Oh Henry
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Once again we participate in the reinvention of the wheel. In goes the good air, out goes the bad air. Pound on the chest, give drugs, give more drugs, pronounce them dead. This seems to be the pattern we have developed in ACLS. Another recent article in the Journal of the American Medical Association (JAMA, November 09) reiterates the point that there has yet to be a paper that proves that the administration of drugs by paramedics in the field does anything to change the outcome of cases. Is it true that a few more people got to the hospital with heartbeats? Yes. Is it also true that there was no difference in who left the hospital with a functioning brain? Absolutely. A save is not a heart-lung preparation. A save is someone who goes back to work, is able to interact with his or her family and have some kind of meaningful life. This concept of meaningful life seems to have escaped everyone. When was the last time that the giving of epinephrine or atropine saved anyone that you were taking care of? Let me be clear, by “save” it means that you shook their hand and they walked out of the hospital.

It seems that no one in the country is willing to come to grips with the concept that we are no longer a rich nation. If you have to make cuts in healthcare, which is undeniable from all camps, where are those cuts going to be? I would propose that end of life resuscitation is a good place to start. It is neat, it is relatively clean and it’s understandable. It starts with health care providers meeting with and counseling families of patients receiving end-of-life care. There is no state where it is required that you die in a hospital. There is no state in which you are not allowed to die in a nursing home. There is no state in which it is important that we beat you with plastic, pump you with drugs and fracture your ribs before we call you dead.

The financial implications of the recent JAMA article are huge. I want you to consider the amount of time, money and effort it takes to maintain the “drug box proficiency” of emergency medicine personnel in the public sector. Fire departments are already a major cost in municipalities. In cities of approximately 100,000, the police and fire department salaries are roughly one-half of the operating cost of the city budget. When you have to send firefighters off for further training and maintain that training, you are extending a cost that is not actually figured in to the health care costs in the United States. During the recent debates in congress concerning health care reform, the comment has been used that healthcare is about one-sixth of the gross domestic product (GDP) of the United States. That number is probably wrong, and if you take into account those medically related services – which are actually performed in other departments, such as fire and police – the number is much closer to one-fifth of the GDP.

We do need to make reasonable adjustments in the healthcare we are providing to make sure we are really providing meaningful care. It seems there is a lack of introspection on what the outcomes are from the amount of lights, sirens, medication and cross-sternal electricity we apply to the situation. It has been my observation that if CPR has gone on for more than five minutes and two hits of electricity did not bring back a perfusing rhythm, prolonged involvement of the paramedics in running the arrest is essentially useless. Nothing is 100%. There is always one case somewhere. But we cannot make public policy based on one case somewhere. What we have to do is decide where we can reasonably spend public money for the betterment of the public. If you had to weigh all of the various forms of health care against which were providing meaningful life to the citizens of the Unites States, then I’m afraid that opening the drug box at the scene of cardiac arrests is going to come up short.

I understand that ACLS has become intellectually a religion and financially a reward for certain organizations that are involved in its teaching and promulgation. That should not be the reason that we continue to perform certain acts. The use of epinephrine might as well be replaced with holy water. The chances that it will resuscitate a person who has been without heartbeat for more than five minutes back to a functional human being is so small as to be beyond statistical probability. If we are brave, we will go back to zero-based budgeting and ask questions about which interventions, be they in the field, in the hospital, in the operating room or in post-hospital care, actually add meaningful life to patients.

It is now time that the national professional organizations start challenging old dogmas about this kind of care. When are we going to see emergency medicine services put under the same microscope as other medical services? No individual doctor can stem the tide of ritualistic ignorance. But professional organizations come together for only a few reasons, one of those being the advocacy of applying reasonable science to improving the health of the populations we serve. Without a public health perspective on this intervention we are in serious trouble.

The most dangerous vehicle per highway mile is the ambulance. Everyone is mesmerized by the sirens and lights, and in its wake, the ambulance has the potential of leaving more medical problems than it solves. If you’re going to put paramedics and the general public at risk by continuing this ritual dance, there better be some definitively-proven, positive outcome that is both understandable and reproducible. 

I UNDERSTAND that there will be those who disagree that this is the point at which money should be saved. I’m fully aware that there are lots of places where money could be saved. To get this discussion going in a positive vein I would like to have readers share their top ways that we could go about reducing the health care budget in the United States while still maintaining reasonable medical care.
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Greg Henry Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.
 

