Footballer Fabrice Muamba survived cardiac arrest but, a new book argues, too few get the same state-of-the-art treatment. Giulia Rhodes reports.
A year ago this month, in front of 35,000 spectators and millions more watching on television, Fabrice Muamba collapsed on the pitch at White Hart Lane after his heart suddenly stopped in an FA Cup quarter final.
Technically, the 23-year-old Bolton Wanderers midfielder had "died" after suffering a massive cardiac arrest. His heart stopped for well over an hour, despite frantic efforts to resuscitate him. Yet four weeks later, against all the odds, he was discharged from hospital very much alive. This June, he is due to become a father for the second time (he and his wife Shauna already have a four-year-old son, Joshua).
Rapid advances in the understanding of cardiac arrest should mean ever more survival stories like Muamba's, according to Dr Sam Parnia, a leading expert in the field of resuscitation. In his new book, The Lazarus Effect, Parnia examines the way our knowledge about this knife-edge of life and death has grown. But, he warns, despite advances in understanding and technology, too few people are offered the cutting-edge care that could save them.
"The overall survival rate for a patient suffering a cardiac arrest in hospital in the UK is estimated at 16-18% ," he says. The equivalent figure for cardiac arrests occurring outside hospital is even lower - at 2-12%, depending on location. "This is similar to 1960s levels, which is shocking. The public is being shortchanged in this very important area of medical care."
Every year in the UK 75,000 people suffer a sudden cardiac arrest, among them 500 young people under 35 with undiagnosed heart problems. Sudden cardiac arrest means the heart stops pumping blood, and is commonly caused by an abnormal heart rhythm, as in Muamba's case (he is now fitted with an implantable convertible defibrillator, or ICD, to monitor and regulate his heartbeat). The condition can also be the result of a heart attack.
"In the past, the moment of death was the cardiac arrest," says Parnia, who divides his time between the US and Britain, as director of resuscitation research at the State University of New York and director of the Human Consciousness Project at the University of Southampton Hospital.
"There was no heartbeat, no respiration and, as a result, no brain function." Later, when ventilators were developed that could temporarily maintain a heartbeat after irreversible brain damage, the concept of brain death was developed. Now, though, Parnia believes such definitions are outdated and we can no longer talk about the "moment of death", since death is a gradual process.
"Cells in the body do start to die after the heart stops," he says. "But while we used to think we only had four to five minutes to save brain cells, we now know that we may have up to eight hours before they actually die.
"What we do or don't do in that time makes all the difference between a footballer coming back to life and another young tragic death, or person with a persistent vegetative state."
Crucial, of course, to survival is immediate CPR (cardio-pulmonary resuscitation) which, when carried out by someone who has not been trained in it, should be hands only, not mouth-to-mouth; and use of a defibrillator (which gives a controlled electric shock that can regulate the heart rhythm).
Yet fewer than one third of cardiac arrest victims outside hospital actually receive CPR, while a survey this week found that more than a third of the public would not use a defibrillator in the workplace for fear of injuring the casualty. Training the public in life support is key, believes Parnia, to improving survival rates.
Also key is the quality of emergency care in hospital - which, he says, is unpredictable. His views are supported by Dr Jasmeet Soar, an intensive care consultant and vice chairman of the UK's Resuscitation Council.
"Muamba had the best possible circumstances: a witnessed cardiac arrest, early CPR, early defibrillation, early transfer to a specialist centre offering the best post-resuscitation care. Most people aren't as fortunate to have all these links in the chain of survival," says Soar.
Doctors treating Muamba, including a cardiologist who leapt from the stands to help, diverted his ambulance to the specialist London Chest Hospital, rather than opt for the closest emergency department. There, his heart was restarted, 78 minutes after it had stopped, using further defibrillator shocks, drugs and a temporary pacemaker inserted through a catheter. In intensive care, his body was artificially cooled.
Therapeutic hypothermia, as it is known, involves reducing body temperature to between 32C and 34C using a special blanket or mattress. It reduces the rate of cell damage in organs deprived of oxygen and is the most significant recent development in resuscitation care, says Parnia. "Cooling changes the game. It means the brain can potentially recover after a much longer period."
Yet while around 90 per cent of UK hospitals now have the cooling technology recommended in resuscitation guidelines, few cardiac arrest patients actually receive it. "In the UK, as in the US, some doctors will cool and others will not, even within one hospital," says Parnia.
"There are no UK figures, but they are believed to be similar to the US, where fewer than 10% of eligible patients were cooled in 2012, despite most hospitals having the technology."
Too many doctors feel uncertain about factors such as optimal temperature and duration, he says. He compares the field of resuscitation medicine to the "early days of aviation when everything came down to the decisions of individual pilots. Now aviation is regulated — and safer."
Looking after the brain and other organs in the 72 hours after resuscitation has been "our Achilles heel", says Parnia. "We need not only to improve survival rates but also to diminish brain injury rate. It is like a space programme - you get astronauts out there but you can't have them burnt in the atmosphere on the way back."
One problem is the lack of research on which to base best practice — something the Resuscitation Council is addressing with the first UK-wide three-year audit of in-hospital cardiac arrests, to be published soon, and a mirror audit of arrests outside hospital, which is being set up.
Traditionally, patients reporting out-of-body experiences, or seeing lights or welcoming figures during a cardiac arrest (a significant minority, says Parnia), have been dismissed as outside the realm of medicine. This reaction, he says, is outdated.
"Rather than approaching this from a religious or philosophical point of view, we can now approach it scientifically. This is a major revolution in resuscitation science. Just as new evidence suggests that brain cells do not die immediately after clinical death, it also suggests that consciousness - what makes us who we are - is not immediately annihilated." Investigating experiences like this could help further our understanding about how the brain works and eventually dies, and how it should be supported during resuscitation.
Muamba is now recovered, but his condition means his footballing career is at an end. Much of his time is spent campaigning with the British Heart Foundation and the UK Resuscitation Council for CPR to be incorporated into the new secondary school curriculum, the consultation on which ends next month.
"People suffer what I did on a daily basis but… most don't make it because nobody knows how to help them," he writes in his book, I'm Still Standing (Sport Media, pounds 12.99). "The guy who collapses in the supermarket should have the same chance I did."
In Norway, where CPR is on the school curriculum, the survival rate for a witnessed cardiac arrest is 50%, according to the British Heart Foundation. Parnia concurs that a similar move in the UK would be "an excellent idea". "We all — the public and the medical profession — need to take ownership of this. For every Fabrice Muamba there are nine others who don't make it. We must change that."