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

- Rogue Medic

The LUCAS, Research, and Wishful Thinking


 

Does the LUCAS improve outcomes?

No. The authors state that clearly.[1]

Do people think that we should use the LUCAS anyway?

Yes. The excuses are presented by many people.

What are the possible benefits?

1. The LUCAS allows us to free up a pair of hands to do other things that do not benefit the patient, so this adds nothing useful.

2. The LUCAS allows us to transport the patient safely. This is a rehash of #1, since routine transport does not improve outcomes.

3. Treatment will be consistent, regardless of the quality of the EMS. Rather than improve quality, we will have a machine take over something we think is done poorly, so that EMS can harm the patient by doing other things poorly.

4. The LUCAS can take over one of the two treatments that can improve outcomes. An AED can take over the other. We no longer need to have EMS respond to cardiac arrest calls until after ROSC (Return Of Spontaneous Circulation).

If the dramatic success of Seattle is due mostly to the frequency of bystander CPR, that would suggest that the best use of the LUCAS is in the hands of bystanders, not EMS.
 


 

If that is too much adult material, we can do the version for kids.
 

[youtube]Ff_kalDZfzU[/youtube]
 

Or we can do the version for toddlers.
 


 

If EMS cannot manage that, should we be giving them equipment to free them up to mess up intubation or drugs or other things that do not improve outcomes.

Why are we so eager to add treatments that do not help patients?

Ethical patient care means limiting ourselves to treatments that 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 Failure of LUCAS to Improve Outcomes in the LINC Trial

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]
 

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.

 

Not just not helpful, but this could be harmful.

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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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AutoPulse Technical Report Number 3 – Part I

Over at EMS 12 Lead, Tom Bouthillet has a post titled Automated Compression Device Wars Turn Hardcore.

ZOLL sent out this technical report press release claiming that their device is safer than the competition. Essentially, this is Coke vs. Pepsi, but the names are different – AutoPulse vs. LUCAS. This is not something that we will find indexed in PubMed or any other catalog of valid research. I can’t even post this review on Research Blogging, because the research is not up to the standards for that blog.

That will not stop those of us in EMS from pointing to this technical report press release as evidence of My brand is better than your brand.

What wonderful entertainment awaits us?

Use of mechanical devices to perform chest compressions during CPR is growing, . . .

. . . However, patient safety has been an issue.[1]

Really?

How many dead patients can dance on the head of a pin after an ambulance crash?

The patient is supposedly dead, otherwise the use of The Crusher or The Squeezer would not be indicated.

The patient has not responded to treatment on scene, so the chances of resuscitation are roughly ZERO percent.

Purpose: This test compared the potential for patient injury of different mechanical CPR technologies by examining their behavior during rapid deceleration.[1]

This is basically just a Keep hope alive paper. ZOLL pretends that they can keep the roughly ZERO percent survival rate from dropping to definitely ZERO percent. There is a problem with that.

Suppose that there is any chance of resuscitating this patient before the crash.

Remember that this slim chance is roughly ZERO percent.

After the crash regardless of which device is being used, the chance of resuscitation drops to definitely ZERO percent.

This paper does nothing to change that.

After the crash, this becomes a triage situation. There are other patients on scene who take priority over the dead body in the back.

Triage –

Pulseless and/or apneic =

DEAD.

We would just be recognizing what we had been ignoring by putting this patient in an ambulance to Keep hope alive.

The patient was dead on scene. Hope dies at the hospital. Reality is acknowledged at the hospital.

Will there be very rare patients who should be transported with compressions?

Yes. Hypothermia will probably be the most common indication. How many of these does any service get in a year?

How many of them survive?

How many ambulances would need to be equipped with The Crusher or The Squeezer? How much would this cost vs. something that would save more lives – teaching people Hands-Only CPR.

Transporting with CPR, we might have, in a large system, one extra save per decade. Maybe.

Teaching people to perform Hands-Only CPR should produce a result that is hundreds of times better.

I am just guessing. I have not looked at the numbers.

 

I challenge anyone from ZOLL or Physio-Control to provide valid research showing that I am wrong.

 

To be continued later in Part II and even later in Part III.

Footnotes:

[1] Patient Injury Potential from Mechanical CPR Devices During Collision: Comparison of Load-Distributing Band Versus Piston-Driven Systems – Technical Report #3
ZOLL Medical Corporation
Free Full Text PDF Download from procamed

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