No Heroics: In-Hospital Resuscitation

What now?

2012-01-28T19:58:00.000-08:00

Now that in-hospital use of AEDs has been discredited, my fear is that recognition of the very real problem of delayed in-hospital defibrillation will fade, due to thinking along these lines:

If AEDs don't help, there's really nothing to be done, or
If AEDs don't help, maybe there wasn't a real problem in the first place.

Regarding the first statement: Simultaneously with the AHA's recognition of the problem, they began to promote AEDs for in-hospital use. This was comfortable for the community of resuscitation specialists, avoiding unpleasant thoughts about lives that might have been saved if the problem had been recognized years earlier. The implicit assumption was that nothing could have been done anyway until the advent of this new technology. If that assumption is accepted, we are left in a state of impotence.

Adding to this obstacle to progress is the likely stance of the AHA over the next few (or many) years. The fraternity of emergency cardiac care specialists that write the guidelines are historically very slow and hesitant to change. Once a recommendation is in the guidelines, a mountain of opposing evidence is often required to remove it—no matter whether the evidence supporting the recommendation is flimsy or nonexistent (see Lilly Fowler's FairWarning article under Links in the right column and the AHA's response here. Given the power of the AHA to set resuscitation standards, I'm afraid that researchers won't get serious about exploring other approaches until the AED recommendation is dropped, which may take a long time.

Regarding the second statement: Ironically, the journal article that has caused the biggest stir in the past several years by highlighting the problem of delayed in-hospital defibrillation (Chan PS, et al., Delayed time to defibrillation after in-hospital cardiac arrest) can be seen as minimizing the problem; this is also true of a number of other articles reporting data on time intervals to first defibrillation. The reason is that the time-interval data are grossly inaccurate—i.e., too short (see “Getting good time-interval data” below). The Chan article raises the alarm that 30% of shocks take longer than two minutes (!). Readers with real experience of the difficulties of code response might reasonably conclude that such response times are pretty darn good—if they accept the reported data at face value (though in my view anyone with such experience who thinks much about it should question the validity of the data). A good example of someone who should know better concluding from the Chan article that there is little room for improvement can be found here; the author goes on to restate the old co-morbidity excuse: in-hospital survival from shockable arrhythmias is low because the victims were so sick to begin with.

The biggest news of the past few years...

2012-01-08T10:40:00.000-08:00

...relating to in-hospital resuscitation, at least in my view, has been rather conclusive evidence that AHA/ILCOR's promotion of AEDs to address the problem of delayed in-hospital defibrillation has been a failure. Three large studies have produced essentially he same results: AED use does not improve survival from shockable arrhythmias and decreases survival from asystole and PEA:

Forcina MS, et al. Cardiac arrest survival after implementation of automated external defibrillator technology in the in-hospital setting. Crit Care Med. 2009;37(4):1229-36.
Chan PS, et al. Automated external defibrillators and survival after in-hospital cardiac arrest. JAMA. 2010;304(19):2129-2136.
Smith RJ, et al. Automated external deﬁbrillators and in-hospital cardiac arrest: Patient survival and device performance at an Australian teaching hospital. Resuscitation. 2011;82(12):1537-1542.

The most noticed (and most convincing) of these is the Chan study, which analyzed data from the AHA's own NRCPR (now Get with the Guidelines--Resuscitation) database that includes hundreds of hospitals.

I know that nobody likes to hear "I told you so," but this is my blog, and just this once I'll say that I did tell them so, in the January 1996 issue of Annals of Emergency Medicine, excerpt below.

The AHA should encourage objective evaluation of innovative approaches to treatment, particularly those that involve new technologies, before they gain widespread acceptance: “In the emotionally charged atmosphere of medical care, the momentum of a new technology too often puts the burden of proof on those who question the evidence for it, rather than on those who propose it. The result is that the technology quickly becomes the accepted thing to do [and] further attempts to test it are subject to the charge of being unethical . . . ”

AED manufacturers will keep the AED option in the forefront of discussions about delayed in-hospital defibrillation; as a public service organization the AHA should actively encourage consideration of a broad range of alternatives. There may be ways to achieve the goal of rapid in-hospital defibrillation less expensively–and much sooner–than by making progress contingent on the successful marketing of AEDs to hospitals.

Changes in BLS

2011-12-10T21:30:00.000-08:00

Since I last was active on this blog, a few important things have happened. The 2010 AHA Guidelines have recommended the Circulation-Airway-Breathing (CAB) sequence, which is a significant improvement. This is a step toward acknowledging that linking rescue breathing with chest compressions for all cardiac arrests 50 years ago was a huge mistake. However, the AHA is not known for acknowledging errors. The usual statement is that previous recommendations were just fine, but now we want you to do this.

The AHA does now say more explicitly that people untrained in BLS should start hands-only CPR--that is, chest compressions only. This ignores a number of good studies showing that hands-only CPR leads to better survival than conventional CPR with rescue breaths for non-asphyxial arrests (which the great majority are). So trained rescuers are still expected to use the less effective method.

Back after long hiatus

2011-12-10T15:17:00.000-08:00

This blog has been inactive since 2007 (!), the result of deep frustration about lack of progress on resuscitation issues that I care about--primarily delayed in-hospital defibrillation. I also took down my web site, In-Hospital Defibrillation, and probably won't put it back up. However, I have not been able to extinguish my interest in these issues, and some recent developments have given me a bit of hope. So, I'll try to "resuscitate" my blog.

The resistance to no-ventilation CPR

2006-08-07T10:29:00.000-07:00

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

2005-12-20T14:18:00.000-08:00

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

2005-12-12T15:19:00.000-08:00

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

2005-05-09T09:26:00.000-07:00

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

2005-04-21T22:33:00.000-07:00

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?

2005-02-27T20:23:00.000-08:00

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

2005-02-27T10:47:00.000-08:00

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. [Please note--defib.net and In-Hospital Defibrillation are now defunct (2011)]

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.