Thursday, October 21, 2010

It makes me want to SCREAM!

 By now everybody is reading, or glancing through the new AHA guidelines. Every 4 years this huge document is released with huge fanfare like it was the second coming. Most of us read it through to see what skills we are going to have to modify "this time around". Those of us who are instructors are trying to figure out how to present these 'new rules' in the classes we present, and how we will jusitfy them to students who have a clue and realize some of them make little, or no sense. ("What do you mean, 'DON'T check for a pulse'!?")
 The AHA bases a lot of their recommendations on things I don't understand like ' It's too hard to teach' or , 'most people won't learn it correctly'. These attitudes, which generate recommendations for millions of providers, just blows my mind. I am an Engineer, and to me, it's either right or wrong and that determination is based on facts, not opinions. The human body is largely a group of mechanical systems (albeit very wondrous in design and execution) which responds fairly predictably in a given set of circumstances.
 I have been reading the Rouge Medic for a couple of years now, and I confess that I don't fully understand many of the things he writes about. I feel like I've missed the pre-class reading assignments most of the time. None the less, I like his stuff because it makes me think, learn, and do a little research to understand what the he is writing about. Anyway, he's been beginning to get on a pretty good roll with the new AHA guidelines and how they reached their conclusions. As I read his stuff I find myself nodding my head a lot.
 This cycle's recommendations hold very few surprises for me. I will of course have to spend some time on a CPR dummy to see how long I can do a rate of AT LEAST 100/minute for full chest recoil and of course get used to this CAB instead of ABC. But I think I can work with that. With the CPR recommendations I think the AHA is making a mistake in making algorithm changes that confuse the students, especially lay rescuers every cycle, many times based on how difficult things are to learn. They are confusing the students every 4 years. They are MAKING it hard to learn. No wonder they are now recommending that even Health Care Providers  need more training than once every two years. (As if actually doing CPR on a regular basis is not enough.)
Reality is that any CPR with decent compressions is better than running around in a circle. There is a limit to what you can expect from a lay rescuers and it takes a good bit of courage to get CPR started.
 It would seem that the AHA is less likely to act on clinical research than my own states EMS council where it takes YEARS to get a change through. What caught my eye in this years epic document is the recommendations which had to do with the First Aid section.
 Read the section on tourniquets. Whereas the extensive research performed by the military overwhelmingly points toward effective use of tourniquets to reduce hemorrhaging and present a patient to the E/D that has sufficient perfusion to move directly to the O/R as oppsoed to the possibility of exanguination enroute or at the least the need for re-perfusion and stabilization prior to surgery.
 Read the extended document (part 13 in this case) which explains the research they reviewed and the how(?) they reached their conclusions. I didn't look at all the research, but I did re-read this piece of work from the Boston Medical Center which I had read when it was originally published. It was one of the things that made me start thinking about tourniquets again. Another was attending a CME at a state conference wich was givenm by a trauma surgeon who gave study after study supporting the use, with some case histories where the device was in place for over 24 hours and full use of the limb was regained after recovery. This reserch piece form BMC makes a very strong case for the use of tourniquets, yet the AHA says there is not enough evidence. If you read the BMC research you will note near the end where they cite a simliar study where no tourniquets were used and all the subjects died.
 We used to be thought that if you put a tourniquet on, the patient would lose the limb. I am still thinking that this would be preferred to losing their life, which appears to be the real choice we are making.
 Now I realize that the AHA recommendations are for First Aiders and not BLS or ALS providers. However, I truly believe the AHA is providing a dis-service to the public by not leaning in the direction that the available research is taking them. Instead they seem to be taking a 'cover your ass' approach. I also note that they do not recommend AGAINST using a tourniquet, only against using it routinely. In other words, try everything else first. So this bring us back to what was taught in the seventies. However, I was very disappointed to see the reference to irreparable vascular damage resulting from tourniquet use.  I need another couple of evenings to work through the rest of their cited research, but I have a feeling they've got some pretty old stuff in there. Which would explain the archaic viewpoint.
 If you don't share my view on tourniquets, that's fine. Go read the sections on Aspirin and hemostatic agents. Sorry, but this stuff blows my mind sometimes.

1 comment:

  1. I have to wonder how much of that section was written by the AHA people and how much by the ARC people.

    I'm all for tourniquets as I've mentioned in my blog. I attended a few lectures over the years by the late Dr. Hirsch and even before the study, he made a compelling case for their use.

    The 2005 and 2010 revisions to the ECC and CPR guidelines both point to the fact that only CPR and electricity have been proven to restore circulation in cardiac arrest patients. Which is the point of the changes, including Compressions first for professional rescuers and Compressions only lay rescuers.

    I think we've seen the last of the massive five year revisions of the ECC and CPR guidelines. In the future, as research continues to accelerate, we'll see yearly or every other year incremental updates to the guidelines.