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The Arizona Daily Star

Friday December 28 02:45 AM EST

City may try cardiac arrest treatment alternative

By Carmen Duarte , ARIZONA DAILY STAR

Some cardiac arrest patients may undergo a new resuscitation procedure

under the care of Tucson Fire Department paramedics next year.

Dr. Terry Valenzuela, the Fire Department's medical director and an

emergency medicine professor in the University of Arizona College of Medicine,

is proposing a one-year clinical experiment that would affect about 350

patients.

Currently, a person who suffers cardiac arrest is given defibrillation -

an electric shock - by paramedics or firefighters, Valenzuela said.

Under the proposed study, half the patients would receive 90 seconds of

cardiopulmonary resuscitation before the shock treatment, and the other half

would receive only the shock treatment.

Valenzuela said he would like more public comment about the proposed

trial. The City Attorney's Office is reviewing the proposal, and one retired

lawyer - one of three people who attended a public meeting about the study - is

concerned that it could open up the city to lawsuits.

While Valenzuela had hoped for a January launch, the trial has no firm

starting date and is still subject to review before being implemented.

Valenzuela said he believes the study will show " potentially more people

will survive by administering CPR and the shock treatment. "

Between 300 and 450 cardiac arrest patients a year are treated within the

city limits by Tucson Fire Department paramedics and firefighters. During the

past three years, 14 percent have survived each year after receiving

defibrillation, Valenzuela said.

He said shocking the heart restores it from shivering to beating. This

resumes blood flow to the brain and vital organs, and the patient awakens.

When CPR is administered first and then followed by defibrillation,

Valenzuela said he believes 20 percent of the patients will survive.

The proposed trial would exclude patients who are age 16 or younger;

patients who suffer injuries from trauma, including traffic collisions,

shootings and stabbings; and patients with a pre-hospital directive stating they

do not want to be resuscitated.

A six-year study in Seattle found that 24 percent of 639 patients survived

cardiac arrests when Seattle Fire Department paramedics and firefighters

immediately shocked patients, Valenzuela said.

In the latter three years of the study, the survival rate rose to 30

percent, or 142 out of 478 patients, when 90 seconds of CPR was administered

first, then defibrillation, Valenzuela said.

The study was co-authored by Dr. Leonard A. Cobb, professor emeritus of

medicine at the University of Washington School of Medicine. His study was

published in the April 7, 1999, issue of the Journal of the American Medical

Association (news - web sites).

Valenzuela, a cardiac arrest expert who has published on patient treatment

for more than a decade, used to work at the University of Washington and with

doctors who medically directed the Seattle Fire Department paramedic program.

In a telephone interview earlier this week, Cobb said that after his

study, Seattle Fire Department rescue workers changed their treatment

guidelines.

Rescue crews administer CPR first, Cobb said, and then defibrillation to

cardiac arrest patients even though the American Heart Association (news - web

sites) supports the standard practice of immediate defibrillation.

Cobb said he proposed the Tucson study to Valenzuela because a randomized

trial needs to be done to show scientific proof.

" The study is not easy to do. It takes a lot of patience and a highly

organized team. It is a major undertaking, " Cobb said.

One dilemma is that patients will not be given a choice about

participating.

" In regular research, you sit down with people and go through the risks

and benefits of the two approaches of treatment. People give consent before they

enter a study, " Valenzuela said.

" In this study, the patient or the patient's family members will not have

a choice. The patients are clinically dead. They have no pulse, no blood

pressure, and they are not breathing.

" Treatment must be given immediately, and there is no time for explanation

or locating family, " Valenzuela said.

" What the animal studies and Dr. Cobb's study group think they

demonstrated is that something happens at about four minutes after collapse. No

one knows exactly what.

" At that time, if you shock people immediately, all the electrical

activity goes out of their heart and you can't revive them.

" If after four minutes of collapse instead of shocking you administer CPR

for 90 seconds, and then shock, you restart their heart and have normal

electrical activity.

" But because they didn't randomize, they can't say for certain that using

CPR first was the reason that the survival rate improved, " Valenzuela said.

In the proposed Tucson study, half of the Fire Department's responding

units would treat cardiac arrest patients by administering CPR then

defibrillation, and the other half of the units would administer defibrillation

only. After six months, the units would switch treatment methods.

Steve Kessler, a retired New York corporate lawyer who lives in Tucson,

attended a Dec. 14 public meeting about the proposed experiment and raised

concerns about delay in standard treatment and liability issues.

" The protocol is to defibrillate immediately. If they wait and don't

defibrillate, the chances of survival drop 7 percent to 10 percent each minute.

This creates a greater risk of death, " Kessler said.

" Who is liable? " asked Kessler, who foresees lawsuits.

" There is a protocol of treatment. They didn't follow the protocol of

treatment. They didn't get the guy's consent and he died. My instinct is that a

personal-injury lawyer will be very successful with a jury. "

Assistant City Attorney Dennis McLaughlin said he is reviewing the

proposal, which still needs to be discussed with administrators of the Fire

Department, the city's risk management division and Valenzuela.

" It is possible the City Council may take a vote on the proposal depending

on the outcome of the review, " McLaughlin said.

If city officials approve the study, it still faces scrutiny from the

Arizona Department of Health Services, which gives the final authorization.

Valenzuela's proposed trial was approved Oct. 12, 1999, by the Human

Subjects Protection Program's Institutional Review Board of the Arizona Health

Sciences Center.

This group reviews study proposals to make sure the patients' rights are

protected in the way the study is to be conducted.

Federal regulations permit emergency resuscitation studies when informed

consent is not possible, but the public must be notified about the experiment.

An ad ran in the Arizona Daily Star and the Tucson Citizen from Nov. 30 to

Dec. 3 describing the study and announcing an invitation to the informational

meeting.

* Contact Carmen Duarte at 573-4195 or at cduarte@....

Arizona Daily Star

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