why do we continue to do cpr????

[Asysin2leads]

The dirty secret behind CPR is two fold. The first is that the new and accepted doctrine of CPR is not that CPR saves lives, but good CPR saves lives, and it does. Very good, regular compressions coupled with adequate ventilations can make a world of difference in a pulseless, apneic patient. That being said, there are very few people running around with AHA BCLS cards, and that includes cops, firefighters, EMTS, and yes you medic-haters out there, paramedics, who cannot do CPR effectively. In the rush to get everyone CPR certified the fact that most people can't do good quality CPR if THEIR life depended on it, makes you wonder if the AHA and certain CPR instructors don't have a little scam going selling pieces of paper for $50-$125.00 a pop.

Secondly you asked about the pulseless, asystolic patient and why we even bother. On some points I agree with you. I am the biggest advocated in the world of pronouncing in the field rather than risk crew and public safety doing CPR in the back of a moving ambulance. I think the power to pronounce an asystolic patient in the field is reason enough to make every ambulance a medic ambulance, but I digress.

The reason, however, that we do CPR even on the 86 year old pulseless and apneic patient is because not everything in medicine or in public safety is always based on evidence. We work in an emotional field. Sometimes what we do has nothing to do with patient outcome but in helping the family start the grieving process by letting them know that at least someone tried to help their family member, that someone cared (even if you don't, really), and that their loved one didn't just drop dead with no one to help, even if that's the truth. In another more cynical vein, you can simply say that medicine, particularly EMS, is about following orders. Our orders are to begin CPR and ACLS procedures on any pulseless or apneic patient who does not have obvious signs of death. This is what our system says to do. If we don't do it, we get sued, our doctor gets sued, our supervisors get sued, and then we don't get to respond when someone really needs our help. Orders don't need to have reason or logic behind them. In fact, they rarely do. But so long as you have sworn to discharge your orders, the ethical thing to do is do discharge them even if they make no sense, in fact, you could say especially if they don't make sense.

So, in conclusion, there maybe no good medical reason to start CPR on an 86 year old pulseless, apneic patient, but there are reasons we do it.

[MSBMEDIC]

don't get stats from AHA, or you will get stats that say grandma and grandpa are saved 50% of the time. people we are at a time when 70 million so-called baby boomers are at the age where people start to become weak, ill, and dye. let's go to the preventive side and enchorage these people to seek and get better care. in addition we can recieve beter training through use of meds, matterials, and tools to prevent this when these pts. are at our side! asking for help. bye the way who has the stats that state what i said about cpr, everyone who works in the medical field, especially "911" and er personell. just ask one another this simple question. how many people have you seen or done yourself who were "dead" that you brought back by using cpr. everone knows there are no suprises. lets stop CPR!!!!!

[ERDoc]

don't get stats from AHA, or you will get stats that say grandma and grandpa are saved 50% of the time. people we are at a time when 70 million so-called baby boomers are at the age where people start to become weak, ill, and dye. let's go to the preventive side and enchorage these people to seek and get better care. in addition we can recieve beter training through use of meds, matterials, and tools to prevent this when these pts. are at our side! asking for help. bye the way who has the stats that state what i said about cpr, everyone who works in the medical field, especially "911" and er personell. just ask one another this simple question. how many people have you seen or done yourself who were "dead" that you brought back by using cpr. everone knows there are no suprises. lets stop CPR!!!!!

:glasses4: The truth is out there, Fox Mulder. :glasses5:

You make the statement, you provide the evidence. Until you supply papers to back up your statments, what you say means nothing. If you want to have an intelligent conversation based on EBM you have come to the right place, but if you are not going to play the game by the rules, then stop. Based on your posts I would guess that you do not have a clue as to what EBM is. Please let the rest of us know where you work so we can avoid calling 911 in that area. If I had to guess I would say Naples, FL.

[ladybear]

don't get stats from AHA, or you will get stats that say grandma and grandpa are saved 50% of the time. people we are at a time when 70 million so-called baby boomers are at the age where people start to become weak, ill, and dye. let's go to the preventive side and enchorage these people to seek and get better care. in addition we can recieve beter training through use of meds, matterials, and tools to prevent this when these pts. are at our side! asking for help. bye the way who has the stats that state what i said about cpr, everyone who works in the medical field, especially "911" and er personell. just ask one another this simple question. how many people have you seen or done yourself who were "dead" that you brought back by using cpr. everone knows there are no suprises. lets stop CPR!!!!!

