Skip to comments.New test may spot futile CPR cases
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.
On the Net:
New England Journal: http://nejm.org
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."
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.
Alright, point #3 really confuses me. Chances are probably high that not many cases involved EMTs that actually witnessed the cardiac arrests - perhaps that's why EMTs were called out - because OF a cardiac arrest? To me, a rescue worker not witnessing a cardiac arrest is a pretty shoddy reason not to do CPR.
Well, they didn't give up on me and saved my sorry ass. Thank you emergency workers!
Now, they're recommending just giving up??? Why don't we just stop saving everyone since we're all going to die someday anyway???????
Having worked more than 100 "codes" during my 20 years as an ambulance medic, I know for certain that several people I worked on who survived an unwitnessed cardiac arrest would not have met this test. However, I agree that efforts are totally futile in some cases, particularly cardiac arrest due to trauma. If your heart stops due to wrapping your chest around a steering wheel your DRT (dead right there).
This article is from Canada. My opinion is that this is an attepted disguise at soft euthanasia - let the person die to save $ since the ODDS are heavily against them. I'm glad the EMT's here don't have that attitude.
Heck get rid of the hospitals under socialized medicine. You might need bigger morgues though.
"And these four would have died if the paramedics had been using the "3 point test.""
Pretty sigificant if you are one of those 4.
How would a person given a "wait to treat" card during triage react? Either doing CPR for 20 minutes or more on every person saves more lives or it doesn't because it uses resources that could save another, less dire, patient.In the first case it should be done all the time, in the second case it shouldn't be done at all. In either case, the decision should be based on medical personnel saving as many lives as possible.
I'm glad the EMTs and paramedics in CA didn't give up on me in '79. I had a trauma induced ruptured spleen, all my ribs broken(flail chest), both lungs collapsed and full of blood, a fractured skull and pelvis; and I was vomiting blood and unconscious(thank God!)
Well, they didn't give up on me and saved my sorry ass. Thank you emergency workers!
----Geeezus i have a aquaintence like you ! He had a accident that fu*ked his azz up like you, different organs, and squashed part of his skull in. He's lucky to be alive, all i have to say is he lives his life as normally as he can, works hard, and is always fun talking to him every morning when i stop in for coffee on my way to work.
It's all about response time. Studies dating from back in '92 show there is no point to doing CPR anymore after the patient has been down 20 minutes or more.
So, let's say John Doe drops. Somebody calls 9/11 after taking 30 seconds or so to try and wake him up. In my town, a city of about 26,000 people, the average response time for an ambulance is a little over 4 minutes. By the time they start working in earnest on him, we're up to five inutes. If they're ten minutes from a hospital and he hasn't revived, we're up to 15 minutes plus whatever time they spent trying CPR at the scene. By the time they hit the doors of the emergency room they are probably bumping up against 20 minutes, and they haven't even seen the doctor yet.
However, if they were out and about and saw the guy drop, they are to him and working in less than a minute. That's why the third criteria is in there, so people who were attended to very quickly are not included in the "futile" group.
You see, that's what I think needs to be done. Lord knows there have to be futile cases, but the criteria probably need to be tighter. My thing is, they say only four people survived, but those four people would be pushing up daisies if they'd been declared "futile."
The original quote: "Should you be taken to the hospital even if you can't be revived and are likely to die?" ************
Do you really want a decision made out in the field about your likelihood of survival? I want whoever is attempting to resuscitate me to make a decision only after doing everything humanly possible.
But they did their best to save him...and he is fully recovered.
Lots of good points being made on this thread, however, you're leaving out the people who "drop" where there are civilians on hand who immediately begin CPR while 911 is being called by someone else. Then, what do you do? The EMTs didn't see the guy drop...
I'd completely accept your premise if a person goes down, nobody sees him go down, and therefore no one knows how long he's been down - other than that or (of course) cases of obviously severe trauma - I would personally want a doctor calling me hopeless, and no one else.
I think you raise an important point. The article doesn't mention socialized medicine but I think it's reasonable to assume that is one of the reasons the issue was raised, regardless of what was claimed.
The reason I asked about 20 minutes is because I saw a study in '92 that showed you will die after twenty minutes with no pulse. You may even make it out of the emergency room, but you will not leave the hospital alive.
So, if the decision is "This guy's been down 20 minutes, stop CPR," I'm fine with that, because they've done everything humanly possible. If it's, "He's not likely to live, let's stop CPR so we can go back on call," then I'm not OK with it.
Good point, which is why they should err on the side of caution instead of assuming civilians can't do CPR.
