

FOR IMMEDIATE RELEASE-EMERGENCYNET NEWS SVC.-10/18/93-1000CDT

JAMA STUDIES CALL FOR PARAMEDICS TO STOP "FUTILE" TREATMENT

By Clark Staten, EMT-P, I/C

Chicago, IL -  Two studies published in the Journal of the
American Medical Association (JAMA) say that paramedics
should be allowed to discontinue Cardio-Pulmonary
Resuscitation (CPR) and other advanced life support
procedures when faced with a cardiac arrest patient that
doesn't respond to aggressive care.  Primary reasons cited by
the study include economic efficiency and more appropriate
use of limited emergency medical care resources.

According to one JAMA study, the cost of "futile"
resuscitations has risen to approximately one billion dollars
($1,000,000,000) per year.  This figure includes the costs of
paramedics, ambulances, nurses, doctors, emergency room
supplies, and intensive care costs for people who never live
to leave the hospital.  The report shows that this enormous
cost is the result of attempting to resuscitate patients who
have suffered serious brain and heart damage and can only
exist through "heroic" measures such as respirators,
pacemakers, and heart-lung machines.

Secondary in consideration is the fact that prolonged
resuscitation of patients in asystole (no viable electrical
activity in the heart) takes valuable community resources
from those that could actually benefit from the efforts of
paramedics and other emergency medical care providers. One of
the studies reported that a single cardiac arrest patient may
require as much as an hour or more of paramedic's time, two
hours of nursing time, and an hour of emergency physician
time. In many communities, the number of paramedics and
Mobile Intensive Care Unit (M.I.C.U.) ambulances is extremely
limited.  Often, paramedics working on "hopeless"
resuscitative procedures cannot respond to other calls where
their presence could make a life-saving difference.

Third, doctors say that the policy of "declaring the patient
dead at the scene" will help to safeguard emergency
responders who are often hurt while bouncing around the back
of a speeding ambulance while enroute to the hospital for the
patient to be pronounced "legally dead" by an emergency
physician.  Doctors say that little is gained by rapid
transport of a non-viable person upon whom aggressive
resuscitative measures have already been undertaken. In fact,
this practice may put additional people at risk for little
benefit.

The doctors warn, however, that the idea of discontinued
resuscitative efforts must be part of a paramedic system that
includes only the "best" Emergency Medical Service (EMS)
providers, (EMT-Paramedics) who have received competent
training and have adequate radio/telephone communication with
an experienced emergency physician.  They cautioned that
lessor trained or uninitiated paramedics or EMTs must
continue to provide CPR and transport even questionable
patients to the nearest appropriate hospital.

Fears have been raised by some physicians that less capable
paramedics will mistakenly not resuscitate patients with
hypothermia, drug abuse, extremely low heart rates, or other
conditions that may mimic death.  At least one case has occured
in New York City, involving a woman who was suffering from
hypothermia, that was not correctly diagnosed by Emergency
Medical Technicians (EMTs).  She was found alive by a coroner's
office worker after being "left for dead" by the ambulance.
These types of conditions have been specifically excluded by
the JAMA studies as causes for non-resuscitation.

Other observers have suggested that paramedics, in general,
are not adequately trained to make such important decisions.
But, Dr. Paul Pepe of the Houston, TX and author of one
JAMA study, disagrees and is quoted in USA Today as saying,
"It's about time we all start doing this formally . . . this
is a universal, aggressive, attempt to save everybody . . . but
if they don't respond to treatment . . . they don't respond".
Supporters of the policy point to EMS systems in Seattle,
Pittsburgh, Milwaukee and Houston, where the concept has
proved to be feasible.

The JAMA report says that the best opportunities for
successful resuscitations include fast access to emergency
dispatch systems (911), immediate initiation of effective
Cardio-Pulmonary Resuscitation (CPR), rapid defibrillation of
fibrillating (uncontrolled quivering) hearts, good
oxygenation of brain and heart tissue, and administration of
appropriate medications to regulate the patient's heartbeat
and blood pressure.  Experts say that paramedic systems are
the most timely and cost effective way of providing these
essential services to those in greatest need.

                             -30-
 
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