Clinical Innovators | Interview by Katlyn Nemani, MD

Lance B. Becker, MD, is a professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania, and an expert in the field of resuscitation science. He was the founder and director of the Emergency Resuscitation Center at the University of Chicago in Chicago, IL, and Argonne National Laboratory, an interdisciplinary team of investigators focused on understanding and treating sudden death from cardiac arrest and traumatic injuries. He is board certified in internal medicine, emergency medicine and critical care medicine. Becker has worked closely with the National Institutes of Health (NIH) as a reviewer, grantee, and in a leadership role as the Chair of the Myocardial Protection Working group for the NIH NHLBI’s sponsored PULSE Conference and PULSE Leadership Group, which is dedicated to support of funding in resuscitation research. He also served as a member of the Food and Drug Administration (FDA) Device Evaluation panels and has appeared as an expert presenter before the FDA panels.

How did you become interested in resuscitation science?

I first became interested in it when I started taking care of cardiac arrest patients as a house officer. We had an Advanced Cardiac Life Support course, and I was so proud that I completed the course and did well. I became certified and ready to save people’s lives. In a general way what I found is that it didn’t work the way the book said it was supposed to work. Despite heroic efforts, the majority of patients would die. And when I read the book they didn’t come out and say that. So I thought that perhaps I had some terrible dark cloud that followed me and all of my patients were doing poorly when everyone else’s patients were doing well. I became more and more interested in it, and that’s when I realized that there was a lot we didn’t know about this whole field. I was thunderstruck. What became pretty clear to me is that we didn’t know very much about it, and we weren’t nearly as successful as we told ourselves. We sort of said, “If you do good CPR, and defibrillate, and give the right drugs, you’ve done everything you can for that patient…if they don’t make it, it’s a sad thing, but that that’s what was meant to be.” I just began to question that whole idea.

I fundamentally do not believe that “it was meant to be.” I do not believe that when patients are routinely declared dead that it has to be that way. That’s not to say that given our current therapies that patients aren’t doing to die, but at that moment in time, after 45 minutes of a cardiac arrest code, perhaps we have not actually reached the point of futility. I became very interested in what the basic science says about this. The conclusion I came to is that there isn’t any particular reason why right at that moment the patient is any more or less dead than they were 5 minutes before, or 5 minutes after. I recognized that this was a field that was crying out for discovery.

We do not seem to accept the futility of other conditions such as stroke or cancer; these are not things we typically consider “meant to be.” You have spoken about the fact that despite its large public health footprint, cardiac arrest does not resonate with the public and policy makers in the same way. Why do you think this is?

It’s complicated and I think there are a lot of reasons. One of the big ones is that doctors think it’s hopeless. When you’re working in the hospital during your training and you’ve seen five or six or seven people who you try really hard to resuscitate and it doesn’t work, you get a little jaded. I think there’s a lot of doctors who say, “This is hopeless.” And they haven’t followed the literature in the last 10 years, which has changed so much of what we think about that. Most haven’t looked at the real evidence of when you can bring somebody back to life, and most practicing cardiologists working in their specific areas of practice do not have the experience with cardiac arrest that they once did. Cardiologists want patients who they feel they can help. Many times the cardiologist doesn’t feel they can help a person with a cardiac arrest. And then it doesn’t resonate with them that we could do better, we can do better as a nation, we can do better with all of these interventions from the community, with the public, with EMS, with dispatchers, with better emergency departments, with better inpatient care. They don’t get that you have to have all of that working to make a difference.

Many of these systemic factors were addressed in a recent report from the Institute of Medicine (IOM)— “Strategies to Improve Cardiac Arrest Survival: A Time to Act,” which you wrote about in the Journal of the American Medical Association. What did we learn from this report?

What is very bold and different about this IOM report is that it addresses a system, not an individual. To be blunt, most doctors do not train to look critically at our system of care. It’s a system that starts in people’s homes. It’s in grocery stores, in churches, in synagogues, parks, recreation centers, malls—anywhere that people are. This is where people have cardiac arrests.

What do you think it will take for this shift in consciousness to take place, to address factors that exist beyond hospital walls?

Well, I’ll be honest. I think what people need to realize is that some communities have it down. Some communities are doing really well. But those are not the communities that most Americans live in. For example, the state of Arizona has almost tripled its survivor rate in the last 5 years. This did not happen by accident. They looked at a state-wide level at their whole system. To me what it’s going to take is for citizens to realize that there are safe and unsafe areas to have a cardiac arrest. Right here in our country, across every state, there are unsafe places. And until we have the data, we won’t even know where those places are. The very first recommendation in the IOM report is that we have good national data, and I think it’s the data that will drive improvements.

