Defending the Pit Crew


Over at Rogue Medic, during a criticism of the latest AutoPulse ASPIRE EXPIRE CIRC trial, he also criticized the Pit Crew approach to resuscitation. Or ADHDCPR, as he likes to call it.  I presented a half-day workshop about the pit crew last month.  Here is why I believe the concept works:

While Rogue Medic describes the pit crew as an unproven therapy, I consider it a conceptual learning tool to approach arrests.  I acknowledge that the only interventions proven to improve long-term survival from cardiac arrest are uninterrupted, high quality chest compressions, defibrillation, and to a lesser extent, hypothermia after ROSC.  I also acknowledge that for at least three more years, unproven and harmful positive pressure ventilation will continue to be delivered in all but a few forward-thinking communities, through one of a dozen or so unproven airway devices.  A number of equally unproven and possibly harmful medications will also be given, through one of a few dozen brands of sharp objects impaled in the poor soul’s body.

Given this unfortunate reality, I believe that that pit crew approach to resuscitation best protects what we know works. Rescuers have assigned roles before they arrive on scene.  One is assigned to chest compressions.  Another is assigned the airway, whose focus is minimizing the damage of positive pressure ventilation.  Another attaches the monitor/defibrillator while someone else does compressions.  An ALS provider’s primary job is to monitor the quality of compressions, check the rhythm, and shock if necessary.  Any other interventions are secondary, and must never compromise the quality of compressions.

When I think of ADHDCPR, I think of arrests with a period of chest compressions and a pause to check the rhythm.  Then compressors switch.  Compressions stop again so someone can place an unproven airway device intubate.  It’s the equivalent of driving a race car a few laps and stopping to get the tires changed.  A few more laps then refuel.  A few more and get the window washed.  During the stops everyone is uncoordinated, runs into each other, and occasionally fist fights.  I’ve done ADHDCPR, and it never worked out well for the patient.

Even if we only deliver the proven interventions – chest compressions and defibrillation – the compressor must be changed frequently and the rhythm must be analyzed.  Unless an unproven expensive compression device and “See Through CPR” option on the monitor are used, there must be a short pause in compressions to swap compressors, analyze the rhythm, and defibrillate.  The goal of the pit crew approach is to coordinate all three during a short, but inevitable, pause.

How often compressors need to be swapped depends on the fitness level of the compressor and the patient’s size.  The compressor’s effectiveness drops much faster then they think it does, especially in the decompression phase.  However often the compressor is changed, the next one should be identified and ready beforehand.  During the swap a rhythm check takes place. Based only on experience, I believe there must be at least five people to do this well on an average size patient.

So add the stuff that, at best, might work.  Compressions are the patient’s “track time.” The next compressor is selected. The next unproven medication and unproven airway strategy is discussed.  A plan for the next compressor change/rhythm is formed to minimize hands-off time.

I have never used a monitor with a “See Through CPR” option, and do not know if it works as well as the manufacturer says it does.  If it does work, and is used with an expensive unproven compression device, there is NO ACCEPTABLE REASON to pause compressions. Not until the patient regains a pulse or the arrest is terminated.  This is the equivalent of having a machine quickly change tires and refuel while a car is still on the track.  Still, first responders may perform manual CPR and defibrillation before that device arrives.  A coordinated effort is also needed to apply it quickly, and the rhythm may as well be checked during that time also.  Given that unproven interventions must still be delivered in most systems, they need to be done around the proven ones.  While less important than with manual CPR, I believe there is an advantage to the pit crew approach.

My take away lesson from the pit crew approach to resuscitation is that during a NASCAR race, every second in a pit stop must be made up on the track.  During a resuscitation, every second off the chest must be made up with better chest compressions and defibrillation after.  Everything else is secondary.

Rogue Medic and I will debate this topic on a special EMS Office Hours podcast Wednesday night.  Tune in, it is sure to be a lively discussion.

 

