Sudden collapse -causes, approach and international standards in management

 Hi Everyone

11 years back a professional footballer collapsed on field in UK. He was in cardiac arrest and successfully resuscitated, diagnosed with a dysrhythmia and treated definitively with an implantable cardiac defibrillator. He could no longer continue as a professional footballer but carried on living a near normal life being a son, brother, husband and father. It could easily have been a tragic end, but a lot of things happened on that day which helped him return back to his near normal life after this life changing event. A year back Karnataka and India were shocked to hear the news of the collapse and death of a film and public superstar. He was only in his forties and was known to be super fit. In recent times most of you might have come across the news of a young person (possibly in 30s/40s/50s) having a tragic early end of his life after suddenly collapsing. In this little reflective writing, I wanted to give junior doctors and allied health professionals some basics about common causes, initial approach and international standards in management of these patients. Please feel free to add comments and forward this to others who might benefit from this article.

A sudden collapse of an adult from standing or sitting position is a rapid event with very little forewarning in most cases. There are only two body organs which can do this to a human being- the brain and the heart. If the primary problem is the brain, they could have a preceding sudden onset of a headache, but this is not always the case. It is the more or less the same for pathologies of the heart. The commonest underlying pathology in both organs is related to the vascular supply. In the case of the heart, it could be due to the electrical wiring of the heart (a dysrhythmia). The most important link in the survival chain of such patients is the provision of appropriate immediate care immediately after a collapse. In the vast majority of situations such care needs to be provided by somebody who is not a health professional. The footballer in the previous paragraph was fortunate to collapse on a football field during a professional match where well-trained paramedics, doctors and nurses are available right next to the playing field. It is mandated by the English football association to have such a support facility at all such matches. There are other health and safety measures mandated in various public places in UK and other well-developed nations the chief among this being training of employees in BASIC LIFE SUPPORT and provision of AUTOMATIC EXTERNAL DEFIBRILLATORS(AED) in key public places like shopping malls and sports facilities like gyms and sports fields. Personally, I felt ecstatic when the UP Chief Minister made arrangements for all governmental offices to be provided with AED. Something which could be emulated by other chief ministers in India.

The person who collapses from a brain pathology is commonly suffering from either a sudden bleeding in the brain (subarachnoid or intraparenchymal) or a large blood clot (cerebrovascular event/Stroke). Other common cause is epilepsy, but this is usually characterized by typical involuntary jerky movements and in the vast majority of cases does not lead to a fatal outcome. Therefore, the key focus for healthcare professionals is to correctly identify the underlying pathology of either a large bleeding or a large clot. The gold standard investigation for this is a CT scan. However, the priority even before the CT scan is to ensure appropriate immediate care in the form of BLS and safe transportation to an appropriate healthcare facility (somewhere were a good quality CT scanner and radiologist is available immediately). Even better would be a place with a good quality emergency physician, anesthesiologist, intensive care specialist, neurologist, neurosurgeon and interventional radiologist. A lot of lives in India are lost because this chain of survival gets broken in multiple places. Only a small proportion of members of public are trained in provision of first aid/BLS, very few cities have access to good quality prehospital team(paramedics/doctors), many times they are taken to a healthcare facility which does not even have the basic facilities needed for immediate care of these patients etc.

The person who collapses from a heart pathology commonly is either having a heart attack (blood clot in the arteries which supply blood to the heart) or is having a fatal cardiac dysrhythmia. In these patients once again the key to survival is good quality immediate care in the form of BLS, however the one single factor which can significantly increase survival percentages is early access and use of a defibrillator. A heart which stops beating suddenly commonly is in ventricular fibrillation (VF). This is a potentially reversible rhythm if there is immediate provision of BLS and use of defibrillation(shock). The easiest and most effective way to achieve this would be train as many members of the public as possible on BLS and ensure that AED is available at strategic places in key crowd gathering venues around a city and in all emergency response vehicles(ambulances). This needs an impetus from a governmental level and will only happen if the regional health minister and chief minister takes an initiative. Doctors in general but emergency physicians and cardiologists in particular need to lobby these decision makers for such a move in every single state in India. 

Basic life support used to be complicated many years back. Maybe the thought of giving mouth to mouth breathing to a random stranger puts off most people. The good news is that this is no longer part of basic life support teaching and training. research over the years has shown that simply providing good quality chest compressions alone at the right rate and depth will save lives without the need for breathing support (mouth to mouth breathing). These days well qualified paramedics and doctors have other easier ways to deliver breathing support during advanced life support (ALS). Small pocket masks with a one-way valve, bag and mask ventilation and supraglottic airway devices(I-gel) have revolutionized ALS and emergency care. I am hoping for a day when India and other similar low/medium income countries make training in BLS mandatory for all school children, employees and citizens. I think it is as important as learning ABDEFGH...Z. In BLS you can stop with just ABCDE! And someday even a common man could get a chance to save somebody's life. As an emergency physician I can guarantee you there is no better feeling you can ever get compared to the ecstasy you feel when you have successfully resuscitated a collapsed person.

