Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

A Comment on Myths and the 2015 ACLS Cardiac Arrest Algorithm

In the comments to 2015 ACLS Cardiac Arrest Algorithm, Mr. M objects to the following statement of mine –

SSM (System Status Management) continues to burn out crews and vehicles, but some administrators continue to believe. Since they administrate in back offices, we do not know where their hands are. Improved response times? The difference in response times is insignificant and response times have never been shown to be important outside of cardiac arrest.

It is not clear if Mr. M intends to defend SSM, but here is his response.

Response times are insignificant outside of cardiac?

Except for cardiac arrest, there is no evidence that quicker response times make any difference in outcomes.

You need to produce some evidence, if you want to claim that response times affect outcomes (except for responses to cardiac arrests).

I am sorry but i very much disagree, if i have a pt who is having a cardiac problem (usually just ‘my chest hurts’, not usually a full blown AMI) it makes not a whole lot of difference if you get there in 10 minutes or 30, they make it to the hospital none the less, there is no field tested proof that a petal to the metal fast response increases chance of survival.

How do you know the difference between just ‘my chest hurts’ and a full blown AMI.

12 lead?

Troponin?

Neither is capable of ruling out a cardiac cause of chest pain.[1]

There may be a reason for that lack of evidence.

However, what about trauma? How could you in good medical reason tell us that there is no difference if response times are fast or slow in trauma? The first thing they hammer into your head in training as EMS and Doctors alike, is the Golden Hour for treatment and the Platinum 10 minutes for EMS transport, it’s there for a reason.

The Bogus Hour Golden Hour is just one of many EMS myths.[2] [3] [4] [5]

The Golden Hour was also the basis for the predictions of death and destruction by Dr. Thomas Scalea when Maryland scaled back their flight criteria so that a doctor would have to be called for permission to fly patients for MOI (Mechanism Of Idiocy Injury).

“Whenever someone says they want to ratchet it back,” says Dr. Thomas M. Scalea, physician in chief at Shock Trauma, “I tell them ‘OK, how many people can die next year to make that worthwhile?’”[6]

As I have mentioned before –

We were promised dead bodies.

Where are the dead bodies?

There does not appear to have been any change in the trauma fatality rate, even though flights have been cut by more than half. 😳

The Golden Hour is just a sales pitch created by R Adams Cowley in a bar to sell his trauma system to the tax payers.

There is no evidence to support the Golden Hour.

The Golden Hour is a just a marketing tactic.

If you want to claim that the Golden Hour is legitimate, then you need to provide some evidence – R Adams Cowley never provided anything except double talk.

Footnotes:

[1] Rule Out MI with 12 Lead ECG
Rogue Medic
Article

[2] The golden hour: scientific fact or medical “urban legend”?
Lerner EB, Moscati RM.
Acad Emerg Med. 2001 Jul;8(7):758-60. Review.
PMID: 11435197 [PubMed – indexed for MEDLINE]

[3] Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort.
Newgard CD, Schmicker RH, Hedges JR. at al.
Ann Emerg Med. 2009;(in press, may end up with a 2010 publication date)
PMID: 19783323 [PubMed – as supplied by publisher]

[4] The Golden Hour
StreetWatch: Notes of a Paramedic
Article

[5] Revisiting the Golden Hour in Trauma
CLIC-EM Clinical Insights from Chicago Emergency Medicine
Article

[6] Advantages of medevac transport challenged
Baltimore Sun
October 5, 2008
Article

.

Comments

  1. Current evidence points to a trimodal distribution of trauma deaths:

    1. Those who die on scene, usually with unsurvivable injuries. EMS cannot help these.

    2. Those who die days or weeks later from sepsis or MODS. EMS cannot help these.

    3. Those who will die without rapid surgical intervention. EMS can potentially help these, but since there seems to be no difference in mortality between those who arrived in surgery within the Golden Hour versus those who arrived in the Aluminum Afternoon, it is also plausible that cab drivers could help them just as much.

    • I suspect that with appropriate early care and “setting the stage,” we can indeed help #2. But that’s just my guess. (Plus it would take convincing us folks with patches on their arms that the actions we take can have an effect on what happens a week from now, which is probably about as hard as making us believe germs are real.)

      • “(Plus it would take convincing us folks with patches on their arms that the actions we take can have an effect on what happens a week from now, which is probably about as hard as making us believe germs are real.)”

        Really? Maybe it’s just different training models… but something that’s being hammered into us in the training school I’m doing at the moment is “you’re part of a continuum of care, you need to think about how what you do at the start affects the way the patient is discharged.”

    • AD,

      Current evidence points to a trimodal distribution of trauma deaths:

      1. Those who die on scene, usually with unsurvivable injuries. EMS cannot help these.

      2. Those who die days or weeks later from sepsis or MODS. EMS cannot help these.

      3. Those who will die without rapid surgical intervention. EMS can potentially help these, but since there seems to be no difference in mortality between those who arrived in surgery within the Golden Hour versus those who arrived in the Aluminum Afternoon, it is also plausible that cab drivers could help them just as much.

      Cab drivers. Hitchhiking, as long as you don’t look like Rutger Hauer. Sail boats. Skate boards. Segways.

      Less oxygen and less immobilization?

      This might explain the patients who are better off without EMS.

      .

    • Brandon,

      I suspect that with appropriate early care and “setting the stage,” we can indeed help #2. But that’s just my guess. (Plus it would take convincing us folks with patches on their arms that the actions we take can have an effect on what happens a week from now, which is probably about as hard as making us believe germs are real.)

      2. Those who die days or weeks later from sepsis or MODS. EMS cannot help these.

      Getting EMS to think beyond placing the patient in a bed in the ED is essential. Eventually, we will get more people to understand this. AD does understand this, but he is making a different point.

      .

  2. No, Tim, the bizarre claim that response times are insignificant comes from non-fire based EMS and their desperate attempt to show that their inability to respond to emergencies in a timely manner is irrelevant. The problem is that third-service EMS can’t function without fire department first response but it’s become the monster that’s slipped its leash. It really doesn’t matter anyway because it’s the taxpayers through their elected representatives who decide what kind of response times they’re willing to pay for, and if that doesn’t having milk shooting out your nose, you know how I feel about the fun and games associated with response time reporting. It’s time for everyone to grow up and work together because it doesn’t matter what response times are reported. What matters is whether or not patients live or die. You can have excellent response times on paper and abysmal survival from sudden cardiac arrest. Clearly there’s more to EMS quality than how fast the meat wagon shows up. But insignificant? You need to ventilate your office my friend.

  3. I read a study in regards to on scene times with cardiac patients that may be relevant today

    http://www.jems.com/article/patient-care/studies-examine-affects-scene-times-stem

    If being on scene less than 10 minutes can benefit a cardiac STEMI patient (“time is muscle”)

    Do we really need a study that says time is blood if you have a leak (trauma) for it to make sense that those 5 minutes MIGHT actually make a huge difference? Or am I way off base?

Trackbacks

  1. […] response to my post A Comment on Myths and the 2015 ACLS Cardiac Arrest Algorithm, which contains a quote from 2015 ACLS Cardiac Arrest Algorithm is an objection from Tom Bouthillet […]

Speak Your Mind