The survival rate for patients with out-of-hospital cardiac arrest is low in communities where emergency service is provided solely by emergency medical technicians. We trained such technicians in a suburban community of 79,000 to recognize and treat out-of-hospital ventricular fibrillation with up to three defibrillatory shocks without the use of medications or special airway protection. Outcomes from cardiac arrest due to underlying heart disease were determined during two periods: two years with standard care by emergency medical technicians and one year with defibrillator-trained technicians. During the period with standard care, four of 100 patients with cardiac arrest were resuscitated and discharged alive from the hospital, as compared with 10 of 54 patients during the period with defibrillator-trained technicians (P less than 0.01). In 12 of 38 patients with ventricular fibrillation, a stable perfusing cardiac rhythm followed defibrillatory shocks given by defibrillator technicians. The enhanced survival after cardiac arrest is encouraging, and further trials of defibrillation by emergency medical technicians are warranted.
Beginning in 1981, collaborative efforts developed between the University of Washington and community hospitals in Washington, British Columbia, Canada, and later outside the Pacific Northwest, have generated important findings about the treatment and outcome of acute myocardial infarction (AMI). These efforts, collectively known as the Western Washington and Myocardial Infarction Triage and Intervention Project trials, have included randomized trials of thrombolytic drugs, direct antithrombins, platelet receptors, antagonists, and cell adhesion blockers, as well as the formation of registries of consecutive patients admitted to coronary care units with the diagnosis of suspected AMI. Results of these trials have demonstrated that thrombolytic therapy significantly reduces mortality and morbidity from AMI with minimal risk to patients, and that early treatment is associated with improved infarct size and better left ventricular function. The efforts of the next decade should be focused on the further removal of barriers to rapid treatment and to the evaluation of new agents, so that the devastating effects of myocardial infarction are minimized to the fullest extent.
Ventricular fibrillation, an abnormal cardiac rhythm, occurs in at least twothirds of the 400,000 people who die out of the hospital from sudden cardiac arrest. This rhythm can be treated successfully by electric countershock, a procedure known as defibrillation. The survival rate following such cardiac arrest is directly related to the rapidity of response; the shorter the time from collapse to defibrillation, the more patients will survive. There are two basic options to shorten the time from collapse to defibrillatory shock. The first is to upgrade the emergency medical system. The second is to provide spouses and family members of potential cardiac arrest patients with automatic home defibrillators. This article considers the effectiveness of the second option, home defibrillation, compared with that of an equally costly upgrade in existing emergency medical service systems. The comparisons depend on the existing level of emergency medical service system, the cost of the home defibrillator, and the rate at which a home defibrillator would be used appropriately. The comparisons suggest that in many circumstances home defibrillation is an appropriate option to be considered.
