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

- Rogue Medic

Where is the evidence that pit crew CPR improves outcomes from cardiac arrest?


Tom Bouthillet of EMS 12 Lead and I sometimes disagree. Most recently, he does not appreciate my comments about the silliness of the latest evidence-free Standard Of Care to be added to the resuscitation magic potion.[1]

You can hate on the pit crew concept all day long, Tim. But having adequate rescuers on the scene matters a lot if you want to do a good job with sudden cardiac arrest.

The pit crew concept is not something that has been demonstrated to improve outcomes.

The number of people required on scene changes as more duties are created. Having adequate people is not the same as having adequate people to play pit crew.

The more people on scene, the more we need to come up with things for them to do. Why not have them play Twister?


Image credit.

Twister is effective at being distracting.

Twister is effective at giving people something to do.

There is no evidence that Twister improves survival from cardiac arrest.

To use your logic, we must prove that having some people play a game of Twister during CPR is worse than Pit Crew CPR.

In many ways, we are still in the Dark Ages. We are not using treatments to improve outcomes, we use treatments because there is not yet enough evidence of harm.

We looked at all the best EMS systems in the nation, with the highest survival rates, and they sent 7-12 people on the first alarm. In my system we send the closest ambulance, two engines and a battalion chief.

Do all systems that send as many people have similar outcomes?

You are drawing a conclusion, but only looking at what supports your bias.

You think you can do better with fewer rescuers? Prove it.

The pit crew method has never been demonstrated to be an effective treatment, so why should I act as if it is any different from any other magic treatment? I do not need to prove that homeopathy doesn’t work, or that any other magical treatment does not work. The burden of proof is on the person proposing the treatment.

Show that it works, or limit its use to controlled trials.

Provide evidence that Pit Crew CPR improves outcomes and I will stop making fun of Pit Crew CPR.

Provide evidence that homeopathy works and I will stop making fun of homeopathy.

The standard is the same for homeopathy, Pit Crew CPR, and reiki –

Without good evidence of improved outcomes the treatment should be presumed to be a scam.

Pit Crew CPR should be presumed to be a scam.
 

We continue to prefer magic over treatments that can be shown to improve outcomes.

We have been mostly using magical treatments, with the occasional valid evidence-based treatment thrown in as if by mistake. It is when we abandon the magic that patient outcomes improve.

Other resuscitation methods have been studied.[2] This resuscitation method should have been studied.

Our patients deserve better.

Our patients deserve treatments that work.

Continued, with a podcast, in EMS Pits Crews – Should A Yellow Flag Be Waved?

Footnotes:

[1] The Circulation Improving Resuscitation Care Trial (CIRC)
Rogue Medic
Wed, 20 Jun 2012
Article

[2] Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial.
Aufderheide TP, Frascone RJ, Wayne MA, Mahoney BD, Swor RA, Domeier RM, Olinger ML, Holcomb RG, Tupper DE, Yannopoulos D, Lurie KG.
Lancet. 2011 Jan 22;377(9762):301-11.
PMID: 21251705 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central

Or the treatments that are well supported by evidence

Chest compressions –

Cardiocerebral resuscitation improves survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Ewy GA.
Am J Med. 2006 Apr;119(4):335-40.
PMID: 16564776 [PubMed – indexed for MEDLINE]

Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest.
Kellum MJ, Kennedy KW, Barney R, Keilhauer FA, Bellino M, Zuercher M, Ewy GA.
Ann Emerg Med. 2008 Sep;52(3):244-52. Epub 2008 Mar 28.
PMID: 18374452 [PubMed – indexed for MEDLINE]

Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed – indexed for MEDLINE]

Free Full Text at JAMA

Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed – indexed for MEDLINE]

And more.

Defibrillation –

Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos.
Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG.
N Engl J Med. 2000 Oct 26;343(17):1206-9.
PMID: 11071670 [PubMed – indexed for MEDLINE]

Free Full Text from NEJM with link to PDF Download

Rapid on-site defibrillation versus community program.
Fedoruk JC, Paterson D, Hlynka M, Fung KY, Gobet M, Currie W.
Prehosp Disaster Med. 2002 Apr-Jun;17(2):102-6.
PMID: 12500734 [PubMed – indexed for MEDLINE]

Use of automated external defibrillators by police officers for treatment of out-of-hospital cardiac arrest.
Mosesso VN Jr, Davis EA, Auble TE, Paris PM, Yealy DM.
Ann Emerg Med. 1998 Aug;32(2):200-7.
PMID: 9701303 [PubMed – indexed for MEDLINE]

And more.

.

Comments

  1. I don’t know how this discussion started, but I figured I’d weigh in with some points because I think the slightly flippant and the good points need separating.

    It is true that resuscitation including compression numbers, ventilations, and the drugs we give are generally poorly researched. This is due in large part to the fact that you can’t ethically start with-holding treatment from people in a cardiac arrest scenario. So the usual controlled trials are not available to study this area.