Comments   

# Healthcare cost fix.........Paramedic 2010-01-04 17:41
I appreciate your comments on the healthcare savings available by discontinuing ACLS. I think we should also differentiate public budgets from healthcare budgets. In most areas, pre-hospital healthcare is performed by Paramedics. These Paramedic units are provided by public tax base, and billings to commercial and state/federal entities. I believe that the actual cure to many of our problems in budgeting is an expansion of the Paramedic role in heatlhcare. Expanded Masters Degree Paramedic and/or PA programs in which Paramedics will travel to the homes of patients in need, evaluate, treat, prescribe, and schedule a follow-up. Millions of dollars could be saved by treating and releasing at the patient residence, rather than transporting a non-injured, non-critical patient to the already overcrowded ED for a broad-spectrum antibiotic prescription. I believe a Masters Degree program for Paramedics that would allow autonomy while working with a Primary Physician would eliminate millions of dollars in Primary Care and Emergency Department visits. It would also transition the Paramedic practice from that of a public safety model, to that of a healthcare practitioner.

-Regarding ACLS in itself, it is very difficult to state that ACLS is useless. I have read the research. You are correct, there are patients that have walked out of the hospital, and there are many, many, more that have not. I believe ACLS is necessary, but I also agree that if the patient arrest is unwitnessed, the patient is deceased. Patients with witnessed Cardiac Arrest should have a resuscitation attempt in their home, where they are found. There is no reason to transport a patient that is asystolic to the ED to be pronounced. Attempts should be made for 20 minutes. If after 20 minutes, the patient is asystolic, a Physician should be contacted via cell to terminate. If, within 20 minutes, the patient has ROSC, then the patient can be transported.
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# jb 2010-01-05 15:10
I say we limit coverage for chemotherapy. It has only proven benefits for testicular cancer, lymphomas, and leukemias. The rest is a total waste. The new "smart" drugs only have shown an increase of three months of life in colon cancer at a cost of over 100 thousand dollars. If surgery cannot totally resect a tumor, then everything else is window dressing, expensive at that.
Furthermore, stop testing and treating prostate cancer too.
Until, we actually start doing cost vs. benefit in determining what we treat, and have legal protections from lawyers for doing less, and get paid more for doing less, and politicians stop pandering to emotionally based interest groups, nothing will change.
Really, the best way for cost to go down is to get the government to get out of healthcare and make the insured have more freedoms economically with more responsibility for cost and the prices will drop, and people will stop demanding useless and expensive care "just to see it works."
No changes will occur though. The public, especially our entitled gerentocracy, will demand everything their heart desires as our civilization spirals towards bankruptcy.
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# me 2010-01-05 18:40
certainly won't see any successful implementation of health care rationing (enough to produce real savings anyway) if docs are held legally responsible for the consequences.
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# physicianERDoc 2010-01-06 20:32
Dr. Henry, in all due respect you have begun to come across as a little "holier than thou" and all knowing in your frequent criticisms of the complex issues in our healthcare system. You present these complex issues as much more simplistic than they are---a "black or white" issue that you could easily solve. This is simply not the case.

You group police and fire department budgets together comprise half the budget in cities greater than 100,000. Well police do not function as medical personnel. This is misleading as best to present the data in this way.

Additionally, if you knew how much tax dollars was going toward pensions for these city employees, you would be baffled. I'm not saying they are not deserving of good benefits, but the benefits are often times excessive. As a result they retire at an age much younger than you and I could ever hope to.

I would imagine if you were to break down the fire department's expenses and see how much were going to pay for code calls and drugs, it would be a very small piece of the pie.

If it's ever my family member I would want all reasonable attempts to be made. We are all well aware that prolonged attempts at resuscitating asystole and PEA are often times futile. But to suggest this will make a substantial difference in our overall healthcare expenditures in the Unites States is just plain misguided.

I suspect if you look at the increase in obesity in our population and the rising health care expenditures, the graphs will look virtually identical. If we could just somehow get 20% of the obese in our population to start taking better care of themselves, we could save substantially and do so in a big hurry. And then we'd probably have fewer of the codes you are referring to as an added benefit.
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# er doc 2 2010-01-06 21:25
EMS providers are not capable now nor ever will be of prescribing medicine or treatment in the field independently. This is true of ACLS and general medicine alike. They are glorified transporters and Dr.Henry's perception of ACLS and the providers is a waste of resources and money.
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# PA-CAnother Guy 2010-01-07 19:21
As an physician assistant practice manager with an MBA and prior special operations medicine experience I have to ask: why exactly do we need Master's level paramedics? We already have a the infrastructure and in place to do what you are describing. It is called doctors and PAs doing house call. It has been around for a while. If the medical profession could bring itself into the current epoch (papyrus was invented when?) and unchain itself from the axis of evil (pharma and "insurance"), PREVENTIVE care would negate the frequent need for most of these services. But hey, what do I know? Here's some Lipitor to wash down with that Twinkie and Starbucks while watching Fox and Friends. For breakfast.
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# Paramedic, Nursing StudentTennessee Paramedic 2010-01-08 17:45
@ER Doc 2 - that's an incredibly biased, shallow, and arrogant opinion - one that's proven wrong by Canada's Advanced Care Paramedic, and systems in the United States in incredibly rural areas which used advanced-traine d paramedics as a primary care level practicioner (Such as certain tribal states and counties out west). A better statement of fact would be with the current abhorrant levels of training and standards for Paramedics, they will never do what you state.