It sounds like this is more than a resources issue. What makes some communities better at improving survival after cardiac arrest?

Some resources are necessary, but these are not extraordinary resources. It’s more about leadership, having the data, and having a system where there is someone who is accountable. The thing about cardiac arrest is that there is no one who is really responsible for it. There needs to be a coming together of public health officials to address this.

In the United States we have had one person die of Ebola in the last 100 years as far as I know. By contrast, with cardiac arrest, we have, give or take, 1,000 people/day arrest. And we know that we could triple or quadruple the survival rate for a city like New York. Think about the public outcry with the Ebola crisis. Public health officials got together, hospitals spent millions of dollars because we were afraid of Ebola and what it might do. And here we have something that is a leading cause of death for which we know there are things we can do, that won’t take as many resources. But what we do need is a reorganization and a commitment to gather truthful data. We need to find places doing poorly and make them better, and we need to find places doing great and make them better, too.

What are some of the key things that communities need to do better?

The first thing is reliable data. We need a national cardiac arrest registry, like what Japan and other places have. Second, we need to educate the public so that they know what to do when a cardiac arrest takes place. We need to develop dispatcher CPR so that when a person calls 911, the dispatcher can get them started. That is how Arizona tripled their survival rate. Third, we need a more team-oriented approach in the way that EMS handles cardiac arrest. It’s called “high performance CPR” and we are now teaching it across the country, and EMS organizations are getting better and better at acting like fast- functioning pit crews when it comes to doing CPR. But not all agencies have adopted that.

We know there are things that can be done in almost every emergency department in the country, like measuring CPR quality, debriefing as a team after a cardiac arrest, ensuring they are looking at the right parameters while going through a code. These things are sometimes, but not always, done. Another thing is quickly getting patients to the cath lab in the event that they had a heart attack. These are all things that are feasible, and places that routinely try to do these things have better survival rates than the places that don’t. Those are all things that we know right now.

What does the future of resuscitation science look like?

Let me tell you about the near future. And by the near future I mean that these are things being done internationally, but not in the United States. There was a recent study from Australia called the CHEER trial, and it is remarkable. It uses a technology available in most hospitals—cardiopulmonary bypass. Essentially any hospital with cardiology patients has one or twenty of these machines, typically in the operating room. The catch is that using these bypass machines is technically difficult. I’ve done it. It’s hard—particularly to start it in a patient who is in cardiac arrest. But let me tell you about the study. They took 26 patients who were in refractory cardiac arrest, who failed 30 minutes of CPR and advanced cardiac life support. And then they did four things as quickly as they could. The first thing was they put them on a mechanical chest compressor that does automatic CPR. Second, they infused two liters of ice old saline to produce intra-arrest cooling (the typical cooling that we do in America is after patients’ hearts have restarted). Third, they put them on a cardiopulmonary bypass machine. And fourth, they then took them to the cath lab for percutaneous intervention. That’s their protocol. What they found was that of the 26 patients they tried this on, 14 of them (54%) were alive and neurologically intact 7 days later. These were patients that could have been declared dead! This was a hard study to do. It took a lot of team work. And that was one of the major lessons—it took a whole team to be able to provide this kind of care. But they went from 0% survival to 54% survival. That is pretty dramatic.

The use of cardiopulmonary bypass in cardiac arrest patients is being pioneered in Japan. It’s being routinely practiced in more than 30 of its major hospitals, and it is dramatically improving the survival rate. Right now they are doing it on patients with nearly 0% chance of survival and they get anywhere from 15% to 25% survival using this, which is pretty amazing. This technique started in the U.S., but it is being developed in Japan to a high degree. I travel there to learn from them.

Tell me about your work at Penn’s Center for Resuscitation Science.

The reason that CHEER study was so successful is that they had a whole bundle of treatment. They didn’t depend on just one thing—they had the automatic CPR machine, they did cooling to protect the brain, they did bypass to get the blood flowing, and then they went to cath lab to fix the heart. It makes sense. We are also trying to put together a bundle of treatment—with drugs that could be neuroprotective in combination with cardiopulmonary bypass. We’re studying this in animals. We know that we can improve survival with cardiopulmonary bypass, but many of these animals are neurologically damaged. We are trying to develop a special “cocktail” to go together with bypass that will provide both circulation and neuroprotection. And that’s the focus of our basic science laboratory. We’re trying to work out the biochemistry, the science of why the cells are injured, and put powerful new drugs into the bypass machine that will allow patients’ hearts and brains to survive an arrest.

The latest evidence is telling us that cardiac arrest patients are not hopeless. We need more research, but the whole paradigm is shifting.

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Katlyn Nemani, MD is a physician at New York University

Keywords: Heart Arrest, Resuscitation, CardioSource WorldNews

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