During 4 years working in a well trained & operated ‘paramedic-EMTA’ ambulance service (in Boulder CO) in the late 1970’s, and while practicing EM from 1998 to 2010 (mostly in the Seattle area), I never saw (or was aware of) a successful OHCA resuscitation. In 2 such cases I was present at the scene (my church) at the time of the witnessed arrest and was able to direct/participate in the resuscitation which was aided by experienced nurses. I saw only once the use of a mechanical CPR machine (the 2nd church case - used by the arriving EMS). I never expected these devices would make any difference…
For those who see the human body as a machine, the progression to a more mechanized way of managing it makes sense. And those who believe that the body runs like a software program see nothing wrong with reprogramming and upgrading. Machines, after all.
So many things we do just because we can. Experimentation is fun.
(When my husband is raised from the grave, I fear I will have to explain why his ribs are broken.)
Hi John, I'm an EM doc in Italy. Big city, large hospital. Fwiw, I have the impression that in-hospital mechanical CPR offers: 2 extra hands on deck. Lower team exhaustion. Better CPR quality consistency (there is always one operator who's weaker/worse than others). Easier to do POCUS/stuff/procedures with the machine than with humans. I don't do prehospital med. so no idea about that (but I guess in a resource-constrained setting it would be even more useful, especially if you cant do CPR while you evacuate). But in-hospital it's a nice tool to have and well worth its cost in terms of ACLS optimization IMO. It's possible it's not going to change outcomes, and that's because it is extremely difficult to change the outcome of cardiac arrest.
I worked 30 years as a firefighter in Grand Rapids, MI (200K population). Never used a CPR device. I could see where they would be useful in rural areas with a long transport time, especially if they only have one ride-a-long person in the back (usually a firefighter).
But, in the urban environment, I don't see the need. Most cities nowadays send fire as the first responders to 911 calls. We dispatched two machines and a BN chief to suspected codes. So, the 1st crew arrives within 5 minutes, the firefighter immediately starts CPR, while the EO gets the AED applied, and the officer starts O2 (and establishes an airway). Once the 2nd machine arrives, we start a CPR rotation with at least 4 firefighters, so everyone only does 2 minute compressions and then rests for 6 minutes. We use a cell phone app to set the pace and it announces time to switch out. Someone coaches and you can watch the monitor's screen to get feedback on whether or not your compressions are actually effective (so you can make adjustments). Eventually, the paramedics show up and do their thing (put in airway tube, meds, etc) until the ED doc calls it or pulses are restored and they transport.
Our system works well. Especially since older firefighters have a LOT more experience doing CPR than anyone else in the medical profession (since paramedics turn over so frequently due to poor pay). IF the code is witnessed & we are called without delay, especially if bystander CPR is applied (even better if AED applied), we have a chance to restore heartbeat. Unfortunately, it's rare that all three occur before we arrive, so even with the best CPR, survival rate to discharge is low.
On two publications the conflict of interest and who received grants during the research should be noted. Also who funded the research. That's the first place I look even before I read the conclusion on most research. Sad, but true!
I see the device frequently in Chicagoland EDs. EMS seem to choose mechanical CPR when they need an extra pair of hands because of other factors: difficult extraction from a residence (3rd floor walk-up), or physical characteristics (morbidly obese), or challenges with other hands on activities (difficult IV stick so they need to do an IO, or difficulty airway). Perhaps the granular data might show benefit in subpopulations. Overall, EMS attempt to restore the ABCs (airway, breathing, circulation) with all their tools while driving as fast as possible to the hospital. Lastly, when a device like mechanical CPR is available but not used if needed (extra hands), it could become a liability in cases that tend to have bad outcomes baked in (Cook County is one of the most litigious areas in the country. This may also drive adoption. “I used all the tools available and didn’t delay CPR”). On my next shift, I plan to ask our EMS coordinator and the various crews what they think about the study.
As a resident, when I worked in the hospital for shifts that lasted up to 24 hours, I participated in probably a dozen codes, all using manual compression, multiple medications and electric shocks when appropriate. Every single one of them was successful in that the patient's pulse was restored. But none of them was successful in that the patient left the hospital alive - or with any semblance of a mental or functional life. In every case, the patient was elderly and had died due to a medical condition that had eroded the organs of their bodies by degrees over years, and so reviving them merely delayed an inevitable ending before they died a second time. Generally, every one of the dozen people in the room know this from the start: the familiar shared glance that communicates a shared knowledge of the futility of what we are doing, the adrenaline rush that is vaguely unsatisfying as the aides change out the bespattered sheets and gowns while the sanitation crew sweeps up the debris of syringe caps and bloody gauze pads and stepped-on tubing. Being DNR/DNI would have been a mercy, not just to the medical staff, but to the patients themselves.
