"High Quality CPR" and You!

CPR as we know it was “invented” by numerous resuscitation scientists working in competing labs during the 1950s.  Since then, CPR has gone through a number of changes, from compression-to-ventilation rates, training programs and even the manner in which it is delivered.  In the 1990s, pubic defibrillators became mainstream.  In the mid 2000s, external CPR devices became more common and in 2010 “hands-only” CPR was the predominant layperson resuscitation method.  The latest iteration of CPR and resuscitation science is the focus on “high quality” CPR, “team-focused” CPR and “cardiocerebral resuscitation” (CCR).

When discussing CPR and the holy grail of evidence-based practice, there are a number of caveats to acknowledge.  Firstly, there have been a very limited number of prospective, randomized and controlled trials on CPR and resuscitation due to many inherent barriers to performing such a study – cost, the infrequency of out-of-hospital cardiac arrest (OHCA), and the difficulty and ethical concerns inherent in studying something which is thought to be efficacious (CPR) against something else which may not be.  Fortunately, there have been a number of trials conducted that can inform our practice, and large, curated resuscitation outcomes databases exist for retrospective studies.  In this article, we’ll discuss CPR, Rhode Island State EMS protocols, and the evidence for and against them.

LifePACT.jpg

In March of 2017, the Rhode Island Department of Health instituted new protocols requiring EMS providers to stay on the scene of an atraumatic cardiac arrest for up to 30-minutes, or until return of spontaneous circulation (ROSC) is achieved[i].  Pre-hospital medicine policies and protocols vary according to the region, state, resources, distance from definitive care, and culture.  When treating trauma patients, for example, EMS providers are instructed to transport as quickly as possible to a hospital.  Traditionally, EMS providers have also been taught to transport OHCA patients to hospitals quickly as well, so asking them to remain on-scene for up to 30-minutes is controversial.  According to the American Heart Association (AHA), approximately 355,000 people each year suffer an OHCA event (110 events per 100,000 population).  Studies vary, but the overall survival rate for OHCA is anywhere from 6-12%[ii],[iii] nationally.  Extrapolating these statistics to Rhode Island’s population of 1 million, we can estimate that approximately 1100 Rhode Islanders are having OHCA each year, or 3 people every day.  Clearly, OHCA is an important topic and is worth exerting considerable effort to improve outcomes.

Historically, we know that certain factors in OHCA have prognostic importance and are associated with better outcomes, including witnessed arrest, time to CPR and defibrillation, initial shockable rhythm (VT/VF), AED use, and patient ageiii,[iv].  Although there are a myriad of factors that play into treating OHCA patients – airway use, mechanical or manual CPR, ACLS drugs, etc., the idea behind emphasizing on-scene CPR is that it gives EMS agencies the opportunity to defibrillate as soon as possible, perform great CPR and increase a patient’s chance of ROSC by re-establishing myocardial perfusion, instead of focusing on patient packaging and transport.  In other words, the theory is that you can run a code in the field, in the ER, or in the back of an ambulance, but the sooner you run it well, the better odds a patient has of a good outcome.  Below, we’ll review some of the key concepts of high-quality CPR.

Continuous Chest Compressions

Chest compressions.JPG

Many simulation, animal and observational studies have been performed on all manner of aspects of CPR, including compression depth, recoil, and speed.  Recently, focus has been drawn to cardiocerebral resuscitation (CCR), or minimally interrupted, continuous CPR.  The concept behind this mode of CPR delivery is that of coronary perfusion pressure – that it takes time giving compressions to reach the threshold at which the heart has enough coronary blood flow to possibly begin beating again, and each pause in CPR resets the pressure to 0. In the 3-phase model of VF arrest, the first 5 minutes are the “electrical phase”, in which defibrillation can result in ROSC. After this is the “hemodynamic phase”, during which restoration of “adequate arterial pressure” by CPR can increase odds of ROSC.  Importantly, it can take up to 45 seconds to establish adequate arterial pressure.  Lastly is the “metabolic phase”, during which outcomes are poor[v],[vi].  According to this theory, the sooner patients get defibrillation and CPR, and the better the CPR is, the higher odds they have of ROSC.  To date, several registry-based studies seem to agree with this idea, and have demonstrated improved outcomes among both VF and non-VF arrests with high chest compression fraction (i.e., less CPR interruptions)[vii].  Assuming that continuous CPR, or high chest compression fraction is beneficial, it also follows that any interruptions during CPR can result in worse outcomes – for example, pauses around defibrillation, intubation and transport, and research has borne this out[viii].  It’s worth noting, however, that although many of these concepts have become resuscitation truths, not all research agrees.  In one of the few RCTs on CPR, published in the New England Journal in 2015, Nichol et al. compared continuous to interrupted chest compressions, and found no statistically-significant difference in favorable neurologic function at discharge, although the protocol compliance was low, and many variables were similar between both groups[ix].  Both groups, for example, had CPR fractions higher than typical, so both study groups may not be representative of the real world.

