# The bad news keeps getting badder



## Smash (Mar 27, 2012)

For epinephrine in cardiac arrest:

Hagihara, A., Hasegawa, M., Abe, T., Nagata, T., Wakata, Y., & Miyazaki, S. Prehospital Epinephrine Use and Survival Among Patients With Out-of-Hospital Cardiac Arrest. JAMA: The Journal of the American Medical Association, 307(11), 1161-1168

A large look at out of hospital cardiac arrest from Japan - over 400 000 patients, 15 000 of whom received epi.  Baseline characteristics favoured those receiving epi over those not - more likely to be witnessed, more of them in VF, more likely to have bystander CPR, more likely to get a physician on the ambulance.

Epi increased survival to hospital, but was an independent predictor of of poor outcome at one month and they were less than half as likely to have favourable neurological outcomes compared to those who didn't receive epi.

There are limitations to the study, discussed on page 1167.  Of note, no hypothermia was carried out when this study was done.  However, it is still another nail in the coffin.

*Cue the "but if we get them to hospital doctors can work their voodoo on them and we feel good about ourselves" argument.

Yay!  We get them back.  Of course they sit in the corner being watered twice a day with the other pot-plants now, but still, we are heroes!


What I find really interesting is the low number of patients receiving epi, and the favourable characteristics of those patients.  It seems spookily as though they are actually thinking about what they are doing, rather than just throwing everything at everyone. h34r:


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## Aprz (Mar 27, 2012)

<joke>If we administer epi to ourselves, will that help?</joke>


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## Smash (Mar 27, 2012)

Aprz said:


> <joke>If we administer epi to ourselves, will that help?</joke>



I've tried it halfway through a night shift.  I got to scenes really quick.  But then I had to go back for the ambulance I left at the station, so it didn't save much time in the end... :blink:


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## Veneficus (Mar 27, 2012)

I am sure somebody can chime in with:

"But we will get sued/fired etc if we don't give it."

So who cares what it does for/to the patient?


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## Melclin (Mar 27, 2012)

I'm totally on board with the idea that 1mg epi, q3 is probably not the way to go. In a few decades we might all have a giggle about it along side blowing smoke up dead arses. 

I also think its a terrible shame the Jacobs et al study was not adequately powered to expand on some of the improvements it showed. 

I've got the article in my figurative in tray, I'll give it a good read after I stumble upon about 19hrs of sleep.



Veneficus said:


> "But we will get sued/fired etc if we don't give it."
> 
> So who cares what it does for/to the patient?



Its not a matter of who cares. Its established practice. Its still recommended in peak body guidelines. Simply omitting it from your own personal algorithm is not the way to go for most paramedics (or indeed many doctors). Making an argument to your medical director/whoever writes your guidelines is another matter.


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## systemet (Mar 27, 2012)

The next ACLS guidelines update should be fun.


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## Melclin (Mar 30, 2012)

I think its probably more to do with low numbers of qualified adrenaline giverer-toers on their trucks. 

Anyway, despite the odd language that made my brain hurt on my last night shift, its a pretty interesting study. 

I'd like to know more about how they adjusted for confounders. My statistics-fu doesn't extend that far. I might be wrong but its seems like they've adjusted for issues that other studies have suffered from in that regard, namely the selection bias involved in epi only being given to pts that failed their first DCCS. 

I'd also like to know why it is that this study showed poorer neuro outcomes in those surviving than other studies.

I'm a little disappointed that it didn't break things down by arrest rhythm a bit more. What was there though was pretty interesting. It seemed to suggest what has been suggested in other studies: that adrenaline in PEA/asystole is basically reanimating corpses, in a very expensive and resource intensive way. 

If I'm reading it right (and god knows I'm probably not), its basically saying that if you manage to survive the insult of being given epi in the first place, your chances of a good neuro outcome will be more then halved specifically because you got epi. 

