.  In t h i s model, need  8  " . . . s e r v i c e s t h a t should be p r o v i d e d to the p u b l i c on the b a s i s of the p e r c e p t i o n s o f the experts... This includes i n t e r p r e t a t i o n of need f o r h e a l t h s e r v i c e s on the b a s i s of h e a l t h s t a t u s i n f o r m a t i o n about t a r g e t groups." Need thus i n c l u d e s e p i d e m i o l o g i c a l analyses assessment by  "experts"  i n the f i e l d .  and  Demand i s d e f i n e d  as:  "...the types and amounts of h e a l t h s e r v i c e s requested or d e s i r e d by the p u b l i c once they know the c o s t s and p r i c e s i n v o l v e d . . . Consumers' wants change with a d d i t i o n a l knowledge of what i t w i l l c o s t (or what a l t e r n a t i v e s would be foregone) to f u l f i l l them... f r e q u e n t l y demand i s expressed i n p u b l i c a c t i o n by informed consumers." Supply i s d e f i n e d  as:  "...a c o n s i d e r a t i o n of 'the numbers and d i s t r i b u t i o n s of f a c i l i t i e s and h e a l t h personnel r e l a t i v e to the p o p u l a t i o n s they serve,' or a c o n s i d e r a t i o n 'of the q u a l i t y of care provided by these s e r v i c e s , "  The  Epidemiology of C a r d i a c A r r e s t coupled  Saskatoon data on c a r d i a c a r r e s t , i s intended estimate  o f need.  The  system i n both g e n e r a l  with  the  to p r o v i d e  d e s c r i p t i o n o f the components o f and  s p e c i f i c terms r e p r e s e n t s  and  to be  have y e t to be e l u c i d a t e d by  research.  the p a u c i t y of data,  To complicate  i n t e r e s t groups present  ( i . e . c a r d i o l o g i s t s and  c o n f l i c t i n g and o p p o s i t e  costs  foregone  not w e l l understood, and  may  easy  In l a r g e p a r t t h i s i s because the r e l a t i v e  b e n e f i t s o f a l t e r n a t i v e s or o p t i o n s  the  supply.  Demand, or want informed by knowledge o f c o s t , i s not to t y p i f y .  an  are further  competing  community  physicians)  p i c t u r e s o f demand  9  u s i n g the fragments of i n f o r m a t i o n t h a t are a v a i l a b l e . t h i r d complicating  i s s u e i s the f a c t t h a t i n a d i s c u s s i o n  o f t h i s most c o n c r e t e becomes clouded  A  "life-or-death" issue, r a t i o n a l i t y  by emotion more than i t would i n more a b s t r a c t  " h e a l t h " debates. The  f i n a l recommendations o f the study  a comparison o f need/demand and gaps or o v e r l a p s options  in service.  supply,  EMS.  seek to  from  identify  They a l s o address the a l t e r n a t i v e  f o r s a v i n g l i v e s , which w i l l be  are a l l o c a t e d to an  and  have evolved  foregone i f resources  10  Chapter I I  Notes  1.  Neighborhood P r o f i l e s . Department. May 1984.  C i t y o f Saskatoon P l a n n i n g p. 54.  2.  Chambers, L.W., C. Woodward, C. Dok. Guide to H e a l t h Needs Assessment: A C r i t i q u e o f A v a i l a b l e Sources o f H e a l t h and H e a l t h Care I n f o r m a t i o n . McMaster U n i v e r s i t y F a c u l t y o f H e a l t h Sciences (mimeograph). November 1979. p. 3.  11  Chapter I I I  The  Epidemiology  Coronary h e a r t d i s e a s e  of C a r d i a c A r r e s t  (CHD)  i s the l e a d i n g cause of  death i n the i n d u s t r i a l i z e d world. all  deaths were due  In Canada i n 1977  to d i s e a s e s of the c i r c u l a t o r y  49%  of  system.  These d i s e a s e s were a l s o the l e a d i n g cause o f h o s p i t a l i z a t i o n and  p o t e n t i a l years of l i f e  cause o f d i s a b i l i t y .  l o s t and were the most  Diseases of the c i r c u l a t o r y  significant system  have been i d e n t i f i e d as the top p u b l i c h e a l t h problem i n Canada.^ In the U n i t e d S t a t e s i n 1978, heart or blood v e s s e l disease 1.5  m i l l i o n people  985,800 persons d i e d of  (51% o f a l l d e a t h s ) .  were expected  4.3  have a h i s t o r y o f acute myocardial For 1981  1981  m i l l i o n l i v i n g Americans  infarction  (AMI),  angina  the p r o j e c t e d c o s t o f a l l c a r d i o v a s c u l a r  d i s e a s e i n the U n i t e d S t a t e s was  $46.2 b i l l i o n , not  l o s s e s i n management s k i l l s , p r o d u c t i o n e x p e r i e n c e , 2 development and  to  to have h e a r t a t t a c k s i n  w i t h a r e s u l t i n g 650,000 deaths.  o r both.  Up  counting personnel  labour.  In s p i t e of the p e r v a s i v e n e s s  of t h i s epidemic o f h e a r t  d i s e a s e , t h e r e has been a remarkable d e c l i n e i n deaths from CHD  i n recent years.  but i t was  The  d e c l i n e began between 1964-69  not f u l l y a p p r e c i a t e d or accepted  u n t i l around 1978. death r a t e s due  F i g u r e 1 shows trends i n  as  real  age-adjusted  t o c a r d i o v a s c u l a r d i s e a s e i n the U n i t e d  between 1950-1976.  The  breaks i n the curves r e p r e s e n t  States the  12  Avwtton* o) ttw tnt*rtwt«n«i Cta»t>c»tton f p n u n 0  1  WMta rnalt  All otter m t o .  •  1  •s / *  /  V v  #  s  /  \ N  \  \  \  \  All ottar *»mala  4  .  ...  >  s  s  Whtta tamat.  v  TEAK  F i g u r e 1.  A g e - a d j u a t e d d e a t h r a t a * f o r l a c h e m l c h e a r t d l a e a a a , by c o l o r and s e x : United S t a t e s , 1950-76  F i g u r e 1 r e p r i n t e d by p e r m i s s i o n from the N a t i o n a l Heart, Lung and Blood I n s t i t u t e Working Group on Heart Disease Epidemiology NIH p u b l i c a t i o n #79-1667 June 1979  3 major r e v i s i o n s i n c l a s s i f i c a t i o n codes o f ICDA. The d e c l i n e has a f f e c t e d a l l age groups, both sexes, and t h r e e ethnic/racial  groups.  Between 1968 and 1976 the age-adjusted o v e r a l l  mortality  from i s c h e m i c h e a r t d i s e a s e i n the U n i t e d S t a t e s d e c l i n e d by 3 20.7%, and by 24% f o r persons over 85 years o f age. 1968 death r a t e s had p r e v a i l e d i n 1978, about deaths would have o c c u r r e d .  I f the  114,000 more  For the e n t i r e decade t h e r e  13  were 568,000 deaths expected  t h a t d i d not occur.  In Canada between 1969 and 1977, m o r t a l i t y - r a t e s f o r CHD dropped 14% f o r males and 21% f o r f e m a l e s However,  5  - overall  16.4%.  6  h o s p i t a l i z a t i o n r a t e s f o r the same d i s e a s e s i n c r e a s e d .  These f i n d i n g s may be c o n s i s t e n t with some improvement i n the case  fatality 7  r a t e o f i n d i v i d u a l s h o s p i t a l i z e d with  myocardial  infarction. There a r e some s t r i k i n g d i f f e r e n c e s i n the p a t t e r n o f d e c l i n i n g r a t e s a c r o s s the i n d u s t r i a l i z e d n a t i o n s .  Table I  shows the r a n k i n g o f t e n i n d u s t r i a l i z e d n a t i o n s e x p e r i e n c i n g a d e c l i n e between 1969 and 1977, and 17 i n d u s t r i a l i z e d showing an i n c r e a s e over the same time p e r i o d .  nations  Among n a t i o n s  with d e c l i n i n g r a t e s , Canada ranks t h i r d , with a d e c l i n e somewhat l e s s than the remarkable changes demonstrated i n the U n i t e d S t a t e s and A u s t r a l i a .  14  TABLE I Countries With Decrease or Increase in Rate of Mortality Due to Coronary Heart Disease (men aged 35 to 74 years, 1S69 to 1977) 1969 Rate  Country  .1977 Rate  Difference  % Difference  A. Countries With a Decrease in Rate 864.7 843.7 703.3 653.3 582.9 126.3 446.1 893.7 813.7 313.0  United Slates Australia Canada Israel Norway Japan Belgium Finland Scotland Italy  669.5 683.1 624.1 581.0* 537.1 102.6 426.8* 876.0* 808.6 309.6"  -195.2 -160.6 -79.2 -72.3 -45.8 -23.7 -19.3 -15.7 -5.1 -3.4  -22.6 -19.0 -11.3 -11.1 -7.9 -18.8 -4.3 -1.8 -C.6 -1.1  B. Countries With an Increase in Rale Bulgaria Poland North Ireland Rumania Hungary Yugoslavia Sweden Ireland German Federal Republic Austria New Zealand Switzerland Netherlands France Denmark Enoland and Wales Czechoslovakia  299.3 186.5 782.4 170.5 441.6 185.0 523.9 662.2 427.3  423.5 307.7 867.1 237.3 499.2 227.6 560.1 697.7" 456.1  + 124.2 + 121.2 + 84.7 + 66.6 + 57.6 + 42.6 + 36.2 + 35.5 + 3C.8  428.3 773.3 290.4 476.7 195.2 566.1 662.1 587.9  455.3 747.1 312.7 500.5 206.9* 576.3 •671.7 590.4'  + 27.0 + 26.2 + 22.3 + 21.8 + 11.7 + 10.2 +9.6 + 2.5  + + + +  41.5 65.0 10.8 39.2 + 13.0 + 23.0 + 6.9 + 5.4 + 7.2 + 6.3 + 3.4 + 7.7 + 4.6 + 6.0  + 1.8  + 1.4 + 0.4  * 1976 data. " 1975 data. ICD 4 1 0 - 1 4 , 8th revision. Rates per 100.000 population are averages of the rates for men aged 35 to 44. 45 to 54. 55 to 64. 65 to 74.  R e p r i n t e d by p e r m i s s i o n from Stamler Jeremiah, Amer. J . C a r d i o l 47 March 1981.4  15  F i g u r e 2 presents  these  group of n a t i o n s .  changes i n r a t e s f o r a more s e l e c t  In Japan throughout t h i s time p e r i o d , r a t e s  have been c o n s i s t e n t l y low.  A u s t r a l i a and  the U n i t e d  began the p e r i o d with high r a t e s but by the end  States  o f the decade  the r a t e s were comparable to those  i n England and Wales, where  a s m a l l i n c r e a s e had  Developing  taken p l a c e .  h i s argument from  the data i n the graph, Rose s t a t e d t h a t the B r i t i s h are  failing  g  t o prevent  a preventable  disease.  The  question  i s , what i s  happening i n the U n i t e d S t a t e s , A u s t r a l i a and Canada t h a t i s not happening i n the U n i t e d  800  Kingdom?  USA Australia  8.T  700  • -'8  600 o  England and  %.  K  ,.P".o-- "-o....o-- --o 0  5 0 0  0  o—• o-" Sweden  g  400  * o  300  D  Wales  200 H Japan 100  1968  70  72  - 74  76  77  F i g u r e 2. Age-adjusted death r a t e s from CHD among men aged 35-74. Reprinted by p e r m i s s i o n from Rose, G, B r i t i s h M e d i c a l J o u r n a l 282 1981.^ 8  16  In the n a t i o n s w i t h s i g n i f i c a n t decreases i n m o r t a l i t y , the d e c l i n e has  been l a r g e enough and  c o n s i s t e n t enough t h a t  p o t e n t i a l a r t e f a c t s such as changes i n completing and  coding  death c e r t i f i c a t e s are c o n s i d e r e d  the  d e c l i n e from peak r a t e s has fully  incidence  Is the r e d u c t i o n  i s milder  but  not  yet  a consequence of reduced  d i e from i t ) or i n c r e a s e d  get h e a r t d i s e a s e  However, a  f o r the d e c l i n e has  (fewer people get h e a r t d i s e a s e ,  proportion  and  been judged as r e a l .  s a t i s f a c t o r y explanation  been found.  inconsequential  but the same  survival  (the same number  fewer d i e , e i t h e r because the  o r because of improved i n t e r v e n t i o n ) ?  disease  Figures  show some o f the p o s s i b l e c o n t r i b u t i o n s o f the v a r i o u s  3a-3d  primary  9  and  secondary i n t e r v e n t i o n s  mortality.  Not  to the d e c l i n e i n coronary  unexpectedly, there are s t r o n g proponents f o r  n e a r l y every p o s s i b l e c o n t r i b u t i n g i n t e r v e n t i o n . ^ S t e r n has and  reviewed the p o s s i b l e causes of the  the evidence f o r each.'*"''"  There i s l i t t l e  what i s happening to i n c i d e n c e , incidence  but  decline  information  Stern p o s t u l a t e d  that i f  r a t e s were i n f a c t known to be dropping, the  decline  i n m o r t a l i t y c o u l d be a t t r i b u t e d t o primary p r e v e n t i o n . the  incidence  r a t e i s steady  prevention  (improved medical care o f p a t i e n t s with c l i n i c a l l y  the d i s e a s e  If  (or r i s i n g ) the d e c l i n e i n  m o r t a l i t y c o u l d be a t t r i b u t e d to secondary  coronary disease).  on  manifest  S t e r n d i d not examine the p o s s i b i l i t y  i s becoming l e s s l e t h a l .  t h a t the nature o f the d i s e a s e  that  However, i t i s u n l i k e l y  c o u l d change so much i n a ten  F i g u r e 3, a-d. Reproduced From: The Epidemiology o f C a r d i o v a s c u l a r d i s e a s e ; L e c t u r e notes Herman T y r o l e r Minneapolis 1931  "^"z 1. Z ""  C A N WE IDENTIFY FACTORS C A U S I N G THE C O R O N A R Y MORTALITY DECLINE AND MEASURE THEIR CONTRIBUTION?  —  tMS/cpn  (mimeo)  18  year p e r i o d .  There are recent  i n d i c a t e a 9% drop i n i n c i d e n c e  data from Minnesota t h a t of AMI  between 1965  and  1975,  13 and  a p a r a l l e l 48%  decline in f a t a l i t y  Primary p r e v e n t i o n  of CHD  rate.  involves preventing  e l i m i n a t i n g known r i s k f a c t o r s f o r the d i s e a s e . r i s k f a c t o r s f o r CHD  are h y p e r t e n s i o n , e l e v a t e d  c h o l e s t e r o l l e v e l s from a d i e t high saturated  f a t , and  or  The  Lesser  three"  serum  in cholesterol  c i g a r e t t e smoking.  "big  and  risk  factors  include  type A p e r s o n a l i t y , p h y s i c a l i n a c t i v i t y , o b e s i t y and . . . 14 perhaps a b n o r m a l i t i e s o f c o a g u l a t i o n , including fibrinogen i , 15 levels. One  argument i n f a v o r of r i s k f a c t o r r e d u c t i o n  contributor  to d e c l i n i n g m o r t a l i t y r a t e s examines  chronological Association  order o f e v e n t s .  issued  cardiovascular first  its first  disease.  c i g a r e t t e smoking.  coronary heart  i n 1961  by i t s  disease.  m o r t a l i t y , the  In  1964,  Surgeon  In 1973  the N a t i o n a l  High Blood P r e s s u r e  launched t o t a c k l e h y p e r t e n s i o n , which  i d e n t i f i e d as an American n a t i o n a l p u b l i c h e a l t h  priority."*"^  P a r a l l e l changes i n consumption of s p e c i f i c r e l a t e d products occurred  and  h i s landmark statement on the hazards o f  E d u c a t i o n Program was was  the American Heart  followed  f i r s t d e c l i n e i n CHD  General p u b l i s h e d  the  statement on c i g a r e t t e smoking  T h i s was  statement on d i e t and  the year o f the  In 1960  as a major  from 1963  to 1980.  consumption o f c i g a r e t t e tobacco was  The  percent change i n  -27.1%, f l u i d m i l k  cream -24.1%, b u t t e r -33.3%, eggs -12.3%, animal f a t s  and  and  19  o i l s -38.8%, v e g e t a b l e f a t s and o i l s +57.6% and f i s h +22.6%. Furthermore, the p e n e t r a t i o n  o f hypertension d e t e c t i o n and  c o n t r o l programs has been f a r g r e a t e r  than expected and i s 18  thought t o have had a major r o l e i n the d e c l i n e . However, the l i n k between the d e c l i n e i n r i s k and  the d e c l i n e i n m o r t a l i t y  ship.  factors  i s not a s t r a i g h t l i n e r e l a t i o n -  Where a l l socioeconomic s t r a t a have e x p e r i e n c e d the  decline  i n m o r t a l i t y i t has been demonstrated t h a t  o f smoking and i n c r e a s e d  cessation  p h y s i c a l e x e r c i s e have been 19  d i f f e r e n t i a l l y taken up by the h i g h e r socioeconomic groups. In Canada the p r e v a l e n c e o f c i g a r e t t e smoking d e c l i n e d by 16%  between 1965-77, but women and younger age groups have  changed t h e i r tobacco consumption minimally and y e t are experiencing  proportionately  greater  m o r t a l i t y from CHD than o l d e r  declines  in their  males.