BY JORDAN LITE
DAILY NEWS HEALTH WRITER
Tuesday, May 24th, 2005
Bill Keating was driving his son Liam home from a basketball game one winter morning last year, wondering out loud why the coach didn't use Liam more.
In the next minutes, it became clear that his son possessed another set of skills that were far more valuable.
As the two approached a stop sign, Keating suddenly leaned forward in the driver's seat. "Something's wrong," he said, before blacking out and slumping backward between the headrest and the door.
Liam, then 15, jerked the steering wheel to the right, and the car rolled to a stop at a snow bank. His father seemed to be sucking air in, but he had no pulse. To Liam, who had learned cardiopulmonary resuscitation in school just four months before, it was clear that his father's heart had stopped, a condition called sudden cardiac arrest that affects 220,000 people in the United States annually, 95% of whom die.
"I was like, 'This can't seriously be happening.' I was one of those people who said, 'It will never happen to me,'" said Liam, now 17.
"Then when it does, you know it," said Liam, who lives in Sag Harbor , N.Y. "It's kind of like an adrenaline rush where you just start doing it automatically. You remember: two breaths, 15 compressions, when to take the pulse."
Liam's lifesaving action is frighteningly rare. Only one-third of New Yorkers perform CPR when they witness someone in cardiac arrest, a new study finds, contributing to the city's poor 2.2% rate of survival when a person's heart stops anyplace other than inside a hospital. The rate is similar to that of Los Angeles , where it is 1.4%, and Chicago , where it is 1.7%, but is still much lower than in places such as Seattle , where some 18% are saved.
Experts attribute the difference in part to a Washington State law requiring anyone with a driver's license to know CPR. The New York State Legislature is considering a bill that would require all high schools in the state to train students in CPR and in using a defibrillator, a machine that can restart the heart when it lapses into a specific, irregular rhythm called ventricular fibrillation.
Performing CPR is especially imperative in New York City , where it takes an average of eight minutes for EMS to reach critically ill patients after they are dispatched by 911 operators, according to FDNY-supported research that will be presented today in Manhattan at a meeting of emergency-room doctors.
While merging EMS with the FDNY in 1996 nudged survival from out-of-hospital cardiac arrest up from 1.4% and cut response time from more than 11 minutes, eight minutes still can be too late. Ideally, CPR should be started within four minutes of a person's heart stopping to ensure that the heart and brain receive oxygen; defibrillation within six.
With each passing minute, the chance of surviving cardiac arrest falls by 10%. After 10 minutes, it is less than 10%.
But when bystanders give CPR before EMS arrives, the survival rate nearly doubles to more than 5%, according to study author Dr. Robert Silverman, director of research for the department of emergency medicine at Long Island Jewish Medical Center. If more people performed CPR, if defibrillators were more widely available and if cities increased their survival rates to 20%, an estimated 40,000 people would survive cardiac arrest each year, according to the American Heart Association.
"CPR buys you time, allowing the defibrillation to be effective when the ambulance gets there," Silverman said.
That's what happened to Keating, now 58. After Liam lifted his dad out of the car with the help of passengers in the car behind them, he performed CPR for the next 3 or 4 minutes. Police arrived just ahead of paramedics, Liam said, and shocked his father back to life with a portable defibrillator, known as an AED, that was stored in the trunk of the patrol car.
All Nassau and Suffolk County Police patrol cars carry AEDs. In New York , there is one AED for the radio car of each of the city's 76 police-patrol precincts, as well as for each of its harbor, aviation, highway, transit district and public service areas, such as housing projects, an NYPD spokesman said. The program began after a 1994 study of EMS response time and survival rates for out-of-hospital cardiac arrests recommended it, noting that police often arrive at an emergency ahead of EMS and are present at the majority of cardiac arrests.
Also as a result of the 1994 study, the Fire Department added 210 defibrillators on engine companies and doubled the number of ambulance tours on the streets, said EMS spokesman Dave Billig.
"Now the only thing left to do is to get the public involved, to train them to recognize the signs and symptoms of cardiac arrest and begin that pre-hospital medical care before we get there," Billig said. "That's what's going to help save more patients." Two deaths averted at Hunts Point
With studies showing that 70% of all cardiac arrests occur in the home, the federal government has approved the sale of over-the-counter AEDs, and a growing number of businesses are buying them as well.
