New Test Can Tell EMS When CPR Is Futile

[JM15 386]

STEPHANIE NANO

The Canadian Press

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?

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 and Sunnybrook Health Sciences Centre.

But 60 per cent 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 three per cent, 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 signalled 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 per cent.

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 eight 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.

On the Net:

New England Journal:

[STAT213 332]

All I can say is...its about time. Dead is dead.

I was calling codes back in the 90's upstate, then moved downstate and was told we don't do that here.

Thankfully, my current protocols allow me to terminate after 20 minutes of BCLS and or ACLS. So, if we don't get 'em back after 20 minutes, its over. OVER. You bring the family in and explain the situation, and then TERMINATE.

Dead is dead folks. Ain't no amount of CPR and drugs that'll fix it.

[JBE 328]

It's been a long time since I have run a code, but isn't this something that could open up a really big can of worms in the area of lawsuits?? What I mean is you go in, start working a patient up and stop, or pronounce someone on the spot. The family thinks you didn't do enough to help that person. BOOM, you're staring down the barrell or a lawsuit.

[STAT213 332]

why?

how is this any different from what an ED doctor would do? we are following the same protocols, written by the same people. you don't get sued for following any other protocols, do you?

oh, and it is OK to stop CPR once you have started. You don't have to continue just because some well intentioned soul started working a corpse. Even in NY, you can do this. Its that box on the PCR that is "obvious death."

Be not afraid.

[JBE 328]

Like I said, it's been a long time since I ran a CPR run and my EMT cert expired in 1999. My memories of protocols are a bit fuzzy. Thank you.

[PC414 0]

Recognizing the overall statistical insignifigance of "a survival rate of 0.5 per cent," I still wouldn't mind someone tryin' to see if I could "make the cut," were I in this position. Assuming, of course, the crew had the time and nothing much better going on back at the house ...

"If the test were applied, it would reduce by about two-thirds the number of patients taken to the hospital, the researchers said."

Well, what can one say? It's a good thing good we're gonna' cut down on the crisis in emergency healthcare by addressing this patient issue instead of the glut of people who clog the ED for coughs, colds, aches and pains and other assorted minor ailments.

Maybe I misread the article. Seems like STAT123 gives it the correct "good ol' college try" with "my current protocols allow me to terminate after 20 minutes of BCLS and or ACLS. So, if we don't get 'em back after 20 minutes, its over. OVER. You bring the family in and explain the situation, and then TERMINATE."

That's all I'd hope for, personally. Article on the study , to me, seemed to not give any "wiggle room" - even 20 minutes worth - which might make a difference to the "statistically insignificant" 0.5 percent.

Any thoughts?

PC414

[ny10570 745]

sorry stat, but around here, as a BLS provider if we come up on body and someone else is cranking away, we have to contine CPR until the ED doc calls it. Even ALS providers need to contact doc in the box if they want to terminate CPR in progress. They cannot decide on their own to do it.

[WAS967 97]

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.

When two more criteria were added - paramedic arrival time of more than eight minutes and the attack wasn't witnessed by a bystander - the test worked even better.

The study only seems to support what we are already doing. The first set of indicators seems to mirror the termination of efforts protocol that we already have in place. The second set of criteria seems to imply that if the other criteria are met, then even in a BLS setting, efforts are futile and should be terminated.

The one thing the study doesn't seem to take into account is extreme cases (like cold water drownings). In the end it all comes down to good clinical judgement.

Edited August 8, 2006 by WAS967

[Guest alsfirefighter]

I really like all the discussion about this topic so far.

The biggest thing I just wanted to reply on was the mention of the word "lawsuit." Anyone can attempt to bring a lawsuit against anyone for just about anything if it warrants merit. If you follow the protocol efficiently and properly it guides you so this cannot happen. It cannot happen if you document properly. Again, anyone can try, but unless you screwed something up significantly it wouldn't see the light of day. I do not worry about lawsuits. If you are, get out of any type of emergency service because its looming just around the corner. The definitions of negligence, breach of duty, assault, battery and abduction are clear cut.

___________________________

Remember, let up for a second....and that is exactly where you will finish.

[Guest]

Until recently I would've been behind the BLS or ALS crews that were in favour of calling the "obvious death" in the field if it were not for the asystole down for 15+ mins maybe 3-5 mins down w/o CPR that the medic was ready to pronounce in the truck that came back w/ a BP and a pulse u/a @ the ED... no matter how many codes you work up 0-100 there will always be that miracle case that rewrites the books... my pt. is still fighting 1 wk. s/P CPR... even if only for the pt. family to say a worthy goodbye it's all worth it

[STAT213 332]

Until recently I would've been behind the BLS or ALS crews that were in favour of calling the "obvious death" in the field if it were not for the asystole down for  15+ mins maybe 3-5 mins down w/o CPR  that the medic was ready to pronounce in the truck that came back w/ a BP and a pulse u/a @ the ED... no matter how many codes you work up 0-100 there will always be that miracle case that rewrites the books... my pt. is still fighting 1 wk. s/P CPR...  even if only for the pt. family to say a worthy goodbye it's all worth it

←

A few responses to some of the things on this thread. I live and work in NH now, and have WAY better protocols than anywhere in NY. That is why after 20 minutes of CPR, an arrest can be terminated.

