Sudden cardiac arrest especially outside hospitals is one of the few medical emergencies where survival is determined within minutes. The science of resuscitation is well established, and the principles of the Chain of Survival have been taught for decades. Yet, survival outcomes remain uneven—particularly in low- and middle-income countries like Pakistan. The reasons are multifactorial including a general lack of knowledge in bystanders, with a resultant lack of effort. Yet the biggest hinderance is a lack of coordination.
In order to understand the value of coordination, let us see the Chain of Survival as a relay race. In a relay, no single runner wins the race alone. Every runner is equally important, and the outcome depends not only on speed, but on how smoothly the baton is passed. A dropped baton, a delayed exchange, or a poorly timed handover can cost the race—regardless of how strong any individual runner may be.
In any coordinated resuscitation, the runners are clear. The first runner is the community: the bystander who recognizes cardiac arrest, activates emergency services, and initiates CPR. The second runner is the emergency medical service, responsible for early defibrillation, high-quality CPR, and rapid transport. The third runner is the emergency department, delivering advanced life support and stabilization. The final runner is post–cardiac arrest care—ICU management and neurological recovery. The finish line is not return of spontaneous circulation; it is meaningful neurological and physical recovery and survival.
In Pakistan, we have come some ways and started creating these runners. What we have to start doing is to start working together with team practice.
Too often, the baton is dropped at the very first exchange. Bystander CPR rates remain low, driven by lack of training, fear of causing harm, legal uncertainty, and cultural hesitation. Emergency medical services operate in parallel systems, with variable training standards and limited interoperability. Prehospital-to-hospital handovers are inconsistent, and post–cardiac arrest care pathways vary widely between institutions. Each link works hard within its own lane, but rarely trains with the others.
We respond to this fragmentation by producing guidelines, forming councils, and conducting certification courses. These are necessary—but they are not sufficient. Guidelines do not save lives unless they change behavior. Certifications occur once every few years; resuscitation happens every day. What is missing is a living platform where people involved in resuscitation talk regularly, train together, reflect on outcomes, and learn from both success and failure.
This is where the idea of a Resuscitation Collaborative for Pakistan becomes relevant.
A collaborative is not a council, not a regulator, and not a replacement for any existing body. It is a voluntary, multidisciplinary forum focused on conversation, capability building, and outcomes. Its strength lies not in authority, but in participation. Emergency physicians, anesthesiologists, cardiologists, nurses, paramedics, EMS providers, educators, and system leaders all have a seat at the same table—because resuscitation does not belong to any single specialty.
Such a collaborative would focus on practical actions: regular resuscitation case discussions across institutions; context-adapted CPR and advanced life support training; faculty development for local instructors; and low-cost, high-frequency simulation. It would encourage honest reflection on what went wrong, not just celebration of what went right. Over time, it could support simple, shared outcome tracking—not to police performance, but to guide improvement.
Most importantly, it would focus on the baton exchanges. Community to EMS. EMS to emergency department. Emergency department to ICU. These handovers—not individual heroics—are where lives are most often lost or saved.
Pakistan has unique challenges, but it also has unique strengths. We have strong community networks, a growing emergency medicine workforce, and a culture of volunteerism. Small, coordinated improvements at each link of the chain could translate into substantial survival gains. But this requires moving away from isolated efforts toward shared ownership of outcomes.
This is an invitation to start a conversation that continues beyond conferences and courses. If we want better survival from cardiac arrest, we must stop running alone and start practicing together. In a relay race, medals are won not by the fastest runner, but by the team that never drops the baton.