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

- Rogue Medic

Comment on Why Did We Remove Atropine From ACLS? Part I

 

In the comments to Why Did We Remove Atropine From ACLS? Part I is this from BLS in Wichita
 

Another important question…why are we even attempting resuscitation on many of the patients we encounter in sudden cardiac arrest. Many of these lives are not savable, yet it’s all hands on deck for a wasted heroic effort. We dump tons of resources in to a futile effort.

 

We do.

The AHA (American Heart Association) continues to try to come up with better answers for these problems, but they are often not easy to solve.
 

Shouldn’t we be applying our resources where they are needed most, rather than on an octogenarian with multiple medical problems and stage 4 cancer?

 

That raises some important questions.

If ACLS is for hearts too good to die, then why apply it to people who are dying from other causes?
 

It now seems possible that with an adequate program of prevention, continuous monitoring and with a prompt aggressive approach to the prevention and ablation of serious cardiac arrhythmias, fewer acute coronary patients will be dead with “hearts too good to die.”[1]

 


 

This is from 1967, so there is mythology that has been discarded, such as the need to give atropine with morphine to avoid arrhythmia.

However, they do describe their rate of successful defibrillation to some sort of improved outcome.

What is the improved outcome?

ROSC (Return Of Spontaneous Circulation)?

Survival to non-arrhythmic death?

Survival to discharge?

We do not know.
 


 

13% survival to discharge would be good for 1967, especially since the expected alternative would be death, but is it 13% survival to discharge?
 

One reason we try to resuscitate far more people than just the hearts too good to die is that arrhythmia is not the only reversible cause of cardiac arrest.

Another reason is that we refuse to differentiate between quantity of life and quality of life.

We also are not good at recognizing our limitations.

What about a DNR (Do Not Resuscitate) order?

Some patients do not have the kind of DNR that EMS is permitted to follow, so we are required to call medical command for orders to follow a legal document that says don’t do all of the things that we do.

We can be a very destructive force once we are set in motion, because we are required to do things that we would be prohibited from doing to other people outside of EMS – and we are not good at recognizing this.

Some EMS providers will decide that it is more important that they attempt resuscitation, than respect the legally valid decision of the patient – and EMS rules do not discourage this.

The patient knows why he does not want to be resuscitated, but some of us only respect a patient when the patient makes the decision we want him to make.
 

A couple of EMTs from the local ambulance company responded to a call I was dispatched on for difficulty breathing. The patient was about 50 years old and had a DNR. The DNR did not affect care on that call, but both EMTs (older than the patient) stated that they would refuse to honor the DNR, because He is too young to have a DNR.

We have people who think they are helping, but are making things worse.

These are people who should not be in EMS.

EMS is not about taking care of the patient not taking care of our egos.

If the patient’s wishes do not match our desires, we need to grow up and provide patient care.

Resuscitating an octogenarian is something that is not bad. An 80 year old male is expected to live for 8 more years, while an 80 year old female is expected to live for 10 more years.

Quality of life is important. Having stage 4 cancer and being resuscitated to be able to have another painful death is not good patient care, unless that is what the patient wants.

We need to pay attention to quality of life and patients’ wishes and stop trying to force patients to live according to our prejudices.

Footnotes:

[1] Hearts too good to die–problems in acute myocardial infarction.
Johnson JB, Cross EB.
J Natl Med Assoc. 1967 Jan;59(1):1-6. No abstract available.
PMID: 6038580 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

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