    However I work in London and we deal with a massive number of cardiac arrests each year and each one is documented and checked and for that reason we can start to see patterns appear and this can guide us. This is why we now focus on almost continuous compressions and this is the priority. The sooner they start the better the outcome. Early defibrillation is seen to work and that is our next priority everything else comes after (there are some exceptions but this is the plan in the main).

    We still do not have any evidence for the use of drugs in cardiac arrest survival rates, but if it becomes apparent they are not working they may well be removed too as we already have for Atropine.

    As for the whole pit crew thing, we would usually have 5-6 people on scene, I would say 4 is a minimum for me, the extra hands do however mean we can swap people doing compressions regularly giving better quality CPR overall and you can see that on our data cards for our Defibs.

    We have improved our cardiac arrest survival rate year on year for a long time now, so we must be doing something right here. It isn’t the most scientific way of looking at it, but it’s the reason we are here, isn’t it?

  2. I do not think it’s necessary to view this as an intervention (and hence requiring evidentiary support). We know what the goals are — high quality compressions, early defibrillation, etc. Those are well-supported and you agree that they’re important. This is just a method of achieving them which may work well.

    I recognize that you’re concerned that making it a “team sport” is a slippery slope towards deemphasizing the important stuff, since all these extra people will need to do something. And that may be true at some point. (Although we’re not necessarily talking about adding personnel — most places already have at least five rescuers on a routine response — but rather about planning and organizing what they’re all doing.) But part of the idea is that you don’t just throw an army at the code and set them loose; people have defined roles and responsibilities, and if we’re smart we’ve set those up to SUPPORT our goals (compressions, etc).

    Suppose we have three people rotating as compressors, one person monitoring the quality of compressions, one person managing the monitor, and one person organizing the whole show to ensure people are actually doing these things. Even if you use the “in the hole” compressor for all other miscellanea, such as gathering history/meds from family to streamline post-ROSC care, we’re already up to six here, and it’s essentially all in direct support of the fundamental goals you and I agree upon.

    Can you manage a code with fewer? Of course. But is there potential value in having enough people to clearly divide responsibilities (rather than wearing three hats at once), rotate compressors regularly, and so forth? I don’t see how you could argue with that — it would be like arguing with someone who says they like driving a different route to work than you. We know the goals, whatever methods work to help you reach them is your own business.

  3. I agree with both Brandon and Andy. The “pit crew” approach works well in-hospital as well with the “rapid response” model. Utilizing an approach where people have clearly defined roles vs. having “whoever is available” do the next intervention is a concept that crosses into any aspect of work involving groups.

    You have a problem with most of the interventions that require extra people; and you’ve clearly demonstrated that there are valid issues with the use of code drugs and airway/ventilation interventions. The “pit crew” concept does not depend on those interventions. The “pit crew” model can be used whether we do the entire old-school ACLS route, or whether we use compression only with defibrillator. It is not an intervention itself; it is a way to make the interventions we do more efficient.

    Every well-run call in the field with a truly sick or injured patient uses the “pit crew” concept. We just don’t use the phrase “pit crew”, we use words such as “appropriate delegation of duties” and “not getting in each others way”.

  4. What was I thinking about challenging you to a duel about resuscitation????

    http://emspatientperspective.com/2012/06/25/defending-the-pit-crew/

  5. How do you define “pit crew”? Whats the appropriate number of responders for CPR?

    While i dont need 100 people at a code, the evidence does show that the longer a person does compressions the worse they get. This requires the use of multiple providers to continue to give the best compressions possible.

    As it stands, i feel that you have 2 doing compressions, one managing the airway and ventilating, and one getting a the info. Thats at least 4. Unfortunately our ALS still runs the old ACLS algorithms so having one do airway, one do drugs and the 2 bls providers from the ambulance do compressions and shock is how we roll. As it stands now we get 2 EMTs, 2 MICUs, 1 4-man Engine, and usually 2-3 cops. We dont really need the engine, but they are good for getting us stuff and assisting in moving.

    Just because they are on scene doesnt mean we have to give them jobs to do or make work for them. They can stand there and BS with the cops for all i care.

  6. Do you use waveform capnography in your service? We don’t yet unfortunately but I think its use may provide insight to the number of people required. As end tidal CO2 drops below an agreed value (I’m guessing about 20), cycle out the person doing compressions and bring in a new one.

  7. Rogue-

    I really hate it when we give catchy names to the things we do. The term ‘pit crew’ conjures up images that don’t necessarily reflect what I do. Here in Wake County we practice what a lot of people refer to as ‘pit crew’ CPR, meaning we come with resources. Once a cardiac arrest is determined, whether by dispatchers or the first arriving unit, the dispatch fills out so that normally there are two ambulances (at least two paramedics and two EMTs), a district supervisor or other quick-response unit (one paramedic), and a fire company (three to five personnel depending on the jurisdiction). That’s a total of from eight to ten people). We’re fortunate to have those resources, I know. There are still places that run an arrest with the initial ambulance crew. Another location I know of gets two ambulances (two paramedics and two EMTs), one supervisor (paramedic), and the local fire department (if they are a first responder department- some departments in this day and age don’t participate).

