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Section V: Prehospital cardiac arrest, in-hospital cardiac arrest, and the ethics of cardiac arrest research
CONCEPTS
cardiac arrest, prehospital cardiac arrest, research
ection V: Prehospital Cardiac Arrest, In-Hospital Cardiac Arrest, and the Ethics of Cardiac Arrest Research From the Department of Internal Medicine, University of Iowa, Iowa City.
Richard E Kerber, MD
Presentedat the Methodology in CardiacArrest Research symposium in Chicago,April I991.
JANUARY1993 22:1
ANNALS OF EMERGENCY MEDICINE
[Kerber RE: Section V: Prehospital cardiac arrest, in-hospital cardiac arrest, and the ethics of cardiac arrest research. Ann EmergMealJanuary 1993;22:103-104.] This section features a heterogeneous group of articles. It begins with a brief overview by Stewart, "Beyond Methodology: Improving Clinical Systems," in which he emphasizes that a series of interdependent developments is necessary for a successful community clinical approach to the problem of sudden cardiac death. Provocatively, he suggests that to the now familiar "chain of survival" we should add two new components: an initial link of prevention and a final line of quality assurance. Although these elements have been suggested by others, Stewart uniquely suggests that emergency medical services (EMS) personnel may have an important role in their implementation. Stewart also emphasizes the importance of tight medical control of emergency medical systems: "The influence of the medical director of an EMS system on the success and improvement of such a system cannot be overstated." The second paper, by Galleher and Vukov, discusses the success of emergency medical technician-defibrillation (EMT-D) systems in rural communities. They emphasize the differences between survival from cardiac arrest in "large" rural communities (population of 15,000 to 40,000) and "small" communities (less than 15,000 people). Although four major studies have suggested that EMT-D programs in rural communities are successful, Galleher and Vukov point out that the success rate in rural communities must be further subdivided; only 19 of 333 patients (6%) from small rural communities survived versus 34 of 233 (15%) from large rural communities (P < .001). The reasons for this difference are attributed to differences inherent in EMS systems: A larger community is more likely to maintain a 24-hour staffed ambulance service with full-time EMTs, a universal access 911 system, and a fully staffed emergency department in the local hospital. None of these facilities are likely to be present in smaller communities, where ambulance services typically
1 03/1
3 1
CARDIAC
ARREST
Kerber
consist of volunteer EMTs with fewer backup facilities. In addition, small rural communities have a low annual volume of patients with cardiac arrests and larger number of volunteer EMTs; the result of this is that each EMT has minimal yearly experience with cardiac arrest patients. It should be noted, however, that even in small communities, EMT-D services do better than control communities with no EMT-D programs, which typically have survival rates of only 2% to 4%. Galleher and Vukov also emphasize that to be meaningful, a designation as a "survivor" should imply return to prearrest neurologic status and lifestyle. Studies should carefully specify the degree of functional recovery that "survivors" achieve. The third paper in this group is by Jastremski and deals with in-hospital cardiac arrest. Jastremski suggests that the in-hospital cardiac arrest situation is an excellent "laboratory" for the evaluation of new therapies and approaches to the problem of cardiac arrest. The in-hospital setting features a more rapid response time, higher survivorship, and better monitoring of data collection. Investigators can feasibly arrive at the bedside early in the arrest to monitor and oversee accepted and new therapies. Jastremski presents a template for reporting in-hospital arrest; such a standardized template system, similar to the Utstein recommendations, would provide key data necessary to understand, replicate, and compare studies. The template in particular emphasizes the importance of reporting prearrest disease severity and long-term functional outcome. As Jastremski states, "It is time for our scientific inquiries concerning inhospital cardiac arrest to shift from observational reports to controlled clinical trials so that the efficacy of existing and new resuscitative techniques can be determined." The final paper, by Miller, reviews the ethical aspects of research in the cardiac arrest situation. He emphasizes that informed consent by an autonomous patient is mandatory. Investigative approaches to cardiac arrest can be justified only if two treatments exist that are so evenly balanced that a physician could honestly say there is no reason to prefer one over the other and no reason to prefer either over treatments currently in use. Miller suggests that broader criteria for exceptions to informed consent may not adequately protect the patient's right to autonomy. This view represents an extension of the familiar medical dictum "primum lion nocere"--here the concept of "do no harm" is applied to ethical as well as physical health. Our challenge, as investigators in cardiac arrest, is to search for ways of implementing bold new initiatives without violating the accepted right of the patient to autonomy.
