Paramedics make difficult decisions every day, but few carry more consequences for the patient than the decision whether to transport people who are in cardiac arrest, or to stay on scene continuing the resuscitation attempt. The colloquial phrases ‘stay and play’ and/or ‘load and go’ are often heard in ambulance station crew rooms referring to these decisions.
UK Resuscitation Council (2010) pre-hospital guidelines state that ‘following out-of-hospital cardiac arrest, failure of ALS-trained emergency medical services (EMS) personnel to achieve return of spontaneous circulation (ROSC) at the scene is associated with an extremely low probability of survival’, with rare exceptions occurring in hypothermic and overdosed patients. The above statement is reflected in this quantitative study from Wampler et al, which aims to examine the influence of pre-hospital ROSC on cardiac arrest survival to discharge rates.
The researchers performed a retrospective analysis of data relating to attempted cardiac arrest resuscitations (2008–2010) from two cities in the United States. In fact, the data was being collected prospectively although not primarily for this study: the San Antonio Fire Department was collecting data for their quality assurance/improvement programme and the Cincinnati Fire Department was participating in another study examining out-of-hospital cardiac arrests.
A total of 2 483 resuscitation attempts were included in the study (n=1 933 San Antonio; n=550 Cincinnati). In total, 165 patients survived to hospital discharge, of which 154 (93.3%) achieved pre-hospital ROSC, with only 11 (6.7%) non-field ROSC patients surviving to hospital discharge. Eight of the 11 non-field ROSCs were witnessed arrests, two arrested in the presence of the emergency services, eight had an initial shockable rhythm, and none of them were found in asystole.
The non-field ROSC survivors represented a very small portion of the overall survivors, which leads the authors to discuss the role of termination of resuscitation (TOR) policies. The authors cite several other studies which suggest that aggressive treatment of the cardiac arrest patient at the scene before transport, compared with rapid transportation, is associated with improved outcomes. However, they also discuss other factors for consideration by rescuers when deciding whether or not to initiate transport to hospital: public and EMS crew safety, the adequacy of chest compressions and ventilations in a moving ambulance, the decreased availability of emergency department beds, and the consideration of continuing to consume resources in a futile situation. Strategies to reduce futile transports are also outlined, although the authors acknowledge that evaluation of TOR was not the primary purpose of this study.
Limitations are discussed in the paper including the absence of some important time intervals from within the datasets, such as response times, time spent on scene, and time from dispatch to hospital arrival. The authors openly discuss that response times may be a reason for the differing rates of shockable rhythms, although factors such as ethnic and socioeconomic differences cannot be excluded. Ethnic and socioeconomic differences between the US and the UK would need to be considered before applying this research to UK practice, along with issues surrounding bystander compliance with ambulance control CPR instructions.
This paper provides valuable information for pre-hospital practitioners, including the recommendation that transportation should be reserved for patients who achieve field ROSC and/or a shockable rhythm, as there seems to be no benefit in transporting patients who are in asystole on arrival of the EMS. Although the findings may be applicable to UK practice, as identified earlier, given differences in culture and EMS systems between the two countries, there is a need for further UK-based research to be carried out first.