From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: CPR (was: Meno "Marketeers")
Date: Wed, 01 Oct 1997
Newsgroups: alt.support.menopause

In <19971001024601.WAA07307@ladder01.news.aol.com> lblanch000@aol.com
(Lblanch000) writes:

>Twenty years ago, when I worked at Rodale and was attending a trade show
>in Atlanta, a total stranger collapsed at my feet and died, gasping for
>breath, a few minutes later. I'll never forget the terror in his eyes or
>the wrenching sense of helplessness I felt. I signed up for a CPR course
>as soon as I got back home and renew my certification regularly.
>
>
>Regards,
>Laura Blanchard



   You understand.  Alas, CPR is only minimally better than nothing at
all for the average person in cardiac arrest from a heart attack.  You
get blood flow to the brain (a trickle) that way for a couple of
minutes, not much more.  It's difficult in the studies to show that
trickle makes any difference at all when used as a bridge to
cardioversion (shock), which is what you're really waiting for.
There's not much doubt the money training people for CPR would be
better spent on getting the paramedics with their defib equipment there
faster, when it comes to cardiac arrest.  We get a very biased view of
CPR and how well it works by watching TV.  Stats show that mostly you
might as well save your breath.

   CPR does work effectively sometimes on drownings and chokings
(primary respiratory arrests), where the heart spontaneously restarts
often, and the victim starts out in better shape, and younger.   And
the old open heart massage can generate very good blood flows to the
brain if you can find somebody who still knows how and has the guts.
And something sharp.

   When somebody's heart has stopped, the clock is ticking on their
brain, and we generally don't have a good way to fix that until the
heart is restarted.  CPR is not the answer.  Transportation is the
answer, and mobile blood pumps, and a resuscitation protocol which will
let us save brains that have been without flow for a much longer time.

                                      Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Meno "Marketeers"
Date: Wed, 01 Oct 1997
Newsgroups: alt.support.menopause

In <60sasc$ktr@ocean.silcom.com> joanliv@silcom.com (Joan Livingston
Attorney at Law) writes:

>As glowing as Steve reports incident of CPR of the kid drowning in the
>swimming pool, I asked my instructor how often this happens in real life
>at my last CPR coures a few weeks ago and he said almost never and that
>he has never seen it happen personally as an EMT. Emergency room docs I
>know cringe when they see this "heroic" CPR on television as it distorts
>the publics expectation of miracles. Just ain't so according to those
>soruces.


   ROFL, I just read this message after writing much the same, and had
to laugh, because you're almost right.  CPR sucks.  Except, BTW, for
perhaps drowning, where CPR does shine and has since the mid 18th
century (never let your instructor tell you otherwise).

   In any case, I didn't report the wonderful drowning story.  And what
I'm talking about in resuscitation technology resembles CPR about like
a 747 resembles a horse-drawn carriage.

                                         Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: CPR
Date: Thu, 02 Oct 1997
Newsgroups: alt.support.menopause

Pikakix@ix.netcom.com


Lblanch000 wrote:

> As I read this exchange, Steve is saying that it's very important to
> call for the emergency medical folks because CPR isn't as helpful as one
> would like. I agree -- and when that man collapsed at my feet, I ducked
> into the nearest store and had an employee call 911. Then I went back
> and stood there while he died. I would have preferred to be trying
> *something,* even it had only a minimal chance of being effective.


>>Steve posted a couple of statements that I was responding to
"CPR sucks" and "Stats show that mostly you might as well save
your breath."   I still  find both of these statements very
inappropriate and unprofessional for this newsgroup.<<


   Comment:  Hey, that's your problem.  CPR does suck-- it's a
rare series in which as many as 10% of people who get it make it
out of the hospital even alive, much less without permanent brain
damage.  And revise that figure down still farther for CPR on
people who've had cardiac arrests from heart problems.  I wish
there were something better (and I'm in fact working on something
better, so this isn't just idle talk).  And in many cases it's
true that you might as well save your breath, though that's not
(please note) the same as a recommendation that nobody do it.