Passive Oxygenation and Delayed Intubation

Bag Valve Mask.jpg

One of the key exposures in the NEJM study by Nichol et al., was the mode of ventilation.  In comparing continuous to interrupted chest compressions, the “interruption” was providing rescue breaths in the traditional 30:2 ratio.  If we subscribe to the idea that it takes up to 45 seconds to develop enough coronary perfusion pressure that defibrillation might be successful, stopping CPR every 30 compressions begins to seem like a bad idea.  We also know that a provider’s focus on airway management can detract from compression quality.  One observational study found that pre-hospital providers caring for OHCA patients paused CPR a median of 109 seconds for airway placement[x].  Coupling this finding with other studies showing that CPR pause duration is associated with increased mortality[xi] leads us to consider forgetting about the airway completely (at least initially).  Other literature seems to support this idea.  McMullan et al published a paper in 2013 on data from the Cardiac Arrest Registry to Enhance Survival (CARES), evaluating different airway management techniques and their association with neurologically intact survival.  The authors found that of 10,691 OHCA patients, survival was highest among those who received neither endotracheal intubation nor supraglottic airways (OR of 1.31)[xii].  Although this appears damning for any types of airway management at face value, it’s worth noting that patients with the best outcome often will have no opportunity for airway management – in other words, they are shocked out of VF, then wake up!  More information is coming soon, with an RCT due to be published in 2020 comparing airway management methods prospectively.

CPR During Transport

Another significant factor in deciding whether to work a code on scene or transport rapidly is the quality of CPR possible.  On scene, with a team of prepared EMS personnel, it seems a reasonable assumption that CPR metrics would be superior.  Prior literature seems to support this conclusion, with a number of simulation studies demonstrating worse or more variable CPR metrics in patients during transport, such as compression depth and rate[xiii].  In a small study published by Olasveengen et al., non-traumatic OHCA patients had increased time without compressions during transport compared with when on scene (27% vs. 19%).  However, in one 2017 registry-based study in Canada, the proportion of OHCA patients receiving “high-quality” CPR, defined as depth >5cm, rate >100/min, and chest compression fraction of >0.7 was similar between on-scene and transported groups[xiv].  Even if EMS providers are able to provide high-quality CPR in the back of a moving ambulance, consideration must be made of the danger to EMS personnel, who are then required to stand and perform a physically demanding task in a moving vehicle.  The science is not completely clear on which method is superior – on-scene or in transport, though clearly these studies have implications for proponents of running on-scene codes.

Team-Focused CPR

Eager to implement these cutting-edge techniques, some EMS systems have published their results with high-quality, “pit-crew style” and “team-focused” CPR.  Stopyra published data from a prospectively collected pre and post-intervention cohort study in rural North Carolina.  Data was collected on OHCA from 1-year prior to the intervention and 1-year after the intervention implementation.  All OHCA of presumed cardiac etiology was included.  The intervention included training of all providers, including police and EMS.  They were instructed to fulfill a choreographed position based on the timing of their arrival to the code.  The first rescuer would begin CPR, the second would place defibrillation pads and insert a blind airway, the third would be the team leader.  After arrival of the third provider, parenteral access could be attempted.  Rescuers continued with resuscitation until ROSC or end tidal <10mm for 20 minutes.  They found that after protocol implementation, there was a significant increase in number of patients achieving ROSC (65.7% vs. 28.4%, p<0.001), though there was no statistically significant change in survival to discharge.  Some of the limitations of this study include the small n (105 total resuscitations), and the lack of ability to control for in-hospital care (with regards to the lack of difference in survival to discharge)[xv].

