The resistance to no-ventilation CPR

The new 2005 Guidelines admit that no-ventilation CPR is probably fine for the first few minutes after witnessed sudden collapse, but it is not recommended because teaching lay rescuers different sequences would be too confusing:

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-206

In another section, the Guidelines instruct healthcare providers to make just such a determination and to tailor their actions accordingly (call first vs. CPR first), but neglect to mention that in response to witnessed sudden collapse no-ventilation CPR is a perfectly acceptable option. There seems to be an inconsistency here. If healthcare providers can determine whether an arrest is primarily asphyxial or cardiac, why can't they then perform (or not) MTM ventilation?

I've been thinking recently about the resistance of the AHA conference participants (or "experts," in the preferred terminology of the Guidelines) to no-ventilation CPR. If no-ventilation CPR were accepted as a first-line response, what would be the consequences for the AHA's Emergency Cardiac Care (ECC) Programs? What if CPR could be taught effectively in a 30-second or one-minute public service announcement (PSA)? I believe that would mean the end of ECC Programs.

My understanding is that ECC Programs are self-supporting (I believe that is unique within the AHA). That is, it does not receive any money from the charitable contributions to the AHA. In addition, ECC Programs are expected to generate revenue for the AHA, primarily through sale of its training materials and fees for its training programs (in recent years, this has taken the form of licensing fees from regional training centers). It seems clear that much of this revenue would dry up, and ECC Programs would have problems sustaining itself, if Basic Life Support classes were no longer necessary (e.g., if BLS could be taught by a PSA).

Is there an institutional conflict of interest here?

New Guidelines continued--Defibrillation

The other major change in the new guidelines is the recommendation for one shock followed by two minutes of CPR before re-evaluation of the rhythm and pulse. That recommendation is strange indeed. It appears to be based on recognition of the problem with current automated-external-defibrillator (AED) algorithms that require long no-compression intervals for rhythm analysis. So why not change the recommendation just for AEDs? I suspect that at least in part the reason is to avoid pointing to a disadvantage of AEDs in comparison to manual defibrillators. If they changed the algorithm just for AEDs, the fact that manual defibrillators don't require such long hands-off periods would be more obvious.

So now we're not supposed to look at the rhythm after a shock until after two minutes of CPR? Does that include shocks given before CPR is started, when the patient quickly regains a perfusing rhythm? The guidelines now seem to be saying this almost never happens, but it is hardly a rare occurrence. This is nutty.

So the one-shock-then-CPR guideline is based on the finding that biphasic defibrillators have a high first-shock success rate. How many hospitals in the US, not to mention the wider world, have biphasic defibrillators? Mine doesn't--at least not in large numbers--and it's not exactly a backwater in the world of health care.

The chapter on electrical therapies shows how truly ga-ga AHA/ILCOR is about AEDs. Most of the chapter concerns AEDs, with a briefer discussion of manual defibrillation toward the end. What's so great about AEDs? There is little doubt that they are useful in certain settings, but for years the AHA has virtually ignored the obvious problem of long mandatory no-compressions intervals in the algorithm. This latest change in the guidelines is a ham-fisted attempt to correct that huge mistake while continuing to gloss over the disadvantages of AED use. Even with the new algorithm, you're waiting ten seconds or more for the device to recognize V-fib--something a minimally-trained human can do almost instantly.

I repeat: this is nutty.

New Guidelines

The new AHA/ILCOR Guidelines were published in the Nov. 29 issue of Circulation. While reading them, I found myself going back to the landmark editorial "Cardiopulmonary resuscitation in the real world: when will the guidelines get the message?" (Sanders AB, Ewy GA; JAMA 2005;293(3):363-5). Apparently, not yet. They are edging slowly toward dropping mouth-to-mouth ventilation, but I guess it will be at least another five years (with the next major revision) before they manage to do it. The big change in basic CPR is the change in compression:ventilation ratio from 15:2 to 30:2. Also, the ratio is now the same for everyone but infants (actually, I had forgotten that it was different for adults and children before). Does anyone really believe that this change will make a significant difference in the frequency or quality of bystander CPR? Somewhere (I think in Currents in ECC) I read that the AHA has a goal of doubling the number of people trained in basic CPR by 2010. How? Do they think that people will flock to CPR courses now that they have to mouth-kiss a corpse only three times per minute instead of five or six times? More later on the flimsiness of the argument against no-ventilation CPR.

Nurse defibrillation and medical emergency teams

I've been talking with a few people at my hospital about my intention to collect time-interval data from codes, and they have wanted to know if I'm involved with the Rapid Response Team. I'm not, at least so far. The RRT is a new thing at my hospital; I think it is the same idea that is more commonly referred to in the professional literature as a "medical emergency team"As I understand the concept, it’s essentially an emergency response team available around the clock for support and consultation for patients whose condition is worsening--comprising a staff physician, a couple of critical care nurses, a respiratory therapist, etc. The big idea is to be proactive (faddish but useful word), getting on top of problems before they deteriorate to the point that a code occurs.