PA-C - Unfortunately for woo, preventative care is a MAJOR issue that both insurance companies and pharma companies pursue. Major insurance companies give incentives based on fitness and preventative care, and even medicare is starting to see what a little prevention can save a few hundred thousand in after-care. For that matter, what about tackling issues such as nosocomial infections during invasive procedues, and the abhorrant involvement of rural healthcare systems in prevention of disease such as cancer, heart disease, and stroke?
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# MDCJK 2010-01-08 19:18
Human beings naturally want everything they can get that might possibly help them as long as they don't have to pay for it up front. The public has been sold an image of miraculous medical cures (while someone else pays) and now frequently feels cheated if they don't get it. What we are unable to do is say when enough is enough while pt's hope for miracles (ie highly improbable events). This society has lost all reasonable perspective and the practice of medicine is often absurd. My ED practice is now frequently peppered with those that should have been dead decades ago much less have heroic measures withheld - but they still insist that the gomers without written DNRs get EGDT & intensive care treatment - all for a 10% improvement in outcomes and a 1000% increase in cost. How will we argue for less medical care in this enviroment of high expectations, quick blame, academic and legal self righteousnous? As suggested by a few; withholding futile and expensive cancer seems rational but try getting that through to a patient or a congressman before the system goes bankrupt. (I've seen a few VIPs that decry health care costs but insist their family gets CT scans for their bruises.) This doesn't happen so severely in Europe where expectations along with the academic and legal enviroments are so different. I don't think we will be able to change the situation until the system breaks down over excessive costs. (Look at the uproar over "death committees" - one of the first thing I whould actually do.) Unfortunately first they will blame it on the physicians making to much while the corporations role in the dough. Watch as the government reimbursements to physicians are dwindled down while payments to lobbying corporations are guaranteed (Medicare part D anyone). I would hope the medical societies are able to argue for more rational treatment restraints but how can democratically elected leaders argue for less income for their members - we have seen the enemy and they are us. This society and it's physicians has benefited greatly from the huge expenditures we have made to medical care. Now we have to grow up and decide how to restrain ourselves - not one of our strengths. Thanks again for your discussion on this, I'm just not to hopeful that rationality will win out.
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# Paramedic 2010-01-10 01:12
I agree with the author when he says treatment should be based on proven science. I think these studies would in fact find that ALCS can and does make a difference. Studies and trials of any kind are things that we in the field of emergency medical care could use more of!


"ER doc 2" as Im sure you will eventually realize (if you dont retire first) your views of EMS are very outdated. Paramedics in many advanced countries are very capable of treating and releasing patients based on the paramedic's assessment. Those countries also happen to spend about half of what we do per person on health care.
I hope that your comments were made in jest. If you actually do feel this way I pity the people who work with you on a daily basis.
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# The Cannulator 2010-01-10 11:38
ER Doc 2. Get out of the US, you might see a few prehospital practitioners who can actually think for themselves....

As for canning Master level Paramedics, why have PAs? Maybe doctors could do your work; like they were supposed to.


Maybe the first cost cutting should be the exorbitant wages of doctors.....

I appreciate your comments Dr Henry, but the darwinistic approach to health care to save a few bucks in a world where money is disproportionat ely spread is a tad unfair.

Similarly where health care is decided by insurance companies as it is in the US, you are always gong to have the dollar leading the horse. A ludicrous system that is a laughing stock. cutting our Chemo? For crying our loud; come to my family and tell me the dollars have dried up and I'd punch your lights out!

Where has the empathy gone in medicine. It's bad enough that violence has increased and we are knocking each other off better than ever. Now it's medicine's turn.

Bring out your dead!
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# MDRWH 2010-01-12 21:43
Your column states that “The financial implications of the recent JAMA article are huge” (but offers no proof – lack of proof being a main point of your column) and then goes on to suggest that EMS training and ACLS courses are, by extension, worthless.