   I'm usually a fix-it kind of person, and favor an active role
for doing something if there's even modest evidence that it may
do good, and the downside is small.  CPR usually fits.  So go for
it-- I never said you shouldn't.   Just remember, however, that
CPR has some of the same problems going toward proving that it
works, as does hormone replacement.  There are no randomized
studies, of course.  The epidemiology we do have to work with is
confounded by all kinds of problems involving that fact that
people who arrive at the hospital in cardiac arrest who got
bystander CPR (who are indeed 2 or 3 times more likely to
survive) are not the same group to begin with as the people who
arrived in arrest without having gotten it.  The people with no
bystander CPR are older, they're sicker, and they are
statistically more likely to have gone down at home rather than
in public, where the more active and healthy people have their
cardiac arrests.  The reasons for their worse outcomes are
probably many, and it's impossible (as I said) to tease out the
CPR contribution.  If CPR was a drug, the FDA would never have
approved it-- so at least Joan is consistent about her attitudes.

   There is also the matter of whether CPR's effectiveness is
technique-dependent, and if so how much.  There is some evidence
that people found being given "effective" bystander CPR on the
scene by paramedics are 2 or 3 times more likely to survive.  But
the same confounders operate as in the CPR/no CPR epidemiology
(in a public place you're more likely to find a few good
operators than the average person is at home).  My own experience
is that CPR is far better taught in ICUs where the pressures can
be watched in real time from arterial lines while the operator is
doing it.  After doing a couple of dozen such cases one learns
the mechanics of the chest (which vary from person to person, but
can be felt during the stroke) and how to manipulate it to get
the best pressure impulses.  It's a bit of an art, and something
completely impossible to pick up from RescusiAnnie the mannequin.
So what do we do about public CPR teaching?   Is Annie still
worth using, or should we encourage people instead to learn "take
your cell phone with you" habits instead?

   And there is a downside to public spending on CPR education,
as opposed to volunteer efforts.  Every public dollar spent on
them is a dollar which could be spent instead buying defibrillat-
ors for public places, and ambulances and communications gear to
decrease paramedic response time, which faster response times we
are far more confident actually do save lives.  So what is the
proper ratio of spending?  With the mortality benefit from faster
response time more easily inferable and qualitatively measurable,
and the benefit from public CPR training not, again it becomes
rather hard to argue that we shouldn't spend money where we have
the much better evidence that is, and will do, a certain good.

   This may not be a politically correct opinion, I realize.
There ARE all those TV shows, and the public does like
empowerment.  CPR classes can be a bit like karate classes, you
know-- you're not really that much less vulnerable, but it can be
important to FEEL that way.

                                  Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: CPR
Date: Thu, 02 Oct 1997
Newsgroups: alt.support.menopause

In <34334DD6.1236@ix.netcom.com> Pikakix@ix.netcom.com writes:

>>  My own experience
>> is that CPR is far better taught in ICUs where the pressures can
>> be watched in real time from arterial lines while the operator is
>> doing it.
>>                                   Steve Harris, M.D.
>
>
>It's been my experience that in doing CPR, we are trying to obtain  a
>cardiac rhythm on the monitor & a palpable pulse.  Since art lines
>measure Blood Pressure, why is that your priority?


   A pulse is what you use if that's all you've got.  But what you
really want to see is the digital MAP (mean arterial pressure) readout
which tells you how you're perfusing your patient.  You simply cannot
tell what your mean pressures were very well by feeling a carotid,
(especially when your MAPs are 60, as in CPR), because the pulse tells
you more about peak pressures and vessel characteristics.

   If you can see the waveform from your A-line on the scope as you
work, this is also even better than feeling it.  Besides the MAP you
can get as good idea of the form of the upstroke by watching it, and
how well you're increasing it with increasing pressure and sharpness of
your downstroke.  It's a simple kind of biofeedback (which you
certainly cannot do with pulse, for no other reason than you can't do
two things at the same time).  With a very little of this you can
increase your MAPs by 10 or 20 points on just about anybody, within in
a minute or two of watching.

   This is all pretty important, because even the best CPR generates
crumby MAPS.  And studies show that flow to the brain disappears pretty
fast mo matter what you do in CPR, even as CPR continues and pressure
stays up.   A patient in fibrillation is a bomb with a fuse burning
down, and all CPR does is make it burn a little slower.  Not much.

                                              Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
	talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 11 Mar 1999 07:23:03 GMT

In <7c68c2$9q6$1@antiochus.ultra.net> wright@nospam.clam (David Wright)
writes:

>>Q: What's the worst thing that can happen at a scene?
>>
>>A: Having a doctor show up.
>
>No kidding.  A friend of mine was a paramedic in Ohio in the 80s; the
>rule there was that the EMTs didn't have to defer to any MD other than
>a trauma doc, and they could get the cops to remove any other MD who
>showed up at an accident scene and tried to take over.



