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

- Rogue Medic

EMS Garage, CPR, Continuous Compressions, and Resuscitation

I have a bunch of comments I should be responding to with posts. At least to do justice to the topics raised. Since today is yesterday was official procrastination day, I am getting a bit side tracked. I was listening to EMS Garage Episode 29: Traction Control, which has a lot of interesting things to say about resuscitation, rather than traction. The social networking takes up about 7 minutes of the beginning of the show, which is not unusual for The View The EMS Garage.

The host(?) of the show is discussing mechanical resuscitation devices. He referred to one device as the Geezer Squeezer, because . . . . Well, I don’t know why they used this terminology. Maybe they figured they had scared off all of the non-EMS listeners and this is like sitting in a bar and swapping stories. Never mind, that probably is how the show was started. Anyway, the host(?) is trying to get Skip Kirkwood to say that this mechanical compression device improves outcomes. The host(?) appears to be shocked when he is told that these devices have not been shown to improve outcomes. Skip Kirkwood, talking about the good resuscitation rates in his system states –

Yes, we have good results. No, you got the Geezer Squeezer. That’s when I said, “No we don’t.” We have a chest compression adjunct that we believe to be far superior to any mechanical device that costs a lot of money. That’s a high speed, low drag City of Raleigh Fire Fighter, with whom we have worked since day one to do uninterrupted compressions, hard and fast, and to apply defibrillators. We attribute the vast majority of our pretty successful cardiac resuscitation numbers to quick, very effective Basic Life Support (BLS).

There is mention of a few resuscitations by BLS-only CPR (CardioPulmonary Resuscitation) and one of the people on the show keeps saying –

That’s incredible.

To quote Inigo Montoya, You keep using that word. I do not think it means what you think it means. Incredible means beyond belief or understanding. Anybody familiar with EMS should not be surprised by these results.

There is no good research to show improved outcomes from ALS (Advanced Life Support) interventions. What is surprising is that people in EMS still have trouble understanding the uselessness of ALS in resuscitation. We keep making progress, but grudgingly. The progress is slow. The progress comes from minimizing/delaying/abandoning ALS treatments.

There was a paper written, following one of the ACLS (Advanced Cardiac Life Support) revisions, a couple of revisions ago. I do not remember the paper, but a quote from it essentially stated, These ALS treatments are based on expert opinions. Not a level of evidence that would be given much weight today. Why does it take large scale randomized placebo controlled trials – the highest level of evidence – to remove these lowest level of evidence treatments from the guidelines?

These treatments have no valid research to support them, but have become standards of care. Because they are standards of care, IRBs (Institutional Review Boards) and the FDA (Food and Drug Administration) have suggested that it is unethical to deprive patients of these standards of care, to find out how much harm we are causing to patients with these standards of care.

ACLS has become a cult. We do not question the standards of care. We do not evaluate the standards of care.

Even though we have no ethical reason to believe that these standards of care are effective.

Even though we have evidence to show that these standards of care are harmful.

ALS is not just useless. ALS is harmful in resuscitation. ALS is one of the excuses for interrupting compressions. Interrupting compressions is probably the most harmful thing we can do in resuscitation. The other harmful thing that we interrupt compressions for, aside from ALS, is to move the patient. Other than to create room to be able to do effective compressions on scene, there is almost never a reason to move a dead body. But we are EMS, and if we are not transporting, we somehow feel inadequate.

EMS is not just transport.

EMS is not giving treatments just because we can.

Viewing EMS as either of those makes for bad EMS.

Medicare reimbursement policies encourage both of those dangerous approaches.

Here is what I think about mechanical CPR devices:

Why have a mechanical CPR device?

  • Our people do not know how to do CPR.
  • Our people are too lazy to do CPR.
  • Our medical director does not allow field pronouncement.
  • We get a kick-back from the company and this money goes to my retirement plan.

If these describe your department, maybe you do need a CPR machine.

One participant does mention that there is no reason to transport patients with CPR in progress, except in the most unusual of circumstances. Somebody else questions this. Obviously, if the patient is responding intermittently, you transport, but you aren’t continuously performing CPR under those circumstances. You are only performing CPR during the time that the patient has no spontaneous pulse.

Later, one of the participants mentions putting dead bodies in helicopters, as long as the dead body had been a police officer. That is before the police officer died. Fortunately, the majority pointed out the mistake of endangering a lot of people, just to make it seem that we did all that we could.

Did we fire the officer’s gun in the air, disregarding where the bullets would land?

No.

Then we did not do everything we could do.

But that is not something that has a chance of improving the outcome.

Putting a dead body in a helicopter is not going to improve outcomes, either. Sure, in the case of a child drowning in freezing conditions, there is a reason. Unless this is a cold, drowned very junior police officer, there is no reason to fly the officer, just to put on a show. Hey, look at this. We even used the Whangdoodle. The Whangdoodle means we really, really, really tried. And then some.

If we are doing things just so we look good, we need to stop doing them. We should be limiting ourselves to things that work. We need to stop doing things that some magical thinker believes will make EMS look good. We need to get rid of these magical thinkers. Perhaps even drive a stake through some of their hearts, if we can find their hearts. We should not consider the results of research to be incredible. Research is how we determine what is credible.

These believers in showy ineffective treatments are the people, who have been keeping resuscitation rates down. These are the people, who have been harming EMS.

The rest of the show has a lot to write about, as well. That will have to be another time.

.