In October 2003, five peace officers at the Hunts Point Terminal Market in the Bronx saved David Benson, a trucker from California whose heart stopped at the market, using CPR and an AED. It was the second such save in the eight years of the market's AED program, which was instituted because of "problems with EMS getting to patients on time" at the sprawling, 130 square-acre facility, said José Colon, the market's chief of public safety.
EMS arrived 15 minutes after Benson went down, according to Colon . ( EMS arrived 11 minutes after it was dispatched by 911, Billig said. The response time, he added, was "an aberration.") "That's after what we call the 'golden 10 minutes' that are ideal for somebody to get a shock," he said. "The fact that he at least got CPR was definitely a plus. Had we not had the machine, this patient probably would not have been with us."
New York 's Good Samaritan law protects bystanders from legal action when they make a good-faith effort to save a life, but experts recommend taking a first-aid training class both for the skills and the confidence to act in an emergency.
'Vertical response time' is the critical factor
In New York , labyrinthine high-rise buildings, broken intercom systems and sluggish elevators are a way of life.
So although it takes an average of 5.7 minutes for EMS to get through traffic to a caller's address, rescuers spend another 2.3 minutes racing the clock to reach patients in critical need of help — a total travel journey of eight minutes, according to a study presented yesterday in Manhattan at a meeting of the Society for Academic Emergency Medicine.
The response time is similar to Los Angeles (5.8 minutes) and Chicago (four to six minutes), though those cities' data do not include "vertical response times," officials there said.
"If you could knock two minutes off that, you're talking about a fair number of lives," said Dr. Neal Richmond, a former FDNY deputy medical director who authored the study.
The study, in combination with several others being discussed this week, for the first time quantifies a problem that experts have long suspected prevents more New Yorkers from being saved.
Previous studies looked only at the amount of time it took for the city's EMS to get to the address of an emergency. This is the first time the city has taken into account "vertical response" — the live-or-die period between when medics shut off the ambulance's ignition and finally make it to a critically sick person.
The lower the floor the better
The chances of being helped in time are worse in certain types of buildings than others, according to investigators.
In residential buildings, the vertical response time was 3.2 minutes, compared to 2.9 minutes for office complexes, 1.7 minutes for private homes of less than three stories and 0.6 minutes for outdoor calls.
Among the more troubling findings was that an average of 50 seconds were added to calls to residential buildings with elevators, and an additional 54 seconds if the elevator stopped before reaching the patient's floor.
When EMS was given an escort, though, vertical response time decreased from 2.5 to 1.9 minutes.
"Our response times are the best they've ever been, and we're getting to patients quicker than we ever have and saving lives," said FDNY spokesman Frank Gribbon.
"I don't know how you make elevators faster," he said. "We can't change the fact that there are very tall buildings in New York City . What we can do is public education."
The FDNY is offering 22-minute CPR classes to schools and community groups. Here's what else you can do to help:
Open the door for EMS . Among the most frustrating obstacles that rescuers face when they reach an apartment or office building are broken or mislabeled intercom systems.
"Basically, you have to press all the buttons," said Capt. Luis Basso, commanding officer for Station 10 in Northern Manhattan . "If you say, 'It's the Fire Department' or ' EMS ,' nobody answers. Then you go, 'Honey, it's me,' and you get a buzzer go off right away."
If possible, send an escort to show medics the way to the patient. "Some buildings have two different sides, and you're not sure to which side you're going," said paramedic Lt. James Bayreuther of Station 20 in the Bronx . "They should tell 911 if they have a family member they can send out to meet us in front of the building and direct us to where we're going."
If you're on an elevator with EMS , allow them to reach the patient's floor before pressing the button for the floor you want to go to. "Everybody's waiting for a long time in a high rise for the elevators to come down. There's normally one elevator working in most of the projects I've dealt with and it's going to take time and everyone's going to want to get on that elevator," Bayreuther said. "We'll have a call on the 15th floor, but we'll get in the elevator with several other people and when we ask them, 'Don't hit anything below the 15th floor,' they'll hit 7, 8, 9, 10 all the way up.
"It's very frustrating," he added. "A lot of times, my guys run up four or five flights and just forget about the elevator. And that's four or five flights with anywhere from 40 to 50 pounds of equipment between them."
J. L.
Could you save someone's life?
Fear and lack of knowledge often discourage bystanders from helping someone in an emergency, said Michelle Bowman, assistant director of training in health and safety services for American Red Cross of Greater New York.
