New Article

I have just published an article in Emergency Medicine News regarding the AHA’s promotion of AEDs in hospitals,recommending changing the guideline (because AEDs don’t help). I say that in addition to the negative evidence, the original decision was illegitimate because evidence detailed in an invited evidence-based worksheet was not considered (i.e., was suppressed). Here is the URL for the article:

http://journals.lww.com/em-news/Fulltext/2015/01000/Viewpoint__Changing_an_ECC_Guid eline__or_Not_.14.aspx

Ancient History

I'm back again after another long hiatus. The two worksheets submitted to the AHA in the run-up to Guidelines 2000, referred to in the post "Handling apparent asystole...," May 28, 2012 (see below) are now available online:

 

AEDs and trained caregivers: http://goo.gl/9E1aCx

 

Shocking apparent asystole: http://goo.gl/OhGIML.

 

Delayed in-hospital defibrillation: Anybody out there?

I’m posting about this again. It is incredibly frustrating to me that some 25 years after I brought the problem of delayed in-hospital defibrillation to the attention of the AHA, nothing effective has been done to address it. Back then I guess I thought (naively, as it turned out) that the remedy to this problem (a rather obvious one, for those who care to look) would be found by a collaborative effort. That was not to be.

A few AHA ECC committee members--the same ones I had contacted about the issue--took it and ran with it, without any credit to me and in a direction I thought was misguided: promoting AEDs for in-hospital use. I believe that approach has rather definitively been shown to have failed (see Chan study cited above and others). Does this mean that that nothing can be done about the problem, or even that it does not exist? No, no, no.

I am apparently a persona non grata with the ECC people. This is partly because I wrote something in the mid-90s that a then-powerful ECC official disagreed with--to put it mildly. Went ballistic is more like it. He notified me later in a letter that he was spreading the word about me, and recommended that I should pursue other interests.  My continued  expressions of skepticism about AEDs in hospitals, conflicting with the AHA’s promotion of them, is another factor.

I have not succeeded in pursuing “other interests.”  This is simply too important an issue to die on the vine. There can be no doubt that quicker defibrillation for in-hospital cardiac arrests would improve survival significantly. I believe I have some good ideas to address the problem. Is anyone, anywhere, interested in working on it? See:

Open-access article in Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine:

http://www.sjtrem/com/content/18/1/42

Handling apparent asystole and the AHA's approach to the exchange of ideas--Part II

My later involvement in this issue and the AHA's response (or non-response) is briefly summarized in a 2008 article:

Stewart JA. The prohibition on shocking apparent asystole: a history and critique of the argument. Am J Emerg Med. 2008 ;26(5):618-22.

However, the main purpose of that article was to critique the AHA's shifting rationales for prohibiting shocks for apparent asystole and to suggest an unstated reason for the prohibition. I'll go more deeply here into my views about the personal/political aspects of the AHA's position.

In 1999, the AHA issued an invitation to the general healthcare community to submit "evidence-based worksheets" for consideration at the conferences that were to determine the 2000 AHA Guidelines for Emergency Cardiac Care. The invitation was long and detailed, saying in part:

A major reason the we are seeking contributions and proposals is to allow everyone interested in CPR and ECC to "have their say" on a guideline proposal. We know that you have good ideas and thoughtful proposals. This worksheet allows you to make your voice heard.

I wrote about the invitation on a listserve I subscribed to at the time that was run by Merginet and dealt with ECC topics. I knew that the AHA physician I had so angered (albeit unintentionally) several years earlier also subscribed (In 1996 I had received a letter from him saying that he had spread the word about me among his colleagues and that consequently my ideas would be given no credence), which I think was the reason that a couple of days later the invitation disappeared from the AHA ECC web site.

A few weeks later, essentially the same invitation appeared in Currents in Emergency Cardiac Care. I had already been working on my two worksheets, a very time-consuming process, and I thought the deadline in this latest invitation was unrealistic (about a month as I remember) if they really wanted to encourage submissions. I said so on the Merginet listserve, and shortly thereafter the deadline was extended by two weeks.

