Continued from Part I. Continuing the comment of JB –
Even for people who don’t end up surviving to hospital discharge. A good friend of mine had his uncle have a sudden cardiac arrest a couple of months ago. The paramedic crew managed to get ROSC (presumably using adrenaline), and took him into hospital. He ended up dying a few days later, but my friend said that having that few days to say goodbye while his uncle was still alive (even though on life support and unconscious) was helpful for him to have some closure. Is this not of benefit, even to the family, to achieve the greater rates of ROSC that adrenaline has been shown to give? (assuming unlimited hospital resources etc… but that’s then a very different ethical discussion!)
What if the cost of the treatment for the resuscitated family member prevents them from being able to afford other medical treatment? What if that cost, in order to say good-bye to a comatose family member, rather than say good-bye to a dead family member, leads to the premature death of someone in the family in order to pay for those few days of ICU (Intensive Care Unit) care? Are we dealing with $50,000? $150,000? How much money is it worth for a family to be able to say good-bye to an unresponsive family member who has a pulse, rather than an unresponsive family member who does not have a pulse? How much is this psychological care worth?
What if the family member is resuscitated in better neurological condition than the coma that only ends in death? What about the patient who is now in need of constant restraint (chemical, physical, or both)? What about the family member who is resuscitated with so much neurological damage, that he does not recognize his family members? Is it a benefit to the family to have a relative become a complete stranger? Would they have been much happier with their last memory of the patient alive being the same family member they knew before the arrest or the new personality that comes with brain damage?
We don’t know which patients will be which. We do not know how each family would answer these questions. We do not know how each patient would answer these questions. Should we believe that we are providing a benefit to patients, or families, by resuscitating more cardiac arrests with more neurological disability?
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Unless adrenaline is shown to *decrease* neurologically intact hospital discharge (as opposed to the nil difference it seems to show at the moment), is there not good reason to use it?
Is there a good reason to believe that epinephrine does not cause more damage than benefit?
If we learn that epinephrine does cause more harm than good, what would we wish we had done to avoid harming patients?
If we learn that epinephrine does provide more benefit than harm, but not in the way we currently use it (different dose, or different timing, or different concentration, or something else, or some combination of these), what will we wish we had done to produce better outcomes than this shotgun dose everyone and let the neurologist sort them out approach?
We are treating patients as if we know what we are doing.
If there is anything that we can be certain of, it is that We do not know what we are doing.
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Of course, to show any of this, further research is required, which was your main point that I agree with.
Until we do the right research, we are just practicing witchcraft.
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Note: I’m just a new student, so there’s quite possibly stuff that I don’t yet understand… so I’m more than happy to be educated!
You provide some great questions.
I wish I could provide more answers. We know a lot about actions at the cellular level, but the combination of all of these individual actions is often very different from what happens with real patients. Also there is a lot of variation in the way real patients will respond to the same treatment.
It is by asking the right questions that we learn what works. Most people don’t seem to understand enough to ask any questions.
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To be continued in Part III.
Also read Adrenaline: Curse or Cure? over at flobachrepublic.
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Thanks for the follow-ups!
Have to admit I didn’t consider the element of financial costs to the family. I’m lucky enough to be in a country where the cost of health care is not a consideration… but that’s not a political hot button I feel like pushing right now!
So the question is, what research? One of my lecturers in my training school this week said that “there’s a clinical trial just waiting for someone to do it, in giving infusions of adrenaline rather than boluses”. I suppose there’s probably a lot of different things to try. How do we go about developing trials to determine what’s good and what’s bad?
JB,
You’re welcome.
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I don’t think that there is any place that does not ration care in some way. The differences are in the ways the rationing is decided and the ways the rationing is explained.
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Exactly.
We have used trials of several different doses of bolus epinephrine because EMS cannot be expected to manage infusions.
This is not always true, but a lot of people do not trust us to give drugs by infusion. What if . . . ?
As Dr. Scott Weingart mentions in his podcast on the 2010 ACLS guidelines, we should be basing our use of epinephrine on an assessment of the needs of the patient. Unfortunately, he is using a central line for this and EMS is probably not going to be doing this any time soon, except in very rare cases.
EMCrit Podcast 34 – 2010 ACLS Guidelines
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