How should we save more lives from cardiac arrests?

During the second week of September, I was in the Department of Emergency Medicine as part of my clinical rotations. Our university hospital focuses primarily on tertiary emergency medicine, therefore, only the most severe patients are carried into the ER here, such as cardio-pulmonary arrests (CPAs). However, there are exceptions, including cases where the ambulance had been refused by other hospitals, which is unfortunately, not rare at all. Through my four days here, there were some things I felt and thought I would like to share.

In emergency medicine, a CPA patient is defined as one who is unconscious, whose breathing cannot be seen, heard, nor felt, and pulse cannot be felt at the common carotid artery. When this patient is carried in, we basically follow either the Immediate Cardiac Life Support (ICLS) or Advanced Cardiac Life Support (ACLS) guidelines and attempt cardio-pulmonary resuscitation (CPR). However, through the days I was there, out of a total of seven CPA patients carried in, none recovered from coma and one reached recirculation but did not regain consciousness. The hospital admits 350 to 400 CPA cases per year, and circulation returns in approximately 50 of them, and total recovery is 10% of that, and that means a single digit number.

When one falls into CPA, which part of the human is most quickly damaged? The brain. Not only is it a damage, but an irreversible one. It is said that if recirculation could not be achieved within five minutes of CPA, chances of full recovery declines to 50%, and after 10 minutes, that plummets to somewhere extremely close to zero. With this considered, in the U.S., some local authorities have begun to adopt the termination of resuscitation (ToR) guideline. It supports termination in the out-of-hospital setting subsequent to failed basic life support (BLS) resuscitation by emergency medical services (EMS) personnel if all of the following are true: (1) no return of spontaneous circulation prior to transport; (2) no shock given prior to transport; and (3) arrest not witnessed by EMS personnel.

Our university hospital concentrates on tertiary emergency medical care, so in other words, patients carried in are those whose chances of full recovery are close to none. But no matter how the situation is, ER personnel will do whatever they can do to resuscitate. In Japan, the average time it takes for an ambulance to reach the site after the 119 call is seven minutes, and it takes 30 minutes from the time of arrival at the site to reach a hospital. It doesn't take a rocket scientist to see that that is well beyond the 5 minute 50-50 tipping point.

Without doubt, knowing the ICLS or ACLS procedure is a must for all health care providers. However, chances of a CPA patient being saved is extremely low, unless someone at the site knows BLS and carries it out. What I would like to clarify here is that yes, knowing the ICLS or ACLS guidelines and being able to perform it is important, however, teaching people the basics of emergency medicine and making sure they can perform BLS promptly and appropriately is the way to significantly cut the number of lives lost from CPA. The good news is, BLS seminars are becoming more common, and organizations from corporations to governments are placing automated external defibrillators (AEDs) here and there. Now, we also need to focus on how to help people keep up with their BLS skills. :-)

Studying for the CBT.

January was a busy month, well sort of.

4th-year medical students in Japan now have to go through a set of exams called the Common Achievement Tests (CAT), which comprises an objective-structured clinical examination (OSCE) and a computer-based test (CBT). The former tests basic clinical skills while the latter checks to see if you have the essential knowledge that is deemed necessary to begin clinical rotations. So basically, the CBT part is a complete review of the 4 years.

However, like most other tests, studying for the CBT is test-focused and test-oriented. It's not something you should start off by opening your textbook from two years ago, but more like get the unofficial guide and workbook (like the First Aid for the USMLE) and study based on that. Why unofficial? Because there's no such thing as an official guide nor workbook. All they give us is a handout with a brief explanation of the exam, and the exam itself is not made public. So what this means is the quality of the exam does not improve. The unofficial workbook is made up of questions that have been remembered by past examinees, and so though it is not the actual past exam, it is the closest one available, and at a glance, there are tons of questions that are not clear and some just lack explanation to the extent that we can come up with more than one answer.

Finished the OSCE two days before Christmas, and now the CBT. One of my biggest concerns is whether I would be able to keep my concentration through the exam, most notorious for its length of seven hours. The unofficial workbook is what I along with everyone else is doing, but there are six volumes to the series totalling over 3,000 questions. Since I'm the kind of person who can't concentrate for long in his own room, people would find me studying in a Starbucks or a McDonald's for hours.

By the way, it's been a pretty cold winter, and Tokyo, which seldom gets snow much less any accumulation of it, has so far had 5 centimeters of snow twice this year.

Looking back at 2007.

Time flies.

Oh boy, I wonder how many times I've said this phrase on this blog. But well, it's true. But it's also true that this year was full of meeting new friends and discovering my interests... and myself.

