Can Open, Worms Everywhere

Hoo boy, did I evoke some comments on my last post!

So much so, that I’ll debate here rather than in comments.

LawDog asked:

So, a 5% chance — one in twenty will survive — isn’t worth trying?

When does the survival chance become worth working on?

10%? 25%? 50%?

The 5% figure refers to medical cardiac arrest. As I stated in the post, there are some places in the country that have ROSC (return of spontaneous circulation) rates that are upwards of 20%. The majority of those “saves” will never leave the hospital alive. Please understand I’m not advocating that we don’t attempt resuscitation on these people, even considering the dismal outcomes. In fact, for the vast majority of medical prehospital cardiac arrests, the patient regains a pulse in the field or not at all.

But to borrow a phrase from LawDog, trauma arrests are another kettle of fish entirely. These people arrested from physical damage to vital organs. Repairing such damage requires rapid surgical intervention – something medics cannot do. A great many of the trauma codes I see brought in by EMS would not have been salvageable even if the accident had occurred in the ER parking lot. The survival rate is substantially less than 1% of all prehospital traumatic arrests. Not to wax hyperbolic, but for some of these attempts, the medic’s chance of dying during the transport comes close to exceeding the patient’s chance of surviving.

Jules said:

I know this because I’ve been there and 3 years later watched him walk down the isle as the Best man to my daughters Maid of honor…humbling to say the least.

So yeah…there is a season and a time…who makes that call?

We make that call. Or at least, we should be. Not to discount what I’m sure was a very happy outcome, but your story equals anecdote, Jules, not evidence. EMS practice cannot be driven by what might happen with that one-in-a-million patient.

I’d like to ask you a couple of questions about the kid saved. Was he multi-systems trauma? Blunt or penetrating? What was his presenting cardiac rhythm?

The data is pretty compelling. Blunt trauma cardiac arrest patients with severe damage to more than one body system do not survive.

Asystolic trauma patients do not survive.

Penetrating trauma arrests with PEA (pulseless electrical activity) rates of less than 40 do not survive.

P.J. Geraghty pointed out:

Keep in mind the >96,000 people waiting for organ transplants. It’s often hard to diagnose internal injuries rapidly upon arrival at a chaotic scene, and if you can restore a pulse in a reasonable time, that patient might be able to donate organs. This has the potential to save several other lives, as well as help console his family in their grief.

It won’t happen in every case, but quite a few of my cases start as out-of-hospital traumatic cardiac arrests that were resuscitated by EMS.

Excellent point PJ, and one I failed to address. But I’ll disagree with you slightly on diagnosing the internal injuries. Yeah, the exact cause of death may only be apparent after an autopsy, but I’d posit that a competent EMT should be able to at least determine the gross extent of injuries. You may not know that it was a dissected aorta that did the job, but you can note that rib fractures, a distended belly, lower extremity long bone fractures and blood/CSF leaking from the ears equals more problems than can be fixed.

I’ll ask you the same question I asked Jules: In your experience, of those organ harvests that started out as prehospital traumatic cardiac arrest “saves,” what percentage of them were multi-systems trauma with asystole or slow PEA as the presenting rhythm? Perhaps you’ll prove me wrong, but I’d bet damned few. I’d bet on most of them being VF, VT or fast PEA rhythms initially, or isolated trauma.

If you have some data that suggests otherwise, I’ll be happy to post it here in an update, and we can all learn something.

Divemedic wrote:

I also practice in an area where our save percentage of WORKED medical arrest patients exceeds 20% for return of pulses. Less than half of those ever survive to hospital discharge. The majority of those that do, present in VF, VT, or a PEA with a rate greater than 40.

Patients presenting with asystole as the initial rhythm rarely survive. Patients who arrest as a result of trauma rarely survive.

I have never seen a trauma patient who presents in asystole survive. Not one. In 18 years, not one.

Your experience mirrors my own, and pretty much falls right in line with NAEMSP’s position paper on the subject.

Mr Fixit wrote:

We do not do what we do based on outcomes. We do what we do because those are the things we can do, and hope for the best outcome.

You are dead wrong there, Blog Brother. We do base our practice on outcomes. This is what drives medical care forward. Why ain’t we giving high dose epinephrine any more? What about pneumatic shock trousers? Rotating tourniquets? Prophylactic lidocaine in myocardial infarction? Bleeding people with leeches? Chanting and incense?

Because those things did not improve outcomes.

You’ve been a medic at least ten years. Think back on all the medical “facts” you learned in medical school that have been proven wrong since then. Paying attention to outcomes in what leads us to abandon old practices that do not work in favor of new ones that do.

Another issue to be considered is finite resources. There comes a time when you stop certain practices because they are simply a waste of time and money. I’ll put it to you this way: If, while you’re feverishly working
a futile traumatic arrest, you get another another call in your district for a 14 year old with severe asthma and respiratory arrest. The covering truck is five minutes further away, and the resultant delay proves fatal for the kid.

