Adding to the Discussion
This month, we feature some strong opinions from readers on two recent articles. The first is a response to a JEMS.com Street Science column “Are the Benefits of Mechanical CPR Worth the Interruption Time?” by Keith Wesley, MD, FACEP, and Marshall J. Washick, BAS, NREMT-P, that reviewed a study examining interruption time in mechanical CPR. The second comment is from one of our Facebook fans, who takes issue with Thom Dick’s August “Tricks of the Trade” column advising on “Psych Transfers: Know how to deal with these types of patients.”
Mechanical CPR Advantages
We read the article “Are the Benefits of Mechanical CPR Worth the Interruption Time?” (www.jems.com/article/patient-care/are-benefits-mechanical-cpr-worth-interr) with great interest. We participated in the NALE project and submitted our data as part of the article published in Resuscitation.
The authors of the review bring up some important points about the findings, but we fear they do not answer the question posed in the title of their article.
We have extensive experience using the mechanical compression device with more than 1,200 uses to date. One of the first things we learned when deploying the device was that crews put it as a priority and the other, time-important interventions were delayed. We had to put it into our protocols and train our people to place it later in the event, after other interventions were completed.
Next, we learned that placing the device tended to cause everyone else to pause and help out. This is much like our previous experience with intubation where everyone stopped what they were doing until the “vital” procedure was completed.
We changed our protocol again and trained our staff how to place the device with no or minimal interruptions in other tasks. We now have a procedure where the device is placed in stages and the maximum interruption in compressions is 15 seconds.
The benefits of the device are many. We can see in our cases that interruptions are minimal and short once the device is placed. That may be the best argument when discussing whether the interruption is worth it. We see it as accepting an early 15 second delay which then prevents multiple delays later in the event. During our quality assurance reviews, we see interruptions as providers tire and switch users, or as the patient’s location is changed.
There is a real challenge in any research pertaining to cardiac arrest right now. That challenge is trying to associate one treatment with a definitive improvement in outcome. This is a rapidly changing body of knowledge and there is no agreed-upon protocol. So the question of whether the delay in compressions when placing the device is worth it is a difficult question to answer and maybe should not be asked. A better question might be “What are the advantages of using a mechanical compression device, and how does it fit into a system approach to care of the cardiac arrest victim?”
Our extensive experience is a resounding “yes,” it is a vital part of our overall approach to improving the community’s and emergency care system’s response to cardiac arrest.
Charles Lick, MD
Paul Satterlee, MD
Allina Health EMS
I am sorry Thom … while I’m sure you are a great medic and all, I just feel much of this is bad advice. The main reason being, why would/should EMS be transporting patients that are currently off their meds and/or known to be diagnosed at the hospital as psychotic, are potentially suicidal and/or homicidal, when we have very little to no education in handling this? Isn’t it enough that we have to occasionally deal with potentially psychotic, suicidal or homicidal patients?
I read a story from a provider just last night who described a situation where a psych patient, who went nuts during an inter-facility transport, was able to free themselves, threaten the provider and then proceed to jump out of the ambulance and run away. The truth is, as long as these patients don’t require some sort of medical intervention en route to the receiving medical/psychological treatment facility, there is absolutely no reason whatsoever that they should not be transported by law enforcement. Law enforcement officers have the training and authority to safely handle these patients, not EMS providers.
Author Thom Dick, EMT-P, responds:
Thanks, Jason, for highlighting these issues. I think no matter who we are or how great our skill, we don’t “know” very much about most of the sick people we meet—certainly not during the brief span of an ED visit. But even if we could be sure somebody’s etiology is psychological, does that somehow transform them into something less than a sick person? I don’t think it does.
I agree with you that we all need and deserve to understand more about behavioral disorders. The Western medicine to which we all subscribe endorses a pathetic approach to people with mental illness. Your health insurance company will typically pay for a 60-minute first visit with an internist. Care to guess what they’ll allow for a first visit with a psychiatrist, for a much more complex problem? On average, they’ll pay a psychiatrist for 15 minutes.
What we call caring for mental patients basically amounts to throwing drugs at them. It’s no wonder. The standard Diagnostic and Statistical Manual (DSM) you’ll find on the desk of every ED physician is republished every few years as a means of classifying people with psychiatric illnesses. The current edition, the DSM-IV, lists six technical editors—all with published direct financial ties to pharmaceutical companies. Five of those six are linked to the same pharmaceutical company (Eli Lilly).
As for bad advice, every one of the suggestions in this article would have helped the crew you describe to sense, predict and prevent the incident they experienced, as well as protect the patient and the public who were also endangered.
It’s sad that, after all these years, the EMS texts we trust either ignore this important part of field medicine or recommend procedures that are sure to get us injured along with the sick people we care for.
In my opinion, this is medicine we’re doing here. Medicine is supposed to help people. We’re supposed to help people. And a cage car is just not part of that process.