"In an emergency, the first few minutes can really make a difference between life and death," Bowman explained. By taking a first-aid class, "not only do they get the skills they need to respond in a situation, they also get the confidence to act." The Red Cross emphasizes the steps of check, call and care:
Check to make sure you're not going to get hurt by assisting someone else; check to see if there are any bystanders to help out; and check the victim for consciousness.
Call 911. "Either send a bystander to call, which is what we recommend whenever possible, or make that call yourself," Bowman said.
Care for the victim depending on the type of emergency. "We don't ask a citizen responder to differentiate between … problems," Bowman said. "What we teach them is how to deal with the symptoms and to sustain that person's life until advanced medical personnel can arrive."
Restoring a person's circulation involves chest compressions, while restoring breathing depends on ensuring that the victim's airway is clear and breathing into their own mouth. The depth of the compressions differs for babies, children and adults, and a class is the best place to learn the proper way to perform them.
Choking:
Stand behind an adult victim and wrap your arms around his abdominal area. Find their bellybutton and put a fist directly above it. Wrap around your other fist as support. Administer sharp upward thrusts to expel the object until the victim either becomes unconscious or the object is expelled. "If they're unconscious, you go through the same steps as you would for CPR because you don't know if that victim is choking or not. When you do the first two initial rescue breaths, if they don't go in, you have a fairly good idea that there's an object lodged in the person's throat."
Insect bites or stings:
See if the stinger is still in the skin. If necessary, scrape the stinger away from the skin with your fingernail or a credit card. Don't remove with tweezers because it might burst the venom sack. Wash and cover the site. Then apply ice or a cold pack for pain and swelling, keeping a towel between the skin and the ice. Continue to monitor the victim's breathing to make sure he's not suffering from an allergic reaction.
Heavy bleeding:
Put pressure on the wound with a gauze pad or any available substitute. Wrap gauze strip around the injury, but not so tight that you stop the flow of blood. Raise the injured body part above the heart to reduce the bleeding. If bleeding continues, add another gauze pad. If the bleeding is really bad, use your finger to put pressure on the artery.
Electrical burn:
Make sure the scene is safe and call EMS immediately. Turn off any electrical current before approaching the victim. When the scene is safe, check for life-threatening conditions such as unconsciousness or respiratory or cardiac arrest. Continue to monitor the victim's airway, breathing and circulation, and administer rescue breathing or CPR if necessary.
Adult CPR:
Tilt the forehead back and check for breathing for five seconds. If the person is not breathing, give them two rescue breaths. Use a face shield and gloves if available to minimize disease transmission. If the breaths go in, look for signs of circulation for 10 seconds by checking for a pulse and signs of breathing. Find the compression by tracing the ribs and putting your hand below the notch where the ribs meet. Give 15 compressions of 1½-2 inches deep, slightly faster than one per second. Give two breaths; you want to do four cycles of 15 compressions and two breaths. Then check for circulation again for 10 seconds. Continue the cycles until you're unable, until the victim's status changes or until advanced help or an AED arrives.
Hypothermia:
Check for shivering, slow and irregular pulse, glassy stare, numbness, apathy and decreasing levels of consciousness. Remove any wet clothing and place the victim in dry blankets or clothing. Move the victim to a warm environment and apply hot water blankets or heat packs or pads over a barrier, such as a blanket or towel. Rewarm the victim gradually and handle him gently. Give a conscious victim warm liquids to drink. Continue to monitor the victim's airway, breathing and circulation, and administer rescue breathing or CPR if necessary.
Fainting:
"Fainting is really just a type of shock," Bowman said. "It doesn't hurt someone." Put the victim on a flat surface and elevate the legs 8-12 inches. Monitor breathing and consciousness. Don't give the victim anything to eat or drink and wait for him to wake on his own, making sure you maintain his breathing and circulation.
Seizure:
Don't hold or restrain the victim. Protect him from injury and make sure he maintains an open airway. Don't put anything in the mouth. After the seizure, if there's any fluid in the victim's mouth, place him on his side so the fluid can drain. Then allow the victim to rest. Call EMS only if the seizure lasts more than a few minutes or the person has repeated seizures, is injured or doesn't have a pre-existing condition and you don't know why the seizure occurred.
RESOURCES:
American Heart Association CPR Classes: 1-877-AHA-4CPR
American Red Cross Training and Certification: 1-877-REDCROSS