I like to "dye" things at time too.. but like grandma, maybe it's just not time to "die"..

I have started CPR on a pulseless, apneic patient on the floor.. not in the ER.. who ended up walking out two weeks later, with cognitive function. I think this particular patient was glad I was there since there weren't enough folks around on that floor who knew GOOD CPR and ACLS skills. As a matter of fact I was thankful the RT's knew the drill too because they were the only other two folks who actually jumped in to do the job effectively.

No I won't stop doing CPR on patients. Not all are ready to die.

<<walks away thinking someone has been watching too much "Bringing out the Dead".... [-X

[VentMedic]

One must also remember that there are many reasons a heart stops. Majority of the patients you see are the multi-system - broken. They may have had a massive CVA, emboli, aneurysm, chronic illness with pulmonary HTN, renal failure, DM, liver failure, cardiomyopathy and just plain ole old age where you may not bring back every 90+ y/o.

However, the importance of CPR for the younger person can not be emphasized enough. Granted I have had many more saves inside the hospital than out but every once in a while you will get someone that had good citizen CPR and they do have a chance. By a save, I mean return to a life with quality life with near or full function.

Surprisingly I have the best luck with dialysis patients. Last week out of the 4 dialysis patients that coded, 2 lived and were extubated within two days. I'm sure if the other 2 had not been over 90 they might also have had a better chance.

I also find the same attitude that is conveyed by the OP in other providers. Thus you get a patient brought to the ED with half arsed CPR. On a NH patient it is difficult to put much into it but they may still be a full code. But when it is done half-arsed on the 20 or 40 y/o because the stats say it is useless and you apply the numbers to mean everyone, then you don't need to be in EMS. If you are going to do CPR with only half the effort put into it, stay at scene and just call it there. Another reason for ineffective field CPR is too many codes are worked in the back of a truck running L/S and the person supposed to be doing compressions is hanging on for his/her own life.

Even in the hospital, we work the patient where we find them no matter if it is in the breezeway to dialysis or on the floor of their room. If we can not get a pulse back, we don't take up an ICU bed. We put our best effort into it and see what happens. Not all will have a good outcome and now physicians are becoming more at ease with getting an end of life statement from the families to terminate life support 24 - 72 hours after the hypothermia protocol is finished. An inhospital hypothermia portocol lasts for 24 hours and then there is a rewarming period that can take several more hours. Only after that will is completed will testing start to determine brain function.

[MSBMEDIC]

Sheryl Ubelacker, THE CANADIAN PRESS

The Toronto Star

There is a huge variation in survival rates among people who receive emergency treatment after suffering cardiac arrest - and the overall prognosis is poor at best, a study of 10 Canadian and U.S. cities and regions has found.

Researchers from the two countries found that overall, less than 8 per cent of people who were treated by paramedics or firefighters for cardiac arrests in the home or elsewhere outside hospital were successfully resuscitated.

Seattle had the best survival rate at 16 per cent, while Alabama had the lowest at 3 per cent. In Toronto andOttawa region, just over 5 per cent of treated victims lived, while in Vancouver, 10 per cent survived.

Cardiac arrest is different from - but may be caused by - a heart attack. It occurs when the heart suddenly stops beating and the person is no longer breathing. One major cause is disruption of normal heart contractions, such as that caused by ventricular fibrillation.

Lead author Dr. Graham Nichol of the University of Washington said the key to saving lives is a quick response by bystanders, who need to perform immediate and continuous CPR until paramedics or firefighters arrive to treat and transport the patient to hospital.

In the study, published in this week's Journal of the American Medical Association, researchers looked at more than 20,000 cardiac arrest cases between May 2006 and April 2007. Resuscitation was attempted in less than 12,000 cases - and only 954 of those felled by a cardiac arrest lived to be discharged from hospital.

[MSBMEDIC]

Simple guideline can identify which patients should be brought to hospitals when emergency efforts to revive them aren't working

ANN ARBOR, Mich. , Sept. 23 /PRNewswire-USNewswire/ -- When someone's heart suddenly stops beating -- a condition called cardiac arrest -- there's a lot that bystanders and ambulance crews can do to get it started again. But if the victim doesn't respond, when should such efforts stop?

And when should emergency crews rapidly transport a patient to a hospital with lights and sirens on, potentially endangering the lives of paramedics and other motorists and pedestrians -- even though the care provided by the emergency crew is the same as what can be provided in the emergency department?

