Notes
one How We Die Suddenly 1 The ratio of ventilations to chest compressions was two to fifteen when this event occurred. Now the ratio is two to thirty. In addition, EMTs and paramedics now follow every shock with two minutes of CPR before assessing the patient’s rhythm. 2 C. S. Fox, J. C. Evans, M. J. Larson, W. B. Kannel, and D. Levy, “Temporal Trends in Coronary Heart Disease Mortality and Sudden Cardiac Death From 1950 to 1999: The Framingham Heart Study,” Circulation 110 (2004), 522–27. 3 R. Davis, “Doctors in Charge Rarely Call the Shots: Most Medical Directors in Big Cities Lack the Power to Improve the System,” USA Today, July 29, 2003. 4 T. D. Rea, M. S. Eisenberg, G. Sinibaldi, and R. D. White, “Incidence of EMS-Treated Out-ofHospital Cardiac Arrest in the United States,” Resuscitation 63 (2004), 17–24. 5 R. D. White, T. J. Bunch, and D. G. Hankins, “Evolution of a Community-Wide Early Defibrillation Programme: Experience over 13 Years Using Police/Fire Personnel and Paramedics as Responders,” Resuscitation 65 (2005), 279–83; T. D. Rea, M. Helbock, S. Perry, et al., “Increasing Use of Cardiopulmonary Resuscitation During Out-of-Hospital Ventricular Fibrillation Arrest: Survival Implications of Guideline Changes,” Circulation 114 (2006), 2760– 65. 6 R. B. Dunne, S. Compton, R. J. Zalenski, R. Swor, R. Welch, and B. F. Bock, “Outcomes from Out-of-Hospital Cardiac Arrest in Detroit,” Resuscitation 72 (2007), 59–65. There was only one cardiac arrest survivor in the Detroit report and this patient had a rhythm other than VF. There were actually no survivors from VF. It is not technically accurate to speak of a 46–fold difference in survival when one of the numbers is zero. Thus, I have taken the liberty to state the survivor rate was ⬍1 percent. As if it weren’t bad enough that Detroit has the lowest survival rate for VF, a recent FBI report listed Detroit as the most dangerous city in the country 215 Notes in terms of crime; see D. N. Goodman, “Detroit Is the Most Dangerous City in Nation, Report Finds,” Seattle Post-Intelligencer, Nov. 18, 2007. I don’t wish to pick on Detroit, especially since I have a soft spot for the city where I was born and spent the first eighteen years of my life. Rather, I admire Dunne and colleagues for their courage in conducting their study and publicizing its findings. 7 G. Nichol, E. Thomas, C.W. Callaway, et al., “Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome,” JAMA 300 (2008), 1423–31. 8 The Leapfrog Group (www.leapfroggroup.org) provides national comparison information on issues of hospital safety and quality. In September 2007, the group reported that 87 percent of 1,256 U.S. hospitals that were surveyed did not have recommended policies in place to prevent hospital-acquired infections. 9 A variety of other rhythms can cause cardiac arrest, but these are much less common than the big three–VF, asystole, and pulseless electrical activity. Pulseless ventricular tachycardia (VT) is one of these other rhythms. Most researchers lump VT with VF because VT usually degenerates to VF in a matter of minutes. Two more rhythms that uncommonly lead to cardiac arrest are fast atrial tachycardia and atrial fibrillation. 10 C. M. Pratt, M. J. Francis, J. Luck, C. R. Wyndham, R. R. Miller, and M. A. Quinones, “Analysis of Ambulatory Electrocardiograms in 15 Patients During Spontaneous Ventricular Fibrillation with Special Reference to Preceding Arrhythmic Events,“ Journal of the American College of Cardiology 2 (1983), 789–97. 11 Potentially correctable causes of PEA include severe volume loss, severe acidosis, hypothermia , severe high or low potassium, severe low blood sugar, toxins and drug overdoses, cardiac tamponade (fluid in the sac surrounding the heart), a collapsed lung, large myocardial infarction, and pulmonary embolus. It may be possible to correct some of these causes with field therapy. 12 Clinicians often speak of coarse, medium, and fine ventricular fibrillation. These are on a continuum, since VF is likely to begin as coarse and then progress to fine and finally to flatlining. Coarse VF has an amplitude of approximately 7–10 mm. and occurs early in cardiac arrest. Medium VF has an amplitude of 3–7 mm. and is likely to occur five to ten minutes into the arrest. Fine VF has an amplitude of 1–2 mm. and is likely to occur after ten to fifteen minutes of...
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