I submitted two worksheets (with co-authors) by the deadline, one on the topic of shocking apparent asystole and another on the AHA's promotion of AEDs for trained caregivers. I did not receive even an automated e-mail acknowledgment of receipt (I had to call), which I thought peculiar given the elaborate and lengthy invitation:

The worksheet is not simply a medium for suggestions--we have other methods for receiving suggestions. You proposal or "great idea" can only be considered if accompanied by a reasonable attempt to complete the Evidence Worksheet. Preparing the worksheet requires an investment of time.

A bit later an invitation appeared for a few members of the general public to apply to attend the first Guidelines 2000 Conference where changes to the Guidelines would be discussed. Applicants were required to submit a form describing their accomplishments in the field of cardiac resuscitation and reasons for wanting to attend. I thought I had a good shot, having been the principal author of two worksheets, and I applied. I was turned down. When I inquired about the reasoning, I was told that all the applicants were deemed equally worthy, so they had simply selected those who had sent in the applications first. A second invitation was issued for the second conference and I applied again, sending my application on the same day the invitation appeared. Again, I was turned down.

I made several subsequent inquiries about the worksheets: How many were submitted, on what topics, and most importantly, why was public acknowledgment of the submissions never given, even though it had been clearly promised in the original invitation? (To quote again from the invitation: "The names of all persons who submit a worksheet will be acknowledged in a credits section of the journal in which the Guidelines 2000 are published.") The replies I received were obfuscations and evasions: a "handful" of worksheets had been received, and apparently no one had kept copies. I suspect that my two worksheets were the only ones submitted, and since I was out of favor with the ECC experts, they had been buried.

Beyond my personal sense of outrage about these events, I think this history shows that for the AHA ECC Committee, personalities and politics can trump ideas, even when many lives may be at stake. More about these matters later.

Copies of the worksheets I and my co-authors submitted are available on request.

Asystole followed by ventricular fibrillation?

This post does not directly continue the previous post (I'll get to that later). This a question that relates to my 2008 publication:

Stewart JA. The prohibition on shocking apparent asystole: a history and critique of the argument.

Am J Emerg Med. 2008 ;26(5):618-22.

However, it is an idea/question that I did not raise in that article. Asystole changing to ventricular fibrillation (VF) is occasionally documented in the literature (Example: Meaney PA. Rhythms and outcomes of adult in-hospital cardiac arrest. Crit Care Med. 2010; 38(1): 101-8)), but I have never seen a hypothesis for the mechanism of such a metamorphosis. I am no cardiologist, much less an electrophysiologist, but my limited understanding of cardiac electrophysiology makes me wonder how electrical silence could spontaneously morph into frenetic (disorganized) electrical activity. I get that automaticity of cardiac cells can begin to generate a ventricular rhythm, but VF? It seems more plausible to me that a moving VF vector might produce the appearance of asystole followed by VF in a single monitoring lead. This of course is relevant to the hypothesis that VF may have a vector. Maybe it is more than a hypothesis: documented cases of "occult" VF seem to be strong evidence that VF can have a vector, though the frequency of the phenomenon is unknown (see my article referenced above). 

Handling apparent asystole and the AHA's approach to the exchange of ideas

Years ago, I think in 1994, I noticed a question in Currents in Emergency Cardiac Care (an AHA-published newsletter for caregivers, apparently since defunct) about shocking apparent asystole (flatline). The answer was that you shouldn't do it. My interest was piqued because not even a hint of a rationale was given in the answer. I decided to look into the matter.