The article to which you refer, however, shows an 8.1 – 9.8% survival with favorable neurological outcome related to interventions by the EMTs (depending on whether drugs were given or not). How many of the CT scans ordered by ER physicians improved patient’s survival by 8-10%? Yet I suspect they overshadow the money spent on EMTs giving epi by a factor of probably 1000 or more.


This is hardly what is breaking the bank. And the idea that ACLS is nothing more than the teaching of CPR for prolonged cardiac arrest is an extremely narrow view of the curriculum. If that is all your ACLS instructors are teaching, they are missing an opportunity to teach critical evaluation and stabilization of many arrest and near arrest situations. And remember that although epi has not been shown to be beneficial - prehospital AEDs, good ventilation technique, pacing for unstable bradycardic rhythms, etc., do improve survival. These, and many other interventions, are also a part of EMS and ACLS training.

It's not a revelation to anybody to say that once the initial defibrillations haven't worked the game is likely over. The recommendations for drugs, at this point, have been based on our best guess of what to do next - like many, many other things in medicine. People like to say "The thinnest book in the world is the book entitled "Proven Interventions by EMS". But there is a book that is thinner - which is "Disproven Interventions by EMS". And EMS interventions are not different in this regard than medical interventions in general. (“Cough medicine” anybody?) The problem, obviously, is what do you do with a 54 year old father in VF who hasn't responded to the first couple shocks? What we have always done is to do what seems to make sense. When that is clearly proven to be worthless or harmful, then we’ll stop. Maybe we are at that point and maybe not. A difference of 8% vs 10% in such a non-controlled environment might be within the margin of error given the chaos of a “code” and the difficulty of controlling the necessary variables.

Furthermore, the amount of money spent to teach EMTs their ACLS algorithms is minimal. As an ACLS Course Director and EMS Medical Director I know that EMTs generally know the basic cardiac arrest algorithms cold and these represent a minority of their calls. Drugs given by EMS is a "spit in the ocean" as far as the contribution to health care costs. If you see this as low hanging fruit, I think you are in the wrong orchard.
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# Reducing Health Care CostsSebastian Wong 2010-01-13 15:08
Dr. Henry, your concern for reducing the cost of our nation's health care costs is admirable. I am a paramedic in San Francisco, CA. Just yesterday, I was showing two attending emergency physicians from Taiwan how our EMS system operated. It was a genial and professional discussion of how our two countries were different. I asked the Attending Physician in Emergency Medicine from the National Taiwan University how they controlled health care costs in Taiwan and he told me that they did it by controlling the salaries of the physicians and nurses. He shared with me that his salary was $80,000.00 in US Dollars and many of his colleagues in private practice were not far off but with the ability to charge for additional procedures. As any astute business person may see, payroll accounts for anywhere from 85-92 percent of the operating costs of a concern. How much money do you think America would save if your salary and all other physicians were reduced to $80,000.00? Perhaps our health care costs would approach one tenth of GDP.
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# MDRWH 2010-01-13 16:02
I agree that decreasing physician salaries might help a little and there are a small percentage that are excessive. As a physician, though, I need to point out that I make much less than many others in the system. (The CEOs of some of the pharmaceutical and insurance agencies make tens of millions of dollars). The average salary for most ER physicians is in the $200,000s.

I went to school/residenc y training for 14 years post-high school and then came out with $140,000 in debt. If I had, instead, made even $50,000/yr (a conservative figure for a smart guy) for those 14 years and didn't end up with such a high debt I would have come out over $700,000-$800,0 00 ahead by the end of the 14 years. What, then, would be the incentive for spending all that time in training so I could work nights and weekends making life/death decisions and getting sued? You also have to look at the Taiwanese salaries in comparison to other salaries in that country and to the cost of living.
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# Salaries in Taiwan for ED MD'sSebastian Wong 2010-01-13 17:52
Dear MD,

Please believe me that I do not advocate for reducing the salary of an emergency physician to the level of $80,000.00 in the United States as accceptable. I know many ED physicians that make the average salary and many physicians in private practice that may make more. Physicians in private practice in the United States are independent business entities of their own with offices to maintain, support salaries to pay, and self directed retirement programs to fund so that they can have a decent retirement.

I agree with you about the excesses that the insurance agencies and pharmaceutical companies create draining our health care dollars. I was hoping for some tort reform in the new health care reform legislation wending it's way through Congress but it will not materialize.

