Improving sudden cardiac arrest (SCA) outcomes in hockey
By Rick Garner CEP, Team Paramedic Arizona Coyotes and Arizona State University Athletics
Firefighters, Paramedics, and EMT’s see and treat more out of hospital cardiac arrests than anyone else. These scenes are much different than in-hospital arrests. I’ve responded to 100’s of arrests during my career with the Phoenix Fire Department, and every scene and circumstance were different. Aside from a pediatric drowning, cardiac arrests are one of the most emotionally traumatic scenes a First Responder will ever face. Due to the unexpectedness of SCA’s, the pain and collateral damage experienced by family/friends is heart wrenching. They realize that just minutes ago their friend or family member was alive and well, and now they lay lifeless on the floor. Like a player who comes off the ice after a shift, then suddenly collapses, becoming apneic and pulseless. Cardiac arrests can happen to anyone, anywhere, at any time. SCA’s leave bystanders in a state of disbelief and shock.
From an emergency medicine standpoint how well we manage an arrest depends largely on how well we’ve prepared for them, and how calm we can stay during them.
If you’ve ever participated in a successful resuscitation you know it’s an incredible feeling to see life return to a lifeless body. Sadly, if you do it for a living, you soon realize that no matter how well you perform during an arrest many times people just don’t survive. It’s out of our hands.
Sudden cardiac arrests (SCA’s) are commonly referred to as “witnessed” or “unwitnessed”, and as “in-hospital” or “out of hospital”. Game time SCA’s are considered “witnessed, out of hospital” arrests. There are over 1000 out of hospital cardiac arrests (OOHCA) each day in the U.S. The current survival rate is less than 6%. That means less than 60 out of every 1000 will survive. However, during a game we have the potential to achieve much higher survival rates if we’re prepared to manage our patients quickly and effectively.
Sudden Cardiac Arrest (SCA) *Estimates suggest that cardiac arrest is the 3rd leading cause of death in the U.S. behind cancer and heart disease. Every year in the U.S., approximately 395,000 cases of cardiac arrest occur outside of a hospital setting, in which less than 6% survive. In hospital cardiac arrests have a 24% survival rate. Survival rates depend greatly on where the cardiac arrest occurs.
*Source: The National Academies of Sciences Engineering Medicine
How can we achieve the best outcomes if/when a SCA happens during a game?
Over the past 6 professional hockey seasons we’ve had 3 game time “witnessed” cardiac arrests. In each of these cases the athlete survived. How did the pre-hospital care of these patients beat the odds and contribute to their survival?
- 2014 Rich Peverley – Dallas Stars
- 2016 Craig Cunningham – Tucson Roadrunners
- 2020 Jay Bouwmeester – St Louis Blues
I’ve been asked how hockey has managed to achieve a 100% survival rate for game time cardiac arrests? My response: “It didn’t happen by accident.” These cases had special advantages. The patients were in great shape, the healthcare providers on scene (along with the emergency departments/hospitals) did an excellent job in managing these arrests, and the game time emergency action plan (EAP) for SCA worked.
Some Keys we’ve learned to having a successful resuscitation:
In each of the arrests I’ve responded to with the Phoenix Fire Department, not a single incident happened at the fire station with crew and equipment ready. Each time we responded 4-8 minutes with lights and sirens before reaching our patient. This response time combined with the time it takes bystanders on scene to recognize the severity of the situation and call 911, negatively effects patient survivability. It can ultimately end up being 10 minutes after the arrest before First Responders arrive.
In each player arrest we had “Luck by Location” and “Early Recognition”. Each arrest happened during a game and was “witnessed” by healthcare providers who could immediately start providing care. Luckily each arrest happened in just about the best possible place it could, outside of an ER or hospital. All of the medical resources needed for a successful resuscitation were already in place and ready to respond. If these arrests would have happened at home, at a restaurant, while driving, or on a plane, the outcome most likely would have been much different.
Unfortunately, I have also been witness to either poor quality CPR or NO CPR on a SCA patient upon EMS arrival. More lives could be saved if people would immediately become hands-on and start doing hard and fast chest compressions prior to the arrival of 911/EMS resources. CPR is a take home skill we should all have.
Effective CPR was started immediately on each player. It’s important to note, these incidents involved elite athletes in great physical condition, and who’s blood was well oxygenated at the time of their arrest. Chest compressions were started immediately to circulate the oxygenated blood to the brain. Without these compressions the brain does not receive the oxygen it needs to survive. This is a learned skill that is practiced each year during the PHATS/NHLTPS conference.
Each year at the annual PHATS/NHLTPS conference the following courses are offered:
1) CPR/AED certification with a focus on high-performance CPR
2) ACLS Refresher course for team physicians
3) Sports Med Team Based EMS training session
During a cardiac arrest it’s important to remain calm and focused on the immediate priorities. We need to get EMS resources coming, clear the patient’s chest for AED pad placement, and begin high-quality CPR. We need to quickly apply an AED to determine if the patient’s heart needs to be shocked. The AED should be applied without stopping chest compressions. The compressions are only stopped when the AED advises “do not touch the patient”. Remember, for every minute it takes to administer a shock the chance of survival goes down by 10%. If the patient’s heart needs to be shocked, the AED will advise to do so. The shock allows the patient’s heart to reboot and start up again on its own, hopefully in a rhythm that will push pulses and create a blood pressure. This is called “Return of Spontaneous Circulation” or (ROSC). The sooner we apply an AED after a cardiac arrest the better chance we have for achieving ROSC and patient survival. *Always remember to say “Clear” and look to make sure nobody is touching the patient prior to pressing the shock button. It’s a good practice to have everyone working close to the patient acknowledge the “Clear” command by also saying “Clear”.
In each arrest a shock was provided in under 2 minutes. In doing this we gave our patients better than an 80% chance of survival.
After achieving ROSC, we still need to manage our patient. This includes assessing vitals, providing oxygen/airway management, administering ACLS medications, providing safe transport, and advising the hospital of the patient’s status. Successfully managing a cardiac arrest is a fluid production and takes an entire team effort to get a win.
Team Practice of the EAP worked. Professional hockey’s medical personnel have put in a great deal of time and effort when it comes to player safety and planning for EMS incidents. SCA scenarios are constantly being reviewed and discussed by Sports Med staffs throughout hockey. You need to practice how you want to play. This is a major contributor to hockey’s success in managing cardiac arrest patients. Each Sports Med team member knows how the play is supposed to be run and how they fit into the play.
At the annual PHATS/NHLTPS conference attendees have the opportunity to participate in a Sports Med Team Based EMS training session.This session is highly attended with excellent hands-on participation from the group. I believe the positive outcomes we’re seeing is a reflection of the work that’s being put in on the front end. During these sessions we have AT’s and team physicians going through EMS scenarios together. The sessions are being led by the paramedics and emergency medicine physicians who cover the games. This educational formula promotes collaboration, discussion, and team building. Ultimately, this model has created a high-performance CPR EAP that appears to be on track.
Moving Forward, we need to remain proactive and prepared for the cardiac arrest patient that doesn’t achieve ROSC on the scene. Remember, maintaining blood flow to the brain is crucial for survivability. If ROSC isn’t achieved, the use of mechanical CPR devices should be considered. They can provide quality chest compressions in the ambulance while advanced airway management and ACLS care is being provided. They will also create a much safer environment in the back of the ambulance while transporting Code 3 to the hospital. At the end of the day patient and provider safety are always the top priority.
“Improving Player Safety through Emergency Medical Preparedness”