^  About 46% o f the Canadian p o p u l a t i o n  now r e g u l a r l y  p a r t i c i p a t e s i n some form o f p h y s i c a l e x e r c i s e ; however, the longterm impact has n o t y e t been assessed because the 21 phenomenon i s so r e c e n t .  S t e r n concluded the review o f the  role of r i s k factor reduction  i n the d e c l i n e i n m o r t a l i t y  by a t t r i b u t i n g h a l f the d e c l i n e i n white males and o n e - t h i r d 22 the d e c l i n e i n white females t o primary Secondary p r e v e n t i v e  prevention.  measures i n c l u d e coronary care  u n i t s , o u t - o f - h o s p i t a l emergency medical s e r v i c e s c o r o n a r y bypass s u r g e r y .  (EMS) and  A l l have been c r e d i t e d with some  impact on the d e c l i n e i n m o r t a l i t y  rates.  20  There have been two  study designs employed to prove  c o r o n a r y care u n i t s  (CCU)  lower m o r t a l i t y :  h i s t o r i c a l c o n t r o l s , and randomized  that  those u s i n g  controlled  Pre-CCU e r a f a t a l i t y r a t e s of 30-40% may w i t h the c u r r e n t 10-20% achieved i n CCU's.  trials. be c o n t r a s t e d  However, the use  o f h i s t o r i c a l c o n t r o l s i g n o r e s the p o s s i b i l i t y of changes over time i n the c h a r a c t e r i s t i c s of p a t i e n t s h o s p i t a l i z e d w i t h acute m y o c a r d i a l i n f a r c t i o n .  there i s wide v a r i a t i o n i n the  mix of m i l d and severe cases i n pre- and post-CCU s t u d i e s ,  and  pre-CCU m o r t a l i t y r a t e s as low as 15% have been r e p o r t e d , as have post-CCU r a t e s as h i g h as 48%.  It i s also possible  that  the case f a t a l i t y r a t e s are b e t t e r i n the post-CCU e r a because p h y s i c i a n s are h o s p i t a l i z i n g m i l d e r cases w i t h b e t t e r prognoses.  P r e v i o u s l y 20-40% of a l l myocardial  infarctions  were unrecognized or " s i l e n t " , but with i n c r e a s i n g  publicity,  p a t i e n t s ' awareness and p h y s i c i a n s ' index of s u s p i c i o n may heightened, w i t h the r e s u l t t h a t m i l d e r cases may being  now  be  be  hospitalized. The p r o s p e c t i v e randomized  c o n t r o l l e d t r i a l s c a r r i e d out t o 2 3 24  date have both been i n England.  '  While n e i t h e r showed an  advantage f o r coronary c a r e u n i t s , both s t u d i e s have been criticized  f o r not d e a l i n g w i t h the c r i t i c a l  two  hours  onset o f symptoms by not beginning randomization  until  r e l a t i v e l y l a t e i n the p r e h o s p i t a l phase.  after  Presumably both  s t u d i e s thereby s e l e c t f o r a group t h a t s u r v i v e d the h i g h e s t r i s k p e r i o d , making i t d i f f i c u l t to show an advantage of  21  CCU's over care at home. A r e t r o s p e c t i v e randomized survey of urban and Manitoba h o s p i t a l r e c o r d s  i n 1974-1976 r e v e a l e d  r a t e s from acute m y o c a r d i a l i n f a r c t i o n (AMI) There was AMI  no  rural  mortality  of 14-15%.  s i g n i f i c a n t d i f f e r e n c e i n m o r t a l i t y r a t e s from  f o r urban h o s p i t a l s w i t h CCU's or r u r a l h o s p i t a l s equipped  a t best w i t h a monitor and  defibrillator.  There was  only  s u g g e s t i o n of a b e t t e r outcome f o r urban h o s p i t a l s . authors p o s t u l a t e d  t h a t the d i s s e m i n a t i o n  a  The  to the r u r a l  h o s p i t a l s ' of the p r i n c i p l e s of s o p h i s t i c a t e d coronary care i f not the  technologic  c a p a b i l i t y / was  the  factor responsible  for  26 comparable CCU  and  non-CCU r a t e s .  Improvements i n h o s p i t a l coronary care beyond a 10-2 0% m o r t a l i t y r a t e w i l l have minimal impact on o v e r a l l mortality.  The  major c r i t i c i s m of the  CHD  impact o f CCU's on  CHD  m o r t a l i t y i s t h a t t w o - t h i r d s of the p a t i e n t s have been dying b e f o r e ever r e a c h i n g  a CCU.  I f a g r e a t e r percentage of  of acute m y o c a r d i a l i n f a r c t i o n have been r e a c h i n g because o f improved EMS, be expected to have had overall mortality. The  the  fall  victims  hospital  i n case f a t a l i t y r a t e s would  a correspondingly  T h i s area r e q u i r e s  greater  impact  on  f u r t h e r study.  impact of emergency medical s e r v i c e s  (programs  t h a t d e l i v e r d e f i n i t i v e care f o r c a r d i o r e s p i r a t o r y a r r e s t i n the  f i e l d ) i s e a s i e r to analyze than the  impact o f CCU's.  P r o t o t y p e systems such as those i n S e a t t l e and Miami r e p o r t t h a t from 10-25% of p a t i e n t s with documented o u t - o f - h o s p i t a l  22  ventricular f i b r i l l a t i o n  are e v e n t u a l l y discharged 27  h o s p i t a l and  about 7-10%  Eisenberg  has  s u r v i v e longterm.  28 '  s t a t e d that a w e l l developed program  lower the annual m o r t a l i t y from ischemic 29 community-wide b a s i s by  8.4%.  such programs are r a r e and  heart d i s e a s e  can on a  However, as Stern p o i n t e d  out,  c o u l d not p o s s i b l y have a f f e c t e d  overall national mortality. Emergency M e d i c a l  from  Only 68 of the  304  American  S e r v i c e s Regions are i n the advanced  life  support phase of a f e d e r a l l y sponsored program designed to  30 a c h i e v e t o t a l n a t i o n a l coverage by Since prevention,  Stern's  1982.  review of the r o l e o f primary and  secondary  r e s u l t s have come i n from a number of major  m u l t i p l e r i s k f a c t o r i n t e r v e n t i o n t r i a l s conducted throughout the i n d u s t r i a l i z e d world.  I t had  been a n t i c i p a t e d t h a t  e f f e c t i v e n e s s of primary p r e v e n t i o n demonstrating t h a t reducing  dismay when the r e s u l t s turned e a r l i e r t r i a l s which modified  clinical  trials  heart d i s e a s e  known o f these t r i a l s study  c o u l d be e s t a b l i s h e d  by  r i s k f a c t o r s would reduce the  i n c i d e n c e of and m o r t a l i t y from CHD.  these c l i n i c a l  the  There was  surprise  out t o be e q u i v o c a l .  and  Unlike  risk factors post-infarct,  s e l e c t e d s u b j e c t s who at entry  were f r e e of  i n t o the study.  The  best  i n c l u d e MRFIT (U.S.), the North K a r e l i a  ( F i n l a n d ) , the Oslo t r i a l  European Coronary P r e v e n t i o n  (Norway) and  the  WHO  Study.  Most o f the t r i a l s were not b l i n d e d e i t h e r because i t was  impossible,  as with smoking c e s s a t i o n , o r u n e t h i c a l ,  as  23  for  example a no-treatment group f o r h y p e r t e n s i o n .  also recognized  that multiple  scientifically The  MRFIT was  It  i n t e r v e n t i o n s would  was  be  l e s s p r e c i s e than s i n g l e f a c t o r i n t e r v e n t i o n . a randomized primary p r e v e n t i o n  12,866 h i g h - r i s k males aged 35-57 y e a r s who  trial  involving  were randomly  a s s i g n e d e i t h e r to a s p e c i a l i n t e r v e n t i o n program c o n s i s t i n g of stepped-care treatment f o r h y p e r t e n s i o n , c o u n s e l l i n g smokers, d i e t a r y advice the u s u a l  to reduce c h o l e s t e r o l l e v e l s , or  sources o f h e a l t h care i n the  f o l l o w u p p e r i o d was a greater  seven y e a r s .  than expected r e d u c t i o n  community.  i n a l l three  to  The  In both groups there  However, the m o r t a l i t y r a t e s i n the group were not  for  average was  risk factors.  special intervention  s i g n i f i c a n t l y d i f f e r e n t from those i n the 31  usual  c a r e group, although they were 7% Three e x p l a n a t i o n s 1)  CHD  The  lower.  f o r these f i n d i n g s were  considered:  o v e r a l l i n t e r v e n t i o n program d i d not a f f e c t  mortality. T h i s was  scientific 2)  r e j e c t e d as i n c o n s i s t e n t w i t h most  published  data. The  i n t e r v e n t i o n does a f f e c t CHD  the b e n e f i t was  not observed i n t h i s t r i a l  mortality of 7  but  years'  duration. I f t h i s i s t r u e then i t i s d i f f i c u l t to continue to a t t r i b u t e 30-50% of the d e c l i n e i n m o r t a l i t y between  1969  and  at  1978  large.  t o changes i n r i s k f a c t o r s i n the p o p u l a t i o n I t was  concluded on the b a s i s o f r e c a l c u l a t i o n s t h a t  24  the second e x p l a n a t i o n 3)  unlikely.  Measures t o d e c r e a s e c i g a r e t t e smoking and  c h o l e s t e r o l may the  was  lower  have d e c r e a s e d m o r t a l i t y w i t h i n subgroups o f  s p e c i a l i n t e r v e n t i o n c o h o r t , whereas t h e r e may  have been  an u n f a v o r a b l e change i n m o r t a l i t y r a t e s among h y p e r t e n s i v e 32 men  w i t h abnormal EKG's on t r e a t m e n t f o r h y p e r t e n s i o n . The  c o m b i n a t i o n of f a v o r a b l e  and  unfavorable e f f e c t s  c a n c e l l i n g out what might have been a s i g n i f i c a n t of m o r t a l i t y rates i s presently  lowering  the i n t e r p r e t a t i o n a c c e p t e d  f o r the MRFIT r e s u l t s . However, O l i v e r  (Edinburgh) has  r e v i e w e d the  results  o f MRFIT, the N o r t h K a r e l i a community i n t e r v e n t i o n and  the  WHO  the  European Coronary P r e v e n t i o n Study and  conclusion  t h a t "the e v i d e n c e a g a i n s t  any  has  come t o  substantial  benefit  t o the community from m u l t i p l e r i s k f a c t o r i n t e r v e n t i o n i s 33 increasing."  A l t h o u g h i n N o r t h K a r e l i a t h e r e was  a g g r e g a t e d f a l l o f 17%  i n c o r o n a r y r i s k f a c t o r s , when compared  t o the c o n t r o l p r o v i n c e Kuopio t h e r e was incidence was  of coronary heart disease.  no change i n i n c i d e n c e  a small increase WHO  an  occurred.  o f CHD "The  and  no change i n the  I n the WHO  study t h e r e  i n the B e l g i a n  section  F i n n i s h , American (MRFIT)  f i n d i n g s — i n s t r i c t primary prevention t e r m s - - a l l  and  suggest  t h a t m u l t i p l e r i s k f a c t o r i n t e r v e n t i o n does not work i n 34 m i d d l e - a g e d men."  O l i v e r recommended a d o p t i o n o f a more  s e l e c t i v e p o l i c y o f i n t e r v e n t i o n f o c u s i n g on t h o s e a t h i g h e s t r i s k even though t h e y are a r e l a t i v e l y s m a l l e r  group.  25  By  c o n t r a s t , Walker  (United  States) i n t e r p r e t e d  MRFIT r e s u l t s to conclude the exact o p p o s i t e , reduction  i s indicated for a l l ,  not  the  that r i s k  factor  j u s t those i d e n t i f i e d  as  35 high  risk.  He p o i n t e d  out  t h a t the usual  care s u b j e c t s made  s i g n i f i c a n t changes to t h e i r r i s k f a c t o r s , and observed m o r t a l i t y r a t e s were 41% the m o r t a l i t y r a t e from CHD  was  that t h e i r  lower than expected.  21%  Further,  lower i n normotensive  males i n the d i e t a r y i n t e r v e n t i o n group than among the However, t h i s e f f e c t was  countered by a h i g h e r m o r t a l i t y i n  a t r e a t e d subgroup of h y p e r t e n s i v e s . f i n d i n g s from the Oslo Study Group out  a prospective  Walker a l s o reviewed (1981) which had  i n t e r v e n t i o n group the  i n f a r c t i o n and  The o f and Stern  incidence  sudden death was  o f these r e s u l t s has contrast  carried  randomized f i v e year study of d i e t and  w i t h i n t e r v e n t i o n i n normotensive males at high In the  controls.  risk for  CHD.  of m y o c a r d i a l  reduced by  been r e l a t i v e l y  smoking  4 7%.  Interpretation  straightforward  in  to the MRFIT r e s u l t s . impact of primary p r e v e n t i v e  m o r t a l i t y from CHD recommended, "...  measures on the  i s not yet c l e a r .  incidence  However, as  l a c k of d e f i n i t i v e data on the  causes  o f the d e c l i n e should not be used as an excuse to slow the 36 implementation of p l a u s i b l e p u b l i c h e a l t h measures."  26  The  Syndrome of Sudden C a r d i a c  Death  "Sudden c a r d i a c death i s the l e a d i n g cause of f a t a l i t y i n the i n d u s t r i a l l y developed world. In the United S t a t e s , someone d i e s unexpectedly every 75 seconds, day or n i g h t . Sudden c a r d i a c death has been shadowing man's l i f e s i n c e the i n c e p t i o n of recorded h i s t o r y . The u n p r e d i c t a b i l i t y of i t s occurrence burdens our dreams and p r o v i d e s an awesome reminder o f the f r a g i l i t y of our b i o l o g y . While i t i s r e c o g n i z e d t h a t sudden c a r d i a c death i s due t o an e l e c t r i c a l derangement of h e a r t rhythm known as v e n t r i c u l a r f i b r i l l a t i o n , no c l e a r acute morphologic l e s i o n s i n the h e a r t have been i d e n t i f i e d which t r i g g e r t h i s event." "Sudden c a r d i a c death presents a paradox: a massive, unheralded c a t a s t r o p h e , y e t i n the h e a r t a p a u c i t y of changes. Extensive coronary a r t e r y d i s e a s e i s the r u l e , but the s e v e r i t y and d i s t r i b u t i o n are not d i s t i n c t i v e . The u n d e r l y i n g p r o c e s s i s known to be caused by a t h e r o s c l e r o s i s but the t r i g g e r f o r the t e r m i n a l , n e a r l y instantaneous event remains undefined."37 Lown's dramatic statement above conveys the g r a v i t y  and  mysteriousness t h a t makes the i s s u e o f r e s u s c i t a t i o n f o r sudden c a r d i a c death Over two-thirds w i t h i n two  (SCD) o f SCD  such an e m o t i o n a l l y  charged i s s u e .  occur o u t - o f - h o s p i t a l , u s u a l l y  hours of the onset of symptoms.  For 25%  of v i c t i m s , 38  SCD  i s the  described  first  s i g n of h e a r t d i s e a s e .  the prodromal symptoms and  K u l l e r et a l  other  f e a t u r e s o f SCD  found t h a t a l a r g e number of t h e i r group o f p a t i e n t s had had  evidence of c a r d i o v a s c u l a r disease  38%  had  and already  at the time o f death.  r e c e i v e d medical care w i t h i n the p r e v i o u s  two  weeks,  so the c o l l a p s e i s not e n t i r e l y unheralded. Surveys from the S e a t t l e Medic I system have c h a r a c t e r i z e d  27  the range o f c o n d i t i o n s which caused o u t - o f - h o s p i t a l a r r e s t and prompted a c a l l Sudden c a r d i a c deaths secondary  t o the emergency medical  (as d i s t i n g u i s h e d from c a r d i a c  t o non-cardiac d i s e a s e ) comprise  m a j o r i t y o f these deaths. were excluded from these  Traumatic  cardiac service. arrest  the g r e a t  causes o f c a r d i a c  arrest  series.  Sudden C a r d i a c Death i n King County, Washington CAUSE OF DEATH  LOCATION, YEAR CITY  primary h e a r t d i s e a s e  1978  3 9  SUBURBS 1979' 40  No.  %  No.  %  931  79.0  528  81.4  respiratory disease  39  3.3  17  2.6  cancer  38  3.2  26  4.0  neurologic disease  37  3.1  18  2.8  sudden i n f a n t death syndrome  23  2.0  10  1.5  drowning  20  1.6  14  2.2  v a l v a r heart disease  14  1.2  —  alcoholism  13  1.1  10  overdose/suicide  12  1.0  7  1.1  overdose/non-suicide  12  1.0  6  0.9  all  40  3.5  13  2.0  1179  100  649  100  other  1. 5  28  In suburban King County the arrest patients 65 y e a r s .  Men  was  average age  61 y e a r s and  comprised 72%  of a l l c a r d i a c  of heart d i s e a s e  of the  patients,  t o t a l group and  74%  40 of the primary c a r d i a c  group.  Another study from suburban King County  described 41  the  epidemiology of c a r d i a c  six  year p e r i o d  arrest in children.  (1976-1982) 119  cardiac  Over a  arrests  receiving  emergency r e s u s c i t a t i o n were documented, f o r a r a t e 12.7/100,000 i n d i v i d u a l s l e s s than 18 years of  of  age.  Sudden i n f a n t death syndrome accounted f o r 38 cases The  next two  respiratory  commonest causes were drowning, 22%, causes, 9%.  c h i l d r e n under one p r e s e n t i n g rhythm the  N e a r l y h a l f the  year of age. (77%)  was  the most common  with v e n t r i c u l a r f i b r i l l a t i o n  c h i l d r e n were s u c c e s s f u l l y  were no  and  a r r e s t s occurred i n  Asystole  p r e s e n t i n g rhythm i n o n l y 9%.  from h o s p i t a l .  (32%).  Overall,  resuscitated  and  8  (7%)  of  being the  discharged  alive  Over h a l f o f these were near drownings.  resuscitations  from among the  There  sudden i n f a n t death  group. During a comparable time p e r i o d 20%  of a d u l t s were s u c c e s s f u l l y  alive. age  The  i n the  resuscitated  major d i s t i n c t i o n between a d u l t  groups i n c a r d i a c  a r r e s t i s the  incidence  of sudden i n f a n t death and  contrasts  sharply  w i t h the  h e a r t d i s e a s e causes 80%  same s e r v i c e  etiology  of c a r d i a c  and and  etiology.  area  discharged pediatric  The  high  drowning i n c h i l d r e n i n a d u l t s , where coronary arrests.  29  Figure in  4 i s an e f f o r t t o summarize the r o l e o f p r e v e n t i o n  CHD.  4  Figure •Health  The  Role o f P r e v e n t i v e  S t r a t e g i e s i n CHD t.  t  Biological Socioeconomic  No r i s k factors  No Atherosclerosis  PRIMARY PREVENTION p e r i o d i c exam f o r high r i s k groups screening f o r hypertension behavior m o d i f i c a t i o n multiple risk factor intervention t r i a l s •No C l i n i c a l Heart Angina ^ Disease AMI I CHD SCD J SECONDARY PREVENTION -EMS -ecu  -Drug Therapy, Surgery • C l i n i c a l Disease •Sudden C a r d i a c Death  TERTIARY PREVENTION Antiarrhythmics Rehabilitation •Implantable C a r d i o v e r t e r • Recurrent SCD • Anoxic Damage  30  From the diagram  i t may  be seen t h a t the outcome of  primary p r e v e n t i o n i n the s t r i c t e s t sense i s absence a l t h o u g h i n the l i t e r a t u r e reviewed i t i s g e n e r a l l y to  mean absence  of c l i n i c a l  c a r d i a c death.  CHD,  taken  h e a r t d i s e a s e i n c l u d i n g sudden  At t h i s e a r l y stage, p r e v e n t i o n i n c l u d e s  f a m i l i a l and socioeconomic v a r i a b l e s which are to  of  modify, and absence  difficult  o f the c l a s s i c a l r i s k f a c t o r s of  smoking, h y p e r t e n s i o n , e l e v a t e d c h o l e s t e r o l l e v e l ,  obesity,  l a c k o f p h y s i c a l e x e r c i s e , and Type A p e r s o n a l i t y b e h a v i o r . Primary p r e v e n t i o n i n c l u d e s measures designed t o i n t e r v e n e and t r e a t b e f o r e e x p r e s s i o n o f d i s e a s e .  I t was  e a r l i e r noted t h a t i n 20-25% o f cases the f i r s t m a n i f e s t a t i o n of  d i s e a s e i s sudden c a r d i a c death.  P r e v e n t i v e measures i n  t h i s c a t e g o r y i n c l u d e the f u l l range o f t e c h n i q u e s a v a i l a b l e to modify of  smoking and d i e t a r y b e h a v i o r , p e r i o d i c  h i g h r i s k groups,  s c r e e n i n g and t r e a t i n g h y p e r t e n s i o n , and  the m u l t i p l e r i s k f a c t o r i n t e r v e n t i o n Secondary  examination  trials.  p r e v e n t i o n i n c l u d e s measures designed to  reduce the s e v e r i t y and sequelae o f e s t a b l i s h e d d i s e a s e ; i n t h i s case m y o c a r d i a l i n f a r c t i o n and sudden c a r d i a c  death.  O u t - o f - h o s p i t a l emergency m e d i c a l s e r v i c e s , coronary care u n i t s and o t h e r d e f i n i t i v e treatment and programs are the major secondary  rehabilitation  level interventions.  has s t a t e d t h a t of the 400,000 people i n the U.S. each year of SCD  Kuller  dying  about 20,000-40,000 c o u l d be saved by CCU's  and e f f e c t i v e EMS,  and t h a t i t was  c l e a r t h a t primary  31  p r e v e n t i o n was the only f e a s i b l e longterm  route.  T e r t i a r y p r e v e n t i o n minimizes the impact and  sequelae  o f e s t a b l i s h e d d i s e a s e and t h e r e are two i s s u e s i n p a r t i c u l a r t o be c o n s i d e r e d  i n t h i s realm.  Resuscitation introduces a  whole new complex o f p o s s i b i l i t i e s , of " r e c u r r e n t sudden death" who  i n c l u d i n g the syndrome  and the tragedy  of i n d i v i d u a l s  have been " s u c c e s s f u l l y " r e v i v e d but have s u s t a i n e d  s i g n i f i c a n t anoxic damage and major motor o r i n t e l l e c t u a l deficits.  32  Chapter I I I  Notes  1.  Morgan, P.P. and D.T. Wigle. M e d i c a l Care and the D e c l i n i n g Rates of Death due t o Heart D i s e a s e and Stroke. CMAJ 125. November1, 1981. pp. 953-985.  2.  Current Cardiovascular M o r t a l i t y ; e d i t o r i a l February 18, 1981. p. 555.  3.  S t e r n , M.P. The Recent D e c l i n e i n Ischemic Heart Disease Mortality. Ann. I n t e r n . Med. 9_1 (4). October 1979. pp. 630-640.  4.  Stamler, J . Primary P r e v e n t i o n o f Coronary Heart D i s e a s e : The L a s t 20 Years. Am. J . C a r d i o l . 47. March 1981. pp. 722-35. p. 730.  5.  Wigle, D.T. Heart Disease M o r b i d i t y and M o r t a l i t y Trends. C h r o n i c Disease i n Canada 2_ (2). September p. 10.  6.  N i c h o l l s , E.S., T. Jung, J.W. D i s e a s e M o r t a l i t y i n Canada. p. 981.  7.  Wigle, D.T.  8.  Rose, G. S t r a t e g y o f P r e v e n t i o n : Lessons from C a r d i o v a s c u l a r D i s e a s e . B r i t . Med. J . 282. June 6, pp. 1847-51. p. 1848.  9.  Primary p r e v e n t i o n i s d e f i n e d as p r e v e n t i o n o c c u r r i n g b e f o r e a d i s e a s e s t a t e becomes e s t a b l i s h e d . Secondary p r e v e n t i o n i s d e f i n e d as p r e v e n t i o n o f c l i n i c a l e x p r e s s i o n of d i s e a s e o r o f e a r l y p r e c l i n i c a l i n t e r v e n t i o n .  i b i d . p.  JAMA 245  (6),  1981.  Davies. C a r d i o v a s c u l a r CMAJ 125. November 1981.  10. 1981.  10.  F o r proponents o f primary p r e v e n t i o n see Walker (1983), Stamler (1981), K u l l e r (1981). For proponents o f secondary p r e v e n t i o n see Cobb and A l v a r e z (1976), Warren (1982) .  11.  Stern.  12.  Wigle, D.T.  ibid. ibid.  p.  10.  33  13.  E p s t e i n , Fh, Z. P i s a . I n t e r n a t i o n a l Comparisons i n Ischemic Heart Disease M o r b i d i t y . In: H a v l i k , R.J., R e i n l e i b , M., eds. Proceedings of the Conference on the D e c l i n e i n Coronary Heart Disease M o r t a l i t y . Bethesda, MD: N a t i o n a l I n s t i t u t e s o f H e a l t h , 1979, p. 58 (NIH P u b l i c a t i o n No. 39-1610) as quoted by Wigle, D.T. i b i d . p. 10.  14.  K u l l e r , L.H. Editorial: Prevention of C a r d i o v a s c u l a r D i s e a s e and Risk F a c t o r I n t e r v e n t i o n T r i a l s . Circulation 61 (1). January 1, 1980. pp. 26-28.  15.  Wilhelmson, L. and o t h e r s . F i b r i n o g e n as a Risk F a c t o r f o r Stroke and M y o c a r d i a l I n f a r c t i o n . New England J . Med. 311 (8), August 23, 1984. pp. 501-5.  16.  Stamler, J .  17.  Walker, W.J. Changing U.S. L i f e s t y l e , and D e c l i n i n g Vascular Mortality - A Retrospective. New England J . Med. 308 (11). March 17, 1983. pp. 649-51. p. 650.  18.  K u l l e r , L.H. Epidemiology o f C a r d i o v a s c u l a r D i s e a s e . L e c t u r e s e r i e s U n i v e r s i t y o f Minnesota. June - J u l y 1981.  19.  Stern.  20.  Wigle, D.T.  21.  Hosking, D.J. An E v a l u a t i o n o f Paramedic S e r v i c e s . U n i v e r s i t y o f Saskatchewan, Department o f S o c i a l and P r e v e n t i v e M e d i c i n e , Saskatoon. February 1982. p. 32.  22.  Stern.  23.  Mather, J.G., D.C. Morgan, N.G. Pearson, e t a l . Myocardial Infarction: A Comparison Between Home and H o s p i t a l Care f o r P a t i e n t s . Br. Med. J . 1976, 1. pp. 925-9.  24.  H i l l , J.D., J.R. Hampton, J.R.A. M i t c h a l l . A Randomized T r i a l o f Home-Versus-Hospital Management f o r P a t i e n t s w i t h Suspected M y o c a r d i a l I n f a r c t i o n . Lancet 1978 1. pp. 837-41.  25.  Crampton, R. P r e h o s p i t a l Advanced C a r d i a c L i f e Support: E v a l u a t i o n o f a Decade o f Experience. T o p i c s i n Emergency Medicine 1 (4). January 1980. pp. 27-35.  ibid.  ibid.  p. ibid.  pp. 722-3.  636. p.  9.  ibid.  34  26.  M o r r i s , A.L., V. Nernberg, N.P. Roos, P. H e n t e l e f f , L. Roos. Acute M y o c a r d i a l I n f a r c t i o n : Survey o f Urban and Rural H o s p i t a l M o r t a l i t y . Amer. Heart J o u r n a l 105 ( 1 ) . January 1983. pp. 44-53.  27.  Cobb, L.A., H. A l v a r e z , M.K. Kopass. A Rapid Response System f o r O u t - o f - H o s p i t a l C a r d i a c Emergencies. Med. C l i n . N. America 6_0. 1976. pp. 283-90.  28.  Cobb, L.A., R.S. Baum, H. A l v a r e z , W.A. S c h a e f f e r . R e s u s c i t a t i o n from O u t - o f - H o s p i t a l V e n t r i c u l a r Fibrillation: Four Years Followup. C i r c u l a t i o n 52 (Supp. I I I ) . 1975, I I I . pp. 223-35.  29.  E i s e n b e r g , M., L. Bergner, A. H a l l s t r o m . Paramedic Programs and O u t - o f - H o s p i t a l C a r d i a c A r r e s t . I. Factors Associated with Successful R e s u s c i t a t i o n . Am. J . P u b l i c H e a l t h 6_9 (1). January 1979. pp. 30-42.  30.  Stern.  31.  MRFIT Research Group. M u l t i p l e Risk F a c t o r I n t e r v e n t i o n Trial. JAMA 248 (12). September 24, 1982. pp. 1465-1477.  32.  MRFIT Research Group.  33.  O l i v e r , M.F. Should We Not F o r g e t About Mass C o n t r o l o f Coronary Risk F a c t o r s ? Lancet. J u l y 2, 1983. pp. 37-38.  34.  O l i v e r , M.F.  ibid.  35.  Walker, W.J.  ibid.  36.  Stern.  37.  Lown, B. I n t r o d u c t i o n t o Cousins, N. The Healing Heart: A n t i d o t e s t o Panic and H e l p l e s s n e s s . George J . McLeod L t d . Toronto 1983. pp. 21-22.  38.  K u l l e r , L., M. Cooper, J . Pepper. Epidemiology o f Sudden Death. Arch I n t e r n Med. 129. 1972. pp. 714-19.  39.  Bergner, L., M. E i s e n b e r g . P r o j e c t R e s t a r t : An Outcome E v a l u a t i o n o f Paramedic Programs (mimeograph). Room 508 South Tower, 506 Second Avenue, S e a t t l e . November 1978.  ibid.  ibid.  p. 637.  ibid.  p. 37.  p. 639.  35  40.  E i s e n b e r g , M.S., L. Bergner, A. H a l l s t r o m . Epidemiology o f C a r d i a c A r r e s t and R e s u s c i t a t i o n i n a Suburban Community. JACEP 8_ (1). January 1979. pp. 2-5  41.  E i s e n b e r g , M., L. Bergner, A. H a l l s t r o m . Epidemiology o f C a r d i a c A r r e s t and R e s u s c i t a t i o n i n Children. Am. Emerg. Med. 12_ (11). November 1983. pp. 672-4.  42.  K u l l e r , L.H. Epidemiology o f C a r d i o v a s c u l a r Disease. Lecture series. U n i v e r s i t y o f Minnesota. June - J u l y 1981.  36  Chapter IV  1.  The  System of Emergency M e d i c a l  Components of the  A f t e r the p u b l i c a t i o n e a r l y r e s u l t s of the the  Services  System  by P a n t r i d g e and  Geddes of  B e l f a s t mobile coronary care  concept of l a y e r e d - r e s p o n s e o u t - o f - h o s p i t a l  systems was States. i n Los  r a p i d l y developed and  Some of the  Seattle.  a c r o s s the U n i t e d S t a t e s was Emergency M e d i c a l S e r v i c e s S t e r n noted t h a t service  i n the  of a f e d e r a l l y - s p o n s o r e d "wall-to-wall" The 1) 2) 3) 4) 5) 6)  regional  Systems Act was  passed.  the  system.  patients  and  w i l l be  1979  "advanced" l i f e - s u p p o r t phase  program designed to 2 s e r v i c e s by 1982."  achieve  3  services.  a r r e s t i n order to  i s e s p e c i a l l y relevant  discussed  E a r l y a c t i v a t i o n of the  are:  making p o t e n t i a l u s e r s aware  of impending c a r d i a c This  By  emergency medical  improvement of o t h e r emergency medical  activate  established  19 7 3  components of an emergency medical system r a p i d (2-5 minute) response r e s u s c i t a t i o n from c i r c u l a t o r y a r r e s t e a r l y therapy f o r the i n i t i a t i n g event ( i . e . m y o c a r d i a l i n f a r c t i o n , trauma and other l i f e - t h r e a t e n i n g situations) d i r e c t admission to a coronary care u n i t e d u c a t i o n of the p u b l i c  warning s i g n s  United  A p r o l i f e r a t i o n of systems  encouraged a f t e r the  Rapid response i n c l u d e s of the  resuscitation  implemented i n the  "...68 of the n a t i o n ' s 304  r e g i o n s are  units,  better-known systems have been  Angeles, Miami and  the  to  CHD  subsequently.  system may  be enhanced by  rapid  37  a c c e s s , such as i s p r o v i d e d number  (911).  by a u n i v e r s a l emergency telephone  The p r o b a b i l i t y o f r a p i d response i s i n c r e a s e d  when a s i g n i f i c a n t p r o p o r t i o n  o f c i t i z e n s are t r a i n e d t o  perform cardiopulmonary r e s u s c i t a t i o n (CPR) o r b a s i c support are  (BLS).  life  I t i s a l s o improved when f i r s t - r e s p o n s e u n i t s  s u f f i c i e n t i n number and are l o c a t e d s t r a t e g i c a l l y i n  the a r e a t o be served. Resuscitation components: BLS  from c i r c u l a t o r y a r r e s t i n c l u d e s  CPR, BLS and ACLS (see below).  i s defined  as emergency f i r s t  the r e c o g n i t i o n o f airway o b s t r u c t i o n , and  three  a i d that consists of respiratory arrest  c a r d i a c a r r e s t and the proper a p p l i c a t i o n o f CPR. CPR c o n s i s t s o f the opening and maintenance o f a patent  airway, the p r o v i s i o n o f a r t i f i c i a l rescue breathing,  and the p r o v i s i o n o f a r t i f i c i a l c i r c u l a t i o n  by means o f e x t e r n a l BLS  v e n t i l a t i o n by means o f  cardiac  compression.  alone i s u n l i k e l y t o r e s t o r e h e a r t b e a t and c i r c u l a t i o n 4  t o normal.  Enns e t a l  demonstrated d e t e r i o r a t i o n o f  rhythm i n 13 o f 21 p a t i e n t s r e s u s c i t a t e d and t r a n s p o r t e d 5 o f 10 p a t i e n t s  i n cardiopulmonary a r r e s t (CPA) by a BLS system.  found i n a tachydysrhythmia  d e t e r i o r a t e d to a s y s t o l e during as d i d 8 o f 9 p a t i e n t s  (VF and others)  transportation  found i n bradycardia  Enns and o t h e r s have r e l e g a t e d  In t h e i r s e r i e s  to h o s p i t a l ,  o r heart  block.  