# STUDY: BLS better than ALS for trauma, stroke, respiratory distress



## Summit (Oct 13, 2015)

*Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies*
Prachi Sanghavi, PhD; Anupam B. Jena, MD, PhD; Joseph P. Newhouse, PhD; and Alan M. Zaslavsky, PhD
http://annals.org/article.aspx?articleid=2456124
Annals of Internal Medicine - October 13th 2015

*BLS had markedly superior outcomes vs ALS for trauma, stroke, and respiratory distress patients.
AMI patients had only a 1% better survival rate with ALS.*

Sum of the samples was about 290K patients.

Population studied was non-rural.

Study funded by National Science Foundation, AHRQ, and National Institutes for Health


----------



## DPM (Oct 13, 2015)

Poorly conducted study. Their determination of a "superior" outcome fails to take into account any sort of diagnosis or intervention that ALS can provide prior to the ER. 

The study looks at Medicare billing, so only takes into account whether or not a call was billed as ALS or BLS, and not if the provider was ALS or BLS. 

It's an urban only study, so response times are not a factor and all we have to do is drive to the ER and let them sort it out...


----------



## Summit (Oct 13, 2015)

DPM said:


> Poorly conducted study. Their determination of a "superior" outcome fails to take into account any sort of diagnosis or intervention that ALS can provide prior to the ER.



Poorer outcomes for being neurologically intact and alive are somehow are irrelevant because of the almighty ALS ability to diagnose and provide symptomatic relief?



> The study looks at Medicare billing, so only takes into account whether or not a call was billed as ALS or BLS, and not if the provider was ALS or BLS.


Read the study. If it was dispatched as ALS, medicare allows ALS billing and the patient was placed in the ALS group.



> It's an urban only study, so response times are not a factor and all we have to do is drive to the ER and let them sort it out...


The study was for NON-RURAL meaning areas that included a cluster of greater than 10,000 people were included. This encompasses 94% of the US population. The county I live in is classified as non-rural due to one "urban cluster" MICROPOLITAN district even though the county population density is 1% of a metro area.

No attempt was made to generalize this for extreme transport times or rural areas.


----------



## DPM (Oct 13, 2015)

Intact neurological survival is not an excellent bench mark to go by for trauma patients, asthma patients etc. Symptom relief is a large part of the hospital treatment, so just because they don't die on the way to the hospital doesn't mean that PT care was not affected, and just because a PT can survive to the ER with BLS care does not mean that this should be the standard. In areas where rapid transport to a hospital is impossible, where does this leave our patients?

This study shows that respiratory, trauma etc patients that only require BLS pre hospital have better outcomes. Is it not saying that patients who are less sick have better outcomes?


----------



## Underoath87 (Oct 13, 2015)

Who would dispatch a BLS unit to any of those emergencies in the first place?  Was it because the pt was not really suffering an emergency, and the ALS crew just transported them as a BLS pt? 
Or is it because they were in a tiered system with few ALS units and the BLS unit just chucked them to the ED in 5 minutes for definitive treatment, rather than wait 30 minutes for ALS backup?  Either of these would explain the skewed results and are not a fair comparison.


----------



## DPM (Oct 13, 2015)

If EMD can triage your "trauma" to an ALPHA level then in many areas BLS can take them. The BLS group in this study is by design going to include more low acuity patients than the ALS group.


----------



## Underoath87 (Oct 13, 2015)

DPM said:


> If EMD can triage your "trauma" to an ALPHA level then in many areas BLS can take them. The BLS group in this study is by design going to include more low acuity patients than the ALS group.



Which would simply mean that low acuity pt + BLS transport > high acuity pt + ALS interventions.  Not really a surprise.


----------



## chaz90 (Oct 13, 2015)

Underoath87 said:


> Which would simply mean that low acuity pt + BLS transport > high acuity pt + ALS interventions.  Not really a surprise.


Except that pesky mention of "propensity score weighting" means they used validated statistical methods to control for the confounding variable (baseline patient acuity) in this observational study. Since a randomized clinical trial of this size is probably impossible with ALS ingrained in EMS and considered the standard of care for high acuity patients, a RCT is probably impossible. 

I'm still a little perplexed as to what may have caused the worsened outcomes for stroke and respiratory cases. I understand trauma a little bit as I imagine ALS likely took longer to transport and may have over administered IVF, but the other two are a bit surprising. 

The percentages are small, but in a sample this large even a small change is compelling. 

I think of the way I run a CVA call as an ALS provider, and the only ALS intervention I provide is an IV (occasionally x2) during transport and a lab draw. I do a 12 lead en route, and occasional suctioning during transport. Unless IVs are actually increasing mortality or other people are doing more things on scene, I really don't get it.

