We use a mechanical CPR device in the ER simply because doing high quality CPR is tiring and really hard especially if prolonged. I'd like to think that all of our "compressors" are buffed, fit and have the endurance of Navy Seals but the reality is most are out of shape, tire easily and all break out in a sweat after a one minute round. There is also a risk of them being injured (back) and falling especially shorter compressors who have to be on a stool or other elevated platform. It also makes sense for EMS who can only cram a couple of people into the back of the ambulance and also have to get IV access, push meds and ventilate. It frees them up to do other important tasks in a tight space. Switching compressors in the back of an ambulance is very difficult and a mechanical device improves this significantly. My expert opinion is that mechanical CPR devices are to save the staff, not the patients.
In our EMS service we focus on quality CPR by humans, which includes feedback devices for both compressions and ventilations, regular education (quarterly review and updates) and regular chart review, to find ways to improve. We always get at least one fire crew (basic training), and 2 ambulances with at least one being ALS.. This allows us to switch out every 2 minutes to reduce fatigue and ensure quality CPR.
The argument for mechanical CPR really becomes more relevant during transport. For the safety of Paramedics trying to do CPR in a moving vehicle, the switch to mechanical CPR reduces the risk of injury to the Paramedics and Firefighters as you cannot do CPR while belted in a seat.
Fortunately if we do not obtain a ROSC, we don't transport in our system (with a few exceptions) but that would be a reason EMS systems continue to embrace mechanical machines.
We did use them during Covid, just to also reduce the number of rescuers that were needed and exposed during the first few years, but much like your findings, we didn't feel the benefit out wayed the cost.
the biggest drawbacks that I have seen in their use is the amount of time it takes to get the patient loaded onto its platform, and for effective CPR to begin.
In an intervention where time is of essence, that is a very high penalty to pay.
with respect to depth of thrusts and the buckling of the rib cage, the use of these devices can indeed be a traumatic sight, as shared by Dr Mandrola.
We used them for a while in my hospital but found them cumbersome and difficult to position correctly, especially on people with certain body types. I feel they took away from quality manual compressions.
Regardless, compressions only seem to do any good on younger, healthier people. On old folks, it simply gives them 12 more ours of 'life'. It's more like torture than life saving.
If a patient is receiving CPR then their prospects are already not great. We don't do it on people with a cold or a twisted ankle. I'm not sure what that has to do with whether this machine is useful. Fatigue is a pretty big factor in CPR, especially when you're not in a hospital, and another advantage is freeing up a pair of hands. I'm not sure why you're suggesting people are in the wrong job if they experience fatigue doing CPR (when that's the whole point of rotating when that's an option), and what this has to do with the machine this post is about.
When I was working at a university hospital and wanted to recruit a patient in a study, we had to get the patient’s consent before enrolling. It was not always easy -think acute PCI trials for example. I wonder how they did it in this context.
Your causal-chain point is the one I would keep. Compression quality is easy to measure and survival is not, and the device only ever addressed the first. During a resuscitation the number I watch is end-tidal CO2, because it tells me whether the compressions are actually moving blood — and a machine can hold perfect depth and rate while that number says it is not working. I would be curious whether anyone has looked at these devices against that measure instead of survival.
I think on the margins, issues like resuscitation team member fatigue (or prevention of injury), or perhaps ability to provide prolonged CPR in the back of an ambulance when there is no lineup of people to take turns doing CPR, may be valid use cases for the device. In that sense, a non-inferiority design might be justifiable.
People are lazy and in long transports, it saves EMS from doing CPR in the back of a truck for 30 mins. Plus it’s less staff. I take the off immediately when the patients arrive. I can’t stand them. The Velcro straps that hold the patients hands up are creepy.
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… but making an effort to save a human being there in front of you leaves no option but to to try - just use what you have to do what you can!
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.