    In my services example we dedicate one person as ‘code commander’ (incident commander), one person for airway, one person for vascular access and medications, at least two people alternating chest compressions in two minute cycles, and one monitor observer. That still gives us one person to tend to family members, and possibly even a third for compressions (keeps them fresh), and possibly even people to assist with ongoing tasks.

    Each crew brings all of their gear to the scene- with EMS resources alone it is three medical bags, three airway bags, three LP15s, and three suction units, plus the gear the fire crew brought.

    Crowded? Yes. Potential to get out of control? Yes- I have seen that. Does it work? Meaning, can we prove it works? Sure. Ask the 74 people that went home last year after an out-of-hospital cardiac arrest. Please note that when we initiated this approach our save rates were nothing near the numbers now. Also, out of fairness, we did also institute continuous compression emphasis and de-emphasized the ‘get control of the airway at all costs’ mentality. We also ‘work ’em where we find them and work ’em like we mean it’.

    Now, here comes the question- could we do it with less resources? Possibly. The second example I noted, while not posting 70+ save numbers, is posting 20+ save numbers as they begin to develop their system and approach.

    But the fact is we have demonstrated that it works and in such a way we can reproduce it.

    Another question- which is more effective, the so-called pit crew or epinephrine?
    With the medication shortages, we just may find out.

  8. Rogue, we recently began the pit crew approach to cardiac arrest, along with CCR for the first 6 minutes of the code. I’ve only ran one pit crew/CCR code so far, but here are some of the things I’ve noticed about it:

    -We are better organized. Yes, really. Before initiating the pit crew approach, it always felt like a guessing game as to who was up next to do CPR, when the rhythm checks were going to be, who was doing what roles. Now that everyone has a clearly defined role, and everyone knows their role, our codes seem to run smoother now–this is what I’ve heard from other crews who have run codes using the pit crew approach. The game of Twister was the way we used to run codes in comparison to how we are running them now.

    -We stay on the chest more. With the increased emphasis on chest compressions, as well as a more organized approach to switching between chest compressors, it seems like we’re keeping on the chest a lot more and have decreased our time off of it.

    -It’s less stressful. Our local fire departments are now the sole providers of CPR, which has freed the paramedics up to investigate any possible reversible causes, obtain pertinent patient information, etc. While no drugs have been definitely proven to increase survival rates from cardiac arrest, having everyone focused on their task has reduced the stress, reduced people’s desire to transport, and kept us on track.

    This is anecdote. It’s not scientific evidence. Our numbers are promising but preliminary. As we continue to run more codes utilizing CCR, we’ll find out if it really does increase survival from cardiac arrest. Is it a magical treatment? We don’t know yet. Is there anything about it that indicates that it may cause harm? No, but we won’t know anything for certain until we’ve run the numbers. What I can say is that since implementing it is that the people I’ve spoken to say that codes run smoother and time on the chest is increased. From my limited perspective, codes go better than they did before; whether or not this will translate into increased survival is up in the air.

    Should we tout pit crew CPR as something that we definitively know improves survival? No. Should we not implement something that, at least on the surface, provides greater organization, control, and a greater sense of calm to the code? Yes.

    • When I speak of “Pit Crew” I am refering to quick, precise, coordinated movements. You have to deliver certain treatments in a timely fashion or they are nost as effective. I am speaking of the collective time it takes you to initiate effective chest compressions, how long it takes you to get medications on board, how long it takes you to begin to cool the patient down with TIH procedures. The quicker you get things done on scene, the quicker you get the patient to the “Cath” lab. I have never been too concerned with how many people were on the scene as long as the required procedures are performed in a timely fashion. American Heart determined that the only true way to improve outcomes is to initiate “life-saving ” procedures sooner after an arrest. Fast, coordinated movements are the quickiest way to get things done. That is all “Pit Crew” mentality means.

      • Harrison Davis III,

        When I speak of “Pit Crew” I am refering to quick, precise, coordinated movements. You have to deliver certain treatments in a timely fashion or they are most as effective.

        Chest compressions and defibrillation are the only treatments that we know are effective.

        I am speaking of the collective time it takes you to initiate effective chest compressions, how long it takes you to get medications on board, how long it takes you to begin to cool the patient down with TIH procedures.

        Medications (and ventilations) have never been demonstrated to work, so having a method of including medications, or ventilations, is probably harmful.

        The quicker you get things done on scene, the quicker you get the patient to the “Cath” lab.

        Just providing chest compressions and defibrillation would be even quicker.

        I have never been too concerned with how many people were on the scene as long as the required procedures are performed in a timely fashion. American Heart determined that the only true way to improve outcomes is to initiate “life-saving ” procedures sooner after an arrest. Fast, coordinated movements are the quickiest way to get things done. That is all “Pit Crew” mentality means.

        But you included medications and other treatments that probably make the outcome worse.

        Since there is no evidence that ventilations improve outcomes, and there is evidence of harm, we should consider ventilations to be harmful.

        Since there is no evidence that medications improve outcomes, and there is evidence of harm, we should consider medications to be harmful.

        That is the problem with the Pit Crew.

        Pit Crew CPR allows us to include harmful treatments, rather than eliminate the harmful treatments.

        .

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