As for Dr. Henry's point to zero base budgets and look at the amount of money spent on attempting resuscitating patients in the prehospital phase, it merits further discussion and research. I do however find it problematic to view it as "low hanging fruit". Cost based analyses of all medical procedures could be done of almost all medical treatments and surgical procedures. The key is to do it in an appropriate and scientifically significant manner without losing sight of the patient's best interests as the goal.
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# Drug box costsPharmacist/physician 2010-01-13 23:35
Dr. Henry:

Calculate the cost vs benefit of every crash cart in the hospital where you work and you will find that much could be done with less cost. We could include the most effective least expensive medications vs everything that someone wants that will fit. Now multiply that drug box by every hospital, clinic, ambulance and helicopter in America......th ere's some real savings to be had....with no change in outcomes.

As far as cutting the salaries of doctors.......t his is a capitalist economy the smart kids might head to Wall Street instead. How high are those bonuses this year? I bet they aren't working midnight shifts.
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# Rogue Medic 2010-01-14 03:48
Dr. Henry. I agree that epinephrine in cardiac arrest has not been shown to be effective at anything other than increasing the number of patients arriving at the ED with a pulse. The same is true for all of the other ACLS drugs in cardiac arrest - atropine, amiodarone, bretylium, and lidocaine.

We are not improving long-term outcomes. We are only changing the vital signs, and only temporarily. The cost savings in the ACLS drugs is not significant, since all are available as generics, and many are about a dollar a dose.

Good CPR and rapid defibrillation are the things that have been shown to lead to improved outcomes - the patients with functioning brains walking out of the hospital.

There does not appear to be a benefit to sending paramedics to treat cardiac arrest patients, unless the patient is resuscitated.

Paramedics can make much more of a difference with other patients, at least the ones with genuine medical emergencies.

If we eliminate ACLS, or reform it to the point, where it is providing education on the things that actually work - CHF treatment with high-dose NTG, CPAP, and ACE inhibitors; pain management with appropriately titrated opioids; asthma treatment with beta agonists (including epinephrine), anaphylaxis treatment with epinephrine; hypoglycemia treatment with infusions of 10% dextrose (rather than boluses of 50% dextrose); et cetera.

We could use that time and money to educate EMS about STEMI alerts, which is more complicated than ACLS and based on research showing improved outcomes. EMS needs better training, so any cost savings should be directed toward improving EMS, rather than minimizing the budgets of already underfunded medical professionals.

We need to eliminate the EMS treatments that have not been shown to improve outcomes. We have done a good job of eliminating snake oil, but plenty still exists.

I will only begin to list them here, because contrary to what RWH writes, the list of disproven EMS interventions is very long, and longer than the list of proven EMS interventions. I will leave out the cardiac arrest drugs, since RWH seems to disagree on the research. MAST, furosemide for CHF, the "Golden Hour" to get trauma patients to surgery, replacing lost blood with saline is good for survival, steroids for spinal injuries, a traction splint protects against femoral artery laceration, ammonia inhalants are appropriate for reviving patients, bicarb is the first drug for hyperkalemia, endotracheal drug administration is helpful, we need to use a credit card, or razor, to remove a bee stinger, more medics means better EMS, this won't hurt, . . . .

Unless we eliminate these treatments based entirely on hunches and "what ifs," we are no better than witchdoctors.

We need to limit EMS to what works. In cardiac arrest, epinephrine, amiodarone, lidocaine, intubation, et cetera do not work. There is no reason to continue to use them outside of well controlled studies, since they have no basis in evidence and should only be described as experimental.
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# MDRWH 2010-01-14 19:33
There are several points from reading of the referenced study that are worth making:

The authors state that this is the first randomized, controlled drug/no-drug study that has been done. History teaches us that research findings may not be repeatable and in fact may send us in completely the wrong direction. We need look no further than the studies on post-menopause hormone replacement or thrombolytics in stroke to find major discrepancies between studies. This study, for example, disagreed with a previous study showing worse outcome after administration of IV epi. It also found no statistical difference in long-term survival in patients with shockable rhythms whether or not IV drugs were given. Is lack of benefit (but not harm) in one study enough to change our approach? It’s not so clear.


The results show that 74 out of the 442 patients in the “Intravenous drugs” group did not actually receive IV drugs – either because they re-established ROSC before they got the IV, they couldn’t get an IV or establishing an IV was considered futile. So the comparison wasn’t actually between those that got IV drugs and those that didn’t – it was between those patients to which the EMTs “intended” to give IV drugs and those to which they intended not to give drugs. Quite a different comparison.

