Forgoing Resuscitation

The Los Angeles County EMS nontraumatic CA resuscitation policy, implemented July 1, 2007, slightly increased cases in which paramedics did not initiate resuscitation, reports Corita R. Grudzen, M.D., MSHS, at Mount Sinai School of Medicine in New York, and her California-based colleagues. The policy expanded guidelines to forgo resuscitation when requested by an on-scene immediate family member without other on-scene family objection, or when patient characteristics indicate little chance of survival without severe neurological impairment (asystole, 10+ minutes from patient collapse to CPR). Prior guidelines only allowed forgoing resuscitation with obvious signs of irreversible death (rigor mortis or decomposition) or when a valid written DNR or similar directive was presented.

Grudzen’s team evaluated 1,656 CA cases—approximately 59 percent men, about 68 years old on average, and fewer than 7 percent with written DNRs. Under the new policy, resuscitation was not initiated in 13.3 percent of patients (101 of 759); under the former policy, it was not initiated in 8.5 percent of all nontraumatic CA cases (76 of 897 patients).

“The evidence shows [the policy change] can be of benefit to patients and families,” Grudzen told Research Monitor. From follow-up focus groups held to assess reaction to the policy change, Grudzen’s group reports nearly unanimous positive reactions to the change among paramedics who implemented the new policy. Paramedics also noted relief of immediate family members who reported no-resuscitation requests and saw those requests honored. However, the change reveals a potential need for increased bereavement training, since medics now spend more on-scene time with distraught families.
— Resuscitation 11(6):685–690, June 2010.

Questioning O2

Take a deep breath … though current practice calls for oxygen delivery to AMI patients, presumably to reduce oxygen deficit to cardiac tissue, the benefit or harm of this practice has not been thoroughly studied. Amanda Burls, MBBS, MSc, and fellow researchers at the University of Oxford, United Kingdom, report that breathing extra oxygen in the first 24 hours after AMI may not benefit—and may actually harm—patients. They reviewed outcomes of 387 AMI patients (74 percent male). About one-half had oxygen via facemask or nasal cannula (4 to 6 L/min); the other half breathed room air either normally or via facemask at 4 to 6 L/min.

Numerous analyses of the data hint that of the 14 patients who died in-hospital, two to three times as many received oxygen rather than air. However, these results stem from a small sampling—and, therefore, Burls’ team notes, may have occurred by chance. They call for a large trial to determine whether oxygen benefits, harms or is simply ineffective for AMI patients.
— Cochrane Database of Systematic Reviews 2010, Issue 6, DOI: 10.1002/14651858.CD007160.pub2, June 16, 2010.

Public Fuzzy on Calling 911 for Stroke

John/Jane Q. Public don’t seem to fully recognize all stroke symptoms or the importance of activating EMS to obtain immediate care, prompting researchers of two studies to call for improved public education of stroke symptoms and when to call 911.
Out of 2,975 strokes in 1999 in a five-county region spanning greater Cincinnati/northern Kentucky, just 1,205 patients were transported because of 911 calls, found Dawn Kleindorfer, M.D., and colleagues at the University of Cincinnati. Overall, the study group was about 72 years old, 54 percent female and 17 percent black, with more than one-quarter having a history of stroke. Weakness, decreased consciousness, abnormal speech, dizziness or balance/coordination problems most often prompted calls for EMS. Numbness, headache and changes in vision were least likely to prompt a 911 call.
— The American Journal of Emergency Medicine 28(5):607–612, June 2010.

Results of a telephone survey of 4,841 adults in Michigan further highlight the average Joe’s disconcerting misunderstanding of stroke emergencies. Fewer than 28 percent of the respondents knew all three classic stroke symptoms—sudden slurred speech, sudden one-sided numbness and sudden blurry vision—found Chris Fussman, M.S., and colleagues at the Michigan Department of Community Health in Lansing. Of the respondents who adequately understood stroke symptoms, fewer than 18 percent said they would call 911 for a patient showing all three classic symptoms.
— Stroke, DOI: 10.1161/STROKEAHA.110.578195, published online May 13, 2010.

Overtime May Hurt Your Heart

Work three to four overtime hours daily and your heart disease risk may be 60 percent higher than peers who don’t. Marianna Virtanen, Ph.D., and colleagues at the Finnish Institute of Occupational Health in Helsinki and the University College of London in the United Kingdom followed 6,014 British civil servants for about 11 years. After allowing for age, gender, marital status, occupational level and multiple heart disease risk factors, they identified the increased risk from three to four—but not one to two—hours of daily overtime. Further research must determine if personality type, behavior/lifestyle factors or stress accounts for increased overtime-related heart risk.
— European Heart Journal, DOI: 10.1093/eurheartj/ehq124, Medical News Today, May 11, 2010.

Shift Start Time Tied to Fatigue

Shifts starting between 8 p.m. and midnight may lead workers to get as little as 4.5 hours of sleep each workday. But shifts starting between 9 a.m. and 2 p.m. are more likely to allow for eight hours of sleep daily, according to research presented at a sleep society meeting.

Angela Bowen, research assistant at Washington State University in Spokane, and colleagues used mathematical models to predict how work schedules affect 24-hour sleep time. Schedules varied by one-hour increments, lasted for six days, and allowed no at-work sleep or any sleep for one hour before or after each shift. Shift start times can maximize sleep and, the researchers note, may result in better employee alertness.
— Abstract 0198: Estimated fatigue risk for duty periods with different start time in 24h operations, Sleep 2010, San Antonio, Texas, June 8, 2010.