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.
Greg Henry Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.