This all seems to match the evidence from other studies both in the lab and the field. Epi increases ROSC but not survival, it may have a mild detrimental effect on survival and it has a notably negative physiological affect that may bugger up a person's chances of a good neuro outcome. 

So...taking bets. Will this be the last nail in the coffin come peak body guidelines season? Are there any other adrenaline studies in the works?


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## Veneficus (Mar 30, 2012)

Melclin said:


> So...taking bets. Will this be the last nail in the coffin come peak body guidelines season? Are there any other adrenaline studies in the works?



Honestly, I hope I am wrong, but I do not see epi or any other drug going away. 

It is hard to put on an ACLS class when the only thing left in it is CPR/AED 

Edit: too eager on the "enter key"

I have noticed over the last couple of years that "guidline" groups have considerable ego in them and very rarely let new science affect thier recommendations. 

Usually the only thing that gets these people to change is a nail in their own coffin and the person who replaces them. 

I have also noticed that doctors who are really breaking ground never issue guidlines and you rarely hear what they have to say because they are in the hospital taking care of patients, not traveling around giving endless speeches and attending "meetings." (case in point a really great speaker I saw last year on the flaws of using bicarb in resuscitation) 

There is also the issue of "the good ol' boy network." Many top journals require invitations to publish or ignore anything that opposes the popular views. So many medical scientists will never see their research published in a top tier journal no matter how good the experiment or results.

I have even seen publications that in their conclusion claim type II statistical errors. With science so bad I would be embarassed to sign my name to it. But it still gets published. 

It is the reward for working on something prior and knowing somebody.

Dr. Podunk could make the most earth shattering discovery this evening and it would never see the light of day.

Consensus is by definition, people who agree with each other, not people who have the right answer.

You must also remember that these guidlines are meant for "most patients," so if all you ever do is follow these guidlines without thought or deviation, you have basically written off every patient who will not be helped by them. (which in the case of SCA, is nearly 30% of them)

It is not that guidlines are bad, they are a starting point, not a definitive answer and not an endpoint.  

There is an inherent flaw when providers see these "standards" as the definitive authority. 

(disclaimer, if you are not authorized to deviate from your guidlines, don't)


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## Melclin (Mar 30, 2012)

I've certainly heard about that kind of culture. I've even seen it in action during the short bursts of formal academia I've stumbled upon. Although it has to be said, the ol' boys network was a force for good in this case.

I suppose I naively thought it might be different at such high levels :wacko:

Oh well, we shall have to wait and see.


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## Arovetli (Mar 30, 2012)

As an aside, I work for a hospital based service who's attached hospital is attached to a medical school, although no formal academic emergency medicine program, and the attendings still want full atropinization of asystole/PEA even 2 years after it was removed from ACLS and with a whole body of evidence backing its removal. If they are that resistant to losing atropine I can't imagine the resistance to the removal of epi. Some attendings order many many many rounds of epi even when survival, not to mention any chance of a decent neuro outcome, is all gone. Last code was asystole with a  downtime of 45 mins. when I hit the ER with the attending still giving 10 rounds of epi before calling it.


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## Melclin (Mar 30, 2012)

Arovetli said:


> Last code was asystole with a  downtime of 45 mins. when I hit the ER with the attending still giving 10 rounds of epi before calling it.



That boggles the mind. I assume you don't have the ability to chose whether or not to work arrests. Thats not a code, that is just a corpse.


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## awesomemedic (Mar 30, 2012)

So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.


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## Veneficus (Mar 30, 2012)

awesomemedic said:


> So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.



But what if that was really the best thing to do?

It is for trauma.


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## awesomemedic (Mar 30, 2012)

I actually agree. That's why I said makes sense.


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## medicsb (Mar 30, 2012)

awesomemedic said:


> So, I suppose it will eventually turn into a true smash and grab operation. Start CPR, defib if necessary (until they say that is detrimental which is only a matter of time), then drive code 3 to the ER. No intubation, no IV. Just CPR and diesel. Makes sense.



