At the MedicCast Jamie Davis (the host of MedicCast) and Tom Bouthillet (of Prehospital 12 Lead ECG) interview Dr. Monica Kleinman, incoming Chair of the Emergency Cardiovascular Care committee at the American Heart Association (Heart.org/cpr).
Emergency Cardiovascular Care 2010 Update Interview.
There is a lot to discuss. Everybody does a great job of examining the changes. However, I have some comments on the changes. First, go listen to the show.
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How do they address changes, or the lack of changes?
Tom Bouthillet asks about how important is it to know the specific rates in your EMS system for each part of the chain of survival?
Dr. Kleinman says, “You have to be able to be measure what you’re doing.” She points out that it is odd that it’s not something we do for emergency cardiac care, even though we track water quality, police response, and other aspects of public services in our communities.
Evaluation of the effect of our treatments is much more important than that.
As I stated in Ethics, Research, and IRBs – Part I –
Without valid research, this is just unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away. And without any attempt at informed consent.
The most important word there is experimentation.
Without evidence that a treatment improves outcomes, we are just experimenting on patients, but we are not being honest and telling people that we are experimenting on patients.
Experimentation is important. Experimentation is the way we learn what works.
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In cardiac arrest, we have evidence of improved outcomes with good chest compressions and with defibrillations. This is due to experimentation.
These guidelines are based almost exclusively on weak evidence.
These guidelines are based on animal experimentation, which is a preliminary form of experimentation, that should be followed up with high quality human experimentation.
These guidelines are also based on human experimentation that is not often of high quality. The human experimentation has generally been poorly controlled, too small, or just not addressed important questions. Most of the well done experimentation has shown that the things we thought were improving survival were not improving survival.
We insist that using treatments right up until we have evidence of harm is good patient care.
We claim that we need clear evidence of harm before we eliminate any harmful treatment.
This is backwards.
This is the antithesis of ethical behavior.
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Measuring what we are doing is just the beginning of evaluating this huge unprofessional, unethical, uncontrolled, unauthorized, unreasonable experimentation on people who are just too dead to run away – without any attempt at informed consent.
For example, where is the evidence that ventilating cardiac arrest patients improves outcomes?
That is in Part II.
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I was more than a little confused when Atropine was taken out because it showed “no clear benefit” (nor harm) yet Lidocaine was left in because it showed “no clear harm” (nor benefit).
Lost on me.
Christopher,
There is a lot for me to write about.
There are some good changes, but mostly there seems to be a lack of change because the evidence of harm has not yet reached a critical mass.
When the AHA does remove a clearly harmful treatment, they will still need to explain to some people why they aren’t leaving well enough alone.
Agreed, it did seem like some of the meds were left in so we could “just do something”.
However, I will say I love the new circular flowchart for cardiac arrest (potential bias: I design visualizations for engineers to help them “see” data). It stresses continuous compressions and almost makes it “feel” like you shouldn’t be stressed out about getting your IV/IO in the first two minutes, or securing the airway rapidly. Perhaps that will take some of the “chicken with their heads cut off” in a code? Perhaps not.
I enjoyed the “don’t check a pulse without ETCO2 rise to physiologic/near-physiologic levels”. It’s about time this was formally acknowledged. Moreover the push to use ETCO2 as a benchmark for CPR efficacy was refreshing to see. A potential problem was that there was no mention that some ETCO2 detectors will not work on neonatal patients due to differences in anatomic dead space and its effect on device design, however, I’m sure that can be addressed elsewhere.
I did not enjoy that drugs down the ET and Esophageal Bulb Detectors are still included….throw that crap out, do we really have to wait until 2015 for these to go away?
Christopher,
They are learning.
We shall see.
We tend to distrust technology that we do not understand and trust other technology that we only think we understand. We might also refuse to pronounce a patient dead without the technology confirming asystole in at least 2 leads.
That can be addressed elsewhere, but neonatal codes in EMS do not often run smoothly, no matter what the guidelines recommend.
Dr. Kleinman did state that there will be changes made before the next full revision of the guidelines, so there is some reason for optimism. However, these are exceptionally ridiculous recommendations that should only ever be used for comic relief.
On one hand, you say you’re practicing real medicine and on the other you’re lamenting that a lot of the stuff you use hasn’t quite been proven, and lotsa stuff being used elsewhere should be taken off the trucks because you recognize our patients are being used as guinea pigs. Still, you DO recognize you are part of an experiment..
That’s not at all unlike the points that I was making in my Experiment Blog
http://emsoutsideagitator.com/2010/10/dr-sanjay-gupta-in-cheating-death-shows-ems-the-experiement-3-of-7
The only thing that I’m adding is that it’s quite myopic to think that the practitioners that came before you didn’t base what they did on science. It was just the science of their times. Just like it was temporary, and soon to be “proven” wrong, so too will yours be. Only remnants of what I used are in your drug box. And most of them don’t at all get used the way I used them because they were found to be, in some cases, dangerous!
We are very far away from the point of having any of our treatments set in stone. On the continuum of medical knowledge, we are still infants. You don’t seem to be willing to live with that.
firetender,
Even though this may be your shortest comment, my response takes up a full post – Comment on ECC 2010 Update Interview – MedicCast – Part I by firetender.