Study: Are EMTs Wasting Time with CPR?

Are EMTs wasting time with resuscitation efforts?

Study suggests benefits to terminating CPR earlier

A new study attempts to validate the argument that emergency medicine services (EMS) not staffed by paramedics could reduce the number of hopeless ambulance trips to the hospital if emergency medical technicians (EMTs) were allowed to end resuscitation efforts sooner in patients who are in cardiac arrest.

But an emergency medicine physician with experience in medical direction of EMS says, because even a small fraction of a percent of those "hopeless" cases could survive, the public would demand all attempts be made to save them.

According to statistics included in a recent New England Journal of Medicine report, some two-thirds of cardiac arrest patients taken to hospitals by EMTs eventually die, and most probably could be declared dead at the scene. According to Laurie J. Morrison, MD, of the University of Toronto, only one in 500 people survived to be discharged from the hospital if EMTs were not able to restart their circulation, rescue workers were not present when the heart stopped, or the patients' hearts were not shocked by automatic defibrillators.

Morrison says revising guidelines to let EMTs know when to give up could result in a decrease in the rate of transportation to the hospital from 100% of patients to 37.4%.

According to James Hubler, MD, JD, FCLM, FAAEM, FACEP, clinical assistant professor of surgery at the University of Illinois College of Medicine department of emergency medicine and EMS medical director for the Peoria (IL) Area EMS System, the idea of allowing EMTs to "call" patients earlier is not a new one, particularly in places where the nearest hospital might be 30 minutes or more away.

However, that doesn't make the proposal any easier when statistics show that some of the people who would be pronounced dead at the scene under such a rule survived when resuscitation efforts were not discontinued.

"It's a protocol used in some systems; because even when [a paramedic] gives them medications, there's not much more that they can get at the hospital, particularly if you've started an IV and secured the airway," he says. Pronouncing so-called hopeless patients dead at the scene "will improve safety, because you don't have ambulances racing to the hospital, with anxious drivers and the risk of accidents, when the person is basically dead."

Morrison says that some 60% of Americans and Canadians live in areas served by emergency rescue personnel who have only basic lifesaving (BLS) skills and are not authorized to do anything but start resuscitation efforts, load the patient, and drive however far it is to the nearest hospital.

Paramedics with advanced training can give drugs and start IVs, and already are authorized to stop resuscitation once they have consulted a physician.

Not only does requiring EMTs to transport and continue resuscitation in these patients create hazards for rescue workers and other motorists and tie up ambulances, which could otherwise be answering more calls, it can create false hope for the families of these patients, who think their loved one has a chance to survive.

A new three-item clinical prediction rule may help emergency medical personnel decide when to terminate BLS resuscitative efforts in cases of out-of-hospital cardiac arrest.

Three-point prediction rule proposed

The rule recommends that in the absence of advanced cardiac life support, EMTs may consider the termination of basic life support resuscitative efforts if: 1) there is no return of spontaneous circulation before transportation to the ED is initiated; 2) the patient received no defibrillator shocks before transportation is initiated; 3) and the cardiac arrest was not witnessed by emergency personnel.

Morrison's study, which included 24 EMS systems in Ontario, looked at cases involving 1,240 adults with presumed cardiac arrest who were treated by EMTs trained in the use of automated external defibrillators. Of the 776 patients for whom the prediction rule called for termination of basic life support, four survived (0.5%).