In spring, I participated in VIA's (a non-profit based in San Francisco and on the Stanford University campus) Exploring Health Care program to learn about health care in the USA and in the Bay Area in general. Along with medical students and undergraduates thinking of going that way, we hopped around the area to see hospitals, clinics (both private and free), homeless shelters, shadow doctors' rounds, participate in class to get a taste of what medical education is like there, and much much more over a period of 2 weeks.

The gay clinic called the Magnet, located in the heart of Castro, the gay mecca of the country, is what sparked me into community-based health care, or in other words health care that involves the entire community. What's amazing is that it's not merely a clinic but has the potential to act as a catalyst to bring a people together and empower them as a whole. I'll talk about this much more in detail another time...

And this summer, I found myself in a 11-day primary health care (PHC) training program at Mahidol University's ASEAN Institute for Health Development (AIHD) in Thailand. Along with nursing school students from that country, we followed a highly-concentrated course to see health care in the urban areas of Bangkok (including the slums), go up 4 hours by bus to the rural areas in Uthai Thani Province and stay in a village to do some epidemiology field work 'for beginners', and do a presentation at the end with our groups.

The rural area home-stay and the interviews and other interactions with the villagers totally changed how I think, and this is where PHC and community-based health care got on me. Again, I have to save another time to tell this in detail...

And last but not least, DOCS (acronym for Development of Clinical Skills), which we formed with the former participants of the Exploring Health Care program in our university to get a head start and practice clinical skills, played an important role in my life this year. We found energetic, passionate, student-caring doctors who were willing to teach us, in a university where we once felt finding those kind of mentors was devastating. Moreover, the activities led me to knowing general medicine, family medicine, and primary medical care, which then led me to Ukima Clinic, a community-based clinic up in northern Tokyo. (See post 2007/11/20.)

The more I look back at this year, the more the activities I was involved in get connected in one straight line. Compared to a year ago, I couldn't have imagined myself where I am now. This year helped me discover what my true interests are in (at least for now), and now I can much better describe the bigger picture of the doctor I have in mind for my future.

Wishing everyone a happy holiday season and another great year! :-)

Patient assessment workshop by young doctors.

What would I do if a person walking in front of me suddenly collapses? He's holding his stomach and seems to be suffering from some kind of severe pain...

Much has been talked about basic life support (BLS), but that algorithm basically only applies to cases where the patient's heart has stopped. Well, then what do we do if a person's heart still seems to be working but he's unconscious and seems to be hurt in some way, is the question here. This is called advanced medical life support (AMLS) or international trauma life support (ITLS), and it's about assessing the condition of the patient in an emergency.

The algorithm consists of three major steps, and the first is called "Scene Size-Up", where the checklist assesses five points: body substance isolation (BSI), scene safety, number of patients, nature of the illness or the mechanism of the injury, and the resources that you have at that moment. The main purposes of this step is to provide safety not only for the patient but also for yourself, and collect information that can be gathered in a glance.

"Initial Assessment" is the second step, which is also the most important of the three. We assess five things here too: general impression of the patient, mental status, airway, breathing, and circulation. Does the patient seem severe? What's the level of consciousness? (AVPU - Alert, reacting to Verbal stimulation, reacting to Pain stimulation, or Unconscious?) Is there anything obstructing the airway? Is the patient breathing? What's the heart rate and condition of the peripheral circulation? Is the patient bleeding? Appropriate assessment in this step is vital, as the third step depends on the condition of the patient.

If the heart is not moving, we move on to BLS or advanced cardiac life support (ACLS). But if that's not the case, we first evaluate whether it's a trauma case or not. If it is, then we see if it's a single trauma or multiple. If it's single, we do a focused rapid examination of the injured area and ask the patient SAMPLE (Sign/symptom, Allergy, Medication, Past medical history, Event prior to the symptom) questions, while if it's multiple, we need to do a rapid thorough trauma survey of the entire body before asking the same set of questions. All of this is done before handing the patient over to the hospital.

Now, if the case is not a trauma, then we first see whether the patient is responsive or unresponsive. In the latter case, we must go through a rapid medical assessment of the entire body and check the vital signs (circulation and blood data). Gathering the medical history of the patient comes last, since one cannot speak at this moment. If the patient can respond to you, you gather this information first and then move on to rapid medical assessment and checking vital signs. Again, this is done outside or in the ambulance, before it reaches a hospital.

Of course, there's more detail and thinking to this, but the important thing about this type of learning right now is for us to do simulations with our fellow peers over and over to memorize the algorithm with your body, instead of the just the brain. Then we can move on to the details and the thinking of case-by-case scenarios. What's amazing about this workshop was that it was planned and carried out by a group of only first and second-year doctors and students. It really motivates you. :-)