The real question is not whether mechanical CPR is better than manual. Eventually, John Henry will get beaten by the machine and his heroism and humanity and sweat will become the stuff of legend and folklore. The real question is whether we should be doing most of these resuscitations at all. The price of the machines is tiny compared to the cost of ICU care over the subsequent days and weeks, or the longterm care in the few cases where the patient leaves the hospital to "convalesce," all of them now, finally, DNR.
Absolutely right. Many of the 10% or so of people who walk out following an in hospital cardiac arrest were on the coronary care unit at the time. The resuscitation gurus are reluctant to release the actual figure.
All this equivocal data is really interesting. Also not particularly surprising given how bad postcardiac arrest outcomes are in general. We use these devices for almost all cardiac arrests in both of my busy New York City emergency departments. I find them to be extremely helpful for the particular situation when there is a prolonged arrest that’s going on for a long time because you had some information that makes you think that this patient might survive. (PE trying to circulate TNK, ventricular arrhythmia, witnessed arrest with immediate CPR, etc.) in my academic centers we do have the staff to tag team CPR, but that would mean that the entire rest of the emergency department is basically shut down.
And someone mentioned what about patient? I agree that that is a consideration, but should only come secondary to the effort of resuscitating a patient who is already dead. For better or worse we do tons of horrifying things to patients. We should do our best to make these things tolerable and comfortable but first comes saving life.
At least one of the studies (CIRC trial) was funded by the ZOLL corporation, a manufacturer of the autopulse device. Hence, the authors of this trial have the incentive to describe the outcomes as 'positive'. An independent look at the study would agree with the Cochrane review that there is no clinical advantage in using the device over conventional CPR.
Possibly, with limited EMS staff working the back of the rig and still needing a driver might be of a benefit, but generally those areas might be more rural and less funds to obtain a such a unit?? I do live rural, but fortunately many Great Vollunteers are among us. Many, many moons ago I was the one alone in the back of the rig.
Yes. We have a small Elder adult care home. Because we are small, we have never used an AED on a resident, though we've had two cardiac arrests. The reason ostensibly is that the population is small, capped at 6 at once present/in residence and these events are very rare at our home. When we know someone has discomfort, we call 911 and they arrive within 2-3 minutes.
At times, we find someone who has passed in the dawn hours. I say they woke up elsewhere, and that's a huge number. Others have a hospice nurse present and I'm usually there when the end is imminent to comfort the resident, by then a dear friend. But we've never had the need, between DNRO and hospice, or the circumstances, to use the AED yet - to tell the truth, staff would be afraid to use it and I'm not so sure about myself - we're at 17 years, well I am. Nobody else is with me that long.
Most of these comments are about the effectiveness of CPR, the exhaustion of the team, and the lack of staff as reason to continue using it. ( Not without truth to it)
No one is talking about the patient.
Doing a procedure on a patient that is already ‘dead’ doesn’t seem as barbaric to our minds. But no-one is talking about the patients that ‘wake up’ while these are in use. It’s not frequent that this happens, but it’s not rare.
It’s also not caught right away because nobody’s actually looking at the patient or has hands on him/her.
Imagine that horror.
I submit that we use these machines because nobody wants to do CPR. It’s actually the most important job of the resuscitation team, but it *is* hard work, and it’s looked at as drudgery.
I feel like you need to look at very specific scenarios, to see a benefit. I don't have data supporting this.
Where I feel it definitely has advantages are:
- short staffing, i.e. cath-lab at the night shift: in my hospital (Austria, Europe, mind you) we have staffing with 1 interventional cardiologist, 1 scrub nurse, 1 additional nurse. In case of cardiac arrest they're joined by the cardiac intensivist on call and one additional ICU-Nurse. With the need of manual chest compressions gone there's so much more freedom for additional tasks.
- also in the cath lab: possibility of ongoing cpr while attempting to fix a "easy"-to-solve problem.
in general i feel like mechanical compression devices add to a calmer environment and better structure of CPR-Settings, this is very subjective, though.
As an aside - as healthcare costs continue to rise, we need to ask ourselves how health systems, physicians, and other clinicians contribute, because ultimately someone is paying for this device. Our natural inclination is to blame others - pharma, the insurance companies, others, etc - rather than looking at how we contribute. Most insurance companies are happy to expand coverage for drugs or devices - they just pass the cost on to who is paying for it. However, for Medicaid and Medicare it has a huge impact on state and federal budgets.