BLS t o the s t a t u s o f a h o l d i n g  a c t i o n t o prevent b r a i n death u n t i l d e f i n i t i v e therapy be  initiated.  could  38  ALS BLS  or ACLS (advanced  cardiac l i f e  support)  i s d e f i n e d as  p l u s the use of a d j u n c t i v e equipment t o support  respiration  and c i r c u l a t i o n ; e s t a b l i s h m e n t of an i n t r a v e n o u s l i n e ,  drug  a d m i n i s t r a t i o n , d e f i b r i l l a t i o n and c a r d i a c m o n i t o r i n g . i n c l u d e s two-way communication w i t h the r e c e i v i n g  It also  institution  and p h y s i c i a n s . ^ R e s u s c i t a t i o n from c i r c u l a t o r y a r r e s t i n c l u d e s bystander CPR  and r a p i d a r r i v a l of a f i r s t - r e s p o n d e r u n i t w i t h  t r a i n e d i n BLS.  In l a r g e m e t r o p o l i t a n a r e a s , f i r e  personnel  fighting  u n i t s are u s u a l l y more w i d e l y d i s t r i b u t e d a c r o s s the community than are ambulance u n i t s . p r o t o t y p e systems i t i s the f i r e i n BLS  t h a t respond  initially.  In the h i g h l y e f f i c i e n t  u n i t s with attendants  trained  The paramedic or ACLS u n i t s  are d i s p a t c h e d s i m u l t a n e o u s l y , but because t h e r e are fewer of  these u n i t s , the response  times are slower.  Definitive  therapy i s begun w i t h a r r i v a l o f the ACLS u n i t .  Removal to  a h o s p i t a l with a coronary c a r e u n i t and s u r g i c a l  capability  g  completes  the system.  The c r u c i a l element i n EMS d e f i n i t i v e treatment  i s time e l a p s e d  can be i n i t i a t e d .  until  Brain c e l l destruction  u s u a l l y begins w i t h i n f o u r minutes of c a r d i a c a r r e s t and a l l e f f o r t s are d i r e c t e d toward r e a c h i n g the i n d i v i d u a l i n c a r d i a c a r r e s t before those f o u r minutes have passed. study i n e l a p s e d time f o r 998 was  p u b l i s h e d i n 1968.  7  f a t a l cases o f CHD  from  A Belfast  A l l deaths a t t r i b u t e d to coronary  a r t e r y d i s e a s e o c c u r r i n g i n B e l f a s t from J u l y 1965  to July  1966  39  were reviewed.  The ACLS system was i n p l a c e f o r a b r i e f  p o r t i o n o f the study but was judged not t o have had an impact because  the time was too s h o r t .  Of 998 c a s e s , 98 (9.8%)  were found dead by ambulance p e r s o n n e l , 389 (38.9%) d i e d e i t h e r b e f o r e an ambulance was c a l l e d (10.9%) were pronounced  f o r , o r a r r i v e d , 109  dead on a r r i v a l a t h o s p i t a l , w h i l e i n  the ambulance, 305 (30.5%) were admitted and d i e d i n h o s p i t a l and 97 (9.7%) were i n h o s p i t a l f o r o t h e r reasons and d i e d o f CHD.  O v e r a l l , 596, o r f u l l y  hospital.  60% o f the cases d i e d o u t - o f -  Of these, 229 were known t o have s u r v i v e d f o r  more than 30 minutes  a f t e r onset o f symptoms, 182 f o r more  than an hour, and 14 3 s u r v i v e d more than two hours. The authors a n a l y z e d s i x c r i t i c a l time p e r i o d s i n t h e i r s e r i e s i n which d e l a y i n r e a c h i n g d e f i n i t i v e care might have been reduced.  Data were not complete  were c a r r i e d out on s m a l l e r subgroups  and c a l c u l a t i o n s  o f the t o t a l 5 96 out-  o f - h o s p i t a l deaths. 1)  Onset o f symptoms t o c a l l i n g f o r h e l p (GP, r e l a t i v e ) : the median time was 1 hour 17 minutes f o r men and 1 hour .6 minutes f o r women. In 20% o f cases the time e l a p s e d was more than 6 hours.  2)  C a l l i n g f o r h e l p t o c a l l i n g ambulance: the median time was 59 minutes f o r men and 1 hour 2 6 minutes f o r women.  3)  Ambulance d i s p a t c h e r r e c e i v e s c a l l t o d i s p a t c h of v e h i c l e : the median time was 3 minutes f o r men and 8.5 minutes f o r women. The sex d i f f e r e n c e here was s i g n i f i c a n t (Pi 0.01) and unexpected. The authors suggested t h a t the onset o f symptoms was more i n s i d i o u s i n women and the p h y s i c i a n was t h e r e f o r e l e s s l i k e l y t o s t r e s s urgency t o the ambulance d i s p a t c h e r .  40  4)  V e h i c l e d i s p a t c h e d to a r r i v a l a t p a t i e n t : median time was 8 minutes f o r men and 8.3 f o r women.  the minutes  5)  Pickup of p a t i e n t t o a r r i v a l at emergency room: t h i s time p e r i o d was not p r e s e n t e d .  Summary of time e l a p s e d : 6)  Ambulance d i s p a t c h e r r e c e i v e s c a l l t o admission to ward: the median time was 74 minutes f o r males and 88 minutes f o r females.  7)  Onset o f symptoms t o admission t o ward: the median time was 7 hours 52 minutes f o r males and 8 hours 4 0 minutes f o r females.  In  t h i s study the g r e a t e s t sources of d e l a y l a y with  p a t i e n t s and t h e i r advocates i n a c t i v a t i n g the In  system.  another review, Doehrman found t h a t although h a l f of  the p a t i e n t s surveyed a r r i v e d a t the h o s p i t a l w i t h i n t h r e e Q  hours o f onset of symptoms, many d e l a y e d e i g h t or more hours. P u b l i c and p r o f e s s i o n a l e d u c a t i o n , and p o s s i b l y a u n i v e r s a l a c c e s s emergency number might p r o p o r t i o n of these deaths. EMS  The response times o f the B e l f a s t  per se were not out of l i n e f o r 1965-66, when the  ambulance procedure was for  have a v e r t e d a s i g n i f i c a n t  "scoop and run", and not unusual  some j u r i s d i c t i o n s today, although t h e r e are d i s t i n c t  d i f f e r e n c e s from the b e s t times c u r r e n t l y b e i n g a c h i e v e d . The o t h e r c r i t i c a l  time p e r i o d t h a t c o u l d have been  reduced to some e f f e c t was of  the time e l a p s e d between a r r i v a l  the ambulance and onset of d e f i n i t i v e therapy.  Had  treatment been s t a r t e d on the spot i n s t e a d o f a t the h o s p i t a l another hour would have been saved.  Bystander CPR,  and  f i r s t - r e s p o n d e r BLS coupled w i t h d e f i b r i l l a t i o n , or ACLS  41  o n s i t e would a l l reduce t h i s time t o a matter o f minutes. Based on experience from l a r g e American c i t i e s i t has been e s t i m a t e d t h a t one primary-response BLS u n i t i s required  f o r every 50,000 people and one d e f i n i t i v e - r e s p o n s e  ALS u n i t f o r every 125,000 - 150,000 people. One ALS u n i t r e q u i r e s a complement o f 5 people i n c l u d i n g dispatcher  and d r i v e r .  To p r o v i d e  24 hour s e r v i c e , 5  such teams o r 25 people are r e q u i r e d . can  Unless an ACLS u n i t  respond i n l e s s than 10 minutes, i t w i l l not improve  m o r t a l i t y from SCD.  In King County i n 1982 the c o s t o f one g  ACLS u n i t s e r v i n g 100,000 people was $415,000 p e r y e a r .  2.  Recent  Modifications  Bystander CPR Several  s t u d i e s have r e p o r t e d  o f o u t - o f - h o s p i t a l advanced l i f e were based on u n c o n t r o l l e d  on the l i f e s a v i n g  support units'*' ^  series.  0  Eisenberg  capabilities but most  and Tweed  c a r r i e d out p r o s p e c t i v e  c o n t r o l l e d s t u d i e s and Wennerblom  conducted a p r o s p e c t i v e  randomized c o n t r o l l e d t r i a l o f  standard latter  care v s . ACLS care  f o r AMI i n Sweden  (1982).  s t u d i e s a l l confirmed the e a r l i e r r e p o r t s  These  that  p a r a m e d i c - t r e a t e d p a t i e n t s had b e t t e r s u r v i v a l r a t e s than p a t i e n t s managed w i t h BLS d e l i v e r e d by l e s s e r - t r a i n e d emergency medical t e c h n i c i a n s  (EMT)_15,16,17  42  T a b l e l l demonstrates t h i s f i n d i n g by summarizing the r e s u l t s of s t u d i e s o f s u r v i v a l t o admission t o o r d i s c h a r g e from h o s p i t a l , f o r paramedic and EMT-treated p a t i e n t s .  Table I I . Rates o f S u r v i v a l (%) f o r Paramedic-Treated or EMT-Treated Cases o f Cardiac A r r e s t  No. o f Patients  Study  Paramedic Admitted Discharged %  Eisenberg et a l " ^ Cobb e t a l  19  Tweed e t a l  20  Eisenberg et a l V e r t e s i et a l  21  2 2  EMT Admitted Dischargee  %  %  %  17  6  21  4  487  39  27  595  44  23  849  — 22  574  6  26  318  7  A s u c c e s s f u l outcome o f r e s u s c i t a t i o n has been v a r i o u s l y found t o be a s s o c i a t e d  with a short access time,  s h o r t response time, l o c a t i o n o f c a l l , p a t i e n t s ' age, and presence o f v e n t r i c u l a r f i b r i l l a t i o n heart  block.  Tweed  has provided  instead of asystole or an important a n a l y s i s o f  some o f the p r e d i c t o r s o f outcome, with p a r t i c u l a r emphasis on bystander CPR and ACLS u n i t s . T a b l e 2 3  III(modified  from Tweed)  shows r a t e s of s u r v i v a l f o l l o w i n g b y s t a n d e r - i n i t i a t e d  CPR.  43  Table I I I Rates o f S u r v i v a l I n i t i a t e d CPR  (%) F o l l o w i n g Bystander-  No. o f Patients  Rate o f S u r v i v a l (%) t o Discharge With Bystander Without CPR Bystander CPR  Study  Type o f EMS  Vertesi et a l  Paramedic EMT  224 98  30 6  8 1  Thompson  Paramedic  316  43  21  Eisenberg  Paramedic  487  23  12  Lund  EMT  631  36  8  Tweed  EMT EMT  226 227  25 30  5 8  Paramedic  115  27  6  Guzy  While bystander CPR has been shown t o be a s s o c i a t e d w i t h improved  s u r v i v a l , t h e r e i s no r e l a t i o n s h i p t o the q u a l i t y o f  performance by the bystander.  S e v e r a l s t u d i e s have shown t h a t  CPR s k i l l s d e t e r i o r a t e r a p i d l y and have v i r t u a l l y d i s a p p e a r e d 24 one year a f t e r t r a i n i n g .  Furthermore, the b e n e f i c i a l  effect  o f bystander CPR d i s a p p e a r s i f the EMS response time i s more than f i v e minutes. "Though bystanders who attempt CPR c o n t r i b u t e i n some way, perhaps by r a p i d l y summoning h e l p , t o a h i g h e r r a t e o f s u r v i v a l , t h e r e i s no evidence t h a t e i t h e r the q u a l i t y o f the CPR o r even t h e ^ attempt a t CPR has any s i g n i f i c a n t i n f l u e n c e . " 2  Bystander CPR has a l s o been found t o be h i g h l y p r e d i c t i v e o f  44  the  presence of v e n t r i c u l a r f i b r i l l a t i o n , which i s a major  determinant of a s u c c e s s f u l yet to be e x p l a i n e d .  The  outcome.  conclusion  The  association  Tweed has  w h i l e some a s p e c t of b y s t a n d e r - a s s o c i a t e d CPR w i t h improved outcome, whether i t i s the the  a b i l i t y to r e c o g n i z e c a r d i a c  promptly i s not Vertesi CPR  has  drawn is' t h a t is  associated  a c t u a l procedure or  a r r e s t and  a c t i v a t e the  system  known. showed a s y n e r g i s t i c e f f e c t of  combined w i t h ACLS.  when o n l y an EMT  Bystander CPR  u n i t responded.  development of these two  d i d not  Vertesi  bystander enhance s u r v i v a l  recommended  components of an EMS  i n concert  rather  than e i t h e r i n i s o l a t i o n . These s t a r t l i n g data on bystander CPR minimum, t h a t except f o r r e s e a r c h u n i t s , no  suggest, at a additional  r e s o u r c e s ought to be d i r e c t e d toward t r a i n i n g the p u b l i c CPR  u n t i l the  understood.  b e n e f i c i a l component i s i d e n t i f i e d and  Alternatives  be  caused by v e n t r i c u l a r  be  expanded.  to Paramedic U n i t s  S i x t y p e r c e n t of o u t - o f - h o s p i t a l fibrillation  r e s u s c i t a t i o n i s more l i k e l y are p r e s e n t .  better  That i s , the p r e s e n t l e v e l of t r a i n i n g may  maintained.but should not  in  Resuscitation  h e a r t b l o c k or a s y s t o l e  i f VF  cardiac  (VF).  arrests  are  Successful  or s i m i l a r dysrhythmias  i s considerably  less likely i f  are the p r e s e n t i n g rhythms.  It  has  45  a l s o been shown t h a t VF  untreated  or t r e a t e d with BLS  alone  w i l l d e t e r i o r a t e to a s y s t o l e i n 50% or more of cases,  decreasing  27  the p r o b a b i l i t y of s u r v i v a l . combination suggest a new o f VF  and  These f e a t u r e s viewed  possibility:  in  that r a p i d recognition  a p p l i c a t i o n of countershock may  be the most  important component of p r e - h o s p i t a l ACLS. 28 T h i s p o s s i b i l i t y was t e s t e d by E i s e n b e r g i n suburban King County, Washington, where emergency s e r v i c e s were being 29 provided  s o l e l y by EMT's.  In other p u b l i s h e d  reports  survival  r a t e s f o r c a r d i a c a r r e s t i n t h i s area were around 6%. t r a i n i n g program was  developed f o r EMT's which c o n s i s t e d  10 hours o f i n s t r u c t i o n i n CPR, emphasis on VF  and  the use  the t r a i n i n g program was  of a d e f i b r i l l a t o r .  $40.00 per  During the p r e c e d i n g  two  student.  s e r v i c e was  cost  Apart  from  authorized. BLS  During one  year when the  augmented by d e f i b r i l l a t i o n only,10 of  Despite  (18%)  of  patients i n cardiac arrest  from h o s p i t a l .  patients i n cardiac arrest (P<0.01).  The  year p e r i o d when o n l y  s e r v i c e s were a v a i l a b l e , 4 of 100  BLS  of  arrhythmia r e c o g n i t i o n w i t h  d e f i b r i l l a t i o n , no other ACLS technique was  (4%) were d i s c h a r g e d  A  were d i s c h a r g e d  from h o s p i t a l  some drawbacks to the study, such  as  non-random assignment, a r e t r o s p e c t i v e c o n t r o l group, p o s s i b l e i n t e r f e r e n c e i n the r e s u l t s by other  54  and  a s p e c t s of  the  t r a i n i n g program, the concept remained an e x c i t i n g p o s s i b i l i t y . 30 S t u l t s and  colleagues  developed a p r o s p e c t i v e l y  c o n t r o l l e d study designed to t e s t the e f f e c t of the  same  two  46  l e v e l s o f i n t e r v e n t i o n i n much s m a l l e r communities i n r u r a l areas  (average p o p u l a t i o n 10,000).  were t r a i n e d i n d e f i b r i l l a t i o n . w i t h EMT  In 18 communities EMT's  Twelve s i m i l a r  s e r v i c e o n l y p r o v i d e d c o n t r o l data.  communities  The 16 hour  t r a i n i n g program was d e l i v e r e d t o EMT personnel i n a l l communities, the o n l y d i f f e r e n c e being t r a i n i n g i n d e f i b r i l l a t i o n was  i n c l u d e d f o r the study communities.  p e r i o d , 19% o f p a t i e n t s  twenty-month  (12 o f 64) i n the study communities  were d i s c h a r g e d from h o s p i t a l compared the c o n t r o l communities  Over a  to 3%  (1 o f 31) i n  (P<0.05).  S t u l t s i d e n t i f i e d s e v e r a l c a u t i o n s i n i n t e r p r e t i n g the data i n c l u d i n g the f a c t t h a t because there are l a r g e numbers o f v o l u n t e e r EMT p e r s o n n e l i n s m a l l communities, and a low i n c i d e n c e o f c a r d i a c a r r e s t , many EMT's t r a i n e d i n d e f i b r i l l a t i o n might not be r e q u i r e d t o use t h e i r s k i l l s f o r y e a r s .  