Hawaii 911 call
survival rate slips

Many die needlessly because
they're reluctant to call
for help, experts say

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By Helen Altonn
haltonn@starbulletin.com

Despite big strides in treating strokes and heart attacks, many islanders die needlessly because 911 is not called soon enough, medical officials emphasize.

And in a June stroke survey of 254 people, about 12 percent did not know how to dial 911 to summon an ambulance. There was also no change in the number who understand stroke and heart attack can be prevented and treated.

"It's scary," said Dr. Cherylee Chang, medical director of the Queen's Medical Center's Neuroscience Institute/Stroke Center. "Older people, more at risk for stroke, did not call 911."

State Emergency Medical Services Director Donna Maiava said she has had increasing calls from seniors because Medicare does not cover emergency transportation unless it is a medical necessity. Passing out does not qualify. "It's almost criminal, and I wonder how much of a deterrent it is," she said.

Experts are worried. Honolulu's "collapse to call" time is creeping up, and the "save" or survival rate is slipping, they point out.

National 911 Day is being recognized across the country today with emphasis on signs of stroke and heart attacks and the importance of calling 911 immediately.

Delays cost lives. That was the emphasis in interviews with Chang, Maiava, Capt. M. Roger Goodell of the Honolulu Fire Department Medical Section and Don Weisman, spokesman for the American Heart Association of Hawaii.

They cited these facts:

>> For the first half of this year, the lag time in calling 911 after witnessing cardiac arrest averaged eight minutes, 17 seconds, up from eight minutes last year and seven minutes, 49 seconds, in 1997.

>> Only 10 percent of patients were alive when they reached the hospital, down from 13.1 percent last year and 13.04 percent in 1999.

In sharp contrast, in King County, Wash. (Seattle), 911 calls in cardiac cases were made in about 1.3 minutes with a 34 percent survival rate.

An exact comparison cannot be made with King County because it uses a different statistical method, Goodell cautioned.

Still, it clearly is way ahead of Honolulu, he said, and one reason is an aggressive cardiopulmonary resuscitation training program, which is mandatory in schools there.

"They have a culture of education and awareness that we don't have," Goodell said.

If it takes eight minutes to call 911, paramedics have only two minutes to get to the patient, Weisman said, pointing out few resuscitation attempts succeed after 10 minutes.

And it is less likely in Honolulu that anyone is doing CPR in those eight minutes, he said. "In King County, even though they're waiting one minute, they're doing CPR."

CPR and the use of defibrillators to shock the heart back to normal rhythm until paramedics arrive greatly improve survival chances because death can occur four to six minutes after cardiac arrest, he said.

A drug called t-PA (tissue plasminogen activator) has increased the survival rate of victims with ischemic stroke, which occurs when blood vessels to the brain become clogged. But it must be given within three hours after symptoms start.

New lifesaving medications also are available for heart attacks, but they are most effective within an hour after symptoms appear.

"It's amazing to me that there are such significant saves," said Maiava. "A guy kind of wakes up and sits up and says, 'What did you hit me for?' and is told, 'My God, man, you were dead.' It is really dramatic."

But the full potential of the new technologies is not being realized, Weisman said, because "people are not acting fast enough to let medical professionals take care of them. A lot of savable lives are being lost because people don't call three digits on the phone."

Instead of calling 911, people drive to the hospital themselves, or they call friends and relatives. "They don't want to cause trouble," Goodell said. "They want to make sure what they're doing is right."

Some do not call at all. "You'd be surprised how many people say, 'I didn't call because I didn't want the ambulance and firetruck (coming to the house),'" Maiava said.

A lot of people do not recognize the warning signs; they have pain and do not tell anyone, or they have subtle weaknesses and think they are just tired, Chang said. "They hope it will go away."

"I read that on reports in case after case," Maiava said.

In a June survey of 254 people, 57 percent said they would recognize signs of stroke, compared with 52 percent in a survey of 252 people in April last year.

The number saying they would call 911 rose to 89 percent from 79 percent. Yet, of 24 persons in the June survey who were present when a stroke occurred, only half called 911, about the same as last year, Chang said.

"It's really disappointing," said Chang, president-elect of the American Heart Association of Hawaii and co-director of Hawaii's Operation Stroke Committee.

Money concerns also keep others from calling 911, although most insurance covers ambulance services, Maiava said. The highest rate is $450; it is $400 if no advance life support is required.

Ethnicity and culture also appear to be factors. Of the 24 cases with someone present when stroke occurred, none of six Japanese families called 911. Seven of nine Hawaiian families did.

Goodell described a case where a Japanese family called an aunty, who called 911. Firefighters went to the address where the call was made and found the victim lived four blocks away.

"That happens all the time," Chang said. "We go to the ER and say, 'Why didn't you do anything?' Even a physician's wife waited hours until her husband came home because she didn't want to bother anyone."

Extreme cases occur in which people call out-of-state relatives who call 911 at their locations, and 911 there calls 911 here, Goodell said. "We had one in 1997 or 1998 where the call originated from London. It's medical section legend."

Data are not available for stroke cases, but Maiava said there were 1,306 cardiac pulmonary arrests last year. Of those, 638 were dead when paramedics arrived, and another 350 were considered dead on arrival at the hospital.

Only 78 patients, or 18 percent, were admitted to the hospital with a restored pulse, she said. However, she said, "Eighteen percent is a heck of a lot better than we were two years ago, at about 9 percent."

She said 56.4 percent of those perceived savable had bystander CPR.

CPR is important because people at the scene do not know if someone can be resuscitated, Chang said. "We don't want them to make a diagnosis."

The AHA of Hawaii last November launched Operation Heartbeat, increasing distribution of automated external defibrillators and expanding CPR classes. It offers free CPR, but people do not take advantage of it, Weisman said.

Goodell said the Fire Department, which provides free blood pressure screenings, this month also will begin passing out stroke and heart attack risk information and actions to take.

Sudden discomfort signals trouble Every second counts in heart attack and stroke emergencies, so call 911 immediately if you see any of these symptoms: Heart Attack Warning Signs >> Chest discomfort, such as pressure, squeezing, fullness or pain that lasts more than a few minutes or goes away and returns. >> Discomfort in other areas of the upper body, such as one or both arms, the back, neck, jaw or stomach. >> Shortness of breath, which often occurs with chest discomfort. >> Other signs, such as a cold sweat, nausea or lightheadedness. Stroke Warning Signs >> Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. >> Sudden confusion, trouble speaking or understanding. >> Sudden trouble seeing in one or both eyes. >> Sudden trouble walking, dizziness, loss of balance or coordination. >> Sudden, severe headache with no known cause. Source: American Heart Association Free CPR classes offered Monday Waikiki residents and employees are urged to attend free cardiopulmonary resuscitation courses offered from 8 a.m. through 3:30 p.m. Monday at the Sheraton-Waikiki Ballroom. The American Heart Association of Hawaii, Honolulu Fire Department, Federal Fire Department and Sheraton-Waikiki Hotel are sponsoring the 90-minute classes, each beginning on the half-hour. Lessons will include tips on assessing and reacting to an emergency situation, an overview of the AHA's Chain of Survival, how to clear obstructed airways and how to perform CPR. Free blood pressure screenings, stroke risk assessments, body fat analyses and cardiovascular disease prevention literature also will be offered. For more information, call the AHA at 1-888-277-5463.