Not at all. It will probably be: start CPR, defib PRN, establish IV or IO access.  Work for 20-30 minutes, if no ROSC then pronounce.  If ROSC, use the IV or IO to initiate hypothermia and sedation.  Load and go is NOT beneficial, except, maybe, if you're using an automated compression device.


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## awesomemedic (Mar 30, 2012)

I would like to think we could pronounce someone in the field that easily, but if I can't tell a 46 year old woman with a stubbed toe to go to the urgent care in the morning, how can I pronounce someone dead. I'm not saying we don't have the ability, I'm saying the staff won't let it happen.

And if I can't give meds (epi, atropine, etc) then why do I need an IV? And what "work" will be done? Currently we can go one round of ACLS, IV, advanced airway, and asystole in 2 leads with unknown downtime relates to calling a physician for direct med control and stopping efforts. But take away meds and airway, we're just pumping chest for however long.


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## Veneficus (Mar 30, 2012)

*Devil's advocate. (because even the devil needs a lawyer)*



awesomemedic said:


> But take away meds and airway, we're just pumping chest for however long.



So what?

If they don't help why bother?


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## medicsb (Mar 30, 2012)

awesomemedic said:


> I would like to think we could pronounce someone in the field that easily, but if I can't tell a 46 year old woman with a stubbed toe to go to the urgent care in the morning, how can I pronounce someone dead. I'm not saying we don't have the ability, I'm saying the staff won't let it happen.
> 
> And if I can't give meds (epi, atropine, etc) then why do I need an IV? And what "work" will be done? Currently we can go one round of ACLS, IV, advanced airway, and asystole in 2 leads with unknown downtime relates to calling a physician for direct med control and stopping efforts. But take away meds and airway, we're just pumping chest for however long.



I was just speculating as to what a protocol/guideline could be for CA if all drugs were removed.  Certainly one could argue to wait on ROSC to initiate an IV or IO.  Many would suggest that hypothermia be initiated prehospital (though there is no evidence to show it to be better than waiting for hospital arrival), so it may be useful to have an IV already established.  Also, remember that just because your area doesn't do something, doesn't mean that others won't too.  A lot of system have protocols for pronouncement.  Additionally, there has been some intensive research in Canada (I think) into criteria for pronouncement for use by paramedics and EMTs and I think some 1 of the 2 sets of criteria has been validated.

By and large, a medical arrest is "stay and play" situation.  It's hard to do good compressions while rolling a patient onto a reeves and then to the stretcher and then to the ambulance and then while the ambulance is in motion.  (obviously in unsafe/hostile scene, etc. one should move the patient sooner.)


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## Arovetli (Mar 30, 2012)

In lieu of epi there is some promising animal research out there on using selective alpha 2 andrenergic agonists in cardiac arrest.


http://www.ncbi.nlm.nih.gov/pubmed/12080325
http://www.ncbi.nlm.nih.gov/pubmed/12668305
http://www.ncbi.nlm.nih.gov/pubmed/11693776
http://www.ncbi.nlm.nih.gov/pubmed/12808484


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## Medic Tim (Mar 30, 2012)

epi was removed from our cardiac arrest protocols in 2008.


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## medicsb (Mar 30, 2012)

Medic Tim said:


> epi was removed from our cardiac arrest protocols in 2008.



What area of Canada?


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## Medic Tim (Mar 30, 2012)

New Brunswick.


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## Smash (Mar 31, 2012)

I have little doubt that the AHA will not change it's stance in the next round of updates.  I have little faith in an organisation that quotes it's own previous guidelines as evidence for it's current guidelines.

Hopefully what these studies will do is make it possible to run a real trial such as was attempted in Western Australia.  It is a bit hard to maintain that epi is standard of care when there are so many observational studies that demonstrate harm.  

I'm excited to hear that at least one service has removed epi, there is hope for us all yet!  Medic Tim, has there been any examination of before and after data since eliminating it from the protocol?