The most confusing result is that there was a large difference in the percentage of patients in whom defibrillation was even “attempted” . Defibrillation was attempted in only 47% of the “drugs” group. This compares defibrillation being attempted in only 37% of the “no-drugs” group. How is this explained and why were such a small fraction in either group defibrillated? Were most of the patients in rigor mortis by the time the ambulance arrived?

Although the difference in long-term survival was not significantly different, short-term survival was significantly higher in the patients given IV drugs. There was also a trend toward better outcomes in most measures of survival: more patients who received IV drugs were discharged alive, more had good cerebral performance at discharge and more were alive one year after cardiac arrest – although none of these differences reached statistical significance.

The study authors agree that the “clinical implications of an increased ROSC rate in the intravenous group are difficult to interpret”. They point out that this may, on the one hand, mean we are only restoring circulation among patients with irreversible brain damage. On the other hand, maybe we need improvements in our post-resuscitat ion care. As they point out: “long-term survival cannot be achieved without first restoring circulation”.

Finally, we have no way of knowing whether we are making the completely wrong conclusion. There was no difference in outcome between those patients with shockable rhythms. May that’s because the epi is given too late! Maybe immediate epi administration by IO (which is usually obtained more quickly) is the way to go. If there was a higher ROSC with epi, maybe it works but we aren’t giving it quickly enough. We have no way of knowing.

It seems that the conclusions from this one study are not so clear as originally presented. What is clear is that this needs further study before we dismiss treatments that, at best, caused a trend toward better long term survival and, at least, caused no harm.
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# Rogue Medic 2010-01-14 21:19
RWH,

"The most confusing result is that there was a large difference in the percentage of patients in whom defibrillation was even 'attempted'."

Not confusing. Epinephrine is similar to amphetamine or cocaine in its ability to stimulate the heart. The larger number of patients defibrillated in the drug group is to be expected with the administration of such a strong stimulant.


"Defibrillation was attempted in only 47% of the 'drugs' group. This compares defibrillation being attempted in only 37% of the 'no-drugs' group. How is this explained and why were such a small fraction in either group defibrillated?"

As they state in the paper, the percentage of patients with VF as the initial rhythm was 34% in the drug group and 33% in the no drug group.


"Were most of the patients in rigor mortis by the time the ambulance arrived?"

If the only time you withhold defibrillation from pulseless patients is when rigor mortis is present, you might want to reconsider your approach to resuscitation.


"If there was a higher ROSC with epi, maybe it works but we aren’t giving it quickly enough. We have no way of knowing."

Epinephrine is probably the most toxic drug we could choose to give to a patient experiencing an MI, but you think we are not giving it fast enough?

The epinephrine dose for living human patients is 2 mcg/minute to 10 mcg/minute. The epinephrine dose for dead humans is 1,000 mcg fast push, repeated every 3 to 5 minutes.

This is a treatment that does improve the return of circulation, but at what cost? High-dose epinephrine had the same effect - improved return of circulation, but eventually we realized that there was an increase in long-term harm.

How much do we need the thrill of getting a pulse back? What part of long term outcomes are we willing to sacrifice for this charade?

Epinephrine has been repeatedly studied, although this is the first prospective IV vs. no IV study. There is still no evidence that it is any better than not using epinephrine. Epinephrine has many harmful side effects. It is interesting that you leap to the conclusion that there is no harm from epinephrine, but you doubt the finding that there is no benefit.


From -

Circulation. 2005;112:IV-58 – IV-66.
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 7.2: Management of Cardiac Arrest
Access for Medications: Correct Priorities

http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-58#SEC1

"During cardiac arrest, basic CPR and early defibrillation are of primary importance, and drug administration is of secondary importance."

Apparently they do not agree with your idea that drugs are the solution to everything.


From -

N Engl J Med. 2004 Aug 12;351(7):647-56.
Comment in:N Engl J Med. 2004 Dec 9;351(24):2553- 4; author reply 2553-4.
Advanced cardiac life support in out-of-hospital cardiac arrest.
Stiell IG, Wells GA, Field B, Spaite DW, Nesbitt LP, De Maio VJ, Nichol G, Cousineau D, Blackburn J, Munkley D, Luinstra-Toohey L, Campeau T, Dagnone E, Lyver M; Ontario Prehospital Advanced Life Support Study Group.
Free Full Text at
http://content.nejm.org./cgi/content/full/351/7/647

"Background The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support to a program of rapid defibrillation."

"There was no improvement in the rate of survival with the use of advanced life support in any subgroup."


