EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
Posted Oct 04 2009 11:13pm
I occasionally appear on EMS Garage. I had to work and missed this episode.  I guess that a lot of people will be glad. Just listening to the first few minutes got me started on this post.
First, Mickey S. Eisenberg, MD is the special guest. He has just written a book called Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest.  He is an excellent person to talk with about this topic. He is one of the people everyone recognizes as an expert. Certainly, I cannot disagree with him, but I do.
Greg Friese is explaining about one of the ideas from the book. That cardiac arrest survival is the best way to determine the quality of a system. I agree that cardiac arrest survival is important, but since cardiac arrest has only been shown to be improved by BLS treatments (compressions and rapid defibrillation - both of which used to be physician-only treatments), it is a mistake to think that this tells you a lot about the quality of an ALS system.
ALS has been shown to worsen the outcome of cardiac arrest, by interfering with good chest compressions, but no ALS treatment has been shown to improve outcome from cardiac arrest. I might even turn that around and say that cardiac arrest outcome may be improved by no ALS.
This may not be entirely true,  but it is not unreasonable. There is evidence to show that rapid ALS leads to worse outcomes.  There is also evidence to show that ALS leads to worse outcomes. 
I do not see evidence that ALS is important in resuscitation. Therefore, how can cardiac resuscitation be an effective measure of the effectiveness of an ALS service?
Cardiac arrest represents about one percent of the EMS calls in any given community, but the management of this one percent encapsulates everything good and bad about a communities EMS system. 
In discussing this, Jamie Davis (I think) comments that resuscitation rates are the easiest metric to quantify. I agree that this is easy to quantify. Being easy to quantify and being important do not necessarily go together. The story of the drunk searching for his keys under the streetlight is relevant. He lost his keys elsewhere, but he is looking where the light is better. It will not improve his ability to find his keys, but he will feel better while he is looking. We should not be imitating a drunk, who cannot find his keys. For all we know, they could still be in his pocket, or the bartender might have taken them.
Now that I got that rant out, the rest of the show was excellent. Everybody asked good questions. A lot was covered. The only complaint I have about the rest of the show is that it was too short. There is so much to cover that much, much more than an hour needs to be devoted to this. If I had been involved, the show might have gotten bogged down on the topic I just covered, and never covered some of the much more interesting material that they did cover.
I will write several posts about the many wonderful, positive points in the show.
^3Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service. Woodall J, McCarthy M, Johnston T, Tippett V, Bonham R. Emerg Med J. 2007 Feb;24(2):134-8. PMID: 17251628 [PubMed - indexed for MEDLINE]
Conclusions: Highly trained ACLS-skilled paramedics provide added survival benefit in EMS systems not optimised for early defibrillation. The reasons for this benefit are multifactorial, but may be the result of greater skill level and more informed use of the full range of prehospital interventions.
My highlighting, but that may be all that is necessary to explain the benefit. The big question is, Where are the studies showing a benefit from prehospital ALS in cardiac arrest? We can theorize endlessly about potential benefits, but where is the evidence of benefit. It is silly to theorize about the reason for a benefit, when we do not even have evidence that the benefit exists.
Maybe we should be optimizing these systems for early defibrillation or look at systems that have already done this.
^4Cardiac Arrest Survival Rates Depend on Paramedic Experience Michael R Sayre, Al Hallstrom, Thomas D Rea, Lois Van Ottingham, Lynn J White, James Christenson, Vince N Mosesso, Andy R Anton, Michele Olsufka, Sarah Pennington, Stephen Yahn, James Husar, Leonard A Cobb. Academic Emergency Medicine; Volume 13 Issue s5; May 2006; pages S55 - S56; abstract number 121 The abstract is available here.
^5Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation Henry E. Wang, MD, MS Scott J. Simeone, BS, NREMT-P Matthew D. Weaver, BS, NREMT-P Clifton W. Callaway, MD, PhD Presented at the Society for Academic Emergency Medicine annual meeting, May 2008, Washington, DC. Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA The abstract is available here.
^6Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest The Big Picture Page 18. Same as footnote .