Is that your fault? No. But was it preventable? I’d say yes. You had finite resources tied up on a patient that 999 times out of 1000, will die anyway. The 1/1000 that lives will most likely be a vegetable.

You went on to say:

Every transport should be the same. We wouldn’t decide that it’s OK to stop by and get a coke while we are transporting a heart attack.

Every patient deserves a prompt and professional response. Not all of those will warrant the same treatment, or even transport at all. You’re confusing my argument for intelligent use of resources with cherrypicking who deserves proper care.

The days of “you call, we haul” will soon be over, if they aren’t already. A more intelligent philosophy would be “you call, we respond.”

While we’re on that subject, how does it make sense that we design EMS systems to best serve less than 1% of our patients (cardiac arrests)? If your fire department served an area that was 99% high rise buildings, what sense would it make to focus your training, deployment and equipment purchases on the 1% that are single story wood frame homes?

Folks, I welcome debate. I consider this your blog, too. I write it to amuse myself, but I’d be lying if I said your opinions don’t matter to me. If or when more people weigh in, I’ll update this post. If this subject bores you to tears, feel free to skip this one and browse the archives or check out the next post.

My opinion is that we shouldn’t attempt to resuscitate multiple systems traumatic arrests, particularly those that present with no cardiac electrical activity. It’s a position based on my experience and good scientific evidence. It’s not playing God. It is intelligent use of resources, including the lives of the rescuers, who are at increased risk every time we turn on those lights and sirens.

I got into this profession to help people. I’ve stayed in it for the same reason. Beneath this hard, cynical exterior is a warm, gooey center. But I’ve come to believe that I need to focus my physical, mental and emotional energy on the patients that can be helped. Doing a resuscitation for the benefit of family or bystanders ultimately only builds false hope that we can’t fulfill, and unreasonable expectations that we as a profession are unprepared to meet.

Y’all take care – of your patients and yourselves.

Update: 5-06-07

Janean wrote:

I hope you won’t think me a chicken if I choose to work a 6 year old neighbor with marked lividity because his mother is standing right beside me begging me to do something when I want to smack her for not taking him to the ER last night when he was coughing so hard and running a fever.

Of course I won’t think you’re a chicken. I’ve done the same thing myself, and I’ve also withheld resuscitation attempts on an obvious SIDS baby while the father took the house apart in his grief and rage. It’s hard.

On the other hand, back in the day I was the Emergency Medical Services for Children program coordinator for Louisiana, for a brief while. One of the projects we were doing was assisting in the formation of infant and child death review panels for each parish – they reviewed the circumstances of out-of-hospital pediatric deaths, and recommended autopsies and further investigation where warranted.

At the formation of one review panel, a coroner (also a pathologist, which isn’t as common as you might think) asked me pointedly, “Why are EMTs required to attempt resuscitation on every baby, even the ones who are obviously dead?”

“They aren’t,” I answered, “most likely they were doing it in a misguided attempt to treat the family’s grief.”

“Well, we’ve had a number of cases of potential child abuse go unprosecuted because the scene and the body were so contaminated by EMS resuscitation attempts,” the coroner and the sheriff told me.

That floored me, I’m here to tell you. Not only does the “courtesy code” cruelly build false help where there is none, but it may also keep a child murderer from being prosecuted. I’d imagine that is a rare occurrence, but it’s food for thought.

And Matt G. asked in a post on his blog:

While you’re passing on such pearls of wisdom, you think that you could circulate the concept to rural fire personnel that they don’t have to run lights and sirens when, say… they’re going to lunch? That it’s possible to run the lights without the siren? That, when they run Code 3 to a Citizen Requests Assistance (Fell down; can’t get back up) call in which the dispatcher specifically said during the page-out that the caller had begged for no lights and sirens in her cul de sac neighborhood, that she’ll likely decide NOT to call, next time she could use the assistance of a burly firefighter or two?

Sad but true, brother. In defense of the fire department, a number of rather large, urban departments have a policy of using lights and siren on every response and every patient transport, no matter how trivial the call or how stable the patient. So it ain’t necessarily limited to rural volunteers.

Lights and siren use is coming under increased scrutiny around the country. More and more insurers and risk managers are asking pointed questions about whether a particular call or condition actually warrants the increased risk of lights and sirens. Many forward-thinking EMS agencies are changing policies to limit the use of lights and sirens. I seem to recall as study that showed, in urban settings, lights and siren use only decreased response time by 30 seconds or so, while exponentially increasing the chances of an accident.

You’ve seen how motorists act when you turn on the woo woo box – most of them lose their freaking minds. Contrary to popular belief, lights and sirens usually increase the likelihood of an accident.

Update, part deux: 5-06-07

Gary makes an excellent point on the percentages in the comments section.