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## Medic Tim (Mar 31, 2012)

Smash said:


> I have little doubt that the AHA will not change it's stance in the next round of updates.  I have little faith in an organisation that quotes it's own previous guidelines as evidence for it's current guidelines.
> 
> Hopefully what these studies will do is make it possible to run a real trial such as was attempted in Western Australia.  It is a bit hard to maintain that epi is standard of care when there are so many observational studies that demonstrate harm.
> 
> I'm excited to hear that at least one service has removed epi, there is hope for us all yet!  Medic Tim, has there been any examination of before and after data since eliminating it from the protocol?



Yes. I am not sure what the numbers are. I will see what a can find out from our cqi department. 

It was pulled for a few different reasons. Prior to 2008 not all services carried it. When the 40 ambulance services were consolidated into 1 it was removed all together. The service switched to the mrx defib with cpr chest sensor. Their goal was to look at the quality of cpr. There is talk that we may get epi in the next year or so as part of another study. The data will be compared and from there who knows. The cqi guys are excited because when the numbers are crunched cpr won't be a factor and they cam better see the effects of the drug. The service is working with a university in Norway . The head guy there has a PhD In cpr. Not sure if they were joking of if that is a real thing.


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## medicsb (Mar 31, 2012)

Smash said:


> Hopefully what these studies will do is make it possible to run a real trial such as was attempted in Western Australia.  It is a bit hard to maintain that epi is standard of care when there are so many observational studies that demonstrate harm.



Lets be fair here - they did NOT _demonstrate_ harm.  They only demonstrated a correlation with harm, which as we all know does not equal causation.  When considering the 2 RCTs (one of which was double blind), we should recall that they both trended in favor of epi and did not demonstrate harm.  

The post hoc analysis of the IV vs. no IV study in Sweden demonstrated pretty well why all these retrospective, observation studies may be inherently biased against epi - all the patients with the best chances of survival (those that respond early to CPR and defibrillation) will be placed in  non-epi group as they will gain ROSC before epi is administration.  And it is also worth noting that the original study was designed based on retrospective, observational studies and their outcomes came no where close to matching the observed outcomes of previous studies, thus their study was grossly underpowered to detect a benefit.  With the 2 RCTs available, I think future research will be (hopefully) more robust and better designed.

And while a before-and-after study of epi use in New Brunswick will probably be better able to inform of us of epi's impact on outcomes, it will still be less informative than a double blind, placebo controlled trial.  Hopefully, IRBs in the US and around the world will grow "a pair" and allow research to be undertaken.  

Anyhow, it will be interesting to see how AHA responds.  I think the argument for epi will be based on the lack of harm demonstrated in the RCTs and they'll keep it based on that.  I think what would be best is to give it an indeterminate status, since, well, it really is undetermined whether it is harmful or beneficial.  Because AHA is viewed as the authority that sets the standard of care for ACLS, I think the only way any RCTs on epi will occur in the US is if they no longer recommend it.  When everything comes up for review, it may be worth sending some letters in their direction.


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## Veneficus (Mar 31, 2012)

medicsb said:


> Lets be fair here - they did NOT _demonstrate_ harm.  They only demonstrated a correlation with harm, which as we all know does not equal causation.  When considering the 2 RCTs (one of which was double blind), we should recall that they both trended in favor of epi and did not demonstrate harm.
> 
> The post hoc analysis of the IV vs. no IV study in Sweden demonstrated pretty well why all these retrospective, observation studies may be inherently biased against epi - all the patients with the best chances of survival (those that respond early to CPR and defibrillation) will be placed in  non-epi group as they will gain ROSC before epi is administration.  And it is also worth noting that the original study was designed based on retrospective, observational studies and their outcomes came no where close to matching the observed outcomes of previous studies, thus their study was grossly underpowered to detect a benefit.  With the 2 RCTs available, I think future research will be (hopefully) more robust and better designed.
> 
> ...



Epi has not shown any benefit in 40 years. We do not give medication based simply on doing no harm.

