Posted on 08/04/2006 8:13:50 AM PDT by Mr. Silverback
If your heart suddenly stopped, how long should rescue workers try to save you? Should you be taken to the hospital even if you can't be revived and are likely to die? Canadian researchers say they've devised a test that helps rescue workers spot those futile cases and save a frantic trip to the hospital.
Some paramedics with advanced training — those who can give drugs and start IVs — already are allowed to stop giving CPR if their efforts fail and they have consulted a doctor, said lead researcher, Dr. Laurie J. Morrison of the University of Toronto.
But 60 percent of Americans and Canadians, mostly in rural areas, are served by rescue workers who only have basic skills and don't have that option, she said.
"Now they make no decisions whatsoever," Morrison said. "They just start the resuscitation, put them in the back of the ambulance and drive."
Taking such lost causes to the hospital ties up ambulances and emergency departments and the race to get there is hazardous for rescue workers and other motorists, researchers said.
Morrison said her group studied the issue after she was approached by two frustrated paramedics. The researchers reviewed old cases, devised a three-point rule, then tested it in urban and rural areas of Ontario. Their findings are in Thursday's New England Journal of Medicine.
Few people survive a cardiac arrest, which is caused by an abnormal heart rhythm and brought on by a heart attack or heart disease, electrocution, drowning or choking. The victim loses consciousness and stops breathing. More than 300,000 Americans die of cardiac arrest each year.
In the Canadian experiment, only 41 of 1,240 patients, or 3 percent, survived. All were given cardiopulmonary resuscitation at the scene, hooked up to a defibrillator to try to shock their hearts back into normal rhythm and taken to the hospital.
Later, the rescue workers filled out a form, applying the three-criteria test to each case to see if it would have signaled that CPR be stopped. Termination was advised if a pulse couldn't be restored, if the defibrillator determined that an electric shock shouldn't be given, and if the cardiac arrest wasn't witnessed by a rescue worker.
The researchers said the test closely predicted who was likely to die. Overall, 776 patients met the three criteria, and all except four died, a survival rate of 0.5 percent.
If the test were applied, it would reduce by about two-thirds the number of patients taken to the hospital, the researchers said.
When two more criteria were added — paramedic arrival time of more than 8 minutes and the attack wasn't witnessed by a bystander — the test worked even better.
Morrison said surveys suggest that families often accept the decision to stop CPR.
Dr. Gordon Ewy, of the University of Arizona College of Medicine, said the guidelines are needed but shouldn't replace medical judgment and won't necessarily apply in every case.
"They're transporting patients that have practically no chance of survival," said Ewy, who wrote an accompanying editorial. "I think that this publication is extremely important because it gives guidelines for that."
The experiment was done before the American Heart Association revised its CPR guidelines last year, putting more emphasis on chest compression than mouth-to-mouth resuscitation. The researchers say the new CPR will likely help revive more people, but their guidelines would still identify those unlikely to survive.
Michael Perkins, director of the Coshocton County Emergency Medical Services in rural northeast Ohio, said there are certain circumstances where emergency medical technicians should be able to decide to stop CPR. He said his paramedics can make that call, but he said the majority of patients are still taken to the hospital.
"As a paramedic, myself included, if you make that commitment to start, you don't want to stop until you get to the hospital," said Perkins.
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On the Net:
New England Journal: http://nejm.org
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Likely to die? Holy mackerel. That's not a decision I want an EMT to make. Or a doctor. Or anyone.
And these four would have died if the paramedics had been using the "3 point test."
Canadian research!
If the State is paying the bill, the State is going to make the call.
Frankly, with an overall 3% survival rate, I surprised Canada even bothers to send out responders for cardiac arrest cases. It just doesn't pay. Probably just force of habit.
Just think, if you're a Canadian EMT, all you have to do is stop by the Tim Horton's on the way to the response, and you'll miss that eight minute window. You could save yourself so much work that way!
Uh Oh is my first thought. Dr. Death is about to strike to make sure you know it is him that has the power to decided whether you live or die. Imagine telling a family, the loved one died just because someone did not do all they could do; but instead decided on their own without much training or effort to oft this person.
Yes...the problem is that on the one hand this seems like the sort of "playing the odds" that we have to do every day as a society in order to function and could end up saving more lives in the long run because of the reduced burden on the medical system, but on the other hand, it is very close to medical rationing and comes out of a country that is already doing medical rationing.
Also, consider this: Back in '93, I remember seeing a study in an EMT magazine showing that people who received CPR for 20 minutes were virtually certain to die. Few left the emergency room alive; almost all who did died in intensive care. I can't recal whether there were survivors, but I ask myself, if the survival rate had been one in a thousand, would it have been wrong for the study to recommend that you never do CPR for 20 minutes or more?
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Makes me glad I'm immigrating to the U.S. from Canada. hte scary thing is that so many people up there have the socialist mindset of what's best for society so they won't care if 4 people die if this proposed 3-point system is applied. It will save money and make the health care system more efficient. To me, it makes the health care system an oxymoron.
If you're down for 20 minutes, you're dead. Should they keep working at that point?
"Taking such lost causes to the hospital ties up ambulances and emergency departments and the race to get there is hazardous for rescue workers and other motorists, researchers said."
What's next? Issuing shovels?
In all seriousness, it has to do with the ethic of lifesaving in the EMS community. That said, you don't know a person who has collapsed is in cardiac arrest until you've reached the scene. Even if somebody at the scene has told you it's cardiac arrest, they probably are also able to start CPR, and that makes it far more likely the patient will survive.
I'm not defending this practice, I'm still on the fence. But your characterization here is way off.
First, every single time that someone dies after a code, it is because someone "did not do all they could do." At some point they stop CPR and defib because it is futile.
Second, no one is being "oft." Being offed would be euthanasia. This is just triage. The question is not whether the EMS people are killing, the question is qhether triage is an apprpriate regime in normal EMS ops or if it should be reserved for mass casualties.
What I would like to see is a study that would confirm or disprove that adopting the three point teest would save the lives of other patients.
What if it saved three lives for every life lost? What if the trade was one life for one life, but the cardiac patients were usually badly brain damged (common in long term CPR cases) and the people saved were usually able to recover fully?
If this saves other lives it might be a justifiable, even merciful, tradeoff. If it doesn't, it's just saving money and amounts to passive euthanasia. We need more facts, IMHO.
You didn't read the whole article, did you?
I wonder how the one-in-a-thousand person would answer that question?
Whenever my son was taken to the hospital by ambulance, the EMTs were on the radio with the hospital constantly.
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