Jen Gagnon was sitting on the couch of her Peabody home when her teenage son rushed in. His friend, Daniel Anderson, had passed out while they were playing basketball in the driveway.
Outside, Anderson lay on the ground, his lips turning blue as the sky darkened. Gagnon shook him, then rubbed his sternum forcefully with the knuckles of her fist — a technique sometimes used by EMS workers to revive patients. Gagnon had learned it decades earlier when she worked in home health care. But Anderson didn’t wake up. She tried a few chest compressions and then called 911.
The next four minutes would dictate if Anderson would survive.
Last week, the nation watched in horror as the Buffalo Bills’ Damar Hamlin collapsed on the field from cardiac arrest, and then saw in real time as team medical staff and emergency responders immediately began to resuscitate him. Outside of sports stadiums and hospitals, however, the vast majority of people who experience emergencies like Hamlin’s do not survive.
Nationally, the odds of surviving a cardiac arrest — a sudden loss of heart function triggered by a heart attack, a blow to the chest, a congenital defect, or another cause — is roughly 10 percent, and those odds worsen by the minute. It is the number one cause of natural death in the country, affecting mostly late middle-aged adults. Just 2 percent of cases are in people younger than 18.
Massachusetts doesn’t track statewide cardiac arrest survival rates, but some municipalities do, and their data shows that survival varies widely. In Boston, 11.2 percent of people who experienced a cardiac arrest in 2021 survived, but in Worcester, one recent study found those rates were between 3 and 4 percent.
Experts say Massachusetts lags other states in how it responds to cardiac arrests. Sparse or lackluster CPR training here is one factor. The state also has a lack of close-at-hand defibrillators — devices that attempt to shock the heart back to a normal rhythm — and a lack of databases or other guides on where to find them.
As a result, as good as Massachusetts health care can be, people suffering cardiac arrest are at the mercy of where they collapse and who comes to their aid. Even during a 911 emergency, when immediate help is essential, advocates argue that it can take too long for over-the-phone CPR instruction to begin.
With the start of a new legislative session, advocates are preparing to reintroduce bills aimed at tracking and improving cardiac arrest survival rates. Similar legislation has failed in the past, with a comprehensive reform package sidelined last year by more pressing COVID-19 matters. A bill that would require CPR instruction in high schools has stalled in the face of opposition from school superintendents, opposed to taking away academic learning time. But advocates hope that, with Hamlin’s case adding urgency to their cause, this time their efforts will succeed.
Transferred calls, repeated info
“911, this call is recorded. What is the address of your emergency?” Peabody’s dispatch says on a recording of the June 2019 call. Gagnon provides it and immediately says she needs an ambulance.
“I have a 17-year-old boy who just passed out,” she said.
The dispatcher told Gagnon to stay on the line, and transferred her to Cataldo Ambulance. At 24 seconds into the call, an ambulance dispatcher was on the line
In Massachusetts, some municipalities handle 911 calls themselves, while others are covered by regional dispatch centers. The majority of dispatch centers handle all emergency calls, whether for fire, police, or ambulance needs. However one-third of dispatch centers — mostly those operated by individual municipalities — only handle police and fire calls, and transfer calls for ambulances and medical aid.
The State 911 Department has strongly advocated that cities and towns work under regional dispatch centers, so calls don’t have to be transferred at all. However compared to a decade ago, calls are now transferred less often and more quickly. Calls are rarely transferred more than once, and no call can be transferred more than three times, according to state regulations.
Each time a call is handed off, though, dispatchers often ask several of the same questions — including address of the emergency and a callback number. This consumes precious time, and even a few seconds can be crucial to a victim in cardiac arrest, advocates and experts argue.
“Every minute [without CPR] that goes by, survival drops 10 percent,” said Dr. Joseph Sabato Jr., an associate professor at University of Massachusetts Medical School, retired emergency physician, and medical director of 911 telecommunications for UMass Medical Center.
