A Response to Aaron Carroll

A Response to Aaron Carroll

Jan 25, 2015

About two weeks ago, Dr. Aaron Carroll published an article in the New York Times entitled “Doing More for patients Often Does No Good.”  This weekend, the article received a significant push on social media, specifically, Facebook, on a number of EMS related pages.  I know Dr. Carroll’s writings, and I have listened to him frequently on Stand Up! with Pete Dominick where he is a frequent guest and occasional guest host.  While Dr. Carroll has a number of citations and makes some valid points, I think that the portion of his story about out of hospital cardiac arrest misses the mark.  Here’s why.

A number of the studies that Dr. Carroll cites were released between 2007 and 2011.  We are learning, and we are evolving.  Systems throughout the United States have changed their protocols and changed how cardiac arrests are run.  My state’s protocols have been rewritten to include the actual words “High performance Pit Crew style CPR” in the BLS cardiac arrest portion.  They’re getting it, and they are seeing an improvement.  Still though, tossing aside ALS care is a short sighted argument to make, even in cardiac arrest.

While I will not dispute that solid BLS care is the foundation and the largest contributor to out of hospital ROSC, we need to look beyond achieving a return of pulses in our prehospital care.  ALS interventions after the return of pulses make a significant difference in patient outcome.  12-lead EKG interpretation, for example, can help determine destination decision for a patient who arrested due to a STEMI.  And let’s not overlook the importance of therapeutic hypothermia, something put on the map in the United States by Wake County EMS in the mid 2000’s.

The point is, resuscitation does not stop once ROSC is achieved.  We don’t stand up, high five each other and say “okay, that’s it.  Let’s drive them to the hospital.”  There is more work to do.

This statement in particular got my blood boiling a bit:

“Some theorize that the things that work have already been incorporated into basic life support.  All that the advanced life support may be doing is slowing things down in the field, distracting people from the useful basic life support measures, and delaying the time until a patient can get to the hospital.”

Slow down, Dr. Carroll.  While there is truth in the statement in the sense that if a paramedic is stopping CPR for a considerable amount of time to get an IV, or drop a tube, then yes, ALS is distracting responders from what is important.  At the same time though, the first principle that Seattle’s Resuscitation Academy teaches us is “EMTs own CPR.”  It does not matter what is happening on that scene, or what anyone is doing, it is the responsibility of the EMT to make sure that compressions are on going.

Furthermore, there is also plenty of evidence out there that CPR while moving, whether it is on a stretcher, or in the back of an ambulance, is not as effective as stationary CPR.  Carrying a patient on a backboard or in a reeves for example during extrication from a residence produces long pauses in CPR and that independently causes worse outcomes in cardiac arrest.

Now, before all of my readers who champion the LUCAS and AUTO-PULSE devices go into their argument about how if you have an automated CPR device you don’t have to worry about those pauses, take a look at the LINC Study.  The study’s lead doctor, Dr. Sten Rubertsson stated that “The study was designed to show a better 4-hour survival in the group treated with mechanical chest compressions, and that was not achieved.”  Humans doing CPR are as effective of achieving not only ROSC but achieving long term survival as the LUCAS device.

The danger in a story like this being published in a medium like the New York Times is it gives the uninformed public half of the story representing it as the whole story.  Somebody might read this article and wonder why their loved one is being worked on the living room floor, and why the ambulance is not flying lights and sirens across the city to their desired hospital.

The point that Dr. Carroll misses here is ALS and BLS systems are improving.  Since the 2005 AHA update which completely changed the face of provider CPR, many, many systems throughout the country have seen significant improvements to their out of hospital ROSC rates.  And at the time of this writing with 263 days until the 2015 standards, the sky is the limit.  We have not reached the pinnacle of what we are capable of.

Finally, I still stand by my theory, although it is one that has not been proven that the argument that “patients who receive ALS care have poorer neurological outcomes” holds water.  I think a more accurate way of saying is that sometimes ALS care achieves ROSC in a patient who otherwise would not have achieved it with BLS care alone.  Its not surprising that patients with BLS care only have better outcomes because a patient who is a witnessed arrest who receives prompt CPR and defibrillation will have a significantly lower chance of sustaining an anoxic brain injury.  That is why dialysis centers, for example, have such a high ROSC rate.  Their patients are so closely monitored that when they arrest, someone is on them pretty quickly.

So I stand by my personal argument that a patient who can be resuscitated with BLS care alone is more likely to have a positive outcome because they were not down so long that ALS interventions were needed to assist them in achieving ROSC.  That, however, is purely anecdotal from experience.  I can’t back it up with evidence. . . yet.

If your goal is to just achieve ROSC, then Dr. Carroll’s argument holds water, but as stated care does not stop there and should not stop there.  We need to have a better idea of what works in out of hospital care to help sustain ROSC and improve long term outcomes.  If there is something that we are doing that is negatively effecting our patients down the road, we need to know about it and we need to stop it.  If there is some time sensitive intervention that needs to be done that we are not doing then again, we need to know what it is so we can try and incorporate it into our care.

Ultimately though, ROSC rates are on the rise.  Those “walkie-talkie” post cardiac arrest patients with a good quality of life after discharge are becoming more and more common.  Keep up the good work, everyone, but do not lose sight of the fact that there is still more work to do.

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