A second North Carolina was undertaken by Pearson et al, and published in Resuscitation, detailing OHCA outcomes before and after an intervention of “team-focused CPR”[xvi].  Researchers evaluated arrest characteristics of nearly 15,000 OHCA patients using CARES registry data.  EMS agencies self-reports compliance with “team-focused CPR”, which emphasized early defibrillation, high quality CPR, and airway management with BVM over advanced airways.  Authors used a logistic regression to control for arrest characteristics, such as CPR device used, witnessed or unwitnessed, race, comorbidities and hypothermia, and found that team-focused CPR had a better odds of good neurologic outcome as measured by cerebral performance category score (OR 1.5) compared with traditional CPR.

A similar effort was undertaken in Salt Lake City in 2011.  The results from SLC Fire Department’s “pit crew approach” were published in 2015 in the Journal of the American Heart Association.  This study had significantly larger numbers (737 attempted resuscitations), and was based in an urban department with 11 ALS units and 8 BLS units.   The intervention in SLC included use of defibrillator real-time feedback to rescuers, strong medical direction and QA of all OHCA calls, rhythm-filtering technology that allowed rescuers to see the rhythm during CPR prior to stopping for pulse-check, limited peri-shock pauses, and encouraged on-scene resuscitation (vs. early transport) to reduce interruptions inherent in transfer and transport.  Additionally, passive oxygen was applied via facemask for the first 6-8 minutes, and asynchronous BVM for all unwitnessed, pediatric and respiratory arrests. 

After the intervention, SLC Fire Department saw more field ROSC (44% vs. 30%, p<0.0001).  Among patients who survived to admission, there was more survival to discharge (50% vs. 37%, p=0.0005), and more patients with favorable neurologic function, defined as Cerebral Performance Category 1 or 2 (46% vs. 26%, p=0.0005), although there was no statistically significant change in survival to hospital admission.  Although these numbers are promising for high-quality CPR, several confounders are present, including improved medical control, and preferential triage of OHCA patients with ROSC to PCI-capable centers, which was not the practice in the pre-intervention period[xvii]

Rhode Island is among the first states to institute a protocol mandating 30-minutes of on-scene CPR. While some have demonstrated improved outcomes with the implementation of similar interventions, bundled together with CPR training, use of novel technology (such as real-time feedback, end-tidal CO2, and rhythm filtration programs), strong medical direction and QA, it remains to be seen whether a statewide intervention can lead to more ROSC in the field, and, more importantly, more neurologically intact survival to discharge.  Reviewing the resuscitation literature, we see the trend toward decreased initial advanced airway use, higher focus on continuous CPR and minimal interruptions, such as the peri-shock pause and, to delay transport of the patient until ROSC is achieved.  While local news reports have highlighted anecdotal success stories[xviii], the full impact of the Rhode Island intervention have yet to be described.

Faculty Reviewer: Nick Asselin, DO

References

[i] Rhode Island Statewide Emergency Medical Services Protocols.” Rhode Island Department of Health, p. 3.03a., health.ri.gov/publications/protocols/StatewideEmergencyMedicalServices.pdf.

[ii] Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Blaha, M. J., Cushman, M., … Turner, M. B. (2015). Heart Disease and Stroke Statistics—2016 Update. Circulation, 133(4), e38–e360. https://doi.org/10.1161/cir.0000000000000350

[iii] Becker, L. B., Aufderheide, T. P., & Graham, R. (2015). Strategies to Improve Survival From Cardiac Arrest. JAMA, 314(3), 223. https://doi.org/10.1001/jama.2015.8454

[iv] Haukoos, J. S., Lewis, R. J., & Niemann, J. T. (2004). Prediction rules for estimating neurologic outcome following out-of-hospital cardiac arrest. Resuscitation, 63(2), 145–155. https://doi.org/10.1016/j.resuscitation.2004.04.014

[v] Weisfeldt, M. L., & Becker, L. B. (2002). Resuscitation After Cardiac Arrest. JAMA, 288(23), 3035. https://doi.org/10.1001/jama.288.23.3035

[vi] Berg, R. A., Sanders, A. B., Kern, K. B., Hilwig, R. W., Heidenreich, J. W., Porter, M. E., & Ewy, G. A. (2001). Adverse Hemodynamic Effects of Interrupting Chest Compressions for Rescue Breathing During Cardiopulmonary Resuscitation for Ventricular Fibrillation Cardiac Arrest. Circulation, 104(20), 2465–2470. https://doi.org/10.1161/hc4501.098926