  Good rule, and one a doc would have to be a fool to try to ignore.
This is one of the reasons they give med students in many places the
chance to ride with EMTs (but not do much more than watch and take
extraneous vitals). That's to show you how much you don't know.

   That said, there are all kinds of degrees of experience in doctors.
Sure the trauma guy should take charge.  But if it's an
anaesthesiologist who happens by an EMT would be a fool not to assign
him or her the intubations.  Or a cardiologist the rhythm strip
intepretation.  So long as not having to supervise, any doc on the
scene can be very useful to take vitals and help triage.  You find out
what people know, and use it.  At the last bad car accident I got to,
the only medical people on the scene were an EMT who wasn't on the job
and had been driving by, and me.  He had a little bit of old equipment
in an emergency kit. He intubated and I did CPR.  We could have done it
the other way, but the intubation had been done when I got there.  We
didn't fight about authority.

   There are all kinds of knowledge, some declarative (what drug does
what) and some procedural (manual skills).  During my residency I
worked on the "code blue team" for a hospital in the days before there
was a lot of attention to advanced directives.  I've done a LOT of CPR,
and a fair amount of it on patients who had A-lines in, and who you
could therefore see pressure tracings from, for direct feedback.
That's the way to learn CPR.  So I'm considerably better at chest
compression than the BLS certified guy who has his nice certificate
from his recent close encounter with a Laerdahl manikin (which, even if
$100,000 models, still don't feel quite right).  But how to communicate
this?  It's not enough to say "I know CPR."  You don't know it till you
KNOW it.  And when you know it, it's like riding a bicycle or skiing.
You don't forget the feel of the chest and what it takes for different
chests of different compliances, in the matter of what kind of impulse
you need to get just the right "bounce" for the best blood pressure.
Procedural-cerebellar memory, that.  The drugs, and when you give what
and when, you do forget.  And besides, it changes.  And further, none
of it makes that much difference anyway with the drugs available now.
A bag valve mask, O2 tank, and a defibrilator is what you need.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.cardiology,alt.health.policy.drug-approval,alt.activism,
	talk.politics.medicine,sci.med
Subject: Re: Doctor-bashing
Date: 12 Mar 1999 08:38:40 GMT

In <36e7befc.50042276@news2.ziplink.net> cgregory@gw-tech.com (Carey
Gregory) writes:

>sbharris@ix.netcom.com(Steven B. Harris) wrote:
>
>>In <36E7A3A9.B2CDE89@gw-tech.com> Carey Gregory <cgregory@gw-tech.com>
>>writes:
>>
>>>Long enough for me to say don't even try, please. I wouldn't want to be
>>>the thing that gets resuscitated.
>>
>>
>>    No reason to think you'd be any different, if the job was done
>>right (of course, we won't know until it's tried on people-- don't hold
>>your breath. It won't be in the US).
>
>I meant with current procedures.  You mentioned doing a lot of CPR in
>an earlier post.  That means you know what 17 minutes of down time
>means today.  If I've been down 17 minutes, just toss some grass seed
>on me and make me into a nice lawn ornament.
>
>--
>Carey Gregory



    Yep.  CPR buys you really very little (enough to be worth doing for
the first ten or fifteen if it's done well, but nothing like enough to
keep damage from happening very rapidly).  It's trickle flow.  At 17
minutes a normothermic adult even with the best CPR is probably indeed
going to wind up as that ornament.

    Though never say never in biology.  I once did CPR on a little
elderly lady who'd been in low output cardiac failure or so long, and
was so skinny, that she perfused well enough to maintain consciousness
with CPR.  And had no rhythm at all.  We'd stop, and 5 seconds later
her eyes would defocus and she'd go out.  Start again and she'd blink
and move her arms.  We finally just had to stop.  While she was still
conscious.  Thankfully I doubt very much if she understood what was
going on.

    There are a few stories of cardiologists and such, who manage to
make it to ERs by themselves in V-fib, managing to perfuse themselves
with "cough-valsalva" self-CPR.  I would not have believed this as a
tale, but it's been seriously reported and documented.  That must be a
fast learning curve.  If you don't grunt hard enough, the lights start
to go out....