We use a mechanical CPR device in the ER simply because doing high quality CPR is tiring and really hard especially if prolonged. I'd like to think that all of our "compressors" are buffed, fit and have the endurance of Navy Seals but the reality is most are out of shape, tire easily and all break out in a sweat after a one minute round. There is also a risk of them being injured (back) and falling especially shorter compressors who have to be on a stool or other elevated platform. It also makes sense for EMS who can only cram a couple of people into the back of the ambulance and also have to get IV access, push meds and ventilate. It frees them up to do other important tasks in a tight space. Switching compressors in the back of an ambulance is very difficult and a mechanical device improves this significantly. My expert opinion is that mechanical CPR devices are to save the staff, not the patients.
In our EMS service we focus on quality CPR by humans, which includes feedback devices for both compressions and ventilations, regular education (quarterly review and updates) and regular chart review, to find ways to improve. We always get at least one fire crew (basic training), and 2 ambulances with at least one being ALS.. This allows us to switch out every 2 minutes to reduce fatigue and ensure quality CPR.
The argument for mechanical CPR really becomes more relevant during transport. For the safety of Paramedics trying to do CPR in a moving vehicle, the switch to mechanical CPR reduces the risk of injury to the Paramedics and Firefighters as you cannot do CPR while belted in a seat.
Fortunately if we do not obtain a ROSC, we don't transport in our system (with a few exceptions) but that would be a reason EMS systems continue to embrace mechanical machines.
We did use them during Covid, just to also reduce the number of rescuers that were needed and exposed during the first few years, but much like your findings, we didn't feel the benefit out wayed the cost.
the biggest drawbacks that I have seen in their use is the amount of time it takes to get the patient loaded onto its platform, and for effective CPR to begin.
In an intervention where time is of essence, that is a very high penalty to pay.
with respect to depth of thrusts and the buckling of the rib cage, the use of these devices can indeed be a traumatic sight, as shared by Dr Mandrola.
We used them for a while in my hospital but found them cumbersome and difficult to position correctly, especially on people with certain body types. I feel they took away from quality manual compressions.
Regardless, compressions only seem to do any good on younger, healthier people. On old folks, it simply gives them 12 more ours of 'life'. It's more like torture than life saving.
The data are what they are, surprising as they seem to me.
However, if there is no strong signal here to suggest worse outcomes with the mechanical device, the push goes to the dealer on this one.
A physically and psychologically exhausted pre-hospital crew is a patient safety issue / liability on the next call.
If the money is there for the line item expense, keep your medics healthy and supported.
If a patient is receiving CPR then their prospects are already not great. We don't do it on people with a cold or a twisted ankle. I'm not sure what that has to do with whether this machine is useful. Fatigue is a pretty big factor in CPR, especially when you're not in a hospital, and another advantage is freeing up a pair of hands. I'm not sure why you're suggesting people are in the wrong job if they experience fatigue doing CPR (when that's the whole point of rotating when that's an option), and what this has to do with the machine this post is about.
5% chance of survival out of hospital. The optimist would say any kind of pumping is better than no pumping.
Reality: By the time the patient gets to you in the ER after long transport with/without the device and DOA, then will remain DOA.
When I was working at a university hospital and wanted to recruit a patient in a study, we had to get the patient’s consent before enrolling. It was not always easy -think acute PCI trials for example. I wonder how they did it in this context.
Your causal-chain point is the one I would keep. Compression quality is easy to measure and survival is not, and the device only ever addressed the first. During a resuscitation the number I watch is end-tidal CO2, because it tells me whether the compressions are actually moving blood — and a machine can hold perfect depth and rate while that number says it is not working. I would be curious whether anyone has looked at these devices against that measure instead of survival.
I think on the margins, issues like resuscitation team member fatigue (or prevention of injury), or perhaps ability to provide prolonged CPR in the back of an ambulance when there is no lineup of people to take turns doing CPR, may be valid use cases for the device. In that sense, a non-inferiority design might be justifiable.
People are lazy and in long transports, it saves EMS from doing CPR in the back of a truck for 30 mins. Plus it’s less staff. I take the off immediately when the patients arrive. I can’t stand them. The Velcro straps that hold the patients hands up are creepy.
Agree 110%. I take them off. Don’t work and a waste of time putting them on.
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… but making an effort to save a human being there in front of you leaves no option but to to try - just use what you have to do what you can!
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...