NO CPR is better than moving CPR...true or false?

[mycrofft]

1. Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially say it works.

2. Here in my area we have a seventeen percent save rate with the AHA guidelines plus making it common practice to have at least 6-9 respond to any code. With only two providers the chance of a save is ten percent or less.

1. With all due respect, nonsense. It starts with a clinically dead person and it has been shown that prompt initiation makes a difference in the cases where it has any chance at all. But I respect your feeling about that.*

2. 17%? Not bad. Don't let Seattle's stats bother you, we all think they cheat. If my kid or my wife or you are down and I have the choice of giving you or them a chance or no chance, what do you think I'm going to do? (I agree lining up the rescuers to take turns on compressions makes a difference, especially in rural areas where ALS arrival is delayed. 100/min and at least 2 inches deep kicks your butt).

And I have never seen that 10% and under stat for single rescuer or 2 rescuer CPR, URL appreciated. I might use it in my next class.


* Know how many people with coronary bypass go on to need another one? Or go on ultimately to die of coronary disease of some sort? Yet they continue to do them, with a great improvement in the patient's quality of life even if it is only for a year or five or fifteen....

 

[JMorin95]

1. With all due respect, nonsense. It starts with a clinically dead person and it has been shown that prompt initiation makes a difference in the cases where it has any chance at all. But I respect your feeling about that.*

2. 17%? Not bad. Don't let Seattle's stats bother you, we all think they cheat. If my kid or my wife or you are down and I have the choice of giving you or them a chance or no chance, what do you think I'm going to do? (I agree lining up the rescuers to take turns on compressions makes a difference, especially in rural areas where ALS arrival is delayed. 100/min and at least 2 inches deep kicks your butt).

And I have never seen that 10% and under stat for single rescuer or 2 rescuer CPR, URL appreciated. I might use it in my next class.


* Know how many people with coronary bypass go on to need another one? Or go on ultimately to die of coronary disease of some sort? Yet they continue to do them, with a great improvement in the patient's quality of life even if it is only for a year or five or fifteen....

I am not saying I'm not going to give these people a chance, I am just saying CPR is a flawed system. No one can definitively say what is the only way to do it. I will post a URL in a few minutes when I reach a computer as to the 10% stat.

 

[mycrofft]

I am not saying I'm not going to give these people a chance, I am just saying CPR is a flawed system. No one can definitively say what is the only way to do it. I will post a URL in a few minutes when I reach a computer as to the 10% stat.

Gotcha. Thanks!!

 

[JMorin95]

http://emedicine.medscape.com/article/1344081-overview here is the article.

 

[Rialaigh]

Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially it works. Her in my area we have a seventeen percent save rate with the AHA guidelines plus making it common practice to have at least 6-9 respond to any code. With only two providers the chance of a save is ten percent or less.

This does not make sense to me. There are plenty of hospital treatments that are "proven" to work but the survival rate is way way less than 17% let alone 50%. CPR improves the chances of survival, it is something we can control, so we do it. Anything that we can control to improve the chances of someone surviving we should do. Things that improve the chances of someone surviving even 5% "Work". I would take an extra 5% all day.

 

[JMorin95]

This does not make sense to me. There are plenty of hospital treatments that are "proven" to work but the survival rate is way way less than 17% let alone 50%. CPR improves the chances of survival, it is something we can control, so we do it. Anything that we can control to improve the chances of someone surviving we should do. Things that improve the chances of someone surviving even 5% "Work". I would take an extra 5% all day.

Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.

 

[Rialaigh]

Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.

Sorry I misread, I was reading that as you saying that CPR does not work. In my opinion anything that improves the chances of survival or improved quality of life "works" as an EMS treatment or protocol

 

[VFlutter]

Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.

Well CPR is pretty much the only option aside from open cardiac massage. Our best bet is to optimize CPR, most likely with mechanical devices. The low survival rate is due to multiple factors not just the process of CPR itself so saying CPR does not work since it has less than a 50% survival rate is misleading.

 

[JMorin95]

Well CPR is pretty much the only option aside from open cardiac massage. Our best bet is to optimize CPR, most likely with mechanical devices. The low survival rate is due to multiple factors not just the process of CPR itself so saying CPR does not work since it has less than a 50% survival rate is misleading.

The mechanical devices are proving to not let enough pressure build up in the lungs, therefore oxygen output is less with mechanical devices.

 

[Tigger]

Again let me repeat myself. I AM ALL FOR GIVING MORE OF A CHANCE. I was just stating that no one truly knows what is the best for survival.

So what do you propose instead?

When we don't do CPR, the survival rate is about zero. The exception being witnessed arrests correctable immediately with electrical therapy.

As for CPR in a moving ambulance, I'm sure it is more effective than no CPR. That said, I wear my seatbelt while the ambulance is in motion unless I absolutely need to get up and get something, and then it goes right back on. I cannot do CPR while seatbelted, which is fine since we don't generally transport arrests.

I do not want to be in a crash without a seatbelt on. It is not an acceptable risk to ride without a seatbelt.

 

[KellyBracket]

Until our CPR is good enough to warrant at least a fifty percent chance of survival, you can not officially it works. ...