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: electrocution cases
Date: 27 Mar 1999 15:02:28 GMT

In <7d6ppm$min$1@nnrp1.dejanews.com> steve1339@hotmail.com writes:

>Information source:Encyclopedia of Occupational Health and Safety, Third
>(revised) edition, Technical editor: Dr. Luigi Parmeggiani -- furnished
>by NIOSH National Institute of Occupational Safety and Health
>
>Excerpts from Volume 1:
>
>
>The reference states that CPR (the external cardiac massage) is first aid
>for ventricular fibrillation - in that it will maintain circulation --
>but it will NOT restore the heart's function.	It will maintain
>circulation until medical help arrives (defibrillator).


   It won't maintain circulation very well-- your brain is still dying.
With CPR you're just buying a tiny bit of time.  The old method of
cutting a hole in the side of the chest and squeezing the heart by hand
really did get blood pressures up to normal, and could be kept up for
astonishingly long times without brain damage (of course, it was gory
and you had to know what you were doing).  With closed chest CPR,
forget it.  You're just slowing damage down.

   And while CPR can't be counted on to stop V-fib, in the very early
stages, when the arteries of the heart still have some oxygen in them,
a sharp blow to the chest will occasionally convert V-fib to normal
rhythm.  If you actually see somebody go down and you very rapidly
determine that they have no pulse, I still think that a good thump or
two on the chest is warrented.  Perhaps even again, after a couple of
chest compressions to get some oxygenated blood into the heart.
There's nothing like early restoration of normal rhythm.

From: David Rind <drind@caregroup.harvard.edu>
Newsgroups: sci.med
Subject: Re: Research Funding: (was jets and propellers)
Date: Wed, 14 Jul 1999 10:03:02 -0400

Steven B. Harris wrote:
> Hey, I have it on good authority that medical students used to cause
> fibrillation in each other with AC, then countershock them out of it,
> for drill.  Just as you saw in flatliners.  Of course, they didn't
> wait several minutes to do it.

Are you serious?  Apart from the risk of death from fibrillation,
an external AC current can cause permanent nerve damage.

--
David Rind
drind@caregroup.harvard.edu

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: morphine & no food/water
Date: 13 Jul 2000 04:58:44 GMT

In <g2ojms8v8snv280ismsu48vsjh9l0gca79@4ax.com> Carey Gregory
<cgregory@gw-tech.com> writes:

>It is DELAYED, not prevented entirely.  CPR (when performed
>flawlessly) produces about 1/3 the normal blood flow to the brain and
>other vital organs.  This is enough to buy some time, but it's not
>enough to prevent permanent damage after more than a few minutes.
>Anything more than about 6-7 minutes will usually leave some degree of
>brain damage.


   Yep.  It's a losing battle, inasmuch as the low brain perfusion
pressure in standard CPR results in regional brain ischemia, which (via
a lot of complicated mechanisms) results in brain capillary blood
sludging and further loss of flow.  This vicious cycle continues until
at about 15 minutes (give or take) of CPR in an older adult at normal
body temperature, you aren't getting enough brain flow to be worth the
trouble, and you might just as well quit.  They don't show you that on
"ER," but it's true.

   The chief value of closed-chest CPR beyond 5 minutes or so is for
resuscitation of people in hypothermia, or children, or in suffocation
deaths (ie, drowning, etc). Here it allows oxygenated blood to be
circulated through the heart, so that defibrillation by shock, when it
is at last available, is successful. When that happens, resuscitation
of the brain is actually done by the re-started heart. In fact, that's
really the only way this all can work.

  Very occasionally a heart in ventricular fibrillation will re-start
itself after CPR, especially in younger people who have suffocated.
This is akin to precordial thump VF conversion.  However, it's not the
general rule. As for the brains of heart attack victims waiting for
electrical defibrillation, the low flows from CPR in the first 10
minutes are better than nothing, but only barely. The tradeoff is poor
enough that ACLS guidelines now suggest you call 911 BEFORE you start
chest massage. Thus, If you're alone and it takes a minute to give the
information, and the patient has no CPR for that minute, it's still
worth it to let him lie there, while you use your cell phone.