Legislation set to be filed by state Senator Michael Moore this week would improve telephone-assisted CPR instruction and its quality. It would also add emergency physicians and EMTs to the state’s 911 advisory board, to help in discussions about providing CPR instruction sooner when someone calls 911. The American Heart Association recommends no more than 90 seconds between the time an address is acquired and when CPR compressions begin. Sabato said communities with high cardiac arrest survival rates such as Seattle adhere to those standards.
“We estimate that if we just go and do what other states do, we’ll save at least 500 lives [a year] in Massachusetts,” Sabato said.
But for municipalities that outsource their emergency medical dispatch, it could prove difficult to provide CPR instruction right away. Chuck Fothergill, director of communications infrastructure at Cataldo Ambulance Service, said some dispatch centers don’t have the size and scale to provide CPR instruction while responding to other calls. And even if that initial dispatcher can provide CPR instruction, they would still have to transfer the caller to dispatch an ambulance, which would be difficult to do while talking someone through CPR.
“The faster a trained emergency medical dispatch telecommunicator is on the phone with the bystander or family member, the sooner we can start CPR,” Fothergill said. In 2022 alone, Cataldo handled 1,620 cardiac arrest calls, providing CPR instruction in 673 of them.
While some advocates criticize the fact that dispatchers ask some of the same questions on each transfer, Fothergill said that it is crucial to ask the phone number and address more than once, in case the caller is disconnected, and to make sure responders go to the correct location.
The fraught scene in Jen Gagnon’s driveway showed the current system at work. After being transferred to the ambulance dispatcher, at 37 seconds into the call, Gagnon repeated the description of the emergency. Cataldo’s dispatcher confirmed the phone number, and asked if Anderson had taken anything. Gagnon said no.
“He’s breathing but it’s like gasping for air,” Gagnon said.
Deprived of oxygen when the heart stops pumping, the brain reflexively prompts the body to gasp for air. But this “agonal breathing” isn’t enough to bring oxygen to the body. It is a sign that a person is near death.
“We may have to start CPR,” the dispatcher said. One minute and 14 seconds had passed.
Lack of CPR training
While a bystander can receive CPR instruction over the phone, whether they feel comfortable performing it is another question. Training could help bystanders recognize when someone needs CPR and perform it before even calling for help.
Yet CPR expertise among the Massachusetts public is lacking, said Allyson Perron Drag, senior government relations director for the American Heart Association, which has been working on legislative reforms.
Massachusetts is one of 10 states that do not require high school students to be educated in CPR, Perron said. While a number of schools offer it, it is usually through health or PE classes, and sometimes as an elective. Representative Patricia Haddad said she is drafting legislation that would increase CPR and defibrillator training for high school students in Massachusetts.
Meanwhile, individual organizations are trying to increase education where they can. Daniel Anderson’s family created a nonprofit to teach CPR and provide communities with defibrillators. At UMass Memorial, doctors created a program called “prescription CPR,” which offers free CPR training at the hospital to individuals whose family members are at high risk of cardiac arrest.
Still, at UMass, only 30 percent of victims who come to the hospital after suffering a cardiac arrest have received bystander CPR, Sabato said. That number is below the national average of approximately 40 percent, according to a 2022 report from the American Heart Association.
Gagnon knew the basics of CPR, having received formal training several times in the past. Once on the phone, dispatch walked her through the steps, telling her to lay Anderson flat and put the phone on speaker. She told Gagnon how to place her hands and where.
“You wanna pump the chest hard and fast at least twice per second and two inches deep,” dispatch said. “We’re going to do this 600 times or until help can take over.”
Gagnon’s mind was racing: two inches deep, how far is that? She worried about how hard to press. Am I going to break him, she thought?
“Say that again,” Gagnon said. The dispatcher repeated the instruction.
Two minutes and 57 seconds had passed. “Ready?” dispatch asked.