Automatic external defibrillators are nifty little gadgets no bigger than a small suitcase and can be securely mounted in strategic public places and be easily carried by emergency responders(paramedics/doctors) in the back of an ambulance or the boot of a car. The additional advantage is that you need no medical knowledge to use these gadgets. They are so beautifully designed that the machine talks you through the steps needed and in most developed countries there is a helpline number which is manned 24/7/365 by trained health care professionals who can talk you through this at the end of phone. My aim in the next few months is to have at least five of these installed in strategic places in my hometown in northwestern Tamil Nadu. If this is successful, I am hoping to lobby the government with the help of other like-minded doctors from IMA, SEMI and Cardiology societies to implement this plan across all towns and cities in Tamil Nadu and beyond.

If anybody reading this is enthused about providing BLS training or be involved in the project to place AED in public places, please email me on drgarun@gmail.com. Every little help will be useful. I have provided a link for some useful websites for further reading. Please have a look at them. 

Thank you for your patience in reading this article. Please feel free to add comments/feedback. Please forward it to others who will benefit from reading this.

Sudden Cardiac Arrest: Causes & Symptoms (clevelandclinic.org)

Sudden cardiac arrest - Symptoms and causes - Mayo Clinic

Sudden Cardiac Death - StatPearls - NCBI Bookshelf (nih.gov)

Learn CPR in 15 minutes | RevivR | BHF - BHF

Basic Life Support BLS Training | American Heart Association CPR & First Aid

3.BLS-Algorithms-STEP-BY-STEP.pdf (cprguidelines.eu)

Provider Course Manual for Paramedics.pdf (mohfw.gov.in)

Basic Life Support (BLS) Course in Delhi, Mohali, Mumbai & Pune (smart-academy.in)

Automated external defibrillators: Do you need an AED? - Mayo Clinic

What Is an Automated External Defibrillator? (heart.org)

Emergency Medicine in India and UK

 

I am an emergency medicine doctor based in NHS, UK. I qualified as a doctor from Madras Medical College in 1995 and MS General Surgery from Manipal in 1998. I have worked briefly in Plastic surgery and General surgery after my qualification in India. In UK, I have worked for a couple of years in Cardiothoracic surgery before entering the field of emergency medicine. I have a keen interest in India and its healthcare and have maintained a blog www.indiahealthwatch.blogspot.com for more than 15 years. This is my own personal reflection on the field of emergency medicine from an Indian perspective. I dedicate this blog to innumerable lives lost and maimed in Orissa from the recent train collision disaster.

Sometime few weeks back I boarded a train from Kochi to Salem. The train was a long-distance train from Kanyakumari to Pune via Salem and Tirupathi. I had not seen the news for almost 12 hours. I am a big fan of train travel in general and train travel in India in particular. I was mighty impressed with the level of service that Indian Railways provides at such an incredibly low cost. The stations, the rest rooms, the coaches, the TTE's and almost every experience of using the Indian railways was a pleasure and I was commenting as such to the kind TTE who managed to get a Tatkal Berth for my unreserved travel. It was at this point he mentioned that it was heartwarming to hear such compliments on a day like today when the entire Indian Railway family is in deep sadness because of a train crash in Orissa. It was another few hours before I actually saw the news and realized what a big disaster it has been.

Sometime in 2000 I was starting my new job in NHS as a junior doctor in Emergency Medicine. A few months earlier there had been a train crash just outside London and about 2 dozen lives were lost and less than a hundred people were injured. There was a detailed enquiry about this train crash which was able to conclude the probable reasons for the crash and how we prevent such disasters in the future. I was gob smacked. I came from a country where such accidents happened every now and then and I have never come across a detailed enquiry report into such accidents. Even if they were conducted, they were rarely published in the news media nor discussed by anybody. Everybody was busy reporting what is Rajinikanth's next movie, why Silk Smitha died, how much money a certain politician made in a scam etc etc. The India I left had very little regulation with regards to health and safety. I have over the years noticed that the risk-taking behavior of the average Indian is baffling. They are like little kittens when they see a water body and will rarely venture into it for a swim but yet they become dare devil tigers on the road zipping at high speed with no care or bother.

Sometime in 2020 I was working in a busy emergency department during the pandemic. I kept a close eye on the developments in India. I was thoroughly impressed with the overall level of planning and implementation of pandemic health response in India. I was however unimpressed with the ad hoc and arbitrary nature of treatment of covid patients in India. I felt that this was a missed opportunity for robust trials and data gathering for educational and training purposes. Overall, I have to say India and its health professionals, healthcare managers and the government did a fantastic job irrespective of their political colours.

Sometime in 2003 I started work in a busy central London University hospital emergency department. I was shocked by the level of activity and the cosmopolitan nature of the patients. I was reminded on my 'casualty days in MMC GGH' back in 1994). There was a medical section manned by house surgeons(interns) and headed by a man who neither had the training nor the inclination to do any actual 'casualty' work. There was next to nothing in teaching and training. In fact, we learnt all the wrong things. And this was then in what was the premier medical college and GGH in the entire state of Tamil Nadu. Today one of my classmates and very good friend is the head of the same 'Emergency department'. Now things are very different. For starters the head is a senior experienced decorated Anesthetist with a passion and commitment for delivering high quality care. Overall, the level of funding and training in MMC and GGH is completely different from 3 decades back. I am looking forward to meeting this friend and visiting her prestigious department soon.