  BTW, this applies only to the new chest compression type CPR. The old
style heart massage where an incission was made between the ribs on the
left and the heart manually squeezed in one or both hands, results in
*excellent* blood pressures and brain perfusion-- nearly normal, in
fact. The reason closed-chest CPR with its poor brain perfusion won out
in hospitals in the 1960's, was simply that it was less icky, and
sometimes still worked if somebody had a defibrillator handy. Nobody
ever did a randomized study to show it was as good as open-chest heart
massage, which is what is supposed to happen (so says the FDA) before
one therapy is replaced by another. And, of course, there is
considerable reason to think closed-chest CPR isn't nearly as good.
However, it is now politically correct, and by now there's almost
nothing that can be done scientifically to prove otherwise. Ethics
committees would not even sanction a study, and this was a done deal
even before HIV sealed us in. The story of how the public got stuck
with an inferior modality which the public somehow was convinced
nevertheless is magic, is quite a tale of salesmanship, denial, and
urban mythology. Such a triumph of public relations and wishful
thinking over the facts, someday deserves a book-length treatment.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: morphine & no food/water
Date: 14 Jul 2000 06:22:42 GMT

In <rzMPWVA16Zb5EwS6@nevis-view.demon.co.uk> Surfer!
<nevis-view@nospam.demon.co.uk> writes:
>
>In article <8kjia4$4pn$1@nntp9.atl.mindspring.net>, Steven B. Harris
><sbharris@ix.netcom.com> writes
><snip>
>>
>>  BTW, this applies only to the new chest compression type CPR. The old
>>style heart massage where an incission was made between the ribs on the
>>left and the heart manually squeezed in one or both hands, results in
>>*excellent* blood pressures and brain perfusion-- nearly normal, in
>>fact. The reason closed-chest CPR with its poor brain perfusion won out
>>in hospitals in the 1960's, was simply that it was less icky, and
>>sometimes still worked if somebody had a defibrillator handy.
>
>And of course thousands of lay people have now been taught chest
>compression CPR, and in their hands it has saved lives which otherwise
>would have been lost while they waited for someone to open their
>chest.


   Yes, and the flip side is people given closed chest CPR in hospitals
who could have been saved with open chest, but instead were given the
wrong treatment, and wound up brain-dead.  The best is ever the enemy
of the good. As I said, closed chest CPR is better than nothing, but
only just barely. I suspect that, over all, it distracts resuscitation
research in bad ways. We have 20 drugs for ACLS heart resuscitation,
but not one for brain resuscitation-- a rather glaring mismatch in
knowledge. If CPR, with all of its bells and whistles, wasn't
distracting people with heart starts, the problem of what to do for
someone warm and dead for 10 minutes would show up more acutely, I
think.  As it is, when the heart re-starts, everybody sighs a sigh of
success and goes away satisfied.  Wow, wonderful stuff that CPR.  Two
days later the patient is a braindead organ donor, but that feedback
isn't immediate.  So it's very easy to fool oneself.

From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med
Subject: Re: morphine & no food/water
Date: 15 Jul 2000 09:03:21 GMT

In <8koo6q$57q$1@freenet9.carleton.ca> as488@freenet.carleton.ca (Tom
Staresinic) writes:

>Steven B. Harris <sbharris@ix.netcom.com> wrote in message
>news:8kmbji$gh9$1@slb7.atl.mindspring.net...
>> ....
>>    Yes, and the flip side is people given closed chest CPR in hospitals
>> who could have been saved with open chest, but instead were given the
>> wrong treatment, and wound up brain-dead.  The best is ever the enemy
>> of the good. As I said, closed chest CPR is better than nothing, but
>> only just barely.
>
>So defribrillation by shock is not considered 'resuscitation' ? Why would
>a hospital give either CPR or heart massage if they have a device for
>defribillation by shock?

Because it's never on-site immediately.  Also, not all arrests are
witnessed, and that loses time.  CPR is a bridge to get to to a
successful shock.


>Are paramedics capable of doing a heart massage during transport to the
>hospital, or can it only be done in a surgical room at the hospital?

   Most paramedics aren't capable of open heart massage, and those that
are, won't.  All are capable of closed chest massage.



>> I suspect that, over all, it distracts resuscitation
>> research in bad ways. We have 20 drugs for ACLS heart resuscitation,
>> but not one for brain resuscitation-- a rather glaring mismatch in
>> knowledge. ....
>
>What does 'resuscitation' mean? What do these drugs do for the organs?


   Broadly, resuscitation means return to normal function after lack of
blood flow. The drugs for the heart do various things.  Drugs that work
in the brain (animal models) do everything from unplug capillaries to
sop up free radicals to block toxicity from over-excreted
neurotransmitters.  Dozens of mechanisms are known.

From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: sci.med,sci.med.cardiology,sci.med.nursing
Subject: Re: To CPR or Not To CPR?
Date: Tue, 11 Jun 2002 16:15:44 -0700
Message-ID: <ae60cf$e0u$1@slb4.atl.mindspring.net>

ton4 wrote in message <550e20a0.0206111349.7da3ee08@posting.google.com>...
>To make a long story short, my elderly father is quite weak, has
>Alzheimer's and congestive heart failure, and lives in a convalescent
>home. He desires a full code advanced directive for CPR should
>circumstances warrant, largely because that's what I want.