There is also no way to tell wether or not renal and cerebral insult from an arrest is made worse by epi or not. However, there is a fair amount of basic science that catecholamines do have an impact on circulation of such.

If endogenous catecholamine has effect, certainly exogenous epi does.

I agree with smash, AHA will do nothing. Writing them ltters is a waste of time. There is always an excuse as to why epi is never removed.


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## medicsb (Mar 31, 2012)

Veneficus said:


> Epi has not shown any benefit in 40 years. We do not give medication based simply on doing no harm.
> 
> There is also no way to tell wether or not renal and cerebral insult from an arrest is made worse by epi or not. However, there is a fair amount of basic science that catecholamines do have an impact on circulation of such.
> 
> ...



There is little I disagree with.  I personally think clinicians should be more involved.  Concluding that all attempts to influence the AHA or some organization is futile is declaring defeat before the battle, in my opinion.


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## Aprz (Mar 31, 2012)

If it's reasonable to believe that the AHA won't change their stance maybe clinicians should not associate with them. Instead of saying "Use AHA recommendations", they could write their own recommendations. That would probably be easier.


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## terrible one (Mar 31, 2012)

Medic Tim said:


> epi was removed from our cardiac arrest protocols in 2008.



What are your protocols for cardiac arrest if you don't mind me asking?


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## Veneficus (Apr 1, 2012)

medicsb said:


> There is little I disagree with.  I personally think clinicians should be more involved.  Concluding that all attempts to influence the AHA or some organization is futile is declaring defeat before the battle, in my opinion.



I think that the best approach would be to start by getting another already established organization or group of them to endorse different guidlines.

I would even suspect that getting a handful of medical colleges to do so would be a fair challenge against AHA supremacy. (which clearly needs to be challenged)


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## Melclin (Apr 1, 2012)

Veneficus said:


> I think that the best approach would be to start by getting another already established organization or group of them to endorse different guidlines.
> 
> I would even suspect that getting a handful of medical colleges to do so would be a fair challenge against AHA supremacy. (which clearly needs to be challenged)



Yond Veneficus has a lean and hungry look.

Methinks there is much reason in his sayings.


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## Medic Tim (Apr 1, 2012)

terrible one said:


> What are your protocols for cardiac arrest if you don't mind me asking?



The quick answer is cpr. We are on scene for a minimum of 5 rhythem checks. We drop a king in at some point and only start a line if we get rosc. Or if we get an extra crew. Currently only 1 crew is dispatched for codes. I addressed that in a thread a few weeks ago. No atropine, lido or any other drugs in code. Though, that will be changing in the not to distant future.

NB isa different system. Up until last year it would only license to the PCP level (EMT-I). But we work on. An expanded scope license so our med director and. The government pick and choose what we can do from the ALS side. The province is now licensing ACP (Paramedic) but there were currently no jobs or protocols so we have to follow the same ones as everyone else. Prior to 2008 a number of services had epi, and other drugs but as i said things were cut back.

Sorry for the random periods my phone is messing up and won't. Let me change them.


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## DrParasite (Apr 1, 2012)

Aprz said:


> If it's reasonable to believe that the AHA won't change their stance maybe clinicians should not associate with them. Instead of saying "Use AHA recommendations", they could write their own recommendations. That would probably be easier.


oddly enough, this was discussed between one of the field bosses (who is a medic) and myself (an uneducated EMT).  He told me ACLS wasn't mandatory, it's just easier than having your medical director write his or her own protocols, as well as stands up better in a lawsuit since it is the standard of care.


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## Veneficus (Apr 1, 2012)

Melclin said:


> Yond Veneficus has a lean and hungry look.
> 
> Methinks there is much reason in his sayings.



It is more of a frustrated look actually. 

The high priests over at the AHA don't seem to want to alter their prayer no matter what is discovered or not, but continue to tout themsleves as the one true and proper faith. 