He  recommended a r i g o r o u s r e c e r t i f i c a t i o n schedule t o prevent inappropriate a p p l i c a t i o n of d e f i b r i l l a t i o n . 31 Most r e c e n t l y E i s e n b e r g and others  expanded on t h e i r  e a r l i e r study by combining EMT personnel t r a i n e d i n d e f i b r i l l a t i o n w i t h backup ACLS u n i t s .  They compared  the impact on  m o r t a l i t y from t h i s expanded team to t h a t o f a standard paramedic team.  With s h o r t response times f o r both l e v e l s  o f treatment the h o s p i t a l d i s c h a r g e r a t e was 39% and 37%.  EMT-  the same,  However, i f the i n t e r v a l between  a r r i v a l of  EMT's and a r r i v a l o f paramedics was longer than four minutes, s u r v i v a l i n the b a s i c EMT-treated group was  18% and 38%  47  in  the  E M T - d e f i b r i l l a t i o n group  (P<0.01).  Even a f t e r  c o n t r o l l i n g f o r other v a r i a b l e s such as age, response time, there was EMT-defibrillation. def i b r i l l a t i o n  T h i s study d i d not  In summary the 1)  CPR,  EMTrather  d e f i n i t i v e randomized yet to be  published.  f o l l o w i n g p o s s i b i l i t i e s have been examined:  When bystander CPR  s u r v i v a l rates  The  treatment modes has  not p r e - h o s p i t a l ACLS, there  2)  compare  s e r v i c e s to paramedic s e r v i c e s , but  comparing the two  initial  a s i g n i f i c a n t positive effect for  a s s e s s e d the a d d i t i v e b e n e f i t . trial  sex and  i s accompanied by EMT has  been no  only  and  improvement i n  ( V e r t e s i ; Tweed).  There i s no evidence t h a t the q u a l i t y of bystander  or the attempt at bystander CPR  has  any s i g n i f i c a n t  i n f l u e n c e on m o r t a l i t y , although some f e a t u r e of i t i s p r e d i c t i v e o f a s u c c e s s f u l outcome 3)  (Tweed).  ACLS u n i t s are very c o s t l y to operate although they  improve s u r v i v a l r a t e s .  Smaller communities do not have  necessary tax base to support a paramedic s e r v i c e 4)  E a r l y d e f i b r i l l a t i o n by m i n i m a l l y - t r a i n e d  p e r s o n n e l i s an e f f e c t i v e and  in  (Stults). EMT  r e l a t i v e l y inexpensive way  dealing with out-of-hospital cardiac  the  of  arrest, particularly  l o c a t i o n s d i s t a n t from l a r g e urban centres  (Eisenberg,  Stults). 5)  I t may  be t h a t there  of s u r v i v a l ; i n i t i a t i o n of CPR cardiac  a r r e s t , and  are only two  key determinants  i n l e s s than 4 minutes a f t e r  early d e f i b r i l l a t i o n  (Tweed).  48  Taken t o g e t h e r ,  these statements suggest t h a t f o r a l l  but the l a r g e s t c i t i e s i n Canada, an adequate EMS to d e a l w i t h c a r d i a c a r r e s t may  be p r o v i d e d  l a t i o n teams i n s u f f i c i e n t numbers and i n the community to be served. may  be components of the  by  designed  EMT-defibril-  appropriate  Bystander CPR  system t h a t c o u l d be  and  locations ACLS u n i t s  foregone u n t i l  f u r t h e r s t u d i e s have been c a r r i e d out. The  most r e c e n t  t e c h n o l o g i c a l development to impinge 32  on t h i s c a t e g o r y of p a t i e n t s i s the implantable  cardioverter.  A small  been t e s t e d  (95 gram) f u l l y programmable d e v i c e  has  i n patients with recurrent v e n t r i c u l a r tachycardia  (VT)  were not c a n d i d a t e s f o r s u r g i c a l treatment o f VT.  Cardioversion  r e q u i r e d a very  small  w e l l t o l e r a t e d by the  shock  ( l e s s than 0.5  subjects.  Joules)  and  who  was  There were s i g n i f i c a n t  d i f f i c u l t i e s i n t h i s t r i a l w i t h d i f f e r e n t i a t i o n of arrhythmias by the c a r d i o v e r t e r . generation SCD  However, i t i s p o s s i b l e t h a t the next  w i l l be able to d e f i b r i l l a t e .  v i c t i m s who  are d i s c h a r g e d  50% m o r t a l i t y over 4 years. r e c u r r e n t SCD  The  20-25% of  from the h o s p i t a l have a  The  main cause o f death i s  induced by v e n t r i c u l a r f i b r i l l a t i o n .  near f u t u r e , t h i s d e v i c e  may  In  the  s i g n i f i c a n t l y improve longterm  s u r v i v a l f o r such p a t i e n t s . 3.  One  Impact of the  System  of the major concerns about management o f  out-of-  h o s p i t a l c a r d i a c a r r e s t i s t h a t r a t h e r than p r o d u c t i v e  lives  49  being saved,  death i s merely  by means o f an extremely  being delayed a few months  expensive  technology.  Twenty t o  t h i r t y p e r c e n t o f c a r d i a c a r r e s t p a t i e n t s are c u r r e n t l y being s u c c e s s f u l l y r e s u s c i t a t e d and d i s c h a r g e d from h o s p i t a l  alive.  However, the age o f the s u r v i v o r s and the q u a n t i t y and quality of l i f e much  a f t e r d i s c h a r g e have been the s u b j e c t s of  debate. There a r e some r e c e n t data on longterm  out-of-hospital cardiac arrest.  survivors of  E i s e n b e r g and o t h e r s  f o l l o w e d a s e r i e s o f p a t i e n t s over f o u r years a f t e r The of  initial  resuscitation.  s e r i e s c o n s i s t e d o f 1567 cases o f c a r d i a c a r r e s t  whom 557 (36%) were admitted and 302 (19%) were d i s c h a r g e d .  Of those d i s c h a r g e d , 276 were a v a i l a b l e f o r longterm Two hundred and f i f t y  followup.  o f the 276 went home; 26 had major  sequelae and went t o n u r s i n g homes o r extended-care  facilities.  F o r t y - s e v e n p e r c e n t o f a group i n t e r v i e w e d a t s i x months p o s t - d i s c h a r g e had worked e i t h e r f u l l o r p a r t - t i m e p r i o r to their arrest. resume f u l l The  T h i r t y - f o u r percent o f t h i s group were able t o  o r p a r t - t i m e work a f t e r the event.  p r o b a b i l i t y o f s u r v i v a l a t 6 months, one year, two  y e a r s , t h r e e years and f o u r years was 81, 76, 66, 55 and 49% respectively. to  The 49% 4-year s u r v i v a l r a t e was c o n t r a s t e d  an 80% s u r v i v a l r a t e f o r an age-sex-matched normal group, and  a 66% r a t e f o r a group w i t h uncomplicated tion. (89%)  myocardial  The cause o f death a f t e r d i s c h a r g e was 33 due t o a t h e r o s c l e r o t i c heart d i s e a s e .  infarc-  overwhelmingly  50  Rockswold and o t h e r s c o l l e c t e d a s e r i e s o f 514 c o n s e c u t i v e patients suffering out-of-hospital cardiac arrest i n Minneapolis  between 1974 and 1976.  d i s c h a r g e d a l i v e from h o s p i t a l .  Of the 514, 83 (16%) were  T h i r t y - f o u r had s i g n i f i c a n t  impairment, p r i m a r i l y n e u r o l o g i c , and 49 were ambulatory, w i t h good mental f u n c t i o n . a p e r i o d o f up t o two y e a r s .  Of those 49. 4 7 were followed f o r O v e r a l l , the s u r v i v a l r a t e s  i n t h i s group were 85% a t the end o f one year and 50% at the end o f two y e a r s .  The m a j o r i t y o f deaths d u r i n g the  f o l l o w u p p e r i o d were a t t r i b u t e d t o SCD. '* 3  Cobb and o t h e r s f o l l o w e d 234 d i s c h a r g e d s u r v i v o r s o f c a r d i a c a r r e s t f o r an average p e r i o d o f 14 months. mean age o f the group was 60 y e a r s .  The  The s u r v i v a l r a t e was  70% a t t h e end o f one year and 59% a t the end o f two y e a r s . T h i r t y o f Cobb's p a t i e n t s (13%), experienced a f t e r discharge.  r e c u r r e n t SCD  F i f t e e n were r e s u s c i t a t e d from t h e i r second  episode, w i t h 10 s u r v i v i n g longterm,  and subsequently  3 of  these were r e s u s c i t a t e d from a t h i r d episode, with one 35 longterm s u r v i v o r . All  t h r e e s t u d i e s p r o v i d e d c l e a r evidence  in ventricular f i b r i l l a t i o n  that patients  (VF) i n the absence o f myocardial  i n f a r c t i o n e x p e r i e n c e d c o n s i d e r a b l y higher m o r t a l i t y than p a t i e n t s r e s u s c i t a t e d from VF a s s o c i a t e d with infarction. proved  myocardial  In p a r t i c u l a r , p a t i e n t s i n VF without  infarction  t o be a t h i g h r i s k f o r r e c u r r e n c e o f VF i n t h e e a r l y  p o s t - d i s c h a r g e phase  (.17 weeks) .  51  As t h i s high r i s k group became apparent, for  p r e d i c t o r s of r i s k i n an e f f o r t to f u r t h e r improve  survival rates. in  a search began  Lesch and Kehoe found a t h r e e - f o l d i n c r e a s e  the r i s k f o r SCD  a f t e r myocardial  i n f a r c t i o n i f frequent  or complex v e n t r i c u l a r e c t o p i c a c t i v i t y was  present.  i n c r e a s e d r i s k rose to s i x - f o l d i f c o n g e s t i v e heart  The failure  36 was  added to the v e n t r i c u l a r e c t o p i c a c t i v i t y .  At  present  t h e r e i s no s i n g l e technique with s u f f i c i e n t s e n s i t i v i t y s p e c i f i c i t y to d i s t i n g u i s h low- arid h i g h - r i s k groups, a combination  of techniques  i s required.  and  and  F u r t h e r , the  u t i l i t y of s u p p r e s s i n g v e n t r i c u l a r e c t o p i c a c t i v i t y , and coronary bypass surgery remain to be demonstrated.  of  For  the p r e s e n t a systematic approach to management i s recommended, i n c l u d i n g a regimen of a n t i - a r r h y t h m i c s a f t e r a complete hemodynamic and e l e c t r o p h y s i o l o g i c review 37  (via Holter  m o n i t o r i n g and r a d i o n u c l i d e imaging). The newest t e c h n o l o g i c a l advance i m p l a n t a b l e c a r d i o v e r t e r , may for  i n the f u t u r e p r o v i d e a method  r e d u c i n g p o s t - d i s c h a r g e m o r t a l i t y i n t h i s group of  patients. of  (vide s u p r a ) , the  However, i t i s s t i l l  i n the very e a r l y  stages  development. To summarize, about 10-20% of v i c t i m s of c a r d i a c a r r e s t  are being d i s c h a r g e d a l i v e from h o s p i t a l .  The  proportion  s u s t a i n i n g s i g n i f i c a n t n e u r o l o g i c damage i s v a r i a b l e but be as h i g h as 40%.  For those d i s c h a r g e d without  may  impairment,  u s u a l l y males i n t h e i r l a t e f i f t i e s to l a t e s i x t i e s , a  52  50-60% two year s u r v i v a l may be expected.  Over a t h i r d of  those a l i v e a t 6 months w i l l be back a t work.  The primary  cause o f death among these longterm s u r v i v o r s i s SCD and e f f o r t s are c u r r e n t l y b e i n g d i r e c t e d toward  identifying  h i g h - r i s k subgroups and d e v i s i n g e f f e c t i v e  interventions  t o prevent r e c u r r e n t SCD. Crampton has reviewed data from s e v e r a l EMS and has expressed the r e s u l t s i n terms of l i v e s saved. was found t o be 6.8 l i f e - s a v e s per 100,000.  The average  He c a l c u l a t e d the  v a l u e o f a l o s t l i v e l i h o o d as worth $41,000 p e r 100,000 38 people i n 1980 d o l l a r s .  I f a d e f i n i t i v e c a r e EMS can save  6.8 l i v e s per 100,000 the gross value per year o f s u r v i v a l w i l l be about  $280,000.  The c o s t o f one ACLS u n i t i n 39  King County, Washington i n 1979 was e s t i m a t e d a t $275,000. I f these data may be compared, they suggest a c o s t : b e n e f i t r a t i o o f 1:1 i n the f i r s t year o f s u r v i v a l .  The b e n e f i t s  w i l l i n c r e a s e w i t h each a d d i t i o n a l year t h a t s u r v i v o r s work, but not a l l s u r v i v o r s are g e n e r a t i n g a l i v e l i h o o d . b a l a n c e , a c o s t : b e n e f i t r a t i o o f 1:1 does l i t t l e a parame d i e ACLS u n i t .  On  t o recommend  Since the impact o f SCD i s undeniably/  l a r g e , however, i t w i l l be worthwhile  t o pursue  the l e s s  c o s t l y but e q u a l l y e f f e c t i v e o p t i o n s d e s c r i b e d i n the preceding  section.  53  Chapter  IV  Notes  1.  P a n t r i d g e , J.F., J.S. Geddes. A Mobile I n t e n s i v e Care U n i t i n the Management of M y o c a r d i a l I n f a r c t i o n . Lancet 2. 1967. pp. 271-73.  2.  S t e r n , M.P. The Recent D e c l i n e i n Ischemic Heart Disease M o r t a l i t y . Ann., I n t e r n Med. 9_1. October pp. 630-640.  3.  Cobb, L.A., H. A l v a r e z , M.K. Kopass. A Rapid Response System f o r O u t - o f - H o s p i t a l C a r d i a c Emergencies. Med. Can. N. America 60 (2). March 1976. pp. 283-91.  4.  Enns, J . , W.A. Tweed, N. Donen. P r e h o s p i t a l C a r d i a c Rhythm: D e t e r i o r a t i o n i n a System P r o v i d i n g Only B a s i c L i f e Support. Amer. Emerg. Med. 12 (8). August 1983. pp. 478-81.  5.  Webster, A.C. E v o l u t i o n of Emergency C a r d i a c Care i n Canada. CMA J o u r n a l 117. December 17, 1977. pp. 1383-86.  6.  McNally, R.H., J . Pemberton. D u r a t i o n of L a s t Attack i n 998 F a t a l Cases of Coronary Ajrtery Disease and i t s R e l a t i o n to P o s s i b l e C a r d i a c R e s u s c i t a t i o n . B r i t Med. J. J u l y 20, 1968. pp. 139-42.  7.  Doehrman, S.R. P s y c h o - S o c i a l Aspects o f Recovery from Coronary Heart Disease; A Review. Soc. S c i . Med. 1_1 1979. pp. 199-218.  8.  Boyd, D.R. Government A d m i n i s t r a t i o n and Funding of Emergency M e d i c a l Care Programs: Role of the F e d e r a l Government i n Proceedings of the F i r s t N a t i o n a l Conference on the M e d i c o l e g a l I m p l i c a t i o n s o f Emergency M e d i c a l Care. D a l l a s , Am. Heart assoc. 1976. pp. 85-110.  9.  E i s e n b e r g , M.S. and o t h e r s . Treatment of V e n t r i c u l a r Fibrillation. JAMA 251 (13). A p r i l 6, 1984. .-pp, 1723-25,  1979.  10.  V e r t e s i , L., L. Wilson, N. G l i c k . Cardiac A r r e s t : Comparison of Paramedic and C o n v e n t i o n a l Ambulance Services. Can. Med. Assoc. J . 128. 1983. pp. 809-83  11.  E i s e n b e r g , M., L. Bergner, T. Hearne. O u t - o f - H o s p i t a l C a r d i a c A r r e s t : A Review of Major S t u d i e s and a Proposed Uniform Reporting System. Am. J . P u b l i c Health 70. 1980. pp. 236-240.  54  12.  Cobb, L., J . Werner, G. Trobaugh. Sudden C a r d i a c Death: A Decade's Experience with O U t - o f - H o s p i t a l Resuscitation. Med. Concepts C a r d i o v a s c . D i s . 49. 1980. pp. 31-36.  13.  Rockswald, G. and o t h e r s . Followup o f 514 C o n s e c u t i v e P a t i e n t s with Cardiopulmonary A r r e s t Outside the Hospital. J . Am. C o l l . Emerg. P h y s i c i a n s 8_. 1979. pp. 216-220.  14.  L i b e r t h s o n , P.R. and o t h e r s . Prehospital Ventricular Fibrillation: Prognosis and Followup Course. N. E n g l . J . Med. 2 9 a . 1974. pp. 317-321.  15.  Eisenberg, M., L. Bergner, A. H a l l s t r o m . Paramedic Programs and O u t - o f - H o s p i t a l C a r d i a c A r r e s t : I . F a c t o r s A s s o c i a t e d with S u c c e s s f u l R e s u s c i t a t i o n . Am. J . P u b l . Health 69 (1). 1979. pp. 30-38.  16.  Tweed, W.A., G. Bristow, N. Donen. R e s u s c i t a t i o n from C a r d i a c A r r e s t : Assessment of a System P r o v i d i n g Only B a s i c L i f e Support Outside o f H o s p i t a l . Can. Med. Assoc. J . 