Sinking heart

December 24, 2018

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The writer is an epidemiologist and senior instructor of research at the Aga Khan University Hospital.
The writer is an epidemiologist and senior instructor of research at the Aga Khan University Hospital.

EVERY hour, approximately 46 individuals die because of cardiovascular disease in Pakistan. About half of these deaths are due to sudden and unexpected cardiac events, leading to cessation of cardiac activity. This is also known as cardiac arrest.

The current structure of pre-hospital care services in Pakistan is unable to deal with this burden, effectively leading to a poor survival rate. Few ambulances are equipped with trained personnel and equipment to provide timely life-support interventions.

Cardiopulmonary resuscitation (CPR) is an emergency life-saving procedure performed when the heart stops beating. The conventional version includes chest compressions and mouth-to-mouth breathing. However, recent focus is on compression-only or hands-only CPR recommended by the American Heart Association for laypersons who see someone suddenly collapse in an out-of-hospital setting.

Even laypersons can save lives if trained in CPR.

We conducted a study involving major hospitals and ambulance services to assess the current scenario regarding sudden cardiac arrests in Karachi. We found that the number of sudden cardiac arrests that occur outside a hospital setting was 166 out of 100,000 population which is higher than estimates reported by North America (median incidence: 96.8 out of 100,000 population, highest: 159 out of 100,000).

In addition, we found that in approximately 93 out of 100 cases, the patient was accompanied by a friend or a family member at the time of cardiac arrest. However, only two out of 100 patients were given CPR. Patients who were transferred to the hospital through an ambulance equipped to provide life support had a longer survival rate compared to those transferred by public/ private transportation such as a taxi or an ambulance without life-support facilities, even though this latter group reached the hospital earlier.

Only five patients were alive and shifted out from the emergency department and only two were discharged out of a total study population of 310 individuals. The percentages of life-saving interventions as well as survival was poor compared to the ones reported from developed countries. Life-saving intervention, such as a CPR, which is supposed to be an immediate intervention, was initiated after 20 minutes of cardiac arrest.

Studies from developed countries suggest a higher number of victims were saved after suffering a cardiac arrest due to the availability of early emergency care provided by either ambulance services or laypersons trained to perform CPR.

Where internationally a single network of ambulances with uniform training and resources provides services throughout the nation, we, on the other hand, have multiple ambulances with an inconsistent level of training and resources to provide emergency care.

For instance a regular Chhipa or Edhi ambulance is equipped with oxygen cylinder and a stretcher only. There is a high dependency on the driver to be able to transport the patient to the hospital quickly with no available facility of any emergency care either on the spot or en route to the hospital.

In such a scenario, where much is required at the governmental/ policy level to improve the systems, how an individual can contribute is an important question.

Studies have shown that when laypersons were trained to provide CPR, it increased the chances of survival of a cardiac arrest patient by two to three times.

In our study, we observed that most of the patients suffered cardiac arrest at home (77 out of 100). In such scenarios, it would be difficult to find a trained healthcare professional in time and would be easier to save someone’s life if a CPR-trained individual were present at the scene.

Considering the imp­­ortance of conducting CPR trainings for local community members, one of our research groups is teaching hands-only CPR (excluding mouth-to-mouth resuscitation) to non-medical professionals in different settings such as sch­ools, hospitals etc, and several other interest groups are also working towards this.

Since the burden of sudden cardiac arrests is higher and survival rate is poor in our country, there is a dire need of such training programmes. Combining efforts in a systematic way in order to target a wider population is something that we need at this point.

In addition, every hospital/ inpatient unit must have a CPR training programme for family members of high-risk patients with cardiac diseases. At this time of the year, when we are observing ‘heart month’ we should join hands to promote or be a part of one of these training sessions to increase the number of people who can provide CPR and reduce the number of deaths due to cardiac arrest.

The writer is an epidemiologist and senior instructor of research at the Aga Khan University Hospital.

Published in Dawn, December 24th, 2018