My favorite from the epi argument is they say in the manual it is level IIB evidence, but on the practical test pass/fail criteria states: "administers a vasopressor such as epi."

I do have an affinity to Martin Luther though.

Whether it is promoting amiodarone, vasopressin, capnography, or curriculum in a can in the form of a DVD, it seems the AHA is more interested in ego and pandering wares than actual logical recommendations based on the very science they study.


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## izibo (Apr 2, 2012)

I'm not really sure why there is all this hate for the AHA. If you actually take a look at Circulation and read through the mega issue they publish every 5 years, I think they do a reasonably good job at looking at all the evidence that is available to make reasonable recommendations. Some recommendations, they admit, is based on strong evidence while others are simply the recommendations of experts in the field. 

At the end of the day, it is inherently difficult to take all of the information available and reduce it to a simple flow-chart that you can teach to any doofus who has 16 hours to spare. ACLS isn't really about diving through all of the information, it is about teaching a provider how to run a code based on expert recommendations.

Things get harder in the case of Epi because there has never really been a well controlled randomized trial with sufficient power that will allow us to settle the debate. I have read through all the data published in the JAMA article, but without a true randomized trial it is impossible to discount all the types of bias that can pop-up.


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## Arovetli (Apr 2, 2012)

izibo said:


> At the end of the day, it is inherently difficult to take all of the information available and reduce it to a simple flow-chart that you can teach to any doofus who has 16 hours to spare. ACLS isn't really about diving through all of the information, it is about teaching a provider how to run a code based on expert recommendations.



I think the negativity towards AHA stems from this. Someone said it in another post but AHA would have a tough time selling ACLS cards if all they had to teach was CPR and early defib. Business and politics, as usual, muddy up the science. As for diving through all the information and developing treatment recommendations...well, that is the point of their existence. They are the ones claiming authority. Also I might add that the videos and teaching methods are pretty lame. When you teach at the 'any doofus who has 16 hours to spare' level you shouldn't be surprised that intelligent people get turned off.

The paper they publish is usually pretty good, except when things appear and disappear without explanation and the paper cites previous iterations of itself as evidence. I'm happy with some of the things they do, such as the hands only cpr initiative and advocating for healthier lifestyles. But you have to wonder what exactly changes hands in order for a product to get that AHA seal of approval...


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## Veneficus (Apr 2, 2012)

Arovetli said:


> I think the negativity towards AHA stems from this. Someone said it in another post but AHA would have a tough time selling ACLS cards if all they had to teach was CPR and early defib. Business and politics, as usual, muddy up the science. As for diving through all the information and developing treatment recommendations...well, that is the point of their existence. They are the ones claiming authority. Also I might add that the videos and teaching methods are pretty lame. When you teach at the 'any doofus who has 16 hours to spare' level you shouldn't be surprised that intelligent people get turned off.
> 
> The paper they publish is usually pretty good, except when things appear and disappear without explanation and the paper cites previous iterations of itself as evidence. I'm happy with some of the things they do, such as the hands only cpr initiative and advocating for healthier lifestyles. But you have to wonder what exactly changes hands in order for a product to get that AHA seal of approval...



I think the AHA people actually believe they are doing the best, even when endosing their drug or gadget of the year. 

I will also concede it is probably very difficult to come up with anykind of consensus on a multidiscipline panel of experts. 

But like you said, they are now pandering to the "doofus." and it is destroying any utility or credibility they have with experts outside of their inner circle.


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## Brandon O (Apr 2, 2012)

Arovetli said:


> I think the negativity towards AHA stems from this. Someone said it in another post but AHA would have a tough time selling ACLS cards if all they had to teach was CPR and early defib. Business and politics, as usual, muddy up the science.
> ... But you have to wonder what exactly changes hands in order for a product to get that AHA seal of approval...