Currently, there's no one "right" answer to these questions, which arise in the majority of the cardiac arrests that strike 166,000 Americans each year -- and kill 93 percent of them. As a result, emergency medical services crews and hospital ER teams spend countless hours and healthcare resources on patients who have no chance of making it home alive -- at the expense of other patients who need an ambulance or have spent hours in an ER waiting room.

Now, a new study in the Journal of the American Medical Association shows that a single standard guideline could help EMS and ER teams determine which cardiac arrest victims might benefit from a trip to the hospital, while at the same time reducing futile efforts on patients who have no chance of surviving a cardiac arrest.

The study shows that EMS teams can use either a simple five- or three-part rule to determine when they should discontinue efforts to revive cardiac arrest patients on the scene where their heart stopped beating. The same rule will also tell them when they should keep trying to resuscitate the patient while transporting him or her to the nearest ER. The three-part rule may be sufficient to identify 99.8 percent of those who need to be transported to the hospital for further care, the researchers say.

The study was performed by a team from the University of Michigan Health System, Emory University and the Henry Ford Health System, using data from 5,505 cardiac arrest patients treated in eight metropolitan areas around the U.S. It did not include patients who suffered a cardiac arrest after a non-heart incident such as drowning. It was funded by the Centers for Disease Control and Prevention.

Comilla Sasson , M.D., M.S., is the study's lead author and a Robert Wood Johnson Clinical Scholar at the U-M Medical School. An emergency physician herself, she began the study after many frustrating experiences in a Chicago ER where she had to stop caring for other critically ill patients whenever a cardiac arrest patient came in the door -- no matter how futile it might be to try to bring the patient back, and no matter how time-sensitive the needs of the other patients in the ER.

Now at the U-M Department of Emergency Medicine, Sasson teamed up with an Emory University group that has been tracking cardiac arrest response. The Emory effort, called CARES, helps EMS crews and hospitals find ways to improve care.

"Many cardiac arrest patients are successfully resuscitated at the scene, with the help of automated external defibrillators and CPR, and the hospital is the right destination for them," Sasson says. "The question has been what to do about patients who fail to respond, despite the best efforts of an EMS team. This study confirms previous findings, and shows that a standard rule could ensure that the right patients get to the hospital while allowing us to use scarce resources wisely."

Sasson notes that many advanced EMS crews now have nearly all the tools and training that ERs have for reviving cardiac arrest patients, including artificial airways, heart-starting injectable drugs and more. Many have radio contact with an emergency doctor at the local medical control authority. In addition, automated external defibrillators (AEDs) are now available in many public places for bystanders to use to restart a stopped heart, in the crucial minutes before an EMS team arrives.

But even still, some patients just don't respond, or their heartbeats are too erratic for the AED to determine that a shock can be delivered. Then, the question for the EMS crew is whether it's worth the risk to the patient, the crew, and nearby motorists and pedestrians to race to the hospital with sirens blaring and lights flashing, and then to tie up the ER team to try to revive the patient.

In the new study, EMS crews pronounced 947 (17 percent) of the 5,505 patients dead at the scene between late 2005 and early 2008. The other 4,558 were transported to one of 111 hospitals by one of 19 EMS agencies. But only 7.1 percent of those transported patients survived long enough to be discharged from the hospital alive.

Sasson and her colleagues, including Bryan McNally , M.D., MPH, and Arthur Kellermann , M.D., MPH of Emory's Department of Emergency Medicine, analyzed the medical records from all 5,505 patients. They ran statistical analyses to determine which patients would have been transported, or survived, if EMS crews had applied the three-part or five-part rule, both of which were developed by a Canadian team as part of the Ontario Prehospital Advanced Life Support study.

The three-part rule, called a 'basic life support' or BLS rule, calls for EMS teams to end their resuscitation efforts if a cardiac arrest occurred before EMS arrived, if no defibrillator was used (for instance, because there was none for a bystander to use, the EMS crew didn't have one, or an AED did not detect a shockable rhythm), and if the team can't get the patient's blood to begin circulating again. All three must apply for resuscitation efforts to be stopped.

If ambulance and fire crews had applied the three-part rule, about 47 percent of all the cardiac arrest patients in the study would not have met the criteria to be transported by ambulance to the hospital. This means that 2,592 patients would have been pronounced dead at the scene -- potentially saving 1,645 trips to the ER, compared with what actually happened.