122. February 9, 1980. pp. 297-304.  17.  Wennerblom, B. E a r l y M o r t a l i t y from Ischemic Heart Disease and the E f f e c t o f Mobile Coronary Care. Acda Med. Scand. 1982. pp. 1-58.  18.  Eisenberg, M. and o t h e r s .  19.  Cobb, L.A. and o t h e r s . R e s u s c i t a t i o n from Out-ofHospital Ventricular F i b r i l l a t i o n : Four Years Followup. C i r c u l a t i o n Supp. I l l 51 and 52. 1975. pp. 223-228.  20.  Tweed, W.A.  21.  Eisenberg, M. and o t h e r s . Management o f O u t - o f - H o s p i t a l Cardiac A r r e s t : F a i l u r e o f B a s i c Emergency M e d i c a l T e c h n i c i a n S e r v i c e s . JAMA 243 (10). March 14, 1980. pp. 1049-1051.  22.  V e r t e s i , L and o t h e r s .  23.  Tweed.  opcit.  24.  Tweed.  opcit.  25.  Tweed.  opcit.  26.  V e r t e s i , L and Others.  and o t h e r s .  p.  opcit.  opcit.  opcit.  430 opcit.  55  27.  Tweed, W.A.  and o t h e r s .  opcit.  28.  E i s e n b e r g , M. and o t h e r s . Treatment of O u t - o f - H o s p i t a l C a r d i a c A r r e s t s with Rapid D e f i b r i l l a t i o n by Emergency M e d i c a l T e c h n i c i a n s . NEJM 302 (25) June 19,1980 1379-83.  29.  E i s e n b e r g , M. and o t h e r s . pp. 1049-1051. opcit.  30.  S t u l t s , K., D. Brown, V. Schug, J . Bean. P r e h o s p i t a l D e f i b r i l l a t i o n Performed by Emergency M e d i c a l T e c h n i c i a n s i n R u r a l Communities. New E n g l . J . Med. 310 (4). January 26, 1984. pp. 219-23.  31.  E i s e n b e r g , M., A. H a l l s t r o m , M. Copass. Treatment of V e n t r i c u l a r F i b r i l l a t i o n : Emergency M e d i c a l T e c h n i c i a n D e f i b r i l l a t i o n and Paramedic S e r v i c e s . MAMA 251 (13). A p r i l 6, 1984. pp. 1723-1726.  32.  Z i p e s , D. and o t h e r s . E a r l y Experience with an Implantable C a r d i o v e r t e r . New E n g l . J . Med. 311 August 23, 1984. pp. 485-490.  33.  E i s e n b e r g , M., A. H a l l s t r o m , L. Bergner. Long-Term S u r v i v a l A f t e r Out-of-Hospital Cardiac A r r e s t . New E n g l . J . Med. 306 (22). June 3, 1982. pp. 1340-43.  34.  Rockswold, G. and o t h e r s . Followup o f 514 Consecutive P a t i e n t s with Cardiopulmonary A r r e s t Outside the Hospital. J . Amer. C o l l . Emerg. P h y s i c i a n s 8_ (6). June 1979. pp. 216-220.  35.  Cobb, L.A., R.S. Baum, H. A l v a r e z and W.A. Schaffer. R e s u s c i t a t i o n from O u t - o f - H o s p i t a l V e n t r i c u l a r F i b r i l l a t i o n : 4 Years Followup. C i r c u l a t i o n Supp. I l l 51-52. December 1975. III-223-228.  36.  Lesch, M. and R.F. Kehoe. P r e d i c t a b i l i t y of Sudden C a r d i a c Death. New E n g l . J . Med. 310 (4). January 26, 1984. pp. 255-57.  37.  Myerburg, R.J. and o t h e r s . Survivors of Prehospital C a r d i a c A r r e s t . JAMA 247 (10). March 12, 1982. pp. 1485-90.  38.  Crampton, R. P r e h o s p i t a l Advanced C a r d i a c L i f e Support: E v a l u a t i o n of a Decade of Experience. Topics i n Emergency Medicine 1_ (4). January 1980. pp. 27-34.  39.  E i s e n b e r g , M., L. Bergner, A. H a l l s t r o m . R e s u s c i t a t i o n i n the Community. JAMA 241 May 4, 1979. pp. 1905-7  JAMA 243  (10).  March 14,  Cardiac (18)  1980.  (8).  56  Chapter  V  1.  Emergency M e d i c a l S e r v i c e s i n Saskatoon  The  Provincial  Context  Because h e a l t h i s a p r o v i n c i a l r e s p o n s i b i l i t y ,  ambulance  s e r v i c e s g e n e r a l l y emanate from p r o v i n c i a l Departments of H e a l t h and each p r o v i n c e has d i f f e r e n t p r i o r i t i e s , l e g i s l a t i o n and d i f f e r e n t p a t t e r n s of o p e r a t i o n . m u n i c i p a l i t i e s w i t h i n p r o v i n c e s have developed EMS  beyond p r o v i n c i a l standards  different Larger  their  local  to meet the unique demands of  c i t i e s , and t h i s has r e s u l t e d i n a m u l t i p l i c i t y o f s t r u c t u r e s , l e v e l s of funding and  services.  P r o v i n c i a l l i c e n s i n g r e g u l a t i o n s f o r ambulances were i n t r o d u c e d i n Saskatchewan i n 1946.  I n i t i a l l y the r e g u l a t i o n s  covered equipment and v e h i c l e s p e c i f i c a t i o n s o n l y . they were upgraded to address ambulance attendants  In  1958  the i s s u e o f t r a i n i n g f o r  (at t h a t time the t r a i n i n g r e q u i r e d was  a  S t . John's F i r s t A i d C e r t i f i c a t e ) . During the 1970's ambulance o p e r a t o r s were s t r u g g l i n g w i t h r i s i n g c o s t s , marginal p r o f i t s and the need to i n c r e a s e user f e e s .  They t h e r e f o r e made p r e s e n t a t i o n s to the  government to develop  a system f o r i n d i r e c t  funding of ambulance s e r v i c e s . Program  provincial  The M u n i c i p a l Road Ambulance  (MRAP) p r o v i d e d funding f o r ambulance s e r v i c e s through  a per c a p i t a grant to m u n i c i p a l i t i e s . through  provincial  The  funds were d e r i v e d  the Revenue-Sharing agreement between the p r o v i n c e  and  57  the m u n i c i p a l i t i e s .  In s e v e r a l geographic areas, n e i g h b o r i n g  communities j o i n e d t o g e t h e r t o form ambulance Currently  there  districts.  are about 100 d i s t r i c t s i n the p r o v i n c e ,  w i t h 95 l i c e n s e d o p e r a t o r s .  M u n i c i p a l i t i e s t r a n s f e r the per  c a p i t a grant t o ambulance boards, which i n t u r n d i s b u r s e the funds t o the ambulance s e r v i c e  providers."'"  In Saskatoon i n 1977, the P r o v i s i o n a l Board o f H e a l t h was  a new e n t i t y c o n s t i t u t e d t o , "formulate the o b j e c t i v e , bylaws, o r g a n i z a t i o n a l s t r u c t u r e and r e l a t e d matters necessary t o the e s t a b l i s h m e n t and f u n c t i o n i n g o f a permanent h e a l t h board capable o f c o o r d i n a t i n g and i n t e g r a t i n g the d e l i v e r y o f h e a l t h care t o the ' c i t i z e n s o f Saskatoon and/or surrounding area." T h i s group was asked t o review the p r e l i m i n a r y  grant p r o p o s a l the  MRAP  and make recommendations t o C i t y C o u n c i l .  Over  f o l l o w i n g year, e f f o r t s were made by a committee o f the  P r o v i s i o n a l Board o f H e a l t h t o b r i n g o t h e r m u n i c i p a l i t i e s i n t o an ambulance d i s t r i c t .  surrounding In a d d i t i o n t o  t h i s major recommendation t o amalgamate urban and r u r a l m u n i c i p a l i t i e s i n t o a d i s t r i c t , with a r e p r e s e n t a t i v e  board,  the committee a l s o recommended: 1)  t h a t there  be an e x c l u s i v e  c o n t r a c t w i t h one  operator; 2)  t h a t standards o f o p e r a t i o n  contractor,  be e s t a b l i s h e d  t o be monitored by a T e c h n i c a l  of t h e Ambulance D i s t r i c t In 1979 f o u r t e e n  Advisory  f o r the Committee  Board.  m u n i c i p a l i t i e s i n c l u d i n g Saskatoon passed  58  bylaws a u t h o r i z i n g p a r t i c i p a t i o n i n a s i n g l e ambulance The r u r a l communities were grouped  i n t o t h r e e geographic  areas, and a board composed o f four Saskatoon r e p r e s e n t a t i v e s was  district.  and t h r e e r u r a l  formed.  During the same timespan  a community board was being  e s t a b l i s h e d t o guide the o p e r a t i o n s o f the Saskatoon  Community  H e a l t h U n i t , p r e v i o u s l y the Department o f H e a l t h f o r the C i t y o f Saskatoon.  The Board o f the H e a l t h U n i t regarded  c o o r d i n a t i o n o f h e a l t h s e r v i c e s as p a r t o f i t s mandate, and sought and was granted the r o l e o f host agency f o r the Saskatoon and Area Ambulance D i s t r i c t Board  (SAADB).  The H e a l t h U n i t  has s i n c e p r o v i d e d a d m i n i s t r a t i v e support f o r the SAADB and i n a d d i t i o n two i n d i v i d u a l s h o l d cross-appointments on both 3  Boards  t o f a c i l i t a t e an exchange o f i n f o r m a t i o n .  Although  t h e r e has n o t been much l a t i t u d e f o r l o c a l d i s c r e t i o n i n a p p o r t i o n i n g the funds p r o v i d e d , the SAADB s i n c e i t s i n c e p t i o n has taken an a c t i v e r o l e i n shaping l o c a l s e r v i c e s , and has p a i d c o n s i d e r a b l e a t t e n t i o n t o the development o f the s e r v i c e and t o measurements o f q u a l i t y  control.  In 1978 a province-wide t r a i n i n q program based i n Regina was developed t o upgrade the q u a l i f i c a t i o n s o f the ambulance a t t e n d a n t s .  By 1980, throuqh e f f o r t s by the  Saskatchewan M e d i c a l A s s o c i a t i o n and the Saskatchewan Road Ambulance A s s o c i a t i o n , t h e p r o v i n c i a l department  of Continuinq  E d u c a t i o n e s t a b l i s h e d the Emergency M e d i c a l T e c h n i c i a n s (EMT-1) program, w i t h a r e f r e s h e r program added l a t e r .  EMT-1  59  certification  i s c o n f e r r e d by a 131-hour program of  instruction.  When augmented by 25 hours of a c t u a l emergency experience, an Emergency M e d i c a l A s s i s t a n t About 300  (EMA-1) c e r t i f i c a t e i s i s s u e d .  ambulance personnel throughout  are c u r r e n t l y c e r t i f i e d at the EMT  or EMA-1  the p r o v i n c e  level.  Regulations  c u r r e n t l y r e q u i r e c i t y o p e r a t o r s t o have a t l e a s t one on f o r each s h i f t . except  EMT-1  The course has not been made a c c e s s i b l e  f o r those near Regina. and r u r a l p e r s o n n e l i n p a r t i c u l a r  e i t h e r do not have the b a s i c c e r t i f i c a t e o r are unable to take the r e f r e s h e r i n o r ^ e r -t-o maintain th«= standardIn a d d i t i o n t o s e r i o u s d i f f i c u l t i e s w i t h  training  ( e s p e c i a l l y when compared w i t h the e x t e n s i v e program o f f e r e d through  the Southern  A l b e r t a I n s t i t u t e of Technology  in  C a l g a r y , f o r example) there were o t h e r major problems with the p r o v i n c e ' s emergency medical s e r v i c e s .  In 1982  the  newly e l e c t e d C o n s e r v a t i v e government e s t a b l i s h e d the Ambulance Review Committee c h a i r e d by MLA  L a r r y B i r k b e c k to review  the  s t r u c t u r e s , standards and f i n a n c i n g f o r ambulance s e r v i c e s i n the p r o v i n c e . The problems noted i n the Birkbeck Report were as f o l l o w s : 1)  l e g i s l a t i o n p e r t a i n i n g t o ambulance s e r v i c e s i s contained w i t h i n f i v e separate a c t s a d m i n i s t e r e d by f i v e  different  departments of government. 2)  t h e r e i s a l a c k of autonomy, e x p e r t i s e , and among the D i s t r i c t  3)  direction  Boards.  t h e r e i s no uniform system of communications and no p o l i c y  60  p e r t a i n i n g to a communications network. 4)  funds used t o support ambulance s e r v i c e s come from a confusing  mix o f p u b l i c and p r i v a t e sources i n c l u d i n g  v a r i a b l e charges to the users o f ambulance s e r v i c e s .  The m a j o r i t y provincial  o f funds  (57% i n 1982-83) are p r o v i d e d  government.  The recommendations o f the Ambulance cautious  by the  but addressed a l l the f o r e g o i n g  Review Committee were issues.  Specifically  they i n c l u d e d recommendations t h a t covered the f o l l o w i n g 1)  areas:  w i t h r e s p e c t t o p r o v i n c i a l organization,,,that a l l  a s p e c t s o f ambulance s e r v i c e s be brought i n t o Saskatchewan Health  and t h a t a d e d i c a t e d  p r o v i n c i a l advisory  administrative  body be e s t a b l i s h e d w i t h the Department.  T h i s change has been i n i t i a t e d . U n i t has been a c t i v e l y o p e r a t i n g 2)  u n i t guided by a  since  The Ambulance  Services  1983.  With r e s p e c t to l e g i s l a t i o n , t h a t Ambulance  Services  be c o v e r e d by a s i n g l e separate p i e c e o f l e g i s l a t i o n . 3) province,  With r e s p e c t  throughout the  that: 3.1  and  to ambulance o p e r a t i o n s  the l o c a l o r g a n i z a t i o n  p r i v a t e agencies,  remain a mix o f p u b l i c  with c o n s i d e r a t i o n  to be given to  r e g i o n a l i z a t i o n o f more s p e c i a l i z e d s e r v i c e s over the longterm; 3.2 EMT-1  t h a t t r a i n i n g be s t a n d a r d i z e d  at the b a s i c  l e v e l and o f f e r e d on a d e c e n t r a l i z e d modular b a s i s  throughout the p r o v i n c e ;  61  3.3  t h a t communication be s t a n d a r d i z e d w i t h  r e s p e c t t o equipment and f r e q u e n c i e s and t h a t improved access via  a toll-free  number o r u n i v e r s a l access number  (911) be  considered; 3.4  t h a t funding be r a t i o n a l i z e d t o r e f l e c t  d i f f e r e n c e s across d i s t r i c t s  i n d i s t a n c e s t r a v e l l e d and c a l l  volumes. A t p r e s e n t the per c a p i t a g r a n t system i s not r e s p o n s i v e to d i f f e r e n t p a t t e r n s o f use. 3.5  t h a t a v a r i e t y o f f u n d i n g sources,  including  f e d e r a l , p r o v i n c i a l and m u n i c i p a l p u b l i c s e c t o r s and the p r i v a t e i n s u r a n c e s e c t o r be encouraged t o c o n t i n u e but t h a t a ceiling  be put on the user f e e t o p r o t e c t c i t i z e n s  ambulance 4)  services. That p u b l i c e d u c a t i o n be u t i l i z e d  a b i l i t y o f c i t i z e n s t o respond  The  requiring  t o improve the  t o emergency  situations.  newly e s t a b l i s h e d Ambulance S e r v i c e s U n i t has been  a c t i v e i n e s t a b l i s h i n g a uniform data base d e r i v e d from s t a n d a r d i z e d r u n - r e p o r t forms t o be completed to e v e r y ambulance.  The U n i t i s a l s o a c t i v e l y  f o r every  call  developing  p r o p o s a l s f o r t r a i n i n g and l i c e n s i n g requirements  and standards.  However, i t has not been i n e x i s t e n c e long enough t o have fully  implemented any o f i t s mandated i n i t i a t i v e s .  In a d d i t i o n ,  w h i l e the r u n - r e p o r t data are b e i n g c o l l e c t e d , a n a l y s i s has not y e t begun.  62  While the Ambulance Review Committee's recommendations  and  the work of the Ambulance S e r v i c e s Unit have been welcomed by the  SAADB, the Board i n d i c a t e d t h a t Saskatoon and  c o n s t i t u t e d a s p e c i a l area because i t i n c l u d e d one l a r g e s t c i t i e s i n the p r o v i n c e .  The  area  of the  Board accepted  two  the  Committee's recommendations as a b a s e l i n e upon which they  intend  t o b u i l d a d d i t i o n a l components r e l a t e d to the needs of a l a r g e metropolitan The  EMS  area  surrounded by  several rural  communities.  