BFD EMT-B, I appreciate your sentiments about the save you had. I can tell you that after 15 minutes of asystole and 3-5 minutes of down, all you are saving is a heart. The person they knew is dead. DEAD. Maybe not today, maybe not tomorrow and in all likelyhood, you just made the family's decision 10 times harder because they are now faced with decisions like withdrawl, life support, etc.

As for the worthy good bye, I would argue that one until I am blue in the face. A week of lingering or fighting in the ICU is not healthy (for the family). The person will die, or will be brain dead. Performing CPR in the hope of a miracle is not worth it. You will cause way more anguish that you solve. (over those 100 arrests.)

The worthy good bye is the one that you arrange in their living room with a calm demeanor and explanation. I have done this many times and it works really well. You calmly explain to the family that their loved one is dead. You explain what you are doing to try and bring them back to life. You bring them into the room where you are working them and let them hold their family members hand. This takes an incredible amount of professionalism and a calm demeanor, but it is very rewarding. Once you end the efforts, you now have a NEW set of patients to deal with: the family. Assist them in getting the PD and the funeral home there. Help them through what is a horrible day.

Now, this has to be done with everyone's agreement, and its not just a rush in, work 'em tell 'em he's dead and leave kinda thing. Its a compassionate, calm effort.

[ny10570 745]

Thank you stat, you explained my feelings with much more eloquence than I am capapble of.

[Guest]

I will fight my bias, and try to answer "STAT213"s post elequently....I was told some time ago that "Your patient's time of death shall not not be determined by a medic's watch, or the clock in your ambulance." While Paramedics are highly trained people, we should NOT be determining time of death, unless there are "obvious signs of death". We also should NOT be leaving grandma in bed for the family, it does the family a great disservice. If you were trained in the REMO region.....you had that drummed in your head.

Bring their deceased to the hospital, where there is approiate grief councilling and clergy to help them.

[Guest EMSwhitecloud]

This is a very gray area, but like said before dead is dead and we're not the morgue, so why transport dead bodies?

Im not cold hearted, every inch of my body says "do cpr till your at the hospital". But the reality of it is, your fighting and fighting for something that may never happen.

About lawsuits, like ALSfirefighter said, If your worried about them then your in the wrong business, anything we say or do as medical providers can end up in court. Do things by the book and your okay.

[WAS967 97]

We also should NOT be leaving grandma in bed for the family, it does the family a great disservice. If you were trained in the REMO region.....you had that drummed in your head.

Bring their deceased to the hospital, where there is approiate grief councilling and clergy to help them.

I have to disagree with you here. In many cases it is actually MORE comforting for the family if the patient passes away at home. Most people associate hospitals with death and dying and suffering and what not as it is.

As for time of death, name one reason why a medic shouldn't be able to post a time for the police report.

[Skooter92 7]

Gotta agree with WAS.....I've called Medical Control many a time, gottten permission to leave the patient as-is, and then agreed with the doc on the time-and passed it on to LE as the official pronouncement time. Not everyone benefits from seeing the body thumped on and hauled to the ED, and many thank us for NOT doing so. Compassion is doing the right thing for the family according to the situation....and not every ED does such a great job taking care of the ones left behind.

[STAT213 332]

Someone above here mentioned... " I learned long ago." There are a lot things that we learned long ago that were wrong. Very wrong. That CPR works and we should do it until we get to the hospital is one of them. It is 1) generally futile and 2) essentially ineffective in the back of an ambulance.

My paramedic instructor taught me that 50 % of what he would teach us would be wrong. He just didn't know what 50 % yet. He was right. I learned about Epi in cardiac arrest, massive fluid resus, MAST Pants and CPR for more than 20 minutes.

There are some golden rules out there. Just once, though, try pronouncing someone in the field (granted of course, you have the protocols for it..) and see how it works. You'll be surprised. A lot of the family's anxiety comes from the way we barrel into their house, pounce on their loved ones and fly out. Slow it down, take a breath and see how it works. You'll be amazed.

RA

[Guest alsfirefighter]

Medic5597, very well articulated post, but I have to disagree with you. With todays soceity becoming what it has, we all have been experiencing a huge increase in the amount of terminally ill persons and independant ederly persons who live at home at all possible costs. We have had extreme success and accolades in my department with pronouncements that are made in the home for the assistance we offer to the family of the deceased. We make every effort along with the PD to ensure that clergy is called if wished and other family members to assist. I also depending on call volume stay and assist with the family until the ME office or the funeral home staff arrives. There isn't any difference in time from my watch to the clock on the wall in the ED. I personally also liked being able to grieve at my own pace in my grandfathers apartment when his time came with my family. Myself and several other co-workers often receive thank you letters from families for how we assisted them dealing with their loss. Leaving grandma in bed and putting a blanket on her to look like she is resting peacefully is a service. Dragging her out, pouding on her chest and her arms flailing around is the disservice when family sees that. I respect your opinion, and I don't know where the "REMO" region is. But no that wasn't pounded in my head and they would probably still be trying if I was. I learned how to tell time whe I was like 5 years old, and I am highly trained. Maybe they should be pounding into the training that a pronouncement is a process not just looking at a watch.

Again it comes down to common sense and having a good paramedic that takes the surroundings into consideration and how the present family is acting. So if you work the arrest transport but if its obvious death then its ok to leave the deceased there with the family? And in their mind this makes what difference?