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On a special mid-week episode of EMS Office Hours, Jim Hoffman, Josh Knapp, Bob Sullivan, and I discuss the many conflicts over who is in charge on scene. David Aber and David Blevins add to the conversation in the chat room. There was a delay getting Bob and me on the show, but we do end up on the show.
EMS Pits Crews | Should A Yellow Flag Be Waved?
It seems that the problem with CPR quality is a lack of excitement, so we are looking for a way to bring back the Run! Run! Run! Go! Go! Go! attitude.
In EMS, we should not run, unless we are running away from danger, or if we are exercising (when not on a call). Running makes it more likely that we will trip, fall, drop something, knock someone else over, and just raises the adrenaline level on scene. If there is one thing that is bad for a calm scene, it is adrenaline (which comes packaged in a syringe labelled epinephrine in the US).
We have learned that appealing to the inner NASCAR driver in EMS is the wrong attitude. So, we are only appealing to the inner pit crew member working in an environment of rapid acceleration, spinning tires, and several crashes a day.
We apparently do not have enough crashes, or enough vehicles (and people) on scene to make CPR exciting enough for us to pay attention to what we are supposed to be doing. This is a problem of management that is not limited to cardiac arrest, so a solution that is limited to cardiac arrest is not going to solve the problem, only address a small part of the management problem.
Tom Bouthillet commented that the EMS systems with the highest resuscitation rates send 7 to 12 people on every cardiac arrest. This is just inviting more Charlies to the Foxtrot. His suggestion is that there is some kind of cause and effect, but that we should not demand evidence, because he has made up his mind.
In the hospital, they will not let that many people in the room, unless it is a teaching hospital. With that many people, we can send one out for pizza, one for coffee, one for donuts, a few for traffic control, and even have a couple set up a lemonade stand for those who don’t want coffee.
Too many people on scene is a management problem. Smart managers do not complicate problems and expect things to get better. Ordering more people around may make us feel as if we are controlling more, but it is an illusion.
I want to know what works and what gets in the way of what works. We don’t learn that by jumping to conclusions or by throwing bodies at the problem. More is not better. Better is better.
If we want to learn what works, we need to stop adding things that cannot be shown to help the patient. This is about the patient. This is not about The Crew.
If we are trying to improve outcomes, we need to study what we do, not claim that our actions are justified because we have made up our minds. That is self-deception.
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While CRM (Crew Resource Management) may not have the appeal of Pit Crewing, it is a much more appropriate way of dealing with all emergencies and we are in the emergency medical business, not just the cardiac arrest business.
We have been renewing CPR cards only every other year, because we have not taken chest compressions seriously. Now that we realize that the problem with resuscitation is poor compressions, we are trying to find excuses to save all of the other treatments we have been using, even though there is no reason to believe that any of them work.
Pit Crewing allows us to pretend that we need more than just a few people to switch out on compressions and another person to run the show and to occasionally charge the defibrillator (if a shockable rhythm is present, press the Defib buttons). We do not need a car full of ADHD circus performers.
The AHA (American Heart Association) has not really been encouraging good resuscitation research. We have a bunch of experimental treatments (experimental because there is no evidence that they work) that we do automatically. The AHA reviews research by assuming that the grandfathered experimental treatments work. The right method of research is to limit the interventions to only what can be shown to improve survival – compressions and defibrillation. Everything else is an unknown variable that must be controlled for (research talk for eliminated). Only add the variable to be studied to what has been demonstrated to improve survival.
Ventilations, airways, vascular access, epinephrine, vasopressin, norepinephrine, phenylephrine, amiodarone, lidocaine, and magnesium are all in the VF(Ventricular Fibrillation)/Pulseless VT (Ventricular Tachycardia) guideline, but there is no evidence that any of them improve survival.
The AHA even points out how useless the research on these experimental treatments has been.
The majority of clinical trials testing these ACLS interventions, however, preceded the recently renewed emphasis on high-quality CPR and advances in post–cardiac arrest care (see Part 9: “Post–Cardiac Arrest Care”). Therefore, it remains to be determined if improved rates of ROSC achieved with ACLS interventions might better translate into improved long-term outcomes when combined with higher-quality CPR and post–cardiac arrest interventions such as therapeutic hypothermia and early percutaneous coronary intervention (PCI).[1]
Unfortunately, rather than recognize the foolishness of this backwards approach to studying resuscitation, we are going to make one small adjustment, claim that we have solved the problem, then continue with the same counterproductive research methods.
Having half a dozen (or more) variables, but controlling for only one of those variables, is not research. This is just going through the motions of research. Eliminating all variables, except for the one variable being studied, is the way to find out what works.
How many more people would we have resuscitated to go home with good brain function if we had approached this the right way? How many have we killed with unreasonable optimism-based treatment?
10,000?
100,000?
1,000,000?
We don’t know. The way we are going, we may never know.
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Footnotes:
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[1] Overview
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Free Full Text from Circulation
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Tim, I think the back-and-forth here is largely due to unclear terms. What do you mean when you use the expression “Pit Crew”?
You appear to mainly be referring to the practice of routinely sending large numbers of responders (perhaps more than 4 — you can clarify if you’d like) to cardiac arrests. If that’s what you’re talking about, some people would disagree, but probably far fewer.
If that’s not what you mean, what do you mean? Specifically?
We first started calling it CRM around these parts, and then every one else started calling it “pit crew”. I guess it is the over driving desire to come up with a catch phrase for every thing to make it sound more glamorous… like “The Golden Hour”. As to resources and the numbers, me personally, I am OK with the added people, as long as someone designates what everyone is doing, even if it is “stand over there” (I’ve done that a few times…). If it is organized, i.e. one person is designated as in charge, it works very well. When you have too many ‘chiefs’…it goes to hell in a hand basket.
In our system, rank has no bearing, usually, on who is the ‘code commander’. The first able paramedic can assume the role. IF they get over burdened, they can pass it along. Usually the problems start when someone of stature or title arrives and ‘takes over’.
To me, the only real drawback to this approach is sometimes the inconsistent response numbers. For example, an EMS response from the fire department can bring you anywhere from two to five people, depending on jurisdiction. Sometimes you get two ambulances and a QRV, other times you get one ambulance and two QRVs. But still, have worked where you got two people on the ambulance and maybe one more person to work an arrest (and we did not call those in the field), I’ll take the new approach, regardless of what people call it.
And finally, our hospitals have a small army working in the rooms with an arrest in the ED. Watching of late, there are 8-12 (or more) people involved.
Great show Tim! I’m sure the discussion is far from over, which is good for everyone.
http://emspatientperspective.com/2012/06/29/podcast-recap-pit-crews-practice/