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

- Rogue Medic

More evidence that interrupting chest compressions kills

 

This article starts with a misunderstanding of evidence that is common in medicine, and very deadly.
 

The trend of treating patients on-site — instead of en route — has become the latest standard in Maine, but until now, there was only anecdotal evidence of its effectiveness widely available.[1]

By cutting out the placement of patients on stretchers and transporting them in an ambulance, responders also are cutting out 30- and 40-second gaps of time in which nobody is administering CPR or other treatments, Kooistra said. Those extra seconds, when the heart needs consistent and regular compressions to restart, are making the difference between life and death, he said.[1]

 

They have it backwards. There is no evidence that transporting cardiac arrest patients improves outcome.

Transport is an intervention. We should not be providing interventions without evidence.

The biggest killer in medicine may be providing interventions without evidence. The problem is that we do not know how dangerous many of our interventions are, because we avoid finding out.

In Portland, Maine, they were killing almost 2/3 of cardiac arrest patients by interrupting compressions just to transport the patient to the hospital.

Is preventing resuscitation the same as killing?

Think of it this way. Your child has a cardiac arrest. GOBSAT methods are used. The GOBSAT methods reduce resuscitation by 2/3. If your child is not resuscitated because of these GOBSAT methods, do you think your child was killed?

What is GOBSAT? Good Old Boys Sitting Around Talking – the way much of medicine is practiced.

Why transport, rather than treat on scene? Maybe because the slightly more effective way of ensuring death, dropping a house on the patient doesn’t look like trying to help. Racing around with lights and sirens gives the appearance of doing something good, but only to those who don’t know what they are doing.
 

Image credit.
 

This is a big part of the reason we have so many dangerous standards of care. A bunch of people think that something makes sense, so they start using the treatment, except –

They just don’t care enough to find out how dangerous it is.

Why do we continue to put up with this corruption?

Because we are hopeless optimists. We really do think that this time the GOBSATs will get something right – after all they mean well.

We probably kill more patients with good intentions, than with anything else.

We just don’t care enough about our patients to want to know the truth.
 

This is not meant as a criticism of EMS in Portland, because they have stopped doing something that never had any evidence to support it. This is meant as criticism of all of us still doing things without evidence to support it.

The AHA (American Heart Association) does not recommend interrupting compressions for transport. The 2005 guidelines did not recommend interrupting compressions for transport. The 2010 guidelines do not recommend interrupting compressions for transport.

Why do so many people claim that they are forced to follow the guidelines, when the guidelines hurt patients, but ignore the guidelines when the guidelines protect patients?
 

Minimize interruptions in effective chest compressions until ROSC or termination of resuscitative efforts. Any unnecessary interruptions in chest compressions (including longer than necessary pauses for rescue breathing) decreases CPR effectiveness.[2]

 

Longer than necessary?

Ventilations are not necessary.

Rapid transport is also not necessary.

No intelligent medical personnel should still be rushing to transport cardiac arrest patients before ROSC (Return Of Spontaneous Circulation).

For those who do not understand the simple concept that interruptions in chest compressions kill, please pay attention.

There is only one interruption in chest compressions that has evidence of improved outcomes.

That interruption is for defibrillation.

Not for charging the defibrillator.

Not for ventilation.

Not for intubation.

Not to move the patient.

Only for defibrillation.

Unless the patient is in a location that makes treatment difficult, or dangerous, we should not be moving the patient before ROSC.

The AHA guidelines still recommend that professional rescuers provide worse CPR than bystander. We need to recognize that there was no evidence for including ventilations in CPR and most of us did not care enough to find out what really works until recently.

When will the AHA correct this mistake?

When will the AHA correct these other mistakes?

When will the AHA demand evidence of improved survival to continue to recommend epinephrine in cardiac arrest?

When will the AHA demand evidence of improved survival to continue to recommend vasopressin in cardiac arrest?

When will the AHA demand evidence of improved survival to continue to recommend magnesium in cardiac arrest?

When will the AHA demand evidence of improved survival to continue to recommend phenylephrine in cardiac arrest?

When will the AHA demand evidence of improved survival to continue to recommend amiodarone in cardiac arrest?

When will the AHA demand evidence of improved survival to continue to recommend lidocaine in cardiac arrest?

The AHA cites a lot of evidence.

There is no evidence of improved survival with good neurological function from cardiac arrest using any of these drugs recommended by the AHA.

Alternative medicine has no evidence. Why not use alternative medicine?

We are using alternative medicine. We just don’t admit this fraud to patients.

Why is the AHA continuing to recommend that we use treatments that cannot be shown to work?

Footnotes:

[1] Portland paramedics skip the ambulance rides, save three times as many lives
By Seth Koenig, BDN Staff
Posted Nov. 27, 2012, at 3:14 p.m.
Last modified Nov. 27, 2012, at 3:29 p.m.
Bangor Daily News
Article

[2] Key Points of Continued Emphasis for the 2010 AHA Guidelines for CPR and ECC
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 1: Executive Summary
Highlights of the 2010 Guidelines
Free Full Text from Circulation

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Comments

  1. We as providers must recognize that there are multiple causes of cardiac arrest, and stop trying to find the “one protocol fits all” approach. The AHA has been moving in that direction with their renewed call to “consider reversible causes (the H’s and T’s)”; but it needs to be hammered in at a deeper level.

    The ONLY intervention that will work for all cardiac arrests is compressions. Defibrillation is proven to work; but only for that subset of cases with a VT/VF rhythm. Calcium Chloride will achieve ROSC in the subset of cases caused by hyperkalemia. Invasive techniques will work for mechanical obstructions such as tamponade and pneumothorax/hemothorax, and help with hemorrhagic issues (patching the internal holes). Other causes can be reversed by other interventions.

    Consideration of reversible cause should not be part of the cardiac arrest algorithm, it should BE the cardiac arrest algorithm, along with high-quality compressions and monitoring of the patient (ECG every 2 minutes, continuous ETCO2).

    For this reason, I think that transport should still be considered in cardiac arrests. Just as we have the ability to reverse certain causes in the field, other interventions and diagnostics are only available at hospitals. If our differential diagnosis leads us to believe that the needed reversal intervention is only available at the hospital, then transport with minimal interruption of compressions should be a primary concern.

  2. Great article! and reply @mpatk! Just did my BLS Instructor Certification with AHA and that’s the deal minimal interruption of compressions…. hard and fast unless to defib.

    Oh and love one of the headers on the top of this blog

    If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation.

    Hahaha….Awesome!

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