Over the last few weeks, I have been reading a lot of medical research on resuscitation. This has made me ponder about the realistic ability to perform “randomized, controlled trials” in the pre-hospital setting on such a dynamic and complicated issue as cardiac arrest. Now, do not get me wrong, I fully understand the need, purpose, and benefit of clinical trials and the scientific method as a whole; however, how realistic is it to perform a large enough study on cardiac arrests in which you can account and control for all variables of patients and clinical care?
It is commonly cited that we have more than 330,000 deaths annually from out-of-hospital cardiac arrests in the United States. The causes, however, are varied and often unknown or initially speculated. Other factors such as down time prior to EMS arrival, quality of bystander CPR, overall health of the patient, and so on, cannot be controlled. One article I read by Dr. Arthur B. Sanders, M.D., M.H.A, in a New England Journal of Medicine (NEJM) editorial from September 1st, 2011, suggested that “it may be more useful to consider out-of-hospital cardiac arrest as a public health problem rather than as a disease process. Randomized, controlled trials may not be the best strategy for making progress in the management of public health problems, such as cigarette smoking or motor vehicle deaths. The efficacy of closed-chest massage, mouth-to-mouth rescue breathing, layperson-administered CPR, and pre-hospital defibrillation by medics were major clinical advances in the field of resuscitation science that were not subjected to randomized clinical trials.” He went as far as to suggest an alternative strategy to improve the science of resuscitation thru the use of a “continuous quality- improvement model.”
As an example, a big driving force in the higher survival rates over the last few years come from a fundamental focus in our performance of cardiopulmonary resuscitation (CPR). Observational analysis showed that the rate of survival improves as the chest compression fraction increases. It is therefore, that the clinical process of increased compression fraction at a proper rate and depth with full chest recoil became a practice that has tripled survival rates in systems. As another example, Dr. Sanders described how “in the ROC PRIMED trial, the baseline database analysis [of CPR performance in perspective sites]… resulted in improvements in the clinical process during the preparation phase of the clinical trial. Ironically, this analysis and the resulting improvements in process may have greater importance for clinical practice than the two randomized trials.”
The point I am trying to make is that we can study techniques that work in saving more lives thru other means. We need to stay open minded and willing to evaluate our own practice and understanding. Just like a cardiac arrest, healthcare is very dynamic and ever changing. I know that medicine is therefore a practice; however, certain proven techniques and fundamental skills like chest compressions have to be practiced as an art.
So please, be an artist. Do the compressions like someones life depends on it! Get it?
How about that!