Comments

  1. Bob,
    I have to agree with you that I too am in disagreement with the view that Rouge Medic has on this subject. In his blog he states “Pit Crew CPR should be presumed a scam.” One of the concepts behind pit crew is to provide a “fresh” compressor to insure adequate compressions. AHA G2010 state that compressions should not be interrupted for more than 10 seconds. That time period is enough to stop compressions, interrupt the rhythm, charge for a shock if needed, and move in a new rescuer to resume compressions. The addition of “see though” monitor technology could even lessen this transition time. I know from watching folks participate in the recert you provided and running one of the skill stations that to make this method effective, providers need to practice over and over and also include outside agencies.
    I will however take a moment to disagree with you about the mechanical CPR and calling it unproven(any more than the pit crew theory). While I concur that it has not been widely shown to improve survival rates, I pose this to you. If this type of device HAS been proven to provide compressions at an adequate rate and at an adequate depth then how could this not provide better compressions than that of a fatiguing EMS provider. Once placed on you don’t have to worry about switching providers. You may actually gain the advantage, if and when a patient needs to be moved while still in arrest, of having effective compressions still being performed. I can attest that when I have been on a call with this type of device, perfusion was being maintained well enough to the level that IV access was difficult to tamponade.
    We all work in different types of systems. What works in some may have no place in others. What works some days may not work the next. NASCAR race teams do not all work the same. Not all races are run the same. Some come in for fuel only others just change out a few tires during a pit stop depending on many race factors. But it is done by a team of dedicated professionals who have the goal of getting their driver to finish-line and hopefully winning the race. If this team waited until the car pulled up and then decided what each one will do, the driver would suffer. It makes sense to me to pre-plan anything we do with the understanding that this is the real world and sometimes things do not goes as planned.
    I look foreword to hearing the lively discussion!

  2. Bob,
    I have to agree with you that I too am in disagreement with the view that Rouge Medic has on this subject. In his blog he states “Pit Crew CPR should be presumed a scam.” One of the concepts behind pit crew is to provide a “fresh” compressor to insure adequate compressions. AHA G2010 state that compressions should not be interrupted for more than 10 seconds. That time period is enough to stop compressions, interrupt the rhythm, charge for a shock if needed, and move in a new rescuer to resume compressions. The addition of “see though” monitor technology could even lessen this transition time. I know from watching folks participate in the recert you provided and running one of the skill stations that to make this method effective, providers need to practice over and over and also include outside agencies.
    I will however take a moment to disagree with you about the mechanical CPR and calling it unproven(any more than the pit crew theory). While I concur that it has not been widely shown to improve survival rates, I pose this to you. If this type of device HAS been proven to provide compressions at an adequate rate and at an adequate depth then how could this not provide better compressions than that of a fatiguing EMS provider. Once placed on you don’t have to worry about switching providers. You may actually gain the advantage, if and when a patient needs to be moved while still in arrest, of having effective compressions still being performed. I can attest that when I have been on a call with this type of device, perfusion was being maintained well enough to the level that IV access was difficult to tamponade.
    We all work in different types of systems. What works in some may have no place in others. What works some days may not work the next. NASCAR race teams do not all work the same. Not all races are run the same. Some come in for fuel only others just change out a few tires during a pit stop depending on many race factors. But it is done by a team of dedicated professionals who have the goal of getting their driver to finish-line and hopefully winning the race. If this team waited until the car pulled up and then decided what each one will do, the driver would suffer. It makes sense to me to pre-plan anything we do with the understanding that this is the real world and sometimes things do not goes as planned.
    I look foreword to hearing the lively discussion!

  3. I concur with your assessment of the focus of Pit Crew CPR. The goal is not to simply add more people, (union or otherwise, so I’m not sure what that had to to with it) but rather seek a coordinated effort centered around the proven resuscitation therapy; minimally interrupted chest compressions.

    Sound like the same thing we’ve always done? The difference in Pit Crew CPR is that this is taught (as I’m sure you did) through empowering each team member to make their own decisions. Doesn’t make sense? Everyone pulling together by “doing their own thing”?

    Example, Paramedic Defibrillates: Regular CPR=crew waits for next directive, medic is contemplating and possibly preparing next appropriate therapy, is hopefully NOT checking for a pulse or otherwise diddling around, directs compressor to resume. In Pit Crew CPR the compressor, regardless of rank, certification or assignment resumes immediately after the shock. Doesn’t need to wait to be told, just like the person starting the IV and administering meds (whatever they may be) doesn’t need to be told to get the stick without interfering with the compressor.

    Pit Crew CPR has clear assignments for each individual to accomplish with the unified goal to absolutely minimize interruptions in compressions without having to take the time to assign roles on-scene or “make it up as we go”, delaying resuscitation efforts.

  4. The “Pit Crew” approach is not some new intervention or concept. If you think about it, it’s the way ALL our calls should be run. All our calls should have people clearly assigned roles at the outset, and the people should carry out those roles without constant prompting. In my paramedic school, we were taught to assign duties to people and then to let them do the job and focusing on the whole patient/scene rather than micromanaging.

    I’m confused about your remark about “unproven” compression devices. As long as they produce the correct compression depth and rate, what is to prove? That’s all we look for in manual CPR compressions, so why should a strictly mechanical device need to meet a higher standard? The device should be treated EXACTLY like a rescuer doing compressions: verify rate and depth, and switch to the device should be fast and done during a rhythm check.

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