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

- Rogue Medic

Keeping ALS Out of Resuscitation

Why do we work so hard at keeping resuscitation rates low?

Rates of bystander cardiopulmonary resuscitation (CPR) in the United States are dismal. A national study showed that only 31% of patients with cardiac arrest treated out-of-hospital received CPR from a bystander.1 The low rates of bystander CPR, a procedure developed over 50 years ago, is particularly notable when compared with the great progress that has been made in making a much newer technology—percutaneous coronary angioplasty—highly accessible.[1]

We could recognize this dismal level of bystander CPR chest compressions.

In America, we seem to be trying to demonstrate how much more intelligent people are in other countries. Here, we have only isolated pockets of high bystander CPR rates.

We spend our time making excuses for the higher resuscitation rates is these places. Seattle is #1, again – and again – and again – and again – . . . .

But they call fine V Fib (Ventricular Fibrillation) asystole!

Is there any validity to that claim?

Probably not.

Is there any evidence that fine V Fib is in any way more responsive to defibrillation than asystole?

Is there any difference between what the critics of Seattle think of as a shockable rhythm and what is programmed into AEDs (Automated External Defibrillators)?

If these critics are so offended by Seattle’s high resuscitation rates, maybe they should submit their own resuscitation rates with their version of fine V Fib and without. Will removing their fine V Fib result in results that compare to Seattle’s resuscitation rates?

Or is the secret of Seattle not the way they measure V Fib, but the way they encourage bystander CPR chest compressions?

Is a cath lab useful without bystander chest compressions?

Is adding more cath labs an expensive way of avoiding the real problem – low rates of bystander CPR chest compressions?

In addition, angioplasty fits our medical model. A person has a medical problem. A subspecialty physician treats it with a high-technology intervention in a hospital setting. Interventions that can be performed by laypersons in nonhospital settings tend to receive less attention.[1]

A medical model of cardiac arrest treatment?

The medical model would not be the BLS treatments. Treatments that we know improve outcomes.

The medical model would be the ALS treatments. Treatments that we only hope improve outcomes.

What has dominated our attention in resuscitation?

Drugs, tubes, ventilations, . . .

We still do not have any evidence that these improve survival with good brain function. Is there any other valid way to measure outcomes?

We know that low rates of bystander CPR limit resuscitation rates, but we continue to make excuses for pushing the drugs, for pushing the tubes, and for squeezing the bag.

The captain of that engine is running that cardiac arrest. His job is to make sure there are good chest compressions and to make sure that the medics, when they arrive, don’t get in the way of good chest compressions.

It is an EMT-Basic skill to run a cardiac arrest now. The paramedics just get in the way.[2]

We can improve resuscitation or we can support paramedic egos.

As a paramedic, I think the choice is easy. We need to improve the rate and quality of bystander chest compressions.

Bystander chest compressions save lives.



[1] Increasing bystander CPR rates: the chest compression-only method puts the goal in easier reach.
Katz MH.
Arch Intern Med. 2011 Jan 10;171(1):87-8. No abstract available.
PMID: 21220665 [PubMed]

[2] Medical Direction Issue
Medical Direction Issue.

Dr. Sporer Interview.



  1. Those are not either-or choices. it’s not bystander compression OR angioplasty – it’s bystander (keep ’em alive) AND angioplasty (open the vessel so they can STAY alive for a while). With a little bit of ALS in between (gotta deal with the things that happen post-resuscitation, and there are a bunch of them).

    But the recommendation really IS correct, in that the only way to meaningfully increase post-arrest saves is to get more good compressions started earlier.

  2. Rogue,

    I agree that drugs and tubes probably do nothing for cardiac arrests, but that ALS procedures are not the same as ALS providers. We need people who understand why pauses in chest compressions and hyperventilating are bad – and understand things like coronary perfusion pressures, to run them effectively. I don’t see that taught at any level, but especially with the first responders who make-or-break a code.

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