Do you want what he would have wanted, when he didn't have Alzheimer's
disease? Is this what you'd want for yourself if you were in his position?
How do you want to end your life?


>In the event of circumstances needing cpr, one of three things can
>happen, depending on the instructions of the advanced directive:
>1. if the advanced directive prohibits cpr, none is given and the
>elderly person likely dies;
>2. if the advanced directive orders cpr be given, then the elderly
>person either doesn't revive or does revive, probably with broken
>ribs, as I understand it, which quite likely will eventuate death
>while greatly diminishing quality of life.


Broken ribs are hardly the worst that can happen. The worst is more brain
damage and/or a long stint on a ventilator in an ICU before eventual death.
Young people take periods of no blood flow to the brain better than old
people with dementia.


>My reasoning is that if the person would have died anyway without cpr,
>nothing is lost in the attempt to revive with cpr, and successful
>application of the procedure means that there is the chance that ribs
>will not be broken and the person will live, or if they are broken and
>death ensues from related complications, then that is what would have
>happened had cpr not been administered, and no one is out anything, as
>it were, for the attempt except perhaps in the context of quality of
>life.


Well, true, you're not out anything if you're not the one who spends his
last days on a ventilator, and you're not the one paying for it.


>My first question is this:
>In order to spare everyone involved the necessity of following what
>seems to be an undesirable procedure in such a case as I've described
>above, why don't nursing homes keep onhand the electric shock
>cardio-resusitating equipment that would avert the need for applying
>cpr in the first place?


It wouldn't.  Most of the CPR applied to elderly people that ends up doing
any good (i.e. with somebody making it out of the hospital), is CPR that was
applied for a respiratory, not a cardiac arrest. Often the heart never does
quite stop, so defibrillators do no good. Even in primary cardiac arrest
(V-fib and the like) you only have about a minute before defibrillation
doesn't do any good without CPR first. The reason is that a heart without
coronaries full of oxygenated blood cannot be defibrillated, and you need
CPR to get some oxygen into the coronaries first.

This is not to say that defibrillators in nursing homes aren't a good idea.
Just don't get the idea that they would replace CPR. They would supplement
CPR only.

>My second question is:
>Is it true that the vast majority of elderly people given cpr
>experience broken ribs or bones from its administration that eventuate
>death?

No, they probably don't-- the broken rib thing is a scare story that they
use to shake some sense into families who think that CPR is magic. Doctors
and nursing homes know it isn't, and that it IS mostly futile, but they have
a hard time getting the idea across without a good metaphor. Crunching ribs
in an elderly person is a good metaphor to explain the problem to the
general public, and indeed, it sometimes happens (I've done it, and the
sensation sticks with you). But it's not the main problem.

The main problem is that the fraction of elderly people getting CPR in an
institutional setting who end up getting out of the hospital and back to the
institution again, is tiny. Something like 5% (though of course it varies
widely due to many variables).

>This issue has haunted the family for over a year. Thank you for your
>response.


You're welcome.

SBH

--
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From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: sci.med,sci.med.cardiology,sci.med.nursing
Subject: Re: To CPR or Not To CPR?
Date: Wed, 12 Jun 2002 11:27:01 -0700
Message-ID: <ae83r4$h1l$1@slb0.atl.mindspring.net>

Richard Cavell wrote in message ...
>CPR is much less effective in the long run than the medical profession will
>let on to.

The medical profession's got nothing to do with it.  It's the popular
misconception spread by TV dramas (E.R.) and the like, where even people who
have arrested from a gunshot bleedout in the field get CPR (now there's a
recipe for futility). TV and movies where the incidence of recovery of
patients who get CPR is hugely larger than in reality (somebody actually did
a stat count on TV resuscitations and found it very misleading).


> The probability of getting more spontaneous heart beats after
>heart attacks requiring CPR in intensive care units is in the order of 70%.
>On the street with untrained operators it's like 2%.  But the long-term
>survival is appalling in both cases.

The difference, we might note, is not mainly due to "trained operators" in
hospitals, but rather the time delay in getting trained operators and a
defibrillation unit to the field (street or home, and BTW, outcome is better
for public cardiac arrests than home arrests, since they are more often
witnessed). If you have V-fib in the E.R. while monitored you have about 2
changes in 3 of being resuscitated, and making it out of the hospital alive
and functional.  But your chances of going home functional degade from that
linearly by about 10% a minute that you don't get ROSC (return of
spontaneous circulation), until at about 10 to 12 minutes, they are about
zero.

