What area of Canada?
The bad news keeps getting badder
- Thread starter Smash
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What area of Canada?
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New Brunswick.
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Smash
Forum Asst. Chief
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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?
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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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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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.
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.
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.
terrible one
Always wandering
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What are your protocols for cardiac arrest if you don't mind me asking?
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)
Melclin
Forum Deputy Chief
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Yond Veneficus has a lean and hungry look.
Methinks there is much reason in his sayings.
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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.
DrParasite
The fire extinguisher is not just for show
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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.
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.
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.
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.
Arovetli
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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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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.
Brandon O
Puzzled by facies
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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.
Arovetli
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...but where's the fun in that???
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)