The five-part rule, called the 'advanced life support' or ALS rule, adds two more criteria to the list: the cardiac arrest had no witnesses at all, and no bystander attempted to perform CPR. If this more conservative rule had been applied to the 5,505 cardiac arrest victims in the study, 1,192 patients would have been declared dead at the scene, saving 245 trips to the ER.

Then, the researchers looked at what actually happened after the patients made it to the hospital, and compared it with what might have happened if the two rules had been applied.

Only 70 patients who would have been declared dead under the BLS rule survived the ER treatment and were admitted to the hospital. But only five were discharged from the hospital alive, and four of them were able to live a relatively normal life afterward. Meanwhile, only 24 patients who would have been declared dead under the more conservative ALS rule were able to be resuscitated in the ER. None of them survived long enough to be sent home from the hospital.

In other words, the BLS rule misclassified only 0.2 percent of patients, and the ALS rule classified all patients correctly. Either rule, the authors say, could be used -- but the BLS rule would save the most emergency medical resources while still meeting ethical criteria for medical care.

"Through our study and others, the BLS rule has now been applied to more than 10,000 patients in the U.S. and Canada , with less than a 0.1 percent misclassification rate," Sasson says. "Currently, EMS systems vary widely in the care they deliver to cardiac arrest patients. To implement the BLS rule more widely would standardize the care and transport of these patients, so that we can reduce the risk of injuries or death to EMS personnel and the public in high speed transports, decrease the pressure on our overcrowded ER's, allow our ER staff to focus on patients who can be treated, and open up intensive care unit beds."

In addition to Sasson, McNally and Kellermann, the study's authors are A.J. Hegg , M.D., a third-year Emergency Department and Internal Medicine resident at Henry Ford Hospital in Detroit ; Michelle Macy , M.D., of the U-M Department of Emergency Medicine, and Allison Park , MPH, of the CARES project. CARES stands for Cardiac Arrest Registry to Enhance Survival. Reference: JAMA, Sept. 24, 2008 , Vol. 300, No. 12.

SOURCE University of Michigan Health System

[MSBMEDIC]

I had the opportunity to attend a life-saving ceremony about 15 years ago. The EMS service involved was featuring and touting its EMTs and paramedics as walking messiahs who could bring virtually anyone back from the dead. One EMT or paramedic after another paraded onto the stage to receive a medal for bringing someone back to life after the patients heart and lungs stopped functioning. At one point, the ceremony was stopped, and the master of ceremonies asked one paramedic to turn and face the crowd as he proclaimed that this individual was responsible for saving eight people in the previous year.

Wow! That was fantastic. I thought this guy must be like one of those preachers I see on television who can lay hands on someone and cure a disease that had plagued the person for years.

The ceremony continued and the long line of employees continued to parade onto the stage as family, friends and fellow employees applauded their achievements. After the ceremony, there was plenty of picturing taking as the EMTs and paramedics held up their awards for the cameras or posed for group photos.

At the eat-and-greet function after the ceremony, I told the EMS division chief that it would be great if some of the cardiac arrest survivors could have been at the ceremony to be reunited with their rescuers. The division chief replied that the department could find only one such survivor and that the person was already scheduled to be out of the country on a cruise.

Wait a minute youre telling me that out of all these saves that you handed out medals for today, you could only find one patient? Yes, the division chief confirmed. I told him I did not understand. He explained that the agency defined a save as anytime a paramedic restored a heartbeat on a patient and the person made it to the floor of the hospital. He said the agency also considered anything a save if the emergency room restored a heartbeat and the patient made it to the floor after the crew began resuscitation efforts in the field.

What happens, I asked the division chief, if the patient dies on the hospital floor three days later or remains the rest of his or her life on a respirator because there is no brain function? The division chief said that his service still considered that a save. I left the ceremony a bit confused, since I considered a save someone who walked out of a hospital.

A series of articles in USA Today last year looked at the 50 most populous cities in the United States and found cardiac arrest survival rates ranging from nearly zero to claims by some cities of survival rates topping 20%. The series made some cities look terrible at saving victims of cardiac arrest while other cities like Seattle (45% save rate), Boston (40%) Kansas City (20%), San Francisco (22%), Houston (21%), Tulsa (26%) and Oklahoma City (27%) looked great. Why the discrepancy? Were the other cities so bad or were places like Seattle and Boston so good?

Part of the secret of success may be the system, but the way in which cities measure cardiac arrest survival rates can provide favorable or unfavorable statistics. It all depends on how some cities measure cardiac arrest survival or, as one may suggest, cook the books.