[vii] Vaillancourt, C., Everson-Stewart, S., Christenson, J., Andrusiek, D., Powell, J., Nichol, G., … Stiell, I. G. (2011). The impact of increased chest compression fraction on return of spontaneous circulation for out-of-hospital cardiac arrest patients not in ventricular fibrillation. Resuscitation, 82(12), 1501–1507. https://doi.org/10.1016/j.resuscitation.2011.07.011

[viii] Cheskes, S., Schmicker, R. H., Christenson, J., Salcido, D. D., Rea, T., … Powell, J. (2011). Perishock Pause: An Independent Predictor of Survival From Out-of-Hospital Shockable Cardiac Arrest. Circulation, 124(1), 58–66. https://doi.org/10.1161/circulationaha.110.010736

[ix] Nichol, G., Leroux, B., Wang, H., Callaway, C. W., Sopko, G., Weisfeldt, M., … Ornato, J. P. (2015). Trial of Continuous or Interrupted Chest Compressions during CPR. New England Journal of Medicine, 373(23), 2203–2214. https://doi.org/10.1056/nejmoa1509139

[x] Wang, H. E., Simeone, S. J., Weaver, M. D., & Callaway, C. W. (2009). Interruptions in Cardiopulmonary Resuscitation From Paramedic Endotracheal Intubation. Annals of Emergency Medicine, 54(5), 645–652.e1. https://doi.org/10.1016/j.annemergmed.2009.05.024

[xi] Brouwer, T. F., Walker, R. G., Chapman, F. W., & Koster, R. W. (2015). Association Between Chest Compression Interruptions and Clinical Outcomes of Ventricular Fibrillation Out-of-Hospital Cardiac ArrestCLINICAL PERSPECTIVE. Circulation, 132(11), 1030–1037. https://doi.org/10.1161/circulationaha.115.014016

[xii] McMullan, J., Gerecht, R., Bonomo, J., Robb, R., McNally, B., Donnelly, J., & Wang, H. E. (2014). Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation, 85(5), 617–622. https://doi.org/10.1016/j.resuscitation.2014.02.007

[xiii] Roosa, J. R., Vadeboncoeur, T. F., Dommer, P. B., Panchal, A. R., Venuti, M., Smith, G., … Bobrow, B. J. (2013). CPR variability during ground ambulance transport of patients in cardiac arrest. Resuscitation, 84(5), 592–595. https://doi.org/10.1016/j.resuscitation.2012.07.042

[xiv] Cheskes, S., Byers, A., Zhan, C., Verbeek, P. R., Ko, D., Drennan, I. R., … Morrison, L. J. (2017). CPR quality during out-of-hospital cardiac arrest transport. Resuscitation, 114, 34–39. https://doi.org/10.1016/j.resuscitation.2017.02.016

[xv] Stopyra, J. P., Courage, C., Davis, C. A., Hiestand, B. C., Nelson, R. D., & Winslow, J. E. (2016). Impact of a “Team-focused CPR” Protocol on Out-of-hospital Cardiac Arrest Survival in a Rural EMS System. Critical Pathways in Cardiology, 15(3), 98–102. https://doi.org/10.1097/hpc.0000000000000080

[xvi] Pearson, D. A., Darrell Nelson, R., Monk, L., Tyson, C., Jollis, J. G., Granger, C. B., … Runyon, M. S. (2016). Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation, 105, 165–172. https://doi.org/10.1016/j.resuscitation.2016.04.008

[xvii] Hopkins, C. L., Burk, C., Moser, S., Meersman, J., Baldwin, C., & Youngquist, S. T. (2016). Implementation of Pit Crew Approach and Cardiopulmonary Resuscitation Metrics for Out‐of‐Hospital Cardiac Arrest Improves Patient Survival and Neurological Outcome. Journal of the American Heart Association, 5(1), e002892. https://doi.org/10.1161/jaha.115.002892

[xviii] http://wpri.com/2017/02/16/new-rule-cpr-for-30-minutes-before-taking-cardiac-arrest-victims-to-hospital/

Money Minutes for Doctors #3 - The Entrepreneurial Doctor

Welcome to this month's edition of Money Minutes for Doctors. In this, our third episode, we discuss the opportunities for physicians to build wealth outside of the traditional W2. Our focus this month looks at the tax benefits of having 'physician partners', S corps, C corps, LLCs that are taxed as C corps, and those opportunities that involve 1099 Income. Back again for another look into the world of personal financial wellness for physicians and their families is Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors.