During 4 years working in a well trained & operated ‘paramedic-EMTA’ ambulance service (in Boulder CO) in the late 1970’s, and while practicing EM from 1998 to 2010 (mostly in the Seattle area), I never saw (or was aware of) a successful OHCA resuscitation. In 2 such cases I was present at the scene (my church) at the time of the witnessed arrest and was able to direct/participate in the resuscitation which was aided by experienced nurses. I saw only once the use of a mechanical CPR machine (the 2nd church case - used by the arriving EMS). I never expected these devices would make any difference…
For those who see the human body as a machine, the progression to a more mechanized way of managing it makes sense. And those who believe that the body runs like a software program see nothing wrong with reprogramming and upgrading. Machines, after all.
So many things we do just because we can. Experimentation is fun.
(When my husband is raised from the grave, I fear I will have to explain why his ribs are broken.)
Hi John, I'm an EM doc in Italy. Big city, large hospital. Fwiw, I have the impression that in-hospital mechanical CPR offers: 2 extra hands on deck. Lower team exhaustion. Better CPR quality consistency (there is always one operator who's weaker/worse than others). Easier to do POCUS/stuff/procedures with the machine than with humans. I don't do prehospital med. so no idea about that (but I guess in a resource-constrained setting it would be even more useful, especially if you cant do CPR while you evacuate). But in-hospital it's a nice tool to have and well worth its cost in terms of ACLS optimization IMO. It's possible it's not going to change outcomes, and that's because it is extremely difficult to change the outcome of cardiac arrest.
I worked 30 years as a firefighter in Grand Rapids, MI (200K population). Never used a CPR device. I could see where they would be useful in rural areas with a long transport time, especially if they only have one ride-a-long person in the back (usually a firefighter).
But, in the urban environment, I don't see the need. Most cities nowadays send fire as the first responders to 911 calls. We dispatched two machines and a BN chief to suspected codes. So, the 1st crew arrives within 5 minutes, the firefighter immediately starts CPR, while the EO gets the AED applied, and the officer starts O2 (and establishes an airway). Once the 2nd machine arrives, we start a CPR rotation with at least 4 firefighters, so everyone only does 2 minute compressions and then rests for 6 minutes. We use a cell phone app to set the pace and it announces time to switch out. Someone coaches and you can watch the monitor's screen to get feedback on whether or not your compressions are actually effective (so you can make adjustments). Eventually, the paramedics show up and do their thing (put in airway tube, meds, etc) until the ED doc calls it or pulses are restored and they transport.
Our system works well. Especially since older firefighters have a LOT more experience doing CPR than anyone else in the medical profession (since paramedics turn over so frequently due to poor pay). IF the code is witnessed & we are called without delay, especially if bystander CPR is applied (even better if AED applied), we have a chance to restore heartbeat. Unfortunately, it's rare that all three occur before we arrive, so even with the best CPR, survival rate to discharge is low.
One could argue the value is in fewer injury claims for EMS staff...
On two publications the conflict of interest and who received grants during the research should be noted. Also who funded the research. That's the first place I look even before I read the conclusion on most research. Sad, but true!
Thanks for the analysis.
I see the device frequently in Chicagoland EDs. EMS seem to choose mechanical CPR when they need an extra pair of hands because of other factors: difficult extraction from a residence (3rd floor walk-up), or physical characteristics (morbidly obese), or challenges with other hands on activities (difficult IV stick so they need to do an IO, or difficulty airway). Perhaps the granular data might show benefit in subpopulations. Overall, EMS attempt to restore the ABCs (airway, breathing, circulation) with all their tools while driving as fast as possible to the hospital. Lastly, when a device like mechanical CPR is available but not used if needed (extra hands), it could become a liability in cases that tend to have bad outcomes baked in (Cook County is one of the most litigious areas in the country. This may also drive adoption. “I used all the tools available and didn’t delay CPR”). On my next shift, I plan to ask our EMS coordinator and the various crews what they think about the study.
As a resident, when I worked in the hospital for shifts that lasted up to 24 hours, I participated in probably a dozen codes, all using manual compression, multiple medications and electric shocks when appropriate. Every single one of them was successful in that the patient's pulse was restored. But none of them was successful in that the patient left the hospital alive - or with any semblance of a mental or functional life. In every case, the patient was elderly and had died due to a medical condition that had eroded the organs of their bodies by degrees over years, and so reviving them merely delayed an inevitable ending before they died a second time. Generally, every one of the dozen people in the room know this from the start: the familiar shared glance that communicates a shared knowledge of the futility of what we are doing, the adrenaline rush that is vaguely unsatisfying as the aides change out the bespattered sheets and gowns while the sanitation crew sweeps up the debris of syringe caps and bloody gauze pads and stepped-on tubing. Being DNR/DNI would have been a mercy, not just to the medical staff, but to the patients themselves.
