Science and Inquiry discussion

New on www.leonardonoto.com

Very interesting article, Leonardo--thanks for the post!

I agree - in the first aid courses I've done the advice continues to change as methods get updated, without necessarily answering the questions why (at least the ones I have). I assume that in the out-of-hospital case,any risk of harm from CPR is outweighed by the potential benefit (despite the low chance of success overall)?

Angus wrote: "I agree - in the first aid courses I've done the advice continues to change as methods get updated, without necessarily answering the questions why (at least the ones I have). I assume that in the ..."

risk of harm from CPR --broken ribs???

the potential benefit -- being alive

The real problem is that CPR won't fix the problem, it just keeps people alive long enough for EMT to arrive and do the real work.

There are a lot of other risks of inappropriately performed CPR (e.g. on a person who doesn't need it)including collapsing lungs and damaging the heart and the great vessels -- but in any person who truly needs CPR (e.g. they're suffering from hemodynamic collapse) the risks are really a none issue because the person is actively dying and it's hard to make a dead person more dead than they already are ;-) It's hard to appreciate how violent well-performed CPR is if you've never witnessed it in a hospital -- the stuff they show on TV usually isn't even close to how it's actually done and one of the major problems with bystander CPR is that most people are afraid to compress the chest hard enough to effectively circulate blood. In most people, well-performed CPR fractures ribs.

Yes, the purpose of CPR out-of-the-hospital is to buy time for EMS to arrive -- in the hospital it also serves the purpose of buying time until an intervention can be performed that (hopefully) can turn the patient around.

Glad you guys liked the article!!!
Leo

Good to get the clarification.

One thing that we often forget is that dying quickly may be preferable to living on in anguish. I haven't read the article originally posted, but this article about how some doctors manage the end of their own lives makes the case that CPR isn't all it's cracked up to be. Many doctors take steps to avoid receiving CPR (I haven't seen scientific surveys of how common this is, however).

I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles ... walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming.

This article notes that CPR effectiveness rates are:

2% to 30% effectiveness when administered outside of the hospital

6% to 15% for hospitalized patients

Less than 5% for elderly victims with multiple medical problems

Compare that to the success rates portrayed on television programs as reported in the New England Journal of Medicine.

Jonathan wrote: "One thing that we often forget is that dying quickly may be preferable to living on in anguish. I haven't read the article originally posted, but this article about how some doctors manage the end ...

You make a good point. In the past aggressive resuscitation was the norm whether the patient wanted it or not. Today every patient is asked when they are admitted to the hospital (supposed to be asked, anyhow) whether they would want chest compressions, intubation, etc. if their medical condition deteriorated. Patients who say "no," assuming they are mentally competent (e.g. not suicidal, severely demented, etc.) are given a DNR/DNI (Do Not Resuscitate/Do Not Intubate) bracelet and their DNR status is written all over the chart -- this is because performing chest compressions on a competent patient who has stated that they do not want them is battery (i.e. it is a crime).

The success rates of CPR and whether it is a reasonable thing to have done or not very much depend on the patient's wishes/values and also on what process is causing the patient to become hemodynamically unstable. A young person whose heart suddenly went into an arrhythmia due to a lightning strike who then had CPR started immediately and was transported to the hospital ASAP would probably have a pretty high chance of survival and of a complete recovery. On the other hand, a 95-year-old with metastatic colon cancer, coronary artery disease, COPD, bleeding gastric ulcers, and a recent pulmonary embolism probably isn't the greatest candidate for CPR/aggressive resuscitation because their prognosis is dismal regardless of what is done or not done -- the patient in this case would be a good candidate for DNR/DNI and hospice/comfort care, assuming that that was what they wanted.

I believe many doctors -- not just Leonardo -- subscribe to this view. At one of my recent visits to the doctor with my mother, we discussed her options for emergency care. She just turned 99 and is somewhat frail, with definite heart issues. Previously she had elected for resuscitation. But at this latest visit, the doctor went through essentially the same arguments as Jonathan and Leonardo. The argument was convincing to Mother. I'm wondering if it wouldn't also be true for me.

Interesting TV study Jonathon.