Now you'd think CPR would make a big difference in this, and there are
studies showing that both bystander and hospital CPR do improve outcomes.
But it's very difficult to disentangle them, not least because bystander CPR
is always applied in situations in which no decent arrest times can be
measured. So all you can calculate is bystander CPR vs none at all.

In hospital CPR, it's still surprising how crappy outcomes are if you don't
get ROSC within 10 minutes (almost always by shock) even if CPR is done. The
probable reason is that CPR gives you less than 50% normal brain flow most
of the time (with a wide dependence in patient and operator) and this just
isn't enough. CPR is no substitute for defib-- you're just dying a little
more slowly is all.

Again the caveat of how and where the CPR is done, in in-hospital. As an
intern in the ICU doing CPR on people with arterial lines in, I could see
the pressure pulse and read the MAP (essentially the average blood pressure)
in real-time, and use that for feedback. With a patient young enough to have
a springy chest, with a bit of practice shaping the impulse I could deliver
MAPs over 80 torr (ie, normal) most for the time for the first few minutes
of CPR at least (and BTW this is a GREAT way to learn chest compression
technique-- must better than ResusiAnnie dolls).  But you don't get all that
in the field.  I sometimes wish there was a device allowing CPR operators to
sense carotid pulse while working. You can have a second person do that FOR
you (and should) but it's not the same as an A-line and the feedback loop is
much inferior. Have any of you EMTs done CPR with carotid doppler on, and
running acustically?

SBH







>
>> will not be broken and the person will live, or if they are broken and
>> death ensues from related complications
>
>After CPR, death will occur because of whatever made them need CPR.  For a
>person's heart to stop beating is catastrophic in and of itself, broken
>ribs or not.
>
>> The entire medical community where I live is unanimous in strongly
>> discouraging my position, given my father's age, but they will abide
>> by our wishes.
>
>Your father's age has nothing at all to do with his quality of life or his
>right to have CPR.  I'd make sure that if a CPR directive is given, that it
>is followed properly.  Medical people sometimes engage in pseudo-codes,
>where they only pretend to resuscitate someone.  Either they're going to do
>it or not.  Nothing would make the sue the Bejesus out of a
>hospital/nursing home, and hunt the deregistration of her carers, like
>finding out that they had failed to properly resuscitate my mother.
>
>> In order to spare everyone involved the necessity of following what
>> seems to be an undesirable procedure in such a case as I've described
>> above, why don't nursing homes keep onhand the electric shock
>> cardio-resusitating equipment that would avert the need for applying
>> cpr in the first place?
>
>In Australia, I think it would be mandatory to have a 'crash cart' with
>defibrillator.
>
>CPR and defibrillators are used in two different circumstances.  CPR is
>when the heart stops beating entirely (and won't defibrillate).
>
>> Is it true that the vast majority of elderly people given cpr
>> experience broken ribs or bones from its administration that eventuate
>> death?
>
>I seem to remember that the incidence of broken ribs is something like 50%.
>But it's not the broken ribs that cause death.  Even if broken ribs
>occurred, if he were in pain, he'd be put on morphine (which might kill him
>anyway).
>
>> This issue has haunted the family for over a year.
>
>Then the answer should be pretty clear to you.  I think you're feeling
>guilty because you're about to provide a no-resuscitate order.  Why would
>you feel guilty about doing all that you can?
>
>
>
>---
>
>Checked by AVG anti-virus system (http://www.grisoft.com).
>Version: 6.0.370 / Virus Database: 205 - Release Date: 6/5/2002
>
>

--
I welcome email from any being clever enough to fix my address. It's open
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From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: sci.med,sci.med.cardiology,sci.med.nursing
Subject: Re: To CPR or Not To CPR?
Date: Thu, 13 Jun 2002 11:17:28 -0700
Message-ID: <aeanlc$498$1@slb1.atl.mindspring.net>

Richard Cavell wrote in message ...
>"Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com> wrote in message
>news:ae83r4$h1l$1@slb0.atl.mindspring.net...
>> and functional.  But your chances of going home functional degade from that
>> linearly by about 10% a minute that you don't get ROSC (return of
>> spontaneous circulation), until at about 10 to 12 minutes, they are about
>> zero.
>
>Well, the brain will be fully dead within those 10 minutes.  And then the
>resuscitation seems to exist mainly to preserve the organs for
>transplantation.