Shocking apparent asystole was first strongly discouraged in the 1992 ACLS Guidelines, based on the rationale that shocks caused a "parasympathetic storm" which would lessen the chance of a natural pacemaker  restoring a cardiac rhythm. I found that the references cited as supportive in the Guidelines did not actually support this hypothesis. I raised this and other objections in a manuscript to Currents. After several months, I learned from the then-editor Mary Newman that the editorial board had accepted the manuscript, which they planned to publish along with a reply from an ECC Committee member. After a few more months, I learned that the reply had been deemed unacceptable for publication by the editorial board and that the author had apologized to the board; the result was that neither the reply nor my original manuscript was published. Ms. Newman was kind enough to supply me with a copy of the reply, and it was clear to me why it had been ruled unacceptable for publication: it was personal, vitriolic--and perhaps most importantly, did not address any of the issues I had raised.

Later, I submitted essentially the same manuscript to the American Journal of Emergency Medicine as an editorial; it was initially rejected on the basis of one reviewer's comments. Based on a brief excerpt from the comments that the editor shared with me, I strongly suspected that the reviewer was the same physician who had gone ballistic in his response to my submission to Currents. (I belatedly noticed that he was on the editorial board of AJEM.) I believe that he should have recused himself, and that not doing so represented a breach of prevailing standards for peer review. I called the AJEM editor, who acknowledged problems with the review and agreed to publish my manuscript as a letter: Stewart JA. Questions remain about shocking asystole. Am J Emerg Med. 1996 May;14(3):337-8.

More later (perhaps).

The "dangers" of defibrillation

Most clinicians have heard tales about defibrillator accidents, and for the most part that is all they are: tales (or urban legends). External defibrillation has been performed for over half a century, with untold millions of shocks delivered. After all that time and all those shocks, the total number of documented deaths or serious injuries to caregivers giving shocks to patients is—none. Zero. Nada. Is this because safety precautions have been scrupulously followed? Of course not. In the often chaotic setting of a code, anything that can go wrong will go wrong—at least occasionally. And yet the record shows that operating a defibrillator is extremely safe.

This is not to say that caregivers have not received mild shocks causing discomfort now and then. Many probably resulted from the use of messy conductive gel with hard paddles. When hard paddles are used at all these days, solid conductive pads are normally used for the skin/paddle interface. But the norm today is dual-function (for monitoring and defibrillation) hands-free, self adhesive pads. Recent research suggests that with these pads the chance of even a mild shock to the operator or bystanders is vanishingly small. There is even growing interest in the possibility of giving a shock without stopping chest compressions. [1-3] Giving a distinct “clear” order is still advisable, but don't make it an elaborate, time-consuming ritual.

What about dangers to patients? If the patient is truly pulseless, it is a stretch to maintain that even an “inappropriate” shock—that is, a shock for pulseless electrical activity (PEA) or asystole (despite what the AHA says; I'll address this in a later post)—would cause real harm. If the patient has an organized rhythm with a pulse and is shocked, there is indeed a chance (around 5%) of causing VF; elective cardioversions are “synchronized” with an organized cardiac rhythm to prevent this possibility by avoiding shock delivery on the vulnerable part of the cardiac cycle. There have been a few reports of attempted cardioversions accidentally causing VF because the shocks were not synchronized. However, those cases are not relevant to emergency defibrillation for cardiac arrest.

Finally, I can't resist referencing one of my favorite movie scenes, which illustrates an extremely unlikely danger to the operator in defibrillating a victim--if the "victim" happens to be a malevolent, shape-shifting alien that has taken on the form of a human being. It's from the 1982 John Carpenter film "The Thing" (warning: this scene is extremely gory and gross). Of course, this isn't real; you can tell because the placement of the paddles is all wrong: http://www.youtube.com/watch?v=JjIXwkX1e48.

1. http://www.resuscitationjournal.com/article/S0300-9572%2809%2900014-8/abstract
2. http://www.resuscitationjournal.com/article/S0300-9572%2811%2900635-6/abstract
3. Perkins GD, Lockey AS. Defibrillation--Safety versus efficacy. Resuscitation. 2008;79(1):1-3.