Sometime in 2017 I was increasingly jaded with the work I do in an NHS emergency department. The work has a large component of non-emergency primary care because the local primary care (GP) services are struggling to keep up with the workload. There was large number of burnt-out nurses and doctors, and we had a huge turnover of healthcare professionals who were either leaving emergency medicine or shortly planning to do so. I was visiting India and as was the norm during my India visits, I visited the local medical college hospital emergency department and met the doctors and nurses working there. This was in a small city in Tamil Nadu. I was impressed with the level of activity in treating real emergencies. Although the funding, equipment, level of training was far superior to 1994, it was still inadequate for the amount of clinical work. I wanted to come and work with them. However due to my commitments in UK and because of the standard NRI fears of 'relocating to India' I put those thoughts and plans away.

Sometime in 2006 the NHS and UK health department decided to abolish permit free training and the visa available for this training. This overnight abrupt decision affected a large number of graduates. The common sense advice was to change to a HSMP visa(this is a special visa category for somebody wanting to emigrate to UK and become an UK citizen who is highly skilled). I was not interested in becoming an UK citizen because I am a sad romantic who prizes his Indian citizenship. I felt such a move would be like spitting on the graves of innumerable freedom fighters of India who gave me the freedom and independence from UK colonialism. Anyhow the effect of this forced exodus of non EU doctors from UK back to their home countries had an adverse impact on the provision of emergency care in NHS hospitals. Overnight non medically qualified clinicians (mainly senior nurses) were thrust into unfamiliar clinical roles amounting to a junior doctor. This issue is by itself a controversial topic and my own personal opinion on this has changed over the years from one of disgust to one of acceptance. I am fortunate to now work in a hospital and department which actively encourages high quality non medically qualified clinicians. I am fortunate to work closely with these enthusiastic clinicians who add a great service to NHS.

Sometime in 2014 an excellent emergency physician from India moved back to UK to further his training. This was one of the doctors who was forcibly chucked out of UK due to the abrupt closure of permit free training in UK in 2006/7. He went on to do a post graduate training in India and gain further experience before deciding to have another go at living and working in UK. As mentioned earlier UK emergency medicine was adversely suffering from the changes in 2007 and for the last few years have gone back to the usual hunting commonwealth countries) for health professionals who can come and prop up the huge gaps in the doctor's Rota in emergency medicine. Indian emergency medicine by now was gathering pace. Indian emergency physicians benefitted from a system where the major bulk of work was actual emergency medicine and with their extended roles into the hospital intensive care units. Overall the type of clinical work done by an emergency physician in India was far more interesting and challenging compared to their counterparts in UK who had a major component of 'urgent' primary care work.

Sometime in 2011, after 11 years in UK I was granted unlimited leave to remain/permanent residency in United Kingdom. I was no longer a bonded laborer to a trust based on work permit rules. The relief an immigrant doctor in NHS feels when he reaches this stage of his visa status is special and can only be understood and appreciated by other immigrants anywhere in the world. I could already see the gradual decaying of service in NHS which was reeling from a combination of poor resources both money and manpower, a country in recession, frozen pay scales and an expectation to deliver 5-star quality on 2-star funding. Unfortunately, NHS is a sacred thing in UK psyche and no political party was willing to be honest with the public that it was broken, decaying and in need of a complete overhaul. India on the other hand was embracing private healthcare and health insurance in an American style and marching ahead. An universal emergency number '108' for emergency services had been launched and there were ambulance services up and down the country being upgraded. 

Now in 2023 this is the situation I see in India in comparison to UK. In Uk the emergency medical services are overwhelmed with the increased levels of activity which is not adequately supported by funding. There is overcrowding in every single emergency department leading to increased morbidity and mortality of patients. More importantly the human cost in terms of burnt-out nurses and doctors is worrying and apart from the RCEM nobody seems to be bothered. Meanwhile in India the standards in emergency medicine has gone many folds up and, in some ways, possibly better than many emergency departments in UK. However, there is a lack of standardization of care, lack of adequate audit and research and most of the high-quality emergency services are in private corporate hospitals in bigger cities. This has meant the quality of care is often variable and frequently substandard in smaller towns and villages. Only a concerted effort from all players involved in the delivery of emergency services would change this scenario. There needs to be a constructive collaboration between public sector and private sector hospitals and the leadership for this needs to come from the health minister and health departments in every state in India. Will we see that one day. At the moment it is looking unlikely for the following reasons- nobody is bothered or interested in this issue. And the few hardy souls who are battling to achieve this are frequently fighting a lonely battle. 

Thank you for reading my random thoughts and observations. Please feel free to add your comments and views. Have a beautiful day filled with happiness and health everyone.

Epadikku 

Anamika Begum (just for today to get a free Biriyani from her Musalman friends!!!)

Happy Eid everyone. 

Remember that Eid is not just about biriyani, know the real purpose behind this festival and follow the real values. Insha Allah.