One doctor who is involved in the RRTs was especially enthusiastic about the concept and went so far as to mention the goal of making code teams "obsolete." My initial (unspoken) reaction to this was that it would never happen. I'm only vaguely aware of the literature on medical emergency teams, but I maintain that even assuming perfect vigilance (which of course is far from reality), totally unexpected arrests will occur in hospitals--just as they do outside, and probably with greater frequency. But then why am I of all people reflexively assuming that this means code teams are needed? Maybe the combination of an effective nurse defibrillation program and the medical emergency team concept makes sense.

I'm not very clear how paging the RRT at my hospital differs from paging a code, but I think that it involves an immediate phone response from one team member, maybe an ICU nurse, to evaluate the nature and urgency of the call and make a decision about whether/when to mobilize the rest of the team. Would this be sufficient for a code on a unit without cardiac monitoring, assuming defibrillation has taken place at the local level if indicated? One could maintain that the big event—determining whether the dysrhythmia is shockable and shocking if necessary—has already occurred at the time of the call, so that any further response needn’t be in super-crisis or “heroic” mode.

Getting good time-interval data

It looks like I'm starting to get a few hits on this blog, which encourages me to keep posting. I assume all of the hits are from the link on the In-Hospital Defibrillation site.

I have just started again to track time intervals in the first minutes of resuscitation attempts at my hospital. It seems to me that it's really quite easy to do, and it puzzles me that no one apparently is doing it. (More about the method later.) I have talked at various times with various people involved in the National Registry of Cardiopulmonary Resuscitation (NRCPR) about problems with their reporting of time-interval data, so far with little effect. The basic problem is that they are reporting time intervals based on handwritten records which are quite clearly invalid. For example, over 25% of time intervals from arrest to first defibrillation are reported as "0 minutes," or instantaneous--nice trick if you can manage it. In my view, this lack of rigor is preventing the NRCPR from fulfilling its most important task: compiling good aggregate statistics showing definitively that there are serious delays in defibrillation in hospitals. Instead, the “data” reported so far seem to show that everything is just fine: see Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME, Berg RA, Nichol G, Truitt TL. Cardiopulmonary resuscitation of adults in the hospital: A report of 14,720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297-308.

Does ACLS work?

I'll have a fair amount to say about my experience of the Guidelines 2005 process later., but for now I'll just note that the only reference I saw to the Stiell et al. study (mentioned below) in the evidence-evaluation worksheets posted on the web was in the worksheet on BVM ventilation. My comment on the validity of this reference can be seen here (comment number 3). As far as I know, the Stiell study received no further attention in the Guidelines 2005 evidence evaluation process. This may be a prime example of not being able to see the forest for the trees. Many very specific worksheet topics were addressed, with the frequent conclusion that insufficient evidence exists to change the existing recommendations. This begs the question of the value of the existing recommendations, which by and large are based on extremely flimsy evidence--or none at all. The Stiell study raises the very real possibility that none of this ACLS stuff makes any difference whatsoever in improving survival.

First post

After neglecting my informational web site (In-Hospital Defibrillation) for way too long, I hope to make it a useful resource again--with my daughter's help. Norah has agreed to give her technical assistance, at least sporadically, to keep the site functioning. Thanks, Norah.

I have decided for the near future to channel my interest in resuscitation issues into writing this blog. I've had a couple of manuscripts turned down by journals recently, and of course with publishing on the web rejection is not a problem--what is a problem is the possibility that nobody much will ever read what you write. But then, I have never received much direct feedback on my journal writings (most of them available at In-Hospital Defibrillation), so for all I know from direct experience, nobody much has read them either. I can at least use the hit counter to see how many people glance at this. Other attributes of the web log medium are of course that it provides the potential for more back-and-forth discussion (though not quite as much as the discussion list format-and I hope to get the discussion list on defib.net working again soon), and it allows far greater latitude for opinions, digressions, rants, etc.

At least for now, I'm calling this blog “No Heroics. ” I've liked the irony of the medical slang term “heroics” ever since I first heard it; it seems to get at a lot of what is wrong with resuscitation efforts. So often they seem to be choreographed responses to reassure caregivers that they are bringing a great armentarium of treatment modalities to bear in a valiant effort to defeat sudden death--more to sustain caregivers' morale and image of themselves as capable and effective in a crisis (not to mention the “legal exposure”--aka “CYA”--aspect) than to provide effective treatment.

That's a pretty harsh view I suppose, and I'm not sure I know anyone in health care that would not try their damnedest to provide effective lifesaving treatment-but the reality I see is that most experienced healthcare providers think that there is a huge element of “just going through the motions” in the whole BLS/ACLS package. And if you take the trouble to look at the literature, this is certainly borne out. One of the most important articles of the past decade in this area, in my opinion, is: Stiell IG, Wells GA, et al., Advanced cardiac life support in out-of-hospital cardiac arrest, N Engl J Med 2004; 351:647-656 Abstract. That study showed pretty convincingly that ACLS interventions as a whole have no beneficial effect on survival.