“There is no price that justifies no improvement” –Rogue Medic
Fellow paramedic and blogger, Rogue Medic recently wrote two blog posts questioning the motives of EMS services that purchase LUCAS devices 1 2. One of the biggest reasons was the failure of the device to improve outcomes during a recent study that compared mechanical CPR to traditional CPR (LINC Trial).
Before I even begin to debate the data, let’s figure out what kind of price we would pay for “no improvement”.
Before writing this response, I took some time to examine the equipment I use on a daily basis. Needless to say, I was shocked to discover that we spend a lot of money of items that really don’t improve patient outcomes at all. One example is the Stryker Power Cot. Although I tried, I couldn’t find any studies that compared patient outcomes to those transported using a manual cot. Another major purchase was the LifePak 15 ECG monitor / defibrillator. Once again, I couldn’t find anything showing improved patient outcomes. It appears that both of these devices only make the responder’s job easier.
All sarcasm aside, I think it’s perfectly acceptable for a service to spend money on equipment that improves the working environment. Stair chairs, video laryngoscopes, fancy heart monitors, power cots, and nice ambulances are all examples of things that don’t improve patient outcomes, but do improve our ability to do our job effectively.
Now, back to the LUCAS. Even if I didn’t dispute the data that Rogue Medic provided during his recent articles (and I will), I could still justify spending the money on the devices. It’s a glass half-full vs half-empty kind of thing. Saying that the device “failed to improve outcomes” makes the thing sound worthless. What if we said that the LUCAS proved to be “just as effective as high-quality manual CPR”? Now it sounds like we’re spending money on something that takes less physical exertion, requires fewer responders and produces the same results. Interesting.
No, there isn’t much data to suggest that using a LUCAS improves outcomes. Likewise, we aren’t discovering that it’s hurting people either. So at the very worst, it’s a luxury item. Most of us that have used it – especially those working in rural areas – know that it’s more than that. Now I’m not running around yelling that the “LUCAS saved my patient”, as Brooks Walsh pointed out in a recent article 3. I am however, saying that it makes my job a hell of a lot easier.
Having spent the last 3 years of my career in rural Texas, I can say that the device has earned its spot on my ambulance. Moving out of the big city and going to work in an area that utilizes volunteers as first-responders means that I often find myself working a resuscitation with just me and my partner. If – and I emphasize the word “if” – we happen to get first-responders to these calls, we still have no idea what kind of training or experience they have.
As I’m writing this article, I can already see the e-mails coming in saying that “the answer is to train our people to do better CPR”. I don’t disagree, but we can only control what’s in our control. If I’m running the EMS system in Seattle and I have direct access to all the responders, then implementing that kind of training should be happening. I’m sorry, but controlling the quality of care provided by the rancher in rural Texas that’s showing up for free on his day off isn’t exactly an easy task.
I’m not knocking the care provided by volunteers. I too have been a volunteer and I know the value of the care they provide. Having said that, it’s hard to get strict on training when they are already going out of their way to provide service to their community.
Now on to the data.
The LINC trial studied 2,589 patients with out-of-hospital cardiac arrest. The patients were randomized to receive either manual CPR or mechanical CPR. They mainly looked at the four-hour survival rate of the selected patients with a secondary focus on six-month survival with good neurological outcome 4. One advantage that the mechanical CPR devices had, was the ability to deliver shocks while continuous CPR was being performed. Many people have argued that this alone should have resulted in a slam-dunk for the LUCAS and the absence of a significant rate of survival proves that it doesn’t do any good.
Now, let’s take a step back and examine our thought process here. Based on what we currently believe to be the best way to improve outcomes, this should have produced better results. The LUCAS does everything we want, right? It delivers hard, fast and continuous chest compressions. It doesn’t stop and it doesn’t fatigue. Hell, it even keeps going during defibrillation. So do these results reflect on a device that’s over-hyped, or are we missing something in our current CPR guidelines? Keep in mind that this study involved highly trained and prepared responders using the most up-to-date recommendations for CPR delivery. We developed a machine to do exactly what we tell it to. It follows the guidelines exactly as we want, and yet, it can’t produce the results we hoped for. Perhaps the machine isn’t the problem.
Another issue I have with this data, is that it doesn’t address the following variables:
- Down time
- Whether or not bystander CPR was performed
- Medications used
- Whether or not an advanced airway was placed
- Length of resuscitation
All of these things are important when looking at the effectiveness of the LUCAS. Had all of these cases been witnessed full-arrests with immediate intervention, then I might feel differently. Perhaps they did look at these things, but from the data that’s available to the general public, I can’t determine whether or not the LUCAS doesn’t “do any good”. From what we can see, at the very worst it keeps up with some of the best-trained responders out there. Not bad, if you ask me.
We need to be looking at the whole picture here. If we can design a machine to do textbook-perfect CPR, and it doesn’t produce textbook results, then maybe we need to re-evaluate our textbook. Even if the studies do prove that the device isn’t improving survival rates, we still can’t discard the device as “worthless”. It has its place in situations with limited responders. And yes, the data supports that.
- The Failure of LUCAS to Improve Outcomes in the LINC Trial. (2014, March 05). Retrieved from Rogue Medic: http://roguemedic.com/2014/03/the-failure-of-lucas-to-improve-outcomes-in-the-linc-trial/ ↩
- The LUCAS, Research, and Wishful Thinking. (2014, March 07). Retrieved from Rogue Medic: http://roguemedic.com/2014/03/the-lucas-research-and-wishful-thinking/ ↩
- Walsh, B. (2014, March 3). “We had a LUCAS save!” – No, you didn’t. Retrieved from Mill Hill Ave Command: http://millhillavecommand.blogspot.com/2014/03/we-had-lucas-save-no-you-didnt.html ↩
- JAMA. (2014, Jan 1). Mechanical chest compressions and simultaneous defibrillation vs conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest: the LINC randomized tria. Retrieved from PubMed: http://www.ncbi.nlm.nih.gov/pubmed/24240611 ↩