When we are providing treatments that cannot be shown to make a difference in outcome, we are practicing witchcraft. This is not medicine.
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# paramedic85paramedic85 2010-01-15 13:03
I agree that EMS has a hole in it into which a ton of money falls that should instead be saved. However it is not ACLS, it is the dual or tiered responce. I have shocked a lot of people and have yet to have one catch on fire. Most cities have an ambulance and a fire truck respond to all or at least most EMS calls. There is no need for that fire truck. When you need a fireman you need a fireman and they should be on the cities payroll and available for when they are needed, but there is no reason to increase thier cost by deciding to send them out on medical calls as an attempt to justify having them. In the city in which I currently work fire only responds to fires and extrications. In my experiance things run smoother then in places where a Paramedic ambulance and a Paramedic fire unit respond, and we don't cost the city a cent. I'm all for saving money by looking at what doesn't need to be there, but I'm absolutly not for deeming a person expendable because a med or procedure probably won't work(in that logic we shouldn't ever do CPR. If they don't have a pulse lets just call them and move on right?)
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# Don' blame EMS or ACLS for high costsTrauma Drama 2010-01-17 21:10
Something tells me that Dr. Henry would be singing a totally different tune if it were, say, his child that had arrested. Would he tell the paramedics that showed up to skip giving any drugs, since they have been shown to have no benefit? I'm guessing not. I'm sure that if a lawyer caught wind that the well meaning paramedics had not given every chemical in that drug box that AHA says should be given, then a lawsuit would be quick to follow. In the 15 years I've been in healthcare, I've seen patients respond positively to treatments that should never have. I can look at research and evidence all day long (and sometimes it feels like I do just that), but the biggest factor in my treatment decisions is that it is not up to me to determine whether I should do something or not just because I don't think they'll have a good quality of life or not; my job is to do everything that patient or family wants done based on their determination of quality of life.

You challenged us to provide alternatives to cut healthcare costs- not that I think it's the government's role to get involved in the healthcare issue at all. Let me provide some savings:

1- Real, meaningful tort reform. This would eliminate junk lawsuits and unnecessary diagnostic procedures done just to keep lawyers from circling like sharks at the smell of blood.

2- Get government out of the insurance regulation business. How much of healthcare costs are related to satisfying some arcane and obscure federal regualtion? How much of the cost of insurance is spent on mandatory minimum coverages determined by politicians vs. the actual needs of a patient. I find it ironic that the very governments that have done more to drive up the cost of healthcare are the ones complaining about it and trying to "fix" it by adding more government (sort of like setting ytour house on fire, complaining about it, then trying to put it out with gasoline).

3- Make Medicare actually reimburse physicians for actual costs, not just made up figures from DRG's. Also, Medicare should focus their attention on preventing fraud (and prosecuting those who are ripping off the system) and not on nitpicking paperwork and refusing legitimate reimbursement because an "i" wasn't dotted or a "t" wasn't crossed.

4- Insurance rates should depend on the patient. Obese people and smokers should pay way more for their healthcare costs, or pay everything out of pocket. Why should everybody else have to pay more because of other's bad habits.
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# Rogue Medic 2010-01-26 03:30
Trauma Drama,

I would hope that patients are receiving treatments that have been shown to work, rather than having the equivalent of pixie dust sprinkled on them just because we've got to do everything.

Don't be surprised when ACLS changes.

Imagine if we were to skip a pulse check after defibrillation. That would have been unthinkable before the 2005 revisions.

ACLS does follow the science, but they still have some traditionalists , who resist progress. Fortunately the traditionalists are dying off.
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# Government is a blunt instrumentJohn Frey 2010-01-26 14:27
Before the government got involved, there were two types of codes: "Slow" and "Fast". And it was up to the participants to decide how to proceed. (94yr old advanced alzheimer's patient would be a slow code). Now we take our orders from a large centralized bureacracy and there is less and less room for customized approaches out of fear of reprisal.
Emergency physicians used to have an instinctive and palpable dislike for bureaucracy/adm inistrative decision making from down the hall. Now it seems many of us are content to ask the people down the hall (or thousands of miles away) for permission to even do nothing! ....this goes against the spirit of the emergency physician as I know it.
It is just not workable to have the government involved to the extent that it is, and wants to be. There can be no 'smart' government, that wisely rations resources and sets 'intelligent' rules. This goes against the very nature of bureacracy itself, which operates in a mass, blunt, and one size fits all manner - by necessity. It will always be a hatchet, and not a scalpel.
It doesn't make any sense for us to buy the premise of the validity of government involvement in medical decision making and consequently appeal for it to make 'wiser' decisions. Instead of appealing to it to be 'smarter', let's tell it to go away.
I would agree with Greg Henry that we need to stop pumping useless medicines into hopeless cases. But I would hope that he would agree that government control of healthcare qualifies as one of these same hopeless cases.
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# Paramedic RepliesStanley Hill 2010-01-31 09:43
Dr; while i certainly share your sentiments regarding the futility of most ACLS resus`s- i certainly need to point out that succesful resus`s (as per your definition of walking out of a hospital- i have participated in two that come to mind, a 6 year old drowning in 1994 and a 79 y/o cardiac arrest who return to full functionality. Its true that we resus`d many non-viable patients and i do agree that we need to be prudent in selecting who we apply the procedures to and move away from resusing everyting without a pulse.