My Grandad died like this. He dropped on the street, and none of the bystanders knew CPR. It took a very long time for the ambulance to get there. He was only 63.
That may be true at present, but how will medicine advance without trial and error? If we simply accept our current abilities, we will not progress. I can't dispute your knowledge on the subject, but I would much rather a medical professional err on the side of doing over and above than the alternative.
It's not sloppy wording. Death is not reversible - that's the medical definition. Cardiac arrest is what these people suffered from - some died, some didn't. When someone says "I died three times on the operating table!", they're using sloppy wording.
The single biggest factor that determines your chances of surviving cardiac arrest is whether you have a "shockable" rhythm - ventricular tachycardia or fibrillation. Defibrillation is more of a lifesaver than CPR is. It's good to see that automated external defibrillators are finally being emphasized as a lifesaving tool. Unfortunately, traumatic cardiac arrest has an extremely poor chance of survival.
It's a time thing. See post 29. BTW, it happens all the time that the EMS guys see someone arrest. They come for chest pain or some other symptom, and the person arrests while they are there.
A family member who worked as an Paramedic for many years told of families who found a member dead and wanted CPR etc even tho it was apparent the person had been dead for some time. In other cases DNR's were ignored and not produced by family members.
My wife is very pro-life, and she hates it when patients die unless they were in very bad shape. But the couple of times she's mentioned family members ignoring DNR's, she has been livid. It's not like anyone who's mentally competent signs one of those on a whim! I don't care how much somebody loves having me around, if I ever sign one of those things and they override it, they'd better hope I die, because if I survive I will beat them with my cane.
My elder son died just over 13 months ago, on June 27. His epilepsy had been fully controlled by drugs for several years after high school, but he started having a few seizures a year a couple of years previously. We believe, and the coroner agreed, that he had a seizure, got turned face down on his bed, and smothered in a pillow. During a seizure he was completely insensible, and could not have experienced any pain or discomfort.
I was in another part of the house when it happened. About 30 minutes earlier he and I had both answered the phone, which was the last time I heard his voice. When the phone rang again, I waited for an extra ring in order to give him time to answer before I did. The call was for him, so I knocked on his door first, then looked out the door for his car (fortunately leaving it unlocked) then went back to his room and opened the door.
His face was in between two pillows, and the back of his arms were already blue. I threw the pillows aside, turned his head, and pressed hard on his back a couple of times, while yelling at the woman on the phone to get off so I could call 911. Then I wrestled him onto his back and started CPR. I am 66, and way out of shape, and he was a tall, strong 35 year old who worked out at a gym every day, so that took 30 seconds or so to get started.
The operator and I were yelling at each other about what to do - she wanted me to check for breathing and a pulse before starting, but that was obviously unnecessary. The EMT's showed up in less than 10 minutes, came right in thanks to the open door, and asked me to leave. I refused to do so until they were in position to relieve me, and then I was too weak and exhausted to walk and had to be helped by the driver. They worked on him for several minutes, but his heart never responded to shock.
I was too late, and it truly was not my fault and beyond my control. I know that I did everything I possibly could have done, and that my efforts brought a pink color back to his cheeks, but not in time to save him. In his case, they did stop, after telling me that it was completely futile. In his case, they did stop, after telling me that it was completely futile. My sincere and heartfelt prayer to exchange my life for his at that moment was answered in the negative - I needed to stay around for my wife while she finished her chemotherapy and radiation.
I still cannot stay in that room for more than a few minutes, and I still have trouble finding motivation for anything - my taxes are done but not checked and submitted, and I still have not been able to bring myself to be declared administrator of his estate. The nightmares have eased, and I can go to sleep now without pills, but if I awaken early I have to turn the radio on as a distraction.
You are correct, at least as far as the law in the State of Wisconsin is concerned. Once CPR is initiated by a trained individual (EMT, Paramedic, Police Officer, Firefighter etc.), there are only three reasons it can be discontinued. The patient begins breathing and his/her heartbeat returns; you become so physically exhausted that you are no longer able to perform CPR or a physician advises you to discontinue CPR.
Please accept my humble prayers for you and your family on the loss of your son. My son died from an epileptic seizure in January of this year. The seizure caused him to stop breathing while he was in the ambulance on the way to the hospital. His heart stopped shortly thereafter. The crash team in the ER tried CPR for 30 minutes before the doctor told us it he thought it was futile and that he recommended that we allow them to stop. He said they would continue as long as we wanted them to. We could see that our son was gone, so we told them to let him go in peace.
Please FReepmail me if you would like to talk more.
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