The defibrillator hunt
CPR will buy a patient time, but it often isn’t enough. For most cardiac arrest patients, shocking the organ back to a normal rhythm is critical to survival.
A defibrillator used in the first minutes after a cardiac arrest can substantially increase the likelihood of survival. But that’s if emergency responders arrive almost immediately, or if a defibrillator happens to be available for a bystander to use. According to a recent study, fewer than 3 percent of out-of-hospital cardiac arrest victims have a defibrillator applied before EMS workers arrive.
Massachusetts has made some progress in making automated external defibrillation devices (AEDs) more readily available, but the state “is pretty far behind on where defibrillators are placed, what’s required, and CPR training,” said Perron of the American Heart Association.. In 2006, legislation passed requiring AEDs in health clubs. Legislation passed in 2017 required all schools to have at least one AED and a person trained in its use on site. AEDs must also be accessible at all school-sponsored athletic events.
Some medical facilities are required by license to have AEDs, such as dental offices and nursing homes. But few other venues are required to have defibrillators on site. Public buildings and professional sports venues can elect to have them voluntarily, but are not required to. Prices for many AEDs start in the $1,000s.
And even though some companies have made apps identifying where AEDs are in a given area, not everyone has such an app installed. The 911 system here has no central database identifying where they are.
Moore’s legislation would create a registry of defibrillators accessible to 911 operators, as well as improve signage alerting people where AEDs can be found.
Legislation being drafted now would also require the department of public health to make sudden cardiac arrest a reportable disease, establishing better baseline data showing how frequently it occurs, and when interventions save lives. Based on data from 2008, Massachusetts likely experiences over 4,500 cardiac arrests annually.
While advocates have tried to pass similar legislation in the past, Sabato is more optimistic this time. He said that he spoke with Governor Maura Healey, who voiced a desire to sign such legislation should it come to her desk. A spokesperson for Healey said she supports efforts to improve emergency responses, and would review legislation that reaches her desk.
Hamlin’s case has “given people a tangible, easy to understand example of how this works,” Sabato said.
In the Gagnon driveway, the dispatcher counted out loud as Jen Gagnon pumped Anderson’s chest: “53, 54, 55.” Three minutes and 31 seconds had passed since Gagnon called 911.
“He’s brea-, he’s blinking,” Gagnon said. If he’s breathing, dispatch instructed, turn him on his side.
Anderson began moaning as he struggled to breathe, the groans growing louder.
“Does anyone have his mom’s number?” Gagnon asked.
Emergency responders from the fire department arrived, four minutes and 19 seconds into the call. Gagnon said they resumed CPR.
The 911 call recording stops at this point, but according to Anderson’s father, who spoke with those at the scene, his son received defibrillation from the fire department. EMTs whisked Anderson to Salem Hospital and later that day he was transferred to Massachusetts General Hospital.
A matter of luck
Anderson is now 20 years old and has almost fully recovered. While he initially experienced some neurological issues, including trouble with word recall, today that is rarely an issue.
Surgery has since corrected what doctors discovered was a rare congenital abnormality. Instead of a left and a right coronary artery, Anderson had two coronary arteries on the right side that supplied blood to his heart. In times of stress or exertion, the blood flow in one artery would cut off. Anderson’s dad, Kurt Anderson, thinks his son that day likely pushed himself to play through discomfort that would normally cause him to stop. His son’s heart stopped instead.
Every year on June 26, the Andersons and Gagnons gather to celebrate the day when everything after that moment went right. Not only was it helpful that Gagnon had previous CPR experience, but she was able to give an exact address to emergency responders. Her home is within eyesight of the fire department down the street, and emergency workers with defibrillators arrived quickly. While most fire engines have AEDs on board, according to Perron, police cruisers often do not.
“Daniel’s story is one of the stories when everything works the way it’s supposed to,” Kurt Anderson said. “We know how fortunate we are.”