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

- Rogue Medic

The Failure of LUCAS to Improve Outcomes in the LINC Trial

ResearchBlogging.org
 

We love gadgets in EMS.

Dr. Bryan Bledsoe tells us that if we paint it orange and put a star of life on it, we can sell any product for a lot more money.

How much would you pay to not improve outcomes?

$10,000.00?

$20,000.00?

$30,000.00?

$40,000.00?

$50,000.00?

Why ask how much money we would pay for no improvement?

There is no price that justifies no improvement.
 


Image credit.
 

Experimental studies with the mechanical chest compression device used in this study have shown improved organ perfusion pressures, enhanced cerebral blood flow, and higher end-tidal CO2 compared with manual CPR, with the latter also supported by clinical data.9- 11 [1]

 

These are surrogate endpoints. What are surrogate endpoints? They are not outcomes that matter. Who cares if you got the pulse oximetry to 100% if the patient died? Survival matters.

There is good evidence that blood-letting improves surrogate endpoints.[2] We know that blood-letting kills.

Should we start bleeding patients based on improved surrogate endpoints?

Of course not. Treating patients based on surrogate endpoints kills patients.

There is good evidence that the LUCAS improves surrogate endpoints.

Should we start treating patients with the LUCAS based on surrogate endpoints?

Of course not. Treating patients based on surrogate endpoints kills patients.
 

The current sample size has a 95% confidence interval for the 4-hour survival ranging from −3.3% to +3.2%. Translated another way, while the point estimate for treatment effect was near 0.0, our study could not rule out the possibility of a 3.2% benefit or a similarly sized harm from mechanical CPR relative to standard CPR.[1]

 

What do you mean by this could be harmful?

The apparent benefit could be misleading and the device really could be more harmful than beneficial.

Anyone telling you otherwise is not being honest.

The authors are honest.
 

Thus, in clinical practice, CPR with this mechanical device using the presented algorithm can be delivered without major complications but did not result in improved outcomes compared with manual chest compressions.[1]

 

If you want to use the LUCAS because you believe in miracles, you are not discussing medicine. The LUCAS is a medical device that has failed to improve outcomes.

Dr. Brooks Walsh also explains the failure of the LUCAS in this study in “We had a LUCAS save!” – No, you didn’t.

Also see-

The LUCAS, Research, and Wishful Thinking.

In Defense of No Improvement by Medic Madness – Part I.

Footnotes:

[1] Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial.
Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, Karlsten R.
JAMA. 2014 Jan 1;311(1):53-61. doi: 10.1001/jama.2013.282538.
PMID: 24240611 [PubMed – indexed for MEDLINE]

[2] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

Rubertsson S, Lindgren E, Smekal D, Östlund O, Silfverstolpe J, Lichtveld RA, Boomars R, Ahlstedt B, Skoog G, Kastberg R, Halliwell D, Box M, Herlitz J, & Karlsten R (2014). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized trial. JAMA : the journal of the American Medical Association, 311 (1), 53-61 PMID: 24240611

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Comments

  1. And when do you think the EMS “leaders” in this country will start caring more about outcomes and less about things that look flashier and more dazzling in a glossy brochure or press release?

  2. (I had a 6 paragraph response written out- then the page refreshed- that’s when I learnt to type my responses in a word processor program.) But in a nut shell.

    I disagree with your use of the word failure to describe the LUCUS. Unless you are implying that roughly a quarter of out of hospital arrests (mechanical or human) achieving ROSC is a failure, then I would agree with you.

    Finding something that shows almost an identical result to an already mediocre treatment shouldn’t be called a failure.

    The difference that you failed to talk about is the difference in providers and the CPR provided. The LUCUS in small town Iowa will be the same as in Seattle- The providers will not be. Are the providers who manage 50 arrests a year any different than the provider who does 1? Is age of the provider a factor? Can a 20 year old do better chest compressions than a 65 year old?

    But the statistics say they are the SAME! Because the systems that are doing arrests every single day with aggressive treatments and care plans are bumping the numbers up for the places that don’t ever see arrests.

    Would you rather arrest in an easily accessible area in Seattle (regarded as a location that provides high quality resuscitation) or arrest in an easily accessible location in a town of 100 with no at hand resources.

    But CPR is CPR! It doesn’t matter! It doesn’t matter that my local hospital can’t provide PCI or similar high level care.

    Maybe the test should be, drive down a county road with manual CPR and test it against the LUCUS. I hope to hear your shouting CPR is the same 100 times a minute.

    What happens if you are sitting in the ER with your STEMI and you arrest- right then and there down for the count. Do you go to PCI with the LUCUS and hope that removal of your clot fixes the problem? Or do you endure CPR hope to achieve ROSC, then hope you don’t re-arrest before PCI can fix the problem. Since intra-arrest thrombolytics have not really shown to be super helpful.

    It is all a very interesting debate and range of topics. It will be interesting in years to look back and think about all that we have done or didn’t do.

    • CPR is CPR, you make a good point, then you made a hard right turn. Like everything else you should be able to do the job you’re required to, and if not, either fix it or find another. And me personally, I think the way Seattle is regarded is just as much due to PR as it is to reality. But again, I did go to EMT clown school so maybe I just don’t quite get it.

    • So, here’s the problem. Everyone holds Seattle up as the holy grail of out of hospital resuscitation. Why is that? Is their survival to neurologically intact discharge rate better than absolutely everyone else?

      Why is it so hard to get systems/hospitals/administrators/etc to quantify between simply being discharged somewhere that’s not a funeral home and someone leaving the hospital with the same quality of life they had before their arrest?

      Why don’t they care about that?

      Are they afraid the numbers would be so mindbogglingly low that the general public will storm their public servant castles with pitch forks and torches?

      Didn’t some, I know it’s not all(I’m looking at you adrenaline junky that’ll get one or more of us killed one day), of us in this profession get in to it to help people? At least that’s what I thought the rationale was/should be.

      If that’s the case, shouldn’t we take a long hard look in the mirror at what we’re doing, and see if it’s worth providing? And if it doesn’t work or hold up to scientific rigor, maybe we toss on it on the trash pile of EMS history(which is way smaller than it should be, what with all the nonsense and voodoo we still perpetuate, I’m looking at you long backboard) and find something that we can quantify and test and prove and move forward?

      Sometimes the machine just isn’t any better. And if we’re going into the realm of anecdotes, I’ve had many an older provider, 50s or 60s in age, do incredibly effective and correct CPR and had providers on the same calls in their 20s or 30s do absolutely atrocious CPR to the point that they couldn’t be corrected and had to be kicked off from doing CPR because they were not providing a benefit. That is, if we want to use anecdotes….

      • Slimm and I affectionately referred to LUCAS as “Luke.” Because he was (and still is) our homeboy.

        The best thing Luke did was free up my hands. The compressions are so much better than a human can do, and I can manage the cardiac arrest literally by myself. There is no need for additional riders, or equipment, and it is a lot easier to do things in the back of the ambulance without having to climb over two firemen who don’t want to be there any ways.

        We did see a whole lot more ROSC, but no more people were leaving the hospital.

  3. An interesting presentation put together by the HCMC guys out of MPLS-

    http://www.mrc.umn.edu/prod/groups/med/@pub/@med/@mnrc/documents/content/med_content_423315.pdf

Trackbacks

  1. […] recently wrote two blog posts questioning the motives of EMS services that purchase LUCAS devices 1 2. One of the biggest reasons was the failure of the device to improve outcomes during a recent […]

  2. […] [1] The Failure of LUCAS to Improve Outcomes in the LINC Trial Wed, 05 Mar 2014 Rogue Medic Article […]

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