Hugh Wong | Jamaica’s chain of survival

Efficient prehospital care plays a critical role in saving the lives of persons experiencing medical emergencies. In cardiac and respiratory emergencies, the focus is in performing early CPR, defibrillation, in field diagnostics (ECG telemetry), initiation of treatment (aspirin, nitrates) as per protocol, and rapid transport to hospitals with capabilities of treating with cardiac emergencies.

These are ideal scenarios, but in resource challenged environments, such as ours, these ideals remain only aspirational.

The chain of survival is a conceptual framework in the emergency cardiac care community that outlines a series of six vital steps that are necessary to maximise a person’s chances of survival during cardiac arrest.

LINK ONE

Activation of Emergency Response: Early recognition and activation of the pre-hospital emergency response is the first link in the chain of survival. Currently there is limited public awareness about recognising cardiac arrest symptoms. As a result, delays in seeking medical help are very common, thus hampering the effectiveness of this link.

LINK TWO

High-Quality Cardiopulmonary Resuscitation (CPR): The immediate initiation of bystander CPR is essential for the success of any emergency medical response for cardiac arrest. In Jamaica, bystander CPR rates are dismally low due to limited knowledge and training among the general population. Reluctance to perform CPR may also be influenced by cultural factors and the fear of doing harm.

Over the past two decades the Heart Foundation of Jamaica has been an advocate for layperson CPR training, as well as providing training for both pre-hospital and in-hospital medical responders. However, greater efforts are required to educate citizens about performing CPR, and to dispel the fears of persons who may be willing to learn.

LINK THREE

Early Defibrillation: This link speaks to the early use of automated external defibrillators (AEDs), on patients who are in cardiac arrest. It is used to deliver a “shock’ to the patient. This is the only treatment for patients who are in cardiac arrest due to the lethal cardiac rhythms of ventricular fibrillation or ventricular tachycardia.

The availability of AEDs in public spaces is very limited. This may be due to two factors. Cost, and absence of legislation. The need for public access defibrillation is a cornerstone of the thrust to strengthen the chain of survival.

LINK FOUR

Early Advanced Care: Pre-hospital emergency, medical care in Jamaica currently has two operational systems. There is a formal Ministry of Health and Wellness (MOHW), Ministry of Local Government and Community Development (MLG &CD) EMS. This service is manned by emergency medical technicians from the Fire Brigade trained to the basic EMT level. This EMS operates in the parishes of Westmoreland, St. James, Trelawny and St. Catherine.

The other system is that of private EMS operators. These private services operate in all parishes and provide a greatly needed service, although operationally, they are largely unregulated.

Great strides have been made over the years in training emergency room staff in basic and advanced life support, but there are still resource issues in our emergency rooms which mitigate against offering patients the full level of care that is routinely available in places with more resources.

LINK FIVE

Integrated Post Cardiac Arrest care: All patients who have achieved return of spontaneous circulation (ROSC) require admission to an intensive care unit. This high level of care is required because the underlying cause of the cardiac arrest often still exists, and the patient is at great risk of going back into cardiac arrest.

The Jamaican reality is that there are simply not enough ICU beds available for the population.

LINK SIX

Recovery: The sixth link is recovery. It focuses on the need for continued treatment and rehabilitation of cardiac arrest survivors. It also focuses on the families and caregivers of the survivors.

Critical concepts for recovery include:

• Comprehensive post cardiac arrest discharge planning for survivors and their families and caregivers. This includes medical follow-up and rehabilitative treatment. Advice on return to activity and work, and management of these expectations.

• Assessment and treatment of the cardiopulmonary, neurologic, and cognitive impairments that often affect cardiac arrest survivors.

• Assessment and treatment of the many psychiatric ailments which beset near-death experiences. These include anxiety, depression, post-traumatic stress and chronic fatigue.

Unfortunately, there is little or no focus on this very important sixth link.

RECOMMENDATIONS

To enhance readiness in providing the chain of survival, the following strategies are suggested.

• Initiate state funded public education programs about recognising the symptoms of cardiac arrest and the steps in performing CPR

• Create cardiac ready communities. This involves the establishment of communities that meet the criteria for having

• Laypersons trained in CPR. Free CPR training to communities empowers the citizens to provide immediate help in emergencies.

• Public access to AEDs. Increasing the availability and deployment of AEDs in public spaces, workplaces and transportation centres can decrease the time to defibrillation.

• Blood pressure, cholesterol, and diabetic screenings. Identifies groups at higher risk of cardiac arrest. Allows for intervention.

• A functional EMS. Ensures timely and effective pre-hospital care and transport.

• Investment in road infrastructure. Improving road networks, and addressing traffic congestion can facilitate faster EMS response.

• A properly equipped and staffed emergency room in the local hospital.

While Jamaica has invested in its healthcare professionals with an emphasis on training, and the existence of public and private emergency medical services, there are significant challenges that impede its readiness to provide all the links in the chain of survival. A chain is as strong as its weakest link; therefore, the thrust must be to strengthen all the links.

By addressing the recognised issues of public awareness, CPR training, AED availability, and resource allocation, Jamaica can strengthen its prehospital, in-hospital and post-hospital care, and contribute to a more robust chain of survival.

Dr Hugh Wong is director of emergency cardiac care at Heart Foundation of Jamaica. Send feedback to columns@gleanerjm.com