1456108851410.jpeg

About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

New and significant benefits under the new tax laws...

Know about the Pass through advantage—and how to shelter more income from taxes:

-applies to those that have income from partnerships or goes onto schedule C of your tax return, but outside the W2 income
-Can deduct 20% of this income and pay federal taxes on the remaining amount (the first 20% is exempt from federal taxes) Whether that income is also exempt from state taxes is variable depending on state
-Upper Limit of Taxable income to qualify for the pass through is $315,000 on MFJ (married filing jointly) and $157,500 if SF (single filer) 
-IF you are MFJ  and have Taxable income of $315-415,000 then the deduction is prorated % and if taxable income > $415,000 then deduction does not apply and phazes out after $207,500 for SF
-More complicated if incomes are above $415,000 (MFJ) as the deduction does not apply and phases  out after $207,500 for SF as then depends on if specified service business (health care qualifies as such). 

Goal:

The doctor who has some self-employment income can use tax planning to lower their taxable income to qualify for the deduction & reduce their overall taxable income.

Recommendations: 
(1) maximize your 401K, 403 B

(2) if you have your own practice consider a defined benefit plan that can be layered onto of 401K or 403b

(3) Make sure you know what business deductions you are eligible for, including the home office and maximize them! 

Need a good accountant and financial advisor to help you with these tax strategies
-this also offers you less risk to be audited and gives you some protection under their error and omissions insurance. 

There has never been a better time for doctors to earn some extra income and shelter it from taxes - Think Big !! 

section199A.png
pinterest.self-employment.png

AEM Early Access 14: Cannabis and Mental Health ED Visits in Colorado

Welcome to the fourteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:(Click title for open access through may 31, 2018)

Mental Health-Related Emergency Department Visits Associated with Cannabis in Colorado. Katelyn E. Hall MPH, Andrew A. Monte MD, Tae Chang, Jacob Fox, Cody Brevik, Daniel I. Vigil MD, MPH,  Mike Van Dyke PhD, CIH,  Katherine A. James PhD, MSPH. Academic Emergency Medicine, 2018.

LISTEN NOW: AUTHOR INTERVIEW

Monte head shot-2014.jpg

Andrew A. Monte, MD

Associate Professor, Departments of Emergency Medicine & PharmaceuticaLSciences
University of Colorado Denver-Anschutz Medical Center Aurora, CO and Rocky Mountain Poison & Drug Center
Denver Health & Hospital Authority
Denver, CO

ARTICLE SUMMARY: 

Objectives:
Across the United States, the liberalization of marijuana use has resulted in a rapid increase in the social acceptability of its use.  Colorado has been at the forefront of marijuana legalization, allowing recreational use beginning in 2014.  Since then, Colorado has positioned itself as the optimal environment to study health-related impacts from marijuana use.  Cannabis use is well-known to exacerbate mental health illness such as schizophrenia, mood disorders, anxiety, and depression.  Since legalization in Colorado, increased healthcare utilization has been associated with acute and chronic marijuana use.  It is currently unknown if cannabis use is associated with increased ED visits in patients with mental illness.  The primary objective of this study was to determine the prevalence ratios of mental health diagnoses among ED visits with cannabis-associated diagnosis compared to those without cannabis-associated diagnoses in Colorado.

Methods:
The study was cross-sectional in design, with discharge diagnostic codes collected from Colorado emergency departments from 2012 to 2014.  Diagnosis codes identified visits associated with both mental health conditions and cannabis.  Prevalence ratios of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis.  Rates of mental health and cannabis-associated ED discharges were examined of the study period.  

Results:
State-wide data demonstrated a five-fold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR: 5.35, 95% CI: 5.27-5.43) compared to visits without cannabis. In the study’s secondary outcome, state-wide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p<0.0001).

Conclusion:
In Colorado from 2012 to 2014 the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis.  Due to the nature of the study design, it is unclear if these findings are attributable to cannabis or coincident with increased use and availability.  Per the authors of the paper, ED physicians nationwide should be aware of the detriments of marijuana use on pre-existing mental health conditions and ED management should include counseling on cessation and rehabilitation.