The cities that can claim cardiac arrest survival rates over 20% use a standard for measuring cardiac arrest survival called the Utstein template. In the 1980s, all around the world, the survival of cardiac arrest victims was measured in different ways and different formats. In response to these differences, the Utstein template came about after an international group of scientists met in June 1990 to address their concerns with research involving out-of-hospital cardiac arrest. These scientists met at the Utstein Abbey in Stavanger, Norway.

A second meeting was held in December 1990, in Brighton, England, and was referred to as the Utstein Consensus Conference. Recommendations from the follow-up conference were published simultaneously in American and European medical journals. The report included uniform definitions, terminology and recommended data sets (the Utstein style) to assist clinical investigators in reporting human resuscitation studies.

With the Utstein template, only those victims who have a good chance to be saved are counted. Further, the Utstein template counts only those survivors who leave the hospital without serious brain damage.

Looking at the Utstein template, you begin to realize how some cities have over a 20% survival rate while others linger below 5%. The Utstein template removes any victim who is in cardiac arrest because of trauma. Think about how many trauma victims you have seen survive cardiac arrest. If your experience is like mine, hardly any survive. If you measured cardiac arrest survival rates and included trauma victims, it would immediately lower your percentage.

The Utstein template counts only patients who suffered a witnessed arrest and had an initial EKG of ventricular fibrillation in the percentage numbers. Other rhythms like asystole are not counted. One benefit of a witnessed arrest is that there is a good possibility that a bystander started CPR, which also increases success percentages.

Unfortunately, few EMS systems in the U.S. use the Utstein template for determining survival of cardiac arrests in their communities. And since most EMS systems are judged based on their cardiac arrest survival rates, (although they usually make up less than 1% of calls), a low survival rate reflects poorly on the EMS system.

Bottom line if you measure only those cardiac arrests that involved witnessed arrests and the patients were in ventricular defibrillation, your numbers would improve. Some people would say this is cooking the books. Id say it is better to be accurate than to parade a bunch of people to receive medals when they really did not save anybody.

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Gary Ludwig, MS, EMT-P, a Firehouse® contributing editor, is deputy chief of EMS in the Memphis, TN, Fire Department. He has 28 years of fire-rescue service experience, and previously served 25 years with the City of St. Louis, retiring as the chief paramedic from the St. Louis Fire Department. Ludwig is vice chairman of the EMS Section of the International Association of Fire Chiefs (IAFC), has a masters degree in business and management, and is a licensed paramedic. He is a frequent speaker at EMS and fire conferences nationally and internationally. He can be reached through his website at www.garyludwig.com.

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[reaper]

I think you need to reread the JAMA article. It no where in it states that CPR does not work and we should stop using it! The article was about working Arrests on scene and calling them on scene, if no ROSC. Also not running L&S for a code or transporting a code that is not save-able!

Both these points have been advocated on this forum for a long time.

But, no where is there any mention of CPR not working or the need to stop doing it! I am sure that 3-20% of survivors appreciated the effort.

You have still shown no proof of your points!

[Asysin2leads]

don't get stats from AHA, or you will get stats that say grandma and grandpa are saved 50% of the time. people we are at a time when 70 million so-called baby boomers are at the age where people start to become weak, ill, and dye. let's go to the preventive side and enchorage these people to seek and get better care. in addition we can recieve beter training through use of meds, matterials, and tools to prevent this when these pts. are at our side! asking for help. bye the way who has the stats that state what i said about cpr, everyone who works in the medical field, especially "911" and er personell. just ask one another this simple question. how many people have you seen or done yourself who were "dead" that you brought back by using cpr. everone knows there are no suprises. lets stop CPR!!!!!

Five. Yes, they were all discharged from the hospital walking and talking. Let me ask you, friendo, before we all lose a few more brain cells from this, are you actually looking at an AHA study or, is this just the stuff you kick around the squad room after a few too many Jagermeister shots? Because the AHA studies I have... in my book... that I read... for my job... shows a rapidly decreasing curve from around about 1% or so on the basis of minutes since cardiac arrest.

Can we please stop this? Its making my head hurt. Go. Read. Educate. Return.

I hereby enact rule #37 of EMS, which is "You can't argue with sheer ignorance. You can't talk to someone who doesn't even know how much they don't know. It only wastes your time and gets nothing accomplished." Arguement done.