Review of: Morrison LJ, Visentin LM, Vermeulen M: "Inter-rater reliability and comfort in the application of a basic life support termination of resuscitation clinical prediction rule for out of hospital cardiac arrest." Resuscitation. 74(1):150 157, 2007.
This is a follow-up study of one I reviewed in August, in "Terminating Resuscitation in Out-of-Hospital Cardiac Arrest." That study, published in the New England Journal of Medicine, validated a field termination of resuscitation (TOR) algorhythm for EMS. This study measured whether or not the paramedic and the EMT applied the protocol correctly, how comfortable they were in its conclusion, and how well they agreed on its recommendation to terminate resuscitation.
Paramedics and EMTs applied the rule with equal perfection and were in agreement 88% of the time.
The study also found that when both the paramedic and the EMT applied the rule correctly, they were significantly more likely to feel completely comfortable with its recommendations. When not applied correctly, they were more likely to feel uncomfortable with the recommendations.
We have already discussed the TOR rule they are proposing. What this study does is show that your providers must feel comfortable in using it if you expect it to be applied correctly. In fact, if EMS providers feel uncomfortable using it they re probably not applying it correctly. This requires better education and training, and perhaps it should be used as a marker to know when to contact medical control for advice.
Great debate over TOR in cardiac arrest continues, with some service directors taking a draconian approach that requires transport because no transport means no reimbursement. While clearly a financial issue is involved in not transporting cardiac arrests, these types of calls represent less than 5% of all calls and do not represent a huge fiscal impact.. The cost of futile resuscitation to the patient and society in general, not only in healthcare costs but in emotional turmoil, is tremendous.
We must continue to find what helps the most people with the limited resources we have. The use of field TOR is just one step toward this goal.