Just to correct a common misperception (though it will not make you feel
better). The brain is not "dead" at 10 minutes, or even 15. Nobody knows
where and when it dies, except that it's some hours after the insult. The
question may not have any philosophical meaning (until you reach critical
information loss you're as dead as your repair technology is bad--- just as
with an old car).  It's not like brain cells go balloey: neurons can be
cultured from cadavers at 8 hours after clinical death with normal morgue
cooling, and such slow air cooling is not that good.

How do we know about the whole brain?  Dogs have about the same sensitivity
to post resuscitative encephalopathy as humans: after 10 minutes of it they
all go to brain death (hours later) or severe damage. But if you cool them
(their brains) very fast after return of circulation (like cooling your
finger after burning it, or cooling a sports injury) and give them a
cocktail of anti-inflammatory drugs, you can get them back with minimal
brain damage after more than 15 minutes of warm (37.5 C) cardiac/circulatory
arrest.  I have one right here named "Bob" who lay on the OR table in V-fib
with NO blood pressure for 15 minutes. He's fine. He's since learned where
the catfood bowls are in the front lab office area, and in all respects
seems to be a normally socialized dog considering his beginnings (he was a
class B dealer hunting dog reject). We have 2 others from past 15 min and
they're fine.

The bad news: this technology requires a dozen drugs the FDA will never
approve separately (each doesn't work powerfully enough) and would never
approve in combination without being proven separately (Catch 22--- try
proving that locking ONE car door out of 4 prevents any fraction of
break-ins). Also it requires an extremely rapid cooling method (-4 C in 15
min) which can't be achieved except by pouring cold fluorocarbon down the
lungs and sucking it out a about 30 times.  The FDA will take 10 years to
approve such a thing, since both fluorocarbon and device would have to be
entirely new NDA (New Drug/Device Application) items.

Your tax dollars at work. None of them come MY way.

SBH


--
I welcome email from any being clever enough to fix my address. It's open
book.  A prize to the first spambot that passes my Turing test.

From: "Steve Harris" <sbharris@ix.RETICULATEDOBJECTcom.com>
Newsgroups: sci.med,sci.med.cardiology,sci.med.nursing
Subject: Re: To CPR or Not To CPR?
Date: Fri, 14 Jun 2002 13:32:29 -0600
Message-ID: <aedgnc$nll$1@slb6.atl.mindspring.net>

"Dr. Andrew B. Chung, MD/PhD" <andrew@heartmdphd.com> wrote in message
news:3D08F3EC.CE72D5FB@heartmdphd.com...
> Actually, this depends on the presenting rhythm and clinical picture.
> Defibrillation is often *better* than CPR.

COMMENT:

It's always better if you can do it.  Of course, after a bit of fibrillation
(something like a minute-- not precisely known, and varying widely) you
can't defibrillate without CPR first. And it gets harder and harder-- the
longer you're without blood pressure, the more poisoned and acidotic you'll
be.

After 20 min of pulselessness from V-fib induced by a 1 sec AC shock, we can
get anesthetized dogs back to sinus rhythm and good blood pressures with
only one or two DC countershocks. Unfortunately that takes fancy pressor and
buffer drugs, and also heart-lung bypass to oxygenate the heart and restore
systemic BP *first*.

And while their hearts are fine, their brains sometimes are not.

I don't know what the limit is for simple closed chest compression CPR in
this model.  Dogs have funny chests anyway, so chest compression is more of
a side-to-side manual thing. Very hard to say how it translates to humans.

A last note: I think medicine does bear some blame for rushing (circa 1960)
into closed chest compression for restoration of BP, before anybody did any
trials to see how it compared with open chest heart massage, which was then
the common modality. Closed chest was pushed for outside the hospital, and
it sort of took over everywhere, even before HIV. So just about everyplace
happily switched to closed chest CPR, which is lucky to give systolics of 40
or 50 without invasive arterial monitoring, when they could have been doing
open chest that gives you normal systolics in a fluid resuscitated patient,
almost guaranteed. Nobody but aggressive ER docs and thoracic surgeons do
that now.

 The reason you have to defibrillate NOW, NOW, NOW is basically to get back
decent blood pressure.  Closed chest CPR is deep, deep shock-- the only
thing you can usually say about it, is that it's better than nothing, if you
want a chance to save the patient.

SBH