Portal de Periódicos da CAPES

Down Time or Rhythm? A New Paradigm

2003; Lippincott Williams & Wilkins; Volume: 25; Issue: 3 Linguagem: Inglês

10.1097/00132981-200303000-00002

1552-3624

Ruth SoRelle,

It's standard procedure. Personnel responding to a call for emergency medical services walk into a room, look at the patient, and ask: “How long has he been down?” Now, however, some emergency physicians are questioning whether the answer to that question should direct the next steps taken. They are asking whether the often-imprecise answer to that question should determine whether a patient is resuscitated. A better measure, they say, would be the heart rhythm in which they find the patient. It gives a better indication of whether the patient can be successfully resuscitated. “The hard part about down time is that it is a very subjective measurement or perception,” said Edward Racht, MD, the medical director of the Austin-Travis County Emergency Medical Services System. “To use someone's perception as a tool to determine whether to initiate or not initiate resuscitation is to use an inaccurate assessment.” The inaccuracy of a person's assessment of time in a stressful situation can be affirmed by looking what happens when a person complains that EMS was slow in responding to a call. When logs are checked, it is often clear that the person's perception of how long he waited is at odds with reality, said Dr. Racht. Not only are time perceptions often wrong, but it is difficult to determine what is meant by the phrase “down time,” he said. For example, he said, “suppose Grandpa goes to bed at 9 p.m. and that was the last time his wife saw him alive. His heart arrests one minute before she comes in to see him the next morning. She inaccurately conveys a sense to the paramedics that he has been in cardiopulmonary arrest since the night before.” It's an extreme example,” said Dr. Racht, but it conveys the point. “The objectivity of cardiac rhythm is a better tool to use in making decisions about stopping or starting CPR than down time,” he said. “Down time, as currently described, is not as consistent as rhythm assessment, but we use it as a primary determinant of starting or stopping CPR. It is still valuable in making decisions about terminating resuscitation, taking into account other variables as well.” Illogical Jump Howard Rodenberg, MD, an emergency physician and the president of Advance Medical Direction, Inc., in Daytona, FL, agreed with Dr. Racht's assessment. “You don't know what you are getting,” he said. “We have labored under this assumption that when we ask how long the patient has been down, each patient was in the same clinical condition all the time described. It's a logical jump you can't make. Someone was last seen yesterday and now that person is in ventricular fibrillation. To say that they have been in VF since yesterday, that is an erroneous assumption. “To use someone's perception as a tool to determine whether to initiate or not initiate resuscitation is to use an inaccurate assessment.” Dr. Edward Racht “We have done such a good job at teaching people that the longer someone is in a poorly perfusing rhythm, the worse they do,” Dr. Rodenberg said. “However, it is wrong to make the assumption that the patient has been in the same rhythm the entire time they were down.” That assumption means that the longer paramedics are told that the patient has been down, the greater the chance that they will not attempt to resuscitate. They assume that the patient will not respond to resuscitation, based on the assumed down time. “You can't make that jump,” Dr. Rodenberg said. “If you are monitoring a patient in a certain rhythm for a certain length of time, it's fair to say that. To withhold resuscitation or make that decision is to assume knowledge that you really don't have.” It is better to look at the patient's rhythm when you arrive and then look at the patient's response to cardiopulmonary resuscitation, he said. “You can't just look at a patient in asystole and say that patient won't come back. If it is in association with other signs of death, that's a different story. Otherwise, you have an obligation to work on that patient unless there is a ‘do not resuscitate’ order,” said Dr. Rodenberg. Medical Futility The rhythms with more favorable outcomes are ventricular fibrillation and ventricular tachycardia, said Dr. Racht. The more “dismal” outcomes are associated with asystole and pulseless electrical activity (PEA), he said. “I think it's a better way to analyze all the variables associated with the pulseless, apneic patients to make a clinically sound decision about medical futility,” said Dr. Racht. “What it does is it takes down time that has been used by many clinicians who say he's been down for 45 minutes and let's not start. It moves it to the end of the decision-making process.” “We have labored under this assumption that when we ask how long the patient has been down, each patient was in the same clinical condition all the time described.” Dr. Howard Rodenberg Instead of relying on the inaccurate perception of bystander recall, he said, “we are trying to put into place an algorithm or scientifically sound decision process.” He said he is trying to figure how where to place a statement about down time in the decision-making process. “What we do in the Austin-Travis County EMS system, we've taken the down time variable out of the decision-making process as a potential primary indicator,” he said. “We understand that patients' families or bystanders are not uniformly angry if resuscitation is not attempted on every patient. We understand there is a difference between end-of-life and cardiac arrest. Resuscitating someone with chronic end-stage disease would only bring them back to that disease. All those variables change the way we do things.” “Many EMS systems are following suit. More are looking at the appropriateness of when they start resuscitation, how they start it, and when they stop. It is less common to have an EMS system that transports every person who is found in cardiac arrest regardless. Now I think systems are trying to find the appropriate tools to make those decisions as they make changes in how to approach this patient population,” said Dr. Racht. “You always want to give the patient every opportunity to be resuscitated and benefit from your bag of tricks. At the same time, we need to respect that the literature tells us this is a medically futile attempt.” Understanding futility spares the EMS providers the risk of going through busy city streets with lights and sirens. It spares the family emotional distress and economic cost. It avoids pulling a potentially life-saving unit out of service when there is no hope. Using the heart's rhythm as a determinant in deciding about resuscitation “focuses on what is realistic for the patient and what is appropriate,” said Dr. Racht. He admitted that he still asks how long the patient has been down when he arrives at a scene. “Even though I get that data, I don't act on it like I used to.”