s e r v i c e i n Saskatoon i s i n a r e l a t i v e l y good  p o s i t i o n with respect  to data a n a l y s i s because of the  early  i n i t i a t i v e of the SAADB to monitor q u a l i t y v i a a computerized a n a l y s i s of l o c a l l y designed r u n - r e p o r t s . been a n a l y z e d o f the  by Feather and  published  6  The  data have  i n the Annual Reports  Saskatoon and Area Ambulance D i s t r i c t Board f o r the  years 1980-81, 1981-82 and prime source o f the  1982-83.  information  T h i s data base i s the  a v a i l a b l e on the  operation 7  o f the  system i n the Saskatoon and Area D i s t r i c t .  2. The  The  System i n Saskatoon  t h r e e most commonly observed o r g a n i z a t i o n a l models  f o r urban EMS  include:  1)  multiple private  2)  one  operator  operators;  holding  the m u n i c i p a l i t y or other  an e x c l u s i v e c o n t r a c t  c o n t r a c t i n g agency;  with  63  3)  The m u n i c i p a l i t y or other agency o p e r a t i n g an  ambulance as a p u b l i c s e r v i c e .  o  In Saskatoon t h e r e i s a d e l i c a t e balance between the two  first  models, with a s i n g l e operator c o n t r a c t e d by a community  board,  but w i t h no m u n i c i p a l or p r o v i n c i a l l e g i s l a t i o n to  prevent o t h e r o p e r a t o r s from e n t e r i n g i n t o c o m p e t i t i o n  with  the c o n t r a c t e d o p e r a t o r . The  c o n t r a c t e d o p e r a t o r , M.D.  Ambulance, has worked w e l l  w i t h the Board and has brought s e v e r a l f e a t u r e s o f the i n t o compliance  EMS  w i t h the recommendations of the Board over  the p a s t s i x y e a r s .  At present the operator has  bases w i t h i n the c i t y , and  11 BLS v e h i c l e s .  three  There i s no s h a r i n g  of space or communications with the F i r e Department.  The  r a t i o o f t e n used i n the l i t e r a t u r e f o r v e h i c l e to p o p u l a t i o n c a l c u l a t i o n s i s 1:50,000.  One  ACLS u n i t i s g e n e r a l l y planned  f o r each 100,000 - 125,000 p o p u l a t i o n . model, Saskatoon would r e q u i r e 4 BLS The and  Using t h i s maximum  u n i t s and  1-2  ACLS u n i t s .  s t a f f o f the ambulance s e r v i c e i n c l u d e s 20  fulltime  10 p a r t t i m e ambulance attendants, 4 d i s p a t c h e r s and 5  administrative staff.  The attendants are u n i o n i z e d .  s t r i k e over wage demands was t h e r e i s a contingency which was  developed  narrowly  A  averted i n 1981,  and  p l a n i n p l a c e to cover such emergencies,  by the o p e r a t o r i n response  to t h i s  earlier  crisis. Personnel  c e r t i f i c a t i o n has been upgraded i n 1984  to the  64  p o i n t where almost a l l s t a f f have EMT T h i s i s the The  or EMA-1  qualifications.  f i r s t year t h a t o n - s i t e t r a i n i n g has  wages of the  been a v a i l a b l e .  f u l l t i m e ambulance personnel i n the  province  are u s u a l l y s l i g h t l y above minimum wage (around $6.00 per Because of the r e l a t i v e l y poor remuneration, s t a f f i s h i g h and s t a f f who the  hour)..  turnover  i t i s r a r e to have a f u l l y t r a i n e d complement o f  a l s o have long f i e l d experience.  In r u r a l  areas  s i t u a t i o n d i f f e r s i n t h a t most f i r s t - r e s p o n s e teams are  comprised of v o l u n t e e r s t h e i r community.  The  who  are committed to remaining i n  problem of turnover  i s replaced  in this  s i t u a t i o n by the problem o f p r o v i d i n g adequate t r a i n i n g to a l a r g e cadre of The  volunteers.  annual budget f o r the BLS  about $600,000.  Increasing  system d e s c r i b e d  above i s  the wages o f the attendants to  $12.00 an hour would b r i n g c o s t s to somewhat over $1 I f the v e h i c l e - t o - p o p u l a t i o n  million.  r a t i o s used i n the l a r g e r systems  were a p p l i e d here, c a p i t a l o u t l a y the f i r s t year would and  operating  c o s t s would r i s e i n p r o p o r t i o n  a d d i t i o n a l c o s t s o f wages and system was d o l l a r s and  benefits.  because of  A 911  triple, the  communications  e s t i m a t e d to c o s t $200,000 per year i n  1982  a p u b l i c education/awareness campaign would a l s o 9  c o n t r i b u t e an a d d i t i o n a l $60,000. With r e s p e c t  to o p e r a t o r s  of the ambulance s e r v i c e  Annual Reports o f the SAADB provide geographic d i s t r i b u t i o n and  data on the number,  type of c a l l  non-emergency or t r a n s f e r , and  the  dead).  (urgent,  prompt,  There are a l s o data  65  on response times which have been used by the Board as a benchmark f o r q u a l i t y o f s e r v i c e . ^  0  Over the course o f  24 hours the t h r e e s h i f t s are covered as f o l l o w s : midnight to 0730, 2 u n i t s ; from 0730 to 1930, from 1930  from  4 units;  and  t o 2400, 3 u n i t s .  Over a year t h e r e are about 10,000 c a l l s , w i t h i n the c i t y l i m i t s .  80% from  The average number of c a l l s per day  i n c r e a s e d from 20 i n 1980-81 to 28 i n 1982-83. more emergency c a l l s on F r i d a y s and Saturdays 12-14% on o t h e r days o f the week).  has  There are (16% compared to  The d i s t r i b u t i o n o f  emergency c a l l s throughout the day i s f a i r l y even a t 5% per hour, except from 0100 around 2%.  t o 0600 when the p r o p o r t i o n drops t o  Most e l e c t i v e t r a n s f e r s tend t o occur d u r i n g  normal working hours. With r e s p e c t t o source o f c a l l , p a t i e n t s and i n i t i a t e 25-30% o f c a l l s , p o l i c e and f i r e o f the remainder are from h o s p i t a l s homes. prompt.  About  relatives  10-12% and the m a j o r i t y  ( t r a n s f e r s ) and n u r s i n g  a q u a r t e r o f the i n s t i t u t i o n a l c a l l s are urgent o r  For the c a l l s i n i t i a t e d by p a t i e n t s o r r e l a t i o n s ,  no i n f o r m a t i o n i s a v a i l a b l e on the time i n t e r v a l between onset o f symptoms and placement o f c a l l . i n t h i s s i t u a t i o n might  A survey o f e l a p s e d time  i n d i c a t e i f delay i s s i g n i f i c a n t ,  and whether p u b l i c e d u c a t i o n may  be r e q u i r e d .  The d i s t r i b u t i o n o f emergency c a l l s through the c i t y i s 30% from the core a r e a and 70% from the p e r i p h e r y (Appendix A ) . Response times are best f o r the core area, and decrease as the  66  city  l i m i t s are approached.  Over the past t h r e e y e a r s 40%  o f emergency c a l l s have been answered  i n f o u r minutes or l e s s ,  50% by 5 minutes, 65% by 6 minutes and 75% by 7 minutes (Appendix B).  With BLS c a p a b i l i t y o n l y , the system's response  c a p a b i l i t y i n under 4 minutes i s u n l i k e l y to be e f f e c t i v e i n d e a l i n g w i t h cases o f SCD.  A p r o s p e c t i v e survey o f numbers  and outcomes f o r SCD w i l l be r e q u i r e d , but a comparable system i n Winnipeg has been shown to produce a 5% r a t e o f d i s c h a r g e from hospital."'"''" The s t a n d a r d f o r the C i t y F i r e Department time o f 5 or fewer minutes. has e s t a b l i s h e d 6 f i r e h a l l s .  i s a response  To achieve t h i s time, the c i t y The P l a n n i n g Department  of  the C i t y o f Saskatoon has suggested t h a t i f a 4 minute response time i s r e q u i r e d f o r ambulance s e r v i c e s , i t i s p r o b a b l e t h a t 5-6  ambulance s t a t i o n s w i l l be r e q u i r e d .  department  has recommended deployment  commercial complexes.  This  i n each o f s i x suburban  These shopping and r e c r e a t i o n a l  areas have been e s t a b l i s h e d i n s p e c i f i c l o c a t i o n s i n o r d e r to p r o v i d e s e r v i c e s t o u n i t s o f 50,000 p o p u l a t i o n .  This  service  u n i t d o v e t a i l s n i c e l y w i t h the standard of one BLS v e h i c l e t o 50,000 p e o p l e .  3.  The Epidemiology o f C a r d i a c A r r e s t i n Saskatoon  The p o p u l a t i o n o f Saskatoon i s c u r r e n t l y 170,000 Saskatchewan  (1984  H o s p i t a l S e r v i c e s Plan) w i t h about 10-11% b e i n g  67  p e o p l e o v e r t h e age o f 65.  While t h e c i t y i s a l r e a d y  e x p e r i e n c i n g t h e " s e n i o r s boom" a n t i c i p a t e d e l s e w h e r e i n Canada o v e r t h e n e x t two decades, age s t a n d a r d i z e d m o r t a l i t y rates of  (ASMR) a r e c o m p a r a t i v e l y low f o r t h e l e a d i n g causes  death. In T a b l e IV d a t a e x t r a c t e d from volume 3 i n t h e s e r i e s ,  M o r t a l i t y A t l a s o f Canada "-Urban M o r t a l i t y , a r e used t o rank Saskatoon w i t h o t h e r s e l e c t e d Canadian c i t i e s f o r deaths due 13 to coronary heart d i s e a s e .  The d a t a a r e a g g r e g a t e d over  1973-1979 and have been drawn from m o r t a l i t y f i g u r e s f o r ICDA codes 410-413 ( 8 t h r e v i s i o n ) and ICDA codes 410-414  (9th r e v i s i o n ) .  TABLE IV Age S t a n d a r d i z e d M o r t a l i t y Rates f o r CHD 1973-1979 S e l e c t e d Canadian C i t i e s , by Sex ICD codes 410-413 1973-76 (8th r e v i s i o n ) ICD codes 410-414 1976-79 (9th r e v i s i o n ) MALE  FEMALE  SASKATOON REGINA  235.4 300.6  52.4 69.9  ST. JOHN, N.B. MONTREAL KINGSTON HAMILTON WINNIPEG CALGARY EDMONTON VANCOUVER WHITEHORSE  446. 0 420.6 430.2 353. 9 362.4 289.7 297. 1 322.0 424. 0  133.5 •127.2 132.4 101. 9 96.1 76.1 77.4 82.3 57.7  68  I t may be seen t h a t Saskatoon  had a s i g n i f i c a n t l y low  m o r t a l i t y e x p e r i e n c e f o r CHD d u r i n g those y e a r s . Hosking has c a l c u l a t e d numbers o f deaths o f Saskatoon 14  r e s i d e n t s coded  ICDA 410 f o r the years 1980 t o 1983.  Table V shows f o r each year the t o t a l number o f deaths i n Saskatoon  a t t r i b u t e d t o code 410 and those o c c u r r i n g o u t -  o f - h o s p i t a l as opposed t o those o c c u r r i n g w i t h i n  hospital  o r i n a s i m i l a r i n s t i t u t i o n , and the average age o f the patients. Table V DEATHS FROM ACUTE MYOCARDIAL INFARCTION (ICDA CODE 410)  SASKATOON 198 0-83 14 From Hosking, D.J.  YEAR  Total Deaths  Average Age  Out o f H o s p i t a l No. %  3  In H o s p i t a l Or I n s t i t u t i o n ' No. % 0  1980  157  78  36  23  121  77  1981  163  71  45  28  118  72  1982  233  75  54  23  179  77  1983  155  N'/A  44  28  111  72  These f i g u r e s are probably c o n s e r v a t i v e s i n c e they are r e s t r i c t e d t o code 410, i n s t e a d o f codes 410-414, the u s u a l r.ange surveyed.  In a d d i t i o n , when G i l l u m and o t h e r s  c a r r i e d out a s i m i l a r study i n M i n n e a p o l i s they  conducted  69  an e x t e n s i v e ascertainment procedure to ensure  complete  c o u n t i n g o f a l l o u t - o f - h o s p i t a l deaths t h a t ought to have been a t t r i b u t e d t o these codes.  They found about 8% of  o u t - o f - h o s p i t a l deaths were i n c o r r e c t l y  coded.  1 5  Given these two p o s s i b l e sources f o r u n d e r e s t i m a t i n g SCD  i n Saskatoon, a f i g u r e o f about 60 such deaths per year  i s proposed as a working average.  E s t i m a t e s d e r i v e d from  l i t e r a t u r e c i t e d p r e v i o u s l y have suggested a f i g u r e of 6 o u t - o f - h o s p i t a l c a r d i a c a r r e s t s a year per 10,000 people (Eisenberg 1978).  In a c i t y o f 170,000, about 100 SCD  have been expected.  would  I f 20-30% s u r v i v e d t o be d i s c h a r g e d from  h o s p i t a l , as happens i n c i t i e s w i t h the most e x t e n s i v e l y developed EMS, per  year.  Saskatoon might e x p e r i e n c e 2 0-30  With 50% m o r t a l i t y i n the f i r s t  about 10-15  people, mainly men  decades would  still  l i v e s saved  two to three y e a r s ,  i n the seventh and e i g h t h  be a l i v e more than two y e a r s a f t e r the  event, and o f those, about 3 to 5 would be working f u l l or part-time. for  1980  However, g i v e n the a c t u a l data from Saskatoon  t o 1983  and b e a r i n g i n mind the s i g n i f i c a n t l y  m o r t a l i t y r a t e s from CHD  from 1973 t o 1979,  low  these "expected"  c a l c u l a t i o n s r e q u i r e r e d u c t i o n by about o n e - t h i r d to o n e - h a l f . The b e n e f i t s o f l i v e s saved have been d i s c u s s e d i n Chapter 4.  If a l i f e  saved p r o v i d e d a b e n e f i t of about  $41,000 per i n d i v i d u a l per year and i f i n Saskatoon i d e a l c i r c u m s t a n c e s 6-10 o v e r a l l b e n e f i t would  under  l i v e s might be saved per year, the  range from $240,000 t o $410,000  70  (1980  dollars).  The  c o s t of d e v e l o p i n g the system t o the  p o i n t where 20-30% of SCD  are d i s c h a r g e d from  has been analyzed i n the f o r e g o i n g s e c t i o n .  hospital Initial  capital  o u t l a y would have to t r i p l e and o p e r a t i n g c o s t s o f j u s t ACLS u n i t would exceed  the c a l c u l a t e d b e n e f i t s .  one  It i s well  r e c o g n i z e d t h a t s m a l l e r communities do not have the tax base to support systems such as those operated i n S e a t t l e or Miami. The  f a c t t h a t the h i g h m o r t a l i t y r a t e s experienced i n l a r g e  American c i t i e s may  not be experienced i n communities  i n o t h e r r e g i o n s a l s o has a s i g n i f i c a n t b e a r i n g on argument.  An adequate and a f f o r d a b l e EMS  be q u i t e d i f f e r e n t from the p r o t o t y p e  4.  the  f o r Saskatoon  will  systems.  A Proposal with A l t e r n a t i v e s  For any s i t u a t i o n t h e r e are t h r e e b a s i c a l t e r n a t i v e options.  F i r s t , p r e s e n t programs may  some cases, the do-nothing  be c o n t i n u e d , and i n  approach may  Second, p r e s e n t programs may  be  justified.  be m o d i f i e d w i t h i n the c o n s t r a i n t s  o f a v a i l a b l e r e s o u r c e s t o address assessed needs i n a more r e s p o n s i v e way.  T h i r d , r e s o u r c e s may  p r e s e n t programs and put i n t o new address  be s h i f t e d away from  programs t h a t more d i r e c t l y  the assessed need.  To continue w i t h the present program means c o n t i n u i n g w i t h inadequate  t r a i n i n g and remuneration  l o c a t e d ambulance s i t e s , a response  of s t a f f ,  ineffectively  time i n 40% of emergencies  71  of g r e a t e r than 6 minutes, minutes,  and i n 60%,  of g r e a t e r than 4  no o r g a n i z e d approach t o f i r s t - r e s p o n s e teams i n  r u r a l a r e a s , no s t a n d a r d i z a t i o n of communication, no  public  awareness programs on e a r l y warnings of impending emergency except  f o r ongoing  bystander CPR  community a g e n c i e s , and on the numbers of SCD  standards  is  data  i n the D i s t r i c t o r t h e i r salvage r a t e . f o r the f o l l o w i n g reasons:  i t i s probably u n e t h i c a l to m a i n t a i n c u r r e n t i n the l i g h t o f minimal  t r a i n i n g and 2)  by  f i n a l l y , no s p e c i f i c a l l y c o l l e c t e d  T h i s o p t i o n i s unsupportable 1)  t r a i n i n g sponsored  c o s t s r e q u i r e d to upgrade  improve deployment of ambulance u n i t s ;  the treatment  of the r u r a l p a r t s o f the  District  inequitable; 3)  which may 4) care may  t h e r e are i n e f f i c i e n c i e s b u i l t i n t o the system be f a i r l y  simply remedied;  bystander CPR  i n the absence of mobile  be doing harm and  definitive  i s p o s s i b l y not doing any good.  