As for your view regarding Paramedics in general terms- my response is an overwhelming |of course we make a differance". In my country (South Africa)i need to bring a few points to the front;

1) we are licensed as Independant Practioners and certainly put it to good use:

2) SA does not have the type of access to large number of definative hospitals (and helicopters) within close proximity such as in the first world- some medical facilities are hundreds of KMs apart- Paramedics get viable patients into ICU beds by practicing roadside medicine.

3)ACLS resus viablity may be questionable with a poor prognosis from the begining, but what about chest decompressions, emergency airways, status epileptics, diabetic emergencies, massive blood loss, arrythmia management, thrombolytic therapy etc etc practiced by the ALS Paramedic/ Ambulance when the nearest facility may be 2-3hours away- surely Para-medicine in this scenario is lifesaving compared to no medicine.

Please take the time to review the latest ITLS teachings- it challenges the old dogma of "staying and playing" on a scene, but it certainly supports agressive, pre-hospital medicine as being a life saver.
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# MDmarcus ma 2010-02-02 15:09
I would like to ask a question for the physician from Taiwan. No system is ever perfect. In our system, we have what is called "fee-for-servic e" where doctors who order more unnecessary tests and treatments are getting reimbursed more than other physicians who are not. One way our society supposedly rewards hard work and ingeniuty is with compensation. If all the doctors in Taiwan are paid relatively the same, where is the incentive for physicians to work harder and see more patients? Does Taiwan have a government healthcare system?
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# MDJerseyjoe 2010-02-06 06:51
We apparently have resolved the emergency physician manpower problem: by removing government interference in medicine we wold roll back the clock to pre Hill-Burton days. There would be no hospital construction explosion. There would be many fewer hospital beds, emergency departments, etc. Thus we would need many fewer emergency physicians.
We would miss those gains from government funded research. We would happily watch our children die from poisoned water and poisoned air as the Clean Water Act and other environmental regulations would not exist.
Have all the respondents here who bemoan government interference missed the economic crises of the past year, or of Long Term Capital, or the Savings & Loan scandals. These all represent failure of the government to properly regulate- mostly due to the "government is the problem" belief that has sprung from deranged Reaganism.
CJK noted the hysteria created by the fiction of death panels in the current reform debate. I believe this may be the most harmful of the many lies propagated by right wing loonies. This hysteria has completely prevented any discussion of end of life care costs in the current debate. If you believe that end of life expenses consume an inappropriate share of our national health care expenses, then contact former Tennessee Senator Fred Thompson and Republican Party shill Betsy McCaughey. They started this destructive myth and they should retract it. Physicians from both the right and left should dispel this falsehood so that this important topic can again be discussed without fear of a tea-bagger party convening on your front lawn.
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# rashood 2010-06-18 10:49 Reply
# paramedico 2011-08-15 06:51
i agree with ERdoc2, as paramedics and EMS providers we can provide necessary treatment but ultimately our job is moving the patient off the stretcher and onto the ER bed. Our most important ability and probably one that has the most impact on the patients outcome is our initial assessment and communication of that information to the ER staff.
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# LOW LIFE EMT-B / PARAMEDIC STUDENTdenny 2011-10-05 17:35
Wow, this is what our world has come to....bitching about which healthcare providers should make less. I am a volunteer EMT, I work 50 - 60 hrs a week at my job and I attend night classes for paramedic, why? So maybe somewhere, someday I can maybe make a difference. If one life is too many to save over a frikin dollar.....may god have pitty on us. If you want to argue about money go talk to some fat insurance guy, my insurance right now costs me 150.00 a week....a week.
Since when do hospitals need advertising ????? It is kind of a given isn't it? People are gonna get sick !!!!!!
I just can't understand why you would choose to be a DR. and wine that you have debt. Training cost money, duh. Is DR. Henry a medical director of a service or just some dude who is bitchin w/o puttin the time in. Be A director then you can have your voice doc.
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