These sorts of remarks seem to have become typical within progressive resuscitation discussions. I realize that as a Big Organization we all have to deal with, the AHA is an easy, faceless target for our frustrations; and I realize that when we're trying to push the plow of progress, the inertia of the Big Organization is often the main obstacle. If anybody has real, substantive reasons to question the ethical basis of the recommendations, or to suggest conflicts of interest for the committee, I think they should be placed on the table for discussion. But if it's just a vague sense that there _must_ be sinister reasons whenever they don't do what we want, maybe we should take a breather and leave it alone.

I was among the most fervent dreamers in hoping for more aggressive changes in the 2010 guidelines; hell, it would've tickled me pink to see us all doing hands-on defibrillation. But if we want to go out on those limbs, we can do so independently on a local basis, and there are indeed services trying great new things and recording that data. The BLS/ACLS guidelines aren't meant to do that; they're baseline recommendations, and increasingly the AHA is emphasizing that they _are_ broad recommendations rather than rules.

In particular, I think we can agree that changing their guidelines every time new toys or new evidence come out would radically compromise their credibility; people complain enough about small changes every five years as it is.

If you review the citations and full text in the latest guidelines, I think you'll find that it's very much in line with the most current literature (as of 2010 anyway) and most reliable standards of evidence; it's not like there are services doing the "real" stuff which radically deviates from this and has far better results. The best results have come from aggressively implementing the foundational recommendations and then adding ideas on top of that.

Certainly we can argue with the conclusions and generalizations that the AHA draws from their interpretation of the state of the evidence, but merely opining that their path is less radical than we'd like seems like an empty gesture.


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## Arovetli (Apr 2, 2012)

Brandon Oto said:


> maybe we should take a breather and leave it alone.



...but where's the fun in that???


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## Veneficus (Apr 3, 2012)

Brandon Oto said:


> The BLS/ACLS guidelines aren't meant to do that; they're baseline recommendations, and increasingly the AHA is emphasizing that they _are_ broad recommendations rather than rules.



I must respectfully disagree with you on this.

When you require a video that demonstrates only 1 way followed by not 1 but 2 tests of rigid pass fail criteria, when students are under threat of not working if they don't hold certification, then it is perceived as rules and I have to agree with that perception.

Once a student has those rules reinforced into them in such a military manner, getting them to actually change behavior in 5 years is more difficult. Getting them to mentally accept and practice the changes near impossible.

I still have seen US providers doing 5:1 compression to ventilations in major facilities because the "do not buy the change and it will change back sooner or later."

I understand what their goal was, but I think they failed in implementation in a big way. Unless they change, they will continue to fail.

I have been involved with the AHA a long time and know many fine people there. But I also know it has its politics like any organization. 

It also has to make money like any organization, therefore some business aspects must be adopted. (the people I know are there for a living, they need to be paid)

It is a fine line between adopting radical techniques and maintaining credibility, I get that. But moving too slow can cause an equal loss of credibility. 

I still think that the classes are good for people who are not resuscitation experts. 

But they really need something addressed to that crowd, and it seems they are ignoring that part and moving away from it. (The EP course doesn't do it and there is no PALS EP)


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## Brandon O (Apr 3, 2012)

I don't really disagree with that, Vene. Like most certifications, the main goal is to establish a minimum baseline to ensure that everybody is at least at that level -- in other words to prevent the guy you describe from still doing 5:1. Hence, since instructors are also a source of potential suck, the attempt to standardize everything by video and test. I don't think it's wrong to improve upon this if you're able, but I also think that 99% of instructors believe they understand the material as well or better than the authors, and 98% of them are wrong. There is a reason why it was assembled this way, and although that reason is full of compromises and lesser-evils, we can do much worse than cleaving everybody to the same "good enough" arbitrary standard.

As sad as it is, we're not going to make 100% of the population into magnificent masters of resuscitation, and that's not where the greatest benefits are anyway. It's in bringing up or knocking out the duds who are blowing the fundamentals. It's not as fun and I prefer the first one, but focusing our attention on the top 1% is like Wall Street discussing how to convert the improverished third world from analog to digital radio.


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