132/ 104
Address for reprints: Richard E Kerber,MD Departmentof Internal Medicine Universityof Iowa Hospital Iowa City, Iowa 52242
ANNALS OF EMERGENCY MEDICINE
22:1
JANUARY
1993
cardiac arrest, prehospital cardiac arrest, research
ection V: Prehospital Cardiac Arrest, In-Hospital Cardiac Arrest, and the Ethics of Cardiac Arrest Research From the Department of Internal Medicine, University of Iowa, Iowa City.
Richard E Kerber, MD
Presentedat the Methodology in CardiacArrest Research symposium in Chicago,April I991.
JANUARY1993 22:1
ANNALS OF EMERGENCY MEDICINE
[Kerber RE: Section V: Prehospital cardiac arrest, in-hospital cardiac arrest, and the ethics of cardiac arrest research. Ann EmergMealJanuary 1993;22:103-104.] This section features a heterogeneous group of articles. It begins with a brief overview by Stewart, "Beyond Methodology: Improving Clinical Systems," in which he emphasizes that a series of interdependent developments is necessary for a successful community clinical approach to the problem of sudden cardiac death. Provocatively, he suggests that to the now familiar "chain of survival" we should add two new components: an initial link of prevention and a final line of quality assurance. Although these elements have been suggested by others, Stewart uniquely suggests that emergency medical services (EMS) personnel may have an important role in their implementation. Stewart also emphasizes the importance of tight medical control of emergency medical systems: "The influence of the medical director of an EMS system on the success and improvement of such a system cannot be overstated." The second paper, by Galleher and Vukov, discusses the success of emergency medical technician-defibrillation (EMT-D) systems in rural communities. They emphasize the differences between survival from cardiac arrest in "large" rural communities (population of 15,000 to 40,000) and "small" communities (less than 15,000 people). Although four major studies have suggested that EMT-D programs in rural communities are successful, Galleher and Vukov point out that the success rate in rural communities must be further subdivided; only 19 of 333 patients (6%) from small rural communities survived versus 34 of 233 (15%) from large rural communities (P < .001). The reasons for this difference are attributed to differences inherent in EMS systems: A larger community is more likely to maintain a 24-hour staffed ambulance service with full-time EMTs, a universal access 911 system, and a fully staffed emergency department in the local hospital. None of these facilities are likely to be present in smaller communities, where ambulance services typically
1 03/1
3 1
CARDIAC
ARREST
Kerber
consist of volunteer EMTs with fewer backup facilities. In addition, small rural communities have a low annual volume of patients with cardiac arrests and larger number of volunteer EMTs; the result of this is that each EMT has minimal yearly experience with cardiac arrest patients. It should be noted, however, that even in small communities, EMT-D services do better than control communities with no EMT-D programs, which typically have survival rates of only 2% to 4%. Galleher and Vukov also emphasize that to be meaningful, a designation as a "survivor" should imply return to prearrest neurologic status and lifestyle. Studies should carefully specify the degree of functional recovery that "survivors" achieve. The third paper in this group is by Jastremski and deals with in-hospital cardiac arrest. Jastremski suggests that the in-hospital cardiac arrest situation is an excellent "laboratory" for the evaluation of new therapies and approaches to the problem of cardiac arrest. The in-hospital setting features a more rapid response time, higher survivorship, and better monitoring of data collection. Investigators can feasibly arrive at the bedside early in the arrest to monitor and oversee accepted and new therapies. Jastremski presents a template for reporting in-hospital arrest; such a standardized template system, similar to the Utstein recommendations, would provide key data necessary to understand, replicate, and compare studies. The template in particular emphasizes the importance of reporting prearrest disease severity and long-term functional outcome. As Jastremski states, "It is time for our scientific inquiries concerning inhospital cardiac arrest to shift from observational reports to controlled clinical trials so that the efficacy of existing and new resuscitative techniques can be determined." The final paper, by Miller, reviews the ethical aspects of research in the cardiac arrest situation. He emphasizes that informed consent by an autonomous patient is mandatory. Investigative approaches to cardiac arrest can be justified only if two treatments exist that are so evenly balanced that a physician could honestly say there is no reason to prefer one over the other and no reason to prefer either over treatments currently in use. Miller suggests that broader criteria for exceptions to informed consent may not adequately protect the patient's right to autonomy. This view represents an extension of the familiar medical dictum "primum lion nocere"--here the concept of "do no harm" is applied to ethical as well as physical health. Our challenge, as investigators in cardiac arrest, is to search for ways of implementing bold new initiatives without violating the accepted right of the patient to autonomy.
132/ 104
Address for reprints: Richard E Kerber,MD Departmentof Internal Medicine Universityof Iowa Hospital Iowa City, Iowa 52242
ANNALS OF EMERGENCY MEDICINE
22:1
JANUARY
1993