By a 50% chance of survival, I take it that you mean that, for example, for every 2 patients in cardiac arrest, 1 lives? Another way to put this is, that the Number of patients you Need to Treat (NNT) in order to get one patient with the desired outcome would be 2.

I think you should understand the greater context in medicine, which is that very few therapies are that effective. Some examples:

Defibrillation of recent-onset VF (< 3 minutes): NNT = 2.5

Hypothermia for pts w/ ROSC: NNT = 6

tPA for stroke: NNT = 8

Treatment of STEMI with lytics versus nothing: NNT = 43

Treatment of STEMI versus lytics: NNT = 50

Look at that last number - we hit the lights and siren to get to the regional PCI center, activating the whole cath team, generating pretty significant costs, and it's only going to save one life out of every 50 patients who otherwise would have gotten tPA for their STEMI.

So, accepting only "50% survival" as a criterion of medical effectiveness doesn't match with how the rest of medicine sees the issue. Interesting perspective?

 

[mycrofft]

http://emedicine.medscape.com/article/1344081-overview here is the article.

Thanks, a thought provoking article. I liked their consideration of variables which might skew the result. The article sidesteps the issue that many bystander CPR's are taking place (not able to gauge, obviously) because a hands-only variant is available. I suppose all of this is "very-mostly" urban or suburban.

Emergency treatment has traditionally advanced initially by empiric observation (especially during war) when to do nothing leads to death; then either validation or rejection ensues. CPR had a lot of that going on, but the latest revisions seem to actually make some difference.

 

[mycrofft]

By a 50% chance of survival, I take it that you mean that, for example, for every 2 patients in cardiac arrest, 1 lives? Another way to put this is, that the Number of patients you Need to Treat (NNT) in order to get one patient with the desired outcome would be 2.

I think you should understand the greater context in medicine, which is that very few therapies are that effective. Some examples:

Defibrillation of recent-onset VF (< 3 minutes): NNT = 2.5

Hypothermia for pts w/ ROSC: NNT = 6

tPA for stroke: NNT = 8

Treatment of STEMI with lytics versus nothing: NNT = 43

Treatment of STEMI versus lytics: NNT = 50

Look at that last number - we hit the lights and siren to get to the regional PCI center, activating the whole cath team, generating pretty significant costs, and it's only going to save one life out of every 50 patients who otherwise would have gotten tPA for their STEMI.

So, accepting only "50% survival" as a criterion of medical effectiveness doesn't match with how the rest of medicine sees the issue. Interesting perspective?

I think the acceptance of such low survival rates applies to situations where grave outcomes are inevitable without intervention; if my wife or kids are that two in a hundred or whatever, then let's find out! Now, if a drug only works half the time or less, you need to find out why it works at all, and if it works part of the time due to something like genetics, interaction with cultural diet, etc.

As I posted above, approaches are tried empirically, then the science catches up and either supports it, changes it, or yanks it off the tracks.

Sometimes medical statistics remind me of Stalin's statement that one man's death is a tragedy, the death of millions is a statistic (paraphrase).

 

[KellyBracket]

... Now, if a drug only works half the time or less...

I wasn't making any comment on whether certain therapies should be used, but rather just making the point that the vast majority of therapies work only in a minority of patients.

I don't think many people, or even some physicians, really understand this point. Most drugs or therapies have only marginal benefits when expressed in terms of a NNT. Heck, PCI for STEMI looks great when you compare it to using aspirin in people who don't have heart disease.

 

[mycrofft]

Got it.

 

[Brandon O]

Heck, PCI for STEMI looks great when you compare it to using aspirin in people who don't have heart disease.

And saying that tPA-for-stroke has an NNT of 8 sounds great until you realize the number needed to harm is also about 8!

Boiling everything down to an NNT for MORTALITY benefit ONLY also has a way of leaving very little left in the pot.

What's that they say? "To cure sometimes, to relieve often, to comfort always." If EBM has an Achilles heel, it's trying to pretend that the only valuable acts are those that save lives, and then acting confused when very little of modern medicine qualifies.

End rant...

 

[mycrofft]

And saying that tPA-for-stroke has an NNT of 8 sounds great until you realize the number needed to harm is also about 8!

Boiling everything down to an NNT for MORTALITY benefit ONLY also has a way of leaving very little left in the pot.

What's that they say? "To cure sometimes, to relieve often, to comfort always." If EBM has an Achilles heel, it's trying to pretend that the only valuable acts are those that save lives, and then acting confused when very little of modern medicine qualifies.

End rant...

To paraphrase part of the Hippocratic Oath: "Might help, Can't Hoit!".

Another aspect of today's PEMS is that the most brutal and outre' methods have been espoused over the years because (1) it originates in wartime or surgery, and (2) we have a cowboy/rescue mentality.

 

[Chief Complaint]

Perhaps i am misunderstanding something...

To anyone who opposes CPR in a moving ambulance, what would we do en route to the hospital? Just sit back and do nothing?

Or do you feel that all codes should be worked on scene until ROSC or termination of efforts?

 

[STXmedic]

Or do you feel that all codes should be worked on scene until ROSC or termination of efforts?

This. Not all, but the vast majority.

 

[mycrofft]

I think I'd step in, grab Granma and haul her to the hospital in my car if you proposed to sit and watch in my living room.