A shock that can save lives

Electric defibrillators in public places were a topic of discussion at an international acute cardiac care conference in Jerusalem.

July 7, 2013 03:37
Man having cardiac arrest

Man having cardiac arrest. (photo credit: Thinkstock/Imagebank)

Death rates from heart attacks have been plunging in recent years, thanks to less smoking, better medications to treat hypertension and high cholesterol and improved angioplasty and open-heart surgery.

But cardiologists still have plenty to do, especially in the field of acute cardiac care, when they have to cope with emergencies.

Hundreds of experts from Israel and abroad – including the US, Canada, Australia, Austria, Denmark, Italy, Cyprus, Germany, Sweden, the Netherlands, France, Belgium and Turkey – came to Jerusalem’s Ramada Hotel recently to attend the Israel Heart Society’s Eighth International Conference on Acute Cardiac Care, organized with the cooperation of the European Society of Cardiology.

The founder of the biennial meeting and its chairman, Prof. Yonathan Hasin of Poriya Medical Center in Tiberias, told The Jerusalem Post in an interview during the conference that the death rate from heart disease has dropped significantly, especially in the center of the country. But he added that more must be done to improve cardiac health in the periphery.

Hasin was a cardiologist at Hadassah University Medical Center and headed its cardiac intensive care unit for years until 2001, when he decided to move to the town of Migdal just north of Tiberias and chair Poriya’s cardiology department.

“I decided to live and work in the periphery. We started from nothing,” he said, “and now the department is very advanced. I am a doctor of intervention to save lives. I developed the connection already between the Magen David Adom ambulance and the hospital so the emergency room team can be prepared to deal with the patient who’s on his way.”

Foreign participants interviewed during the conference said that electric defibrillators in public places (to jumpstart hearts stilled by electrical failures or clots in coronary arteries) are widespread, and that not only are people trained to use them but public service ads on TV show laymen how to save lives using the electrical devices.

Abroad, they can be found in sports stadiums, wedding halls, shopping malls, museums and other places frequented by large numbers of people.

“They can be purchased for only NIS 2,000 apiece,” said Hasin. “It’s a shame that several years after the law requiring the purchase, maintenance and storage in an accessible place of the defibrillators, there are very few. Ra’anana, for example, does have them. But most other places don’t, and the law has not been implemented as it should have been.”

Dr. Boaz Lev, associate director-general of the Health Ministry, told the Post that the law was written with the stipulation that the Economy and Trade Ministry (then Industry and Trade) was responsible for ensuring installment of the devices. The reason was that companies, for example such as those owning shopping malls where there is high pedestrian traffic, would have to pay for and maintain them.

The Health Ministry was required only to provide guidelines on their use.

“We sat with Economy and Trade Ministry people many times over three or four years and did our part, but it still isn’t finished. Until it is implemented by the Economy and Trade Ministry, we have purchased defibrillators for installation in governmentowned outpatient facilities where at least 500 people pass in and out daily. We have put in dozens of them.”

Lev could not say when he thought the law would be implemented, “because we are not responsible, but I hope it will be soon.”

The Economy and Trade Ministry said in response to a request for comment that “this [issue] involves a complex law. The legislative work needed to amend and suit it for implementation required the cooperation of many bodies. The Economy and Trade Ministry has invested much time and effort in preparing amendments. The proposed amendment to the law and regulations that have been prepared have been on the Knesset’s table for some time, but because of the elections, the discussion of them was postponed. We are now working to get approval of continuity so that they can be advanced,” the spokesman said.

Prof. John Horowitz, director of the cardiology unit at the Queen Elizabeth Hospital in Adelaide, Australia, said that “defibrillators in public places in my country have really made a difference. I was one of the first doctors to use a defibrillator in an airplane.

An elderly Chinese passenger suddenly went unconscious in the economyclass section two seats from me. He was returning from the toilet and fell into a seat. I thought for a split second: ‘I’d better call a doctor! But then I realized that I am a doctor – a cardiologist! An intravenous drip was put into him by a flight attendant. I gave atropin and used the defibrillator on board. He recovered.”

Prof. Joseph Alpert, a cardiologist at the University of Arizona College of Medicine and editor-in-chief of the American Journal of Medicine recalled that among the first people saved by public defibrillators were spectators at a Cleveland Browns football game.

“The stadium is very close to the Cleveland Clinic. In the past two years, maybe eight to 10 fans who had heart attacks were saved with defibrillators.”

Alpert noted that numerous cities in the US such as Seattle, Washington and Portland, Oregon have held mass courses in cardiac resuscitation for residents, and that as a result, many people whose heartbeats suddenly stopped have collapsed next to people who had learned how to try to save them. It has saved many lives, he said. US fire departments have “emergency medical technicians” on staff who know how to deal with such cardiac emergencies.

Both cardiologists from abroad said that although cardiopulmonary resuscitation (CPR), in which the rescuer has to breathe into the victim’s mouth alternating with rhythmically pumping his chest, is very well known, it has been discovered that mouth-to-mouth respiration is not necessary.

“You just have to pump the chest to get the heart going again,” said Alpert. “Instead of CPR, it is called cardiocerebral resuscitation [CCR], which creates a better flow of oxygen to the brain.”