Another a l t e r n a t i v e i s t o r e a l l o c a t e r e s o u r c e s away from the e x i s t i n g program i n order to begin new t h i s i n s t a n c e the new  initiatives.  In  i n i t i a t i v e s would probably i n c l u d e  smoking c e s s a t i o n , d i e t a r y c o u n s e l l i n g and f i t n e s s campaigns. Strictly  speaking t h i s may  s o l u t i o n i n the longterm.  t u r n out t o be the most e f f e c t i v e However, the c a l c u l a t e d  beneficial  e f f e c t s o f primary p r e v e n t i o n i n i t i a t i v e s on CHD m o r t a l i t y were s e t a t o n e - h a l f f o r white males and o n e - t h i r d f o r white  72  females.  The f a i l u r e o f any c l e a r , p o s i t i v e answers t o emerge  from t h e m u l t i p l e r i s k f a c t o r i n t e r v e n t i o n t r i a l s d e t r a c t s from the s t r e n g t h o f t h i s o p t i o n .  further  F i n a l l y i t would  almost c e r t a i n l y be p o l i t i c a l l y unacceptable t o reduce e x i s t i n g s e r v i c e s , p a r t i c u l a r l y when the p r e s e n t government has s i g n a l l e d i t s i n t e n t t o move i n the o p p o s i t e d i r e c t i o n . The  f i n a l o p t i o n i s t o modify p r e s e n t programs i n the  l i g h t o f a s s e s s e d needs.  The system r e q u i r e s b e t t e r response  times t o i n i t i a t i o n o f CPR i n both urban and r u r a l areas b e f o r e any o t h e r changes  are i n t r o d u c e d .  Improved time t o  onset o f d e f i n i t i v e therapy and improved p u b l i c response may a l s o be r e q u i r e d but f u r t h e r i n f o r m a t i o n must be gathered  first.  The C i t y o f Saskatoon has an unusual urban p l a n n i n g c a p a b i l i t y i n t h a t the neighborhood d i s t r i c t s t h a t  comprise  the community a r e based on a g r i d compatible w i t h census t r a c t boundaries.  The age-sex p o p u l a t i o n pyramid f o r any  o f the 54 neighborhood d i s t r i c t s i s known, as are standard census sociodemographic d a t a .  In the immediate  future,  a p o s t a l code t r a n s l a t i o n program w i l l be added t o the p r e s e n t system which w i l l enable the C i t y t o a t t r i b u t e h o s p i t a l m o r b i d i t y and m o r t a l i t y data back t o neighborhood of r e s i d e n c e .  T h i s f e a t u r e w i l l permit a n a l y s i s o f the  d i s t r i b u t i o n and c o n c e n t r a t i o n o f t a r g e t c o n d i t i o n s a c r o s s c i t y d i s t r i c t s w i t h known p o p u l a t i o n bases.  I t w i l l be  p o s s i b l e w i t h i n the next year t o p l o t the d i s t r i b u t i o n o f  73  SCD  and o t h e r emergencies by l o c a t i o n and  time.  The p r o p o s a l f o r managing o u t - o f - h o s p i t a l c a r d i a c a r r e s t i n Saskatoon and area has 1.  s i x components:  Assessment of the geographic  d i s t r i b u t i o n of  i n both the urban and r u r a l areas of the D i s t r i c t . c i t y t h i s may  In the  be achieved by u s i n g the program o u t l i n e d above.  In r u r a l area^s, a p r o s p e c t i v e survey w i l l be 2.  SCD  A p r o s p e c t i v e survey of SCD  necessary.  i n c i d e n c e and  r a t e s t o be undertaken w i t h i n the D i s t r i c t .  salvage  This w i l l  provide  a b a s e l i n e from which to r e f i n e c a l c u l a t i o n s of c o s t s and benefits. 3.  A p l a n n i n g e x e r c i s e to be undertaken r e g a r d i n g  the number and deployment o f v e h i c l e s i n the c i t y and  the  l o c a t i o n o f f i r s t - r e s p o n s e teams i n the r u r a l area of the District.  The  e x e r c i s e w i l l be s p e c i f i c a l l y d i r e c t e d toward  r e d u c i n g response 4.  time t o f o u r minutes or l e s s .  A p u b l i c awareness campaign to be i n i t i a t e d i f  p r o s p e c t i v e surveys  i n d i c a t e t h a t there are s i g n i f i c a n t  delays  between onset of symptoms and a c t i v a t i o n of the system. 5.  A l l ambulance attendants t o be upgraded to  EMT-1  with r e g u l a r r e c e r t i f i c a t i o n . 6. i n one  A pilot  study of E M T - d e f i b r i l l a t i o n to be  ambulance u n i t f o r the c i t y s e r v i c e and  area o f the r u r a l p a r t of the  District.  initiated  i n one  geographic  74  Some o f these components may be undertaken s i m u l t a n e o u s l y which w i l l Except  reduce the time r e q u i r e d f o r the study.  f o r the p u b l i c  awareness campaign and the p i l o t  of E M T - d e f i b r i l l a t i o n ,  r e s o u r c e s r e q u i r e d can come from  existing  Presumably  allocations.  study  both components w i t h  s i g n i f i c a n t c o s t s a t t a c h e d w i l l be o f i n t e r e s t to the provincial  government because  application.  o f the p o s s i b i l i t y o f wider  The l i k e l i h o o d o f funding f o r these two  components seems r e a s o n a b l e .  75  Chapter V  Notes  1.  Saskatchewan Department o f H e a l t h : Report o f the Ambulance Review Committee. Towards a Comprehensive and I n t e g r a t e d Ambulance S e r v i c e f o r Saskatchewan. L. B i r k b e c k (Saskatchewan, 198.3. p. 3-5).  2.  Report o f the P r o v i s i o n a l Board of H e a l t h . mimeo. 19 77.  3.  Slimmon, J . The H i s t o r y o f the Saskatoon Area Ambulance District. Unpublished mimeo 19.83. SAADB O r i e n t a t i o n Manual. 350 - 3rd Avenue N., Saskatoon.  4.  Saskatchewan  Health.  ibid.  5.  Saskatchewan  Health.  ibid.  6.  The run r e p o r t s were designed, implemented, and monitored by Mrs. Joan F e a t h e r , the s e c r e t a r y t o the SAADB from i t s i n c e p t i o n t o 1981.  7.  Annual Reports o f the Saskatoon and Area Ambulance D i s t r i c t Board 1980-1983. 350 - 3rd Avenue N. Saskatoon.  8.  Matthews, V.L. L e t t e r t o the P r o v i s i o n a l Board o f Health. December 6, 1978. Saskatoon.  9.  Hosking, D.J. An E v a l u a t i o n o f Paramedic S e r v i c e s February 1982. A Report t o the SAADB, Saskatoon.  Unpublished  p. 35-39.  10.  Annual Reports o f the SAADB.  ibid.  11.  Tweed, W.A. , G. B r i s t o w , N. " R e s u s c i t a t i o n from C a r d i a c System P r o v i d i n g Only B a s i c Hospital. CMA J o u r n a l 122  12.  Annual Report 198 3 Saskatoon Community H e a l t h U n i t Saskatoon October 1984 156 p.)  13.  H e a l t h and Welfare Canada. M o r t a l i t y A t l a s of Canada, V o l . 3 : Urban M o r t a l i t y (Ottawa 1984 139 p.)  14.  Hosking, D.J. i b i d . I am g r e a t l y i n d e b t e d t o Dr. Hosking f o r p e r m i t t i n g me t o use t h i s m o r t a l i t y i n f o r m a t i o n .  Donen. A r r e s t : Assessment o f a L i f e Support Outside o f February 9, 1980. pp 297-304.  G i l l u m , R.F. and o t h e r s . "Sudden Death and Acute M y o c a r d i a l I n f a r c t i o n i n a M e t r o p o l i t a n Area 1970-1980. New E n g l . J . Med. 309^ (.22). December 1, 1983. pp. 1353  77  Chapter VI  Summary and Recommendations  There are s e v e r a l key p o i n t s c o n t a i n e d i n the m a t e r i a l reviewed i n t h i s study. F i r s t CHD  i s the l e a d i n g cause o f death i n North  and i n the c i t y o f Saskatoon.  However, i n Saskatoon  r a t e s are c o m p a r a t i v e l y low.  Sudden c a r d i a c death i s  America the  n u m e r i c a l l y an important category o f m o r t a l i t y from CHD  in  much of North America, but does not appear t o be as p r e v a l e n t as expected i n Saskatoon.  An estimate o f 60 cases per year has  been made f o r the c i t y , but f u l l y a c c u r a t e d a t a are not available.  A p r o s p e c t i v e survey may  determine i n c i d e n c e o f SCD  be the b e s t way  to  f o r Saskatoon.  The i n c i d e n c e of and m o r t a l i t y from CHD s i g n i f i c a n t l y i n North America.  are d e c l i n i n g  An e s t i m a t e d o n e - t h i r d  to o n e - h a l f o f the d e c l i n e has been a t t r i b u t e d t o primary p r e v e n t i o n but the data are not c l e a r enough f o r t h i s estimate to be u n a s s a i l a b l e .  Secondary p r e v e n t i v e measures a p p l i e d  o p t i m a l l y can salvage o n l y about 10% of v i c t i m s o f CHD, t h e r e f o r e do not p r o v i d e a longterm s o l u t i o n .  Until  and  further  s t u d i e s are done, both primary and secondary p r e v e n t i v e measures should be maintained. With r e s p e c t t o EMS  systems  i n o p e r a t i o n today, i t i s  known t h a t one o f the major sources o f d e l a y l i e s w i t h p a t i e n t s not a c t i v a t i n g the system.  The importance o f  p u b l i c awareness o f the symptoms o f impending  collapse  78  cannot be o v e r s t r e s s e d . Although the l i f e s a v i n g c a p a b i l i t i e s a s s o c i a t e d with ACLS and bystander CPR  have been w e l l documented, i t i s not  c l e a r t h a t e i t h e r component per se d i r e c t l y a f f e c t s I t appears now  t h a t s h o r t time t o i n i t i a t i o n o f CPR,  s h o r t time to d e f i n i t i v e therapy key and may CPR.  survival.  ( d e f i b r i l l a t i o n ) may  permit i n n o v a t i v e v a r i a n t s on ACLS and  Bystander CPR  and  i n the absence  be the  bystander  of ACLS, or without  the p r o v i s i o n o f d e f i n i t i v e care i n l e s s than 10 minutes,, does not improve  s u r v i v a l , and may  u n i t s have r a r e l y been viewed  a c t u a l l y do harm.  ACLS  as having u n i v e r s a l  application.  They cannot work i n r u r a l or remote a r e a s , and appear to be too expensive t o be supported by s m a l l e r c i t i e s and towns. Given p r e s e n t c o s t - e s t i m a t e s and the c u r r e n t m o r t a l i t y r a t e s from SCD  i n Saskatoon  the c o s t b e n e f i t r a t i o f o r a  t i e r e d - r e s p o n s e system i n c l u d i n g ACLS and bystander i n t h i s area i s u n l i k e l y to exceed i s new  evidence t h a t scaled-down  def i b r i l l a t i o n may advantage  F o r t u n a t e l y , there  a l t e r n a t i v e s such as  similar benefits.  EMT-  The added  i s t h a t E M T - d e f i b r i l l a t i o n has been shown t o work  i n a t l e a s t one  study i n a r u r a l a r e a .  The r e l a t i v e l y not be d i s c o u n t e d . later in l i f e ,  few l i v e s now  being saved by EMS  Not only are people s t a y i n g  but t h e r e are a l s o new  developed t h a t may patients.  produce  1:1.  CPR  should  healthier  t e c h n o l o g i e s being  enhance the longterm s u r v i v a l of these  79  F i n a l l y , Saskatchewan i s undergoing a process of review and and  upgrading of EMS  the l o c a l ambulance board i s s t r o n g l y committed to  developing The  s e r v i c e s on a province-wide b a s i s ,  the best  s e r v i c e p o s s i b l e f o r the resources  available.  p o l i t i c a l w i l l to improve e x i s t i n g systems i s on  record,  as i s community support f o r the best  affordable  service. Some o f the d i f f i c u l t i e s w i t h the Saskatoon Ambulance s e r v i c e may  be r e c t i f i e d at minimal c o s t .  Other changes  ought t o be preceded by a p e r i o d o f l o c a l study. set  forth i n i t i a l l y  i n t h i s paper may  now  The  questions  be answered i n  part. 1.  A properly  i n terms of r e d u c i n g 2.  The  can p r o v i d e  small  gains  m o r t a l i t y from c a r d i a c a r r e s t .  components r e q u i r e d to achieve t h i s  i n m o r t a l i t y may anticipated.  designed EMS  reduction  not be as c o s t l y or complex as once  They i n c l u d e a p u b l i c e d u c a t i o n campaign,  enough ambulance u n i t s i n s t r a t e g i c l o c a t i o n s t h a t w i l l BLS  response i n four minutes, adequately t r a i n e d and  ambulance a t t e n d a n t s ACLS, and 3.  remunerated  (EMA-1), d e f e r r a l of c o n s i d e r a t i o n  of  p o s s i b l y a t r i a l of E M T - d e f i b r i l l a t i o n . Saskatoon and  area may  be able to a f f o r d the  scaled-down v e r s i o n of the most e f f e c t i v e 4.  permit  The  EMS.  epidemiology of c a r d i a c a r r e s t i n Saskatoon  appears to be d i f f e r e n t enough from p u b l i s h e d f u l l y developed ACLS system i s not  warranted.  data t h a t  the  80  5.  CHD  and c a r d i a c a r r e s t , n o t w i t h s t a n d i n g  the  r e l a t i v e l y low r a t e s i n Saskatoon, remain l e a d i n g causes of death  i n the community. 6.  There are o t h e r ways o f impacting on CHD m o r t a l i t y  t h a t may  be more e f f e c t i v e i n the l o n g run.  modest improvements i n our EMS  should be pursued  w i t h f u r t h e r development o f primary  The  However, i n tandem  p r e v e n t i o n programs.  recommendations a r i s i n g from t h i s study are as  follows: 1.  Both primary  and  secondary  p r e v e n t i v e programs  d i r e c t e d toward r e d u c i n g m o r t a l i t y from o u t - o f - h o s p i t a l c a r d i a c a r r e s t ought to be maintained  and where p o s s i b l e  improved. 2. event, EMS  P u b l i c awareness o f t h e " s i g n s of an impending c a r d i a c and a p p r o p r i a t e response,  i s one  component o f an  t h a t r e q u i r e s immediate a t t e n t i o n . 3.  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C a r d i o l . 5 0 . August 1 9 8 2 . pp. 3 7 0 - 7 2 . p. 3 7 0 . Webster, A.C. E v o l u t i o n of Emergency C a r d i a c Care i n Canada. CMA J o u r n a l 1 1 7 . December 1 7 , 1 9 7 7 . pp. 1 3 8 3 - 8 6 . Wigle, D.T. Heart Disease M o r b i d i t y and M o r t a l i t y Trends. C h r o n i c Disease i n Canada 2_ ( 2 ) . September 1 9 8 1 . p. 1 0 . Z i p e s , D. and o t h e r s . E a r l y Experience w i t h an Cardioverter. New. E n g l . J . Med. 3 1 1 ( 8 ) . pp.  485-490.  Implantable August 2 3 , 1 9 8 4 .  SASKATOON AREA AMBULANCE DISTRICT CITY OF SASKATOON ONLY F i g u r e 3:  Pick-up L o c a t i o n s f o r Emergency c a l l s (Codes 3 and 4)  Legend:  •  No c a l l s , o r l e s s than 3 percent of t o t a l calls I'll,-!,- ' : 1  3.0  - 5 . 9 percent  6.0  - 8 . 9 percent  1  - 11.7 percent  "It. Scale: metric Grid:  i I  if  -•  1:50,000  1 square  3  mile  •1 ^  IiT>  '-••vr»  ^  J  i it  1,7if.I .^jv• v J APPENDIX A 1  rj  i?flifti.fti  .J  •'•  \  SASKATOON AREA AMBULANCE DISTRICT CITY OF SASKATOON ONLY  Figure  5"  P r o p o r t i o n o f Emergency C a l l s (Codes 3 & 4) f o r which Response Time Exceeded S i x Minutes  Legend:  0 - 39 percent f! v ^ ~ ' T 4C - 59 percent  60 - 79 percent  r 4 ! ' . .  '^•'0".  r  w  fit  '  i.lJui.l.LI  --Vn j's?1  r//on!i::a  ft  1 » ' 11 i • ,  80 - 100 percent \  ,:i ;;>. : m i.i.u.i t ^ J s r  Scale: metric 1:50,000 Grid:  1 sinmre m i l e h*&m*M  //>. "I  l -\ . f ! h;i ' . ' . C O  .IS.  !.«> i ,/  V < i; i  ( :,  i•j'Y'.!l  «II?: I  1  if  iMrJjX,  If. « I J f j i if I l i t 11 TIT. U ^ ^ : . j y » - . y ^ S f e ^ i £  APPENDIX  B  1  I!  I  X- ' >  

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