When the heart stops

If someone suffers cardiac arrest in their living room or on the street, should they be rushed to the hospital?

For most people, the answer is a resounding “yes.” But within medical circles, it’s not so clear. Some 90 percent of out-of-hospital cardiac arrests prove fatal. And some argue that given the lack of effective treatment — and because defibrillators are no longer confined to hospitals — a well-trained ambulance crew can do as much for patients as a hospital.

Dr. Bruce Adams, chairman of emergency medicine at the UT Health Science Center and University Hospital, thinks the hospital is still the best place for those patients to be seen. Dr. Adams this week faced off against Dr. Jonathan Benger, a professor of emergency care at the University of West England, Bristol, in a high-profile debate in the pages of the British Medical Journal.

That low survival rate, Dr. Adams wrote, leads to two schools of thought: “The ‘glass 90 percent empty’ skeptics, who see one arresting patient after another come in dead and stay dead, versus the glass 10 percent full optimists, who look to return more survivors to productive life.”

Over the past decade, clinical-decision rules have provided guidelines on resuscitating patients and when to transport them. But validation studies of those rules “have almost always found a handful of survivors who would have been declared dead,” Dr. Adams wrote, and many paramedics have expressed discomfort in following them.

Taking them to the hospital has little impact on medical costs, he added. If every patient who died after being transported had instead died at the scene, it would only have saved the Medicare program $58 million. Given the margin of error in the guidelines, such a policy would have resulted in more than 20 unnecessary deaths.

Such a policy would also hurt the availability of organs for transplant, since 5 percent of donor organs are from brain-dead patients who received CPR.

And even if the goal were to reduce the risk of injuries and accidents among ambulance crews racing to the hospital, it would require eliminating 2,178 ambulance transports to prevent one injury, Dr. Adams wrote.

Apparently most doctors agree with Adams, according to an online survey by the British Medical Journal that found more than 80 percent of respondents think cardiac arrest patients should go to the hospital.