Alpert noted that 30 percent of people whose hearts stop outside hospitals survive today, compared to only 10% a decade ago.

“It is not always a heart attack. It can also be electrical problems in the heart, so the defibrillator is especially effective in these cases.”

He bemoans the fact that in general, “Americans are very fat. We worry about the fact that they observe a bad diet and do not exercise as needed,” said Alpert, whose medical journal in its print and online editions is read by 130,000 internal medicine and cardiology specialists around the world.

Discussing the future of print medical journals, Alpert said: “We think print will persist. Doctors go on vacation, sit on an exercise bike, and they want to read. A computer – even a tablet – is not convenient.

They want to hold a magazine in their hands. I myself read seven or eight journals in my field each month.”

Horowitz agreed that he had no objection to reading a few paragraphs on the screen, but he found it impossible to read whole texts that way.

Keeping up with medicine by reading journals and attending lectures and courses is mandatory in both the US and Australia.

If you don’t do continuing medical education and follow new things, in seven years much of what you know becomes obsolete, said Horowitz. The exams are very basic. “I suppose it would be hugely expensive if intensive exams were given to all specialists.”

In the US, specialists must undergo recertification exams every 10 years, but only a small percentage don’t pass. The repeat exam is less difficult than the first, said Alpert. “If you are not board recertified, health insurance companies and health maintenance organizations won’t pay you.”

Both were quite surprised to learn that taking and passing mandatory exams to be recertified as specialists is not required in Israel, and that no doctor is forced to earn continuing medical education points to continue working. He joked that as a medical student, his lecturer said that “about what half of what I’ve taught you is right, and the other half is wrong. The problem is I don’t know which half.” It used to be thought, for example, that beta blockers could be used for everything except heart failure. Today, it can be used for heart failure and not much for other things.

Alpert, who has visited Israel several times before, said that Israeli cardiologists are equal in skill to their American counterparts.

Horowitz agreed, noting that about half of them go to the US for additional studies and research after graduation, “and some come even to Australia.”

The Australian cardiologist was saddened to see the health situation of some Beduin in unrecognized settlements in the south, but he is also upset about the health problems of the Aborigines in his own country.

In the Australian outback, “problems start with recurrent ear infections. They don’t get antibiotics, so they lose their hearing. Then they have trouble in school.

There is also trichoma, the risk of blindness and of acute rheumatic heart disease. The unemployment rate among the Aborigines is very high. Although they comprise 2% of the Australian population, they are 15% of the prison population. They suffer from heart disease, diabetes and alcoholism and live 15 years less, on average, than the Western population of Australia.”

“I despair about the process of giving them medical treatment. I don’t do very well with them, and it’s not from the lack of trying,” said Horowitz. “A group’s social aspirations is the key. If we dumped some European Jews in the outback, and they became poor, they would have upward aspirations and do their best. We have absorbed Vietnam refugees, and they did fine. The problem isn’t genetic, but the social mores of the group. Australians as a group are reasonably well-intentioned people.

Some of the Aborigines would like to remain hunter-gatherers. They don’t do any better in cities.”

Asked to guess about cardiology in another decade or two, Alpert suggested that there will be wider use of artificial hearts, at least partial ones, but it will still be applicable only for small groups of patients. “They are very expensive. Instead, much emphasis must be put on prevention.

Stem cells will probably have a future in cardiology, but it looks like we have a long way to go.”

Cost is a major limitation to improved cardiological treatment, added Horowitz. “Prevention cannot solve everything. After all, one has to die of something. But we have to get the best bang for the buck. People should be able to live the longest time possible, with the highest-possible quality of life and at the lowest cost for treatment.

But medicine is seduced by expensive things such as stem cells. We must get as many people to reach the age of 80 without major illnesses. But the world of medicine is failing to do this.”

Prof. Peter Clemmensen, the Danish president of the European Association of Acute Cardiac Care, was visiting Israel for the third time to attend the conference.

“I have been only to meetings and sessions this time, but my impression is that Israeli cardiologists are very well read and innovative. They are very good in telemedicine and information technology. The cardiac health of Danes has improved a lot, but we are still behind neighboring countries like Sweden, Norway and France. We still have a high burden of smoking and drinking.”

Life expectancy is lower in Denmark than the US, said Clemmensen. “We put taxes on foods with bad fat, and people are adopting a more Mediterranean diet. There is plenty of fish, but consumption of meat remains high. There are relatively few vegetarians. We are worried that people get too much salt from processed foods.”

He was pleased to report that his country now has a “visionary health minister in her 30s, Astrid Krag, who is dynamic and very interested in public health.”

The location and numbers of installed defibrillators in the Scandinavian country are not what they should be, said Clemmensen.

“Many have not been installed in places where heart attacks occur, but we do have an official website where the devices can be registered. There are also smartphone apps to find closest ones. The Danish Heart Foundation and others are active in teaching residents how to use defibrillators at work places and in sports clubs. It sent out 100,000 educational kits and CD-ROMs on how to use it.”

There is still no law, said Clemmensen of the Hearts Center in Copenhagen, that public places have to have one, and sometimes they are locked up and not accessible to the public, or it is not known in an organization that one exists. “If used the device can save many lives,” he continued, “and does not make things worse even if used by a layman. Bystanders could get involved by doing resuscitation it if didn’t work.”

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