The real question is not whether mechanical CPR is better than manual. Eventually, John Henry will get beaten by the machine and his heroism and humanity and sweat will become the stuff of legend and folklore. The real question is whether we should be doing most of these resuscitations at all. The price of the machines is tiny compared to the cost of ICU care over the subsequent days and weeks, or the longterm care in the few cases where the patient leaves the hospital to "convalesce," all of them now, finally, DNR.
Absolutely right. Many of the 10% or so of people who walk out following an in hospital cardiac arrest were on the coronary care unit at the time. The resuscitation gurus are reluctant to release the actual figure.
All this equivocal data is really interesting. Also not particularly surprising given how bad postcardiac arrest outcomes are in general. We use these devices for almost all cardiac arrests in both of my busy New York City emergency departments. I find them to be extremely helpful for the particular situation when there is a prolonged arrest that’s going on for a long time because you had some information that makes you think that this patient might survive. (PE trying to circulate TNK, ventricular arrhythmia, witnessed arrest with immediate CPR, etc.) in my academic centers we do have the staff to tag team CPR, but that would mean that the entire rest of the emergency department is basically shut down.
And someone mentioned what about patient? I agree that that is a consideration, but should only come secondary to the effort of resuscitating a patient who is already dead. For better or worse we do tons of horrifying things to patients. We should do our best to make these things tolerable and comfortable but first comes saving life.
At least one of the studies (CIRC trial) was funded by the ZOLL corporation, a manufacturer of the autopulse device. Hence, the authors of this trial have the incentive to describe the outcomes as 'positive'. An independent look at the study would agree with the Cochrane review that there is no clinical advantage in using the device over conventional CPR.
Possibly, with limited EMS staff working the back of the rig and still needing a driver might be of a benefit, but generally those areas might be more rural and less funds to obtain a such a unit?? I do live rural, but fortunately many Great Vollunteers are among us. Many, many moons ago I was the one alone in the back of the rig.
Yes. We have a small Elder adult care home. Because we are small, we have never used an AED on a resident, though we've had two cardiac arrests. The reason ostensibly is that the population is small, capped at 6 at once present/in residence and these events are very rare at our home. When we know someone has discomfort, we call 911 and they arrive within 2-3 minutes.
At times, we find someone who has passed in the dawn hours. I say they woke up elsewhere, and that's a huge number. Others have a hospice nurse present and I'm usually there when the end is imminent to comfort the resident, by then a dear friend. But we've never had the need, between DNRO and hospice, or the circumstances, to use the AED yet - to tell the truth, staff would be afraid to use it and I'm not so sure about myself - we're at 17 years, well I am. Nobody else is with me that long.
Most of these comments are about the effectiveness of CPR, the exhaustion of the team, and the lack of staff as reason to continue using it. ( Not without truth to it)
No one is talking about the patient.
Doing a procedure on a patient that is already ‘dead’ doesn’t seem as barbaric to our minds. But no-one is talking about the patients that ‘wake up’ while these are in use. It’s not frequent that this happens, but it’s not rare.
It’s also not caught right away because nobody’s actually looking at the patient or has hands on him/her.
Imagine that horror.
I submit that we use these machines because nobody wants to do CPR. It’s actually the most important job of the resuscitation team, but it *is* hard work, and it’s looked at as drudgery.
No one likes doing prolonged CPR. At the very least these devices take away the drudgery.
I feel like you need to look at very specific scenarios, to see a benefit. I don't have data supporting this.
Where I feel it definitely has advantages are:
- short staffing, i.e. cath-lab at the night shift: in my hospital (Austria, Europe, mind you) we have staffing with 1 interventional cardiologist, 1 scrub nurse, 1 additional nurse. In case of cardiac arrest they're joined by the cardiac intensivist on call and one additional ICU-Nurse. With the need of manual chest compressions gone there's so much more freedom for additional tasks.
- also in the cath lab: possibility of ongoing cpr while attempting to fix a "easy"-to-solve problem.
in general i feel like mechanical compression devices add to a calmer environment and better structure of CPR-Settings, this is very subjective, though.
As an aside - as healthcare costs continue to rise, we need to ask ourselves how health systems, physicians, and other clinicians contribute, because ultimately someone is paying for this device. Our natural inclination is to blame others - pharma, the insurance companies, others, etc - rather than looking at how we contribute. Most insurance companies are happy to expand coverage for drugs or devices - they just pass the cost on to who is paying for it. However, for Medicaid and Medicare it has a huge impact on state and federal budgets.