Respiratory cases are just as baffling. Inhaled beta agonists and anticholinergics are pretty well supported for asthmatics and COPD patients, and clearly a part of most hospital courses of treatment too. IV steroids, CPAP and BiPAP as necessary? I wouldn't think these should increase mortality either, judiciously applied. 

Obviously this study didn't look for the reasons in differences, and those are the big questions. Are these common medical interventions truly harmful to patients, or are we as paramedics that bad at deciding when to apply them?


----------



## chaz90 (Oct 13, 2015)

The temptation we're faced with is always going to be following the knee jerk reaction of "poorly designed study" when faced with results that aren't necessarily positive towards our career. There may be problems with this study design, but anything showing statistically significant results with hundreds of thousands of patients reviewed at least deserves some critical review.


----------



## Summit (Oct 13, 2015)

DPM said:


> If EMD can triage your "trauma" to an ALPHA level then in many areas BLS can take them. The BLS group in this study is by design going to include more low acuity patients than the ALS group.



They used severity scores and statistical analysis methods to test for confounders and sample differences to see if the exact things you pointed out were the issue.

Do you really think the 3 PhDs and 1 MD PhD from Harvard Medical School didn't think of those things and that the peer review board for the Annals of Internal Medicine didn't consider it before publishing? 

Thank heavens you don't need to read a study to dismiss it.

READ. THE. STUDY.


----------



## DPM (Oct 13, 2015)

chaz90 said:


> Except that pesky mention of "propensity score weighting" means they used validated statistical methods to control for the confounding variable (baseline patient acuity) in this observational study...



When the authors analysed their own data using different methods (propensity score analysis vs instrumental variable analysis) they had different and contradicting results. So it may seem knee jerk, but when their own methods come up with contradictions then it's hard to take it seriously.


----------



## Summit (Oct 13, 2015)

DPM said:


> When the authors analysed their own data using different methods (propensity score analysis vs instrumental variable analysis) they had different and contradicting results. So it may seem knee jerk, but when their own methods come up with contradictions then it's hard to take it seriously.


Where did they say that? DID YOU READ THE STUDY? YES OR NO?

Here is a relevant excerpt from the discussion section (emphasis added):


> For 3 of the 4 conditions we studied, unadjusted survival rates were higher among patients receiving BLS despite these patients being older and having more comorbid conditions on average than those receiving ALS. After adjustment, these outcome differences persisted; *we found similar or better health outcomes associated with prehospital BLS than ALS in all of our analyses for major trauma, stroke, and respiratory failure. Because these high-acuity conditions necessitate early optimization of care, one would have expected any advantage of ALS over BLS to manifest itself in these diagnoses. *Although ALS may be expected to improve outcomes because of early treatment, the opposite may occur in practice if ALS is associated with delays in hospital management or iatrogenic injury (3, 5–7, 31). We used 2 methodological approaches to adjust for potential confounders of comparisons between BLS and ALS outcomes. One analysis used propensity score methods to balance observed characteristics. This approach is susceptible to confounding by any unobserved patient characteristics associated with survival and ALS use; however, because ambulance dispatch protocols prioritize ALS for the conditions we studied, such individual-level confounding is plausibly minimal. Our second approach used the instrumental variable of county-level variation in overall ALS prevalence to predict the likelihood that a patient would receive ALS. This approach is less susceptible to confounding by unobserved patient characteristics but is subject to confounding by associations between rates of ALS use and other county characteristics that affect mortality. However, our falsification tests suggest that such confounding is unlikely
> ...
> *With the exception of patients who had AMI, BLS was associated with outcomes similar to or significantly better than ALS using both methodological approaches. Survival after AMI was substantially better with BLS than ALS in instrumental variable analysis (between 4 and 8 percentage points across all time points), but the propensity score analysis found higher survival with ALS than BLS (between 1 and 2 percentage points at 90 days, 1 year, and 2 years). We did several sensitivity analyses (Appendixes 9 to 16 of the Supplement), none of which changed the direction or significance of our main findings. Our findings are consistent with other evidence for cardiac arrest (Appendix 17 of the Supplement) and trauma (4, 5, 7, 10 – 18). Little prior evidence, however, exists for patients with stroke, AMI, and respiratory failure.*
> ...
> Our study has several limitations. Selection bias may confound our findings if patients receiving ALS and BLS differ in unobserved illness severity or in the quality of hospital care that they receive. *To address this issue, we did 2 types of analyses that are subject to different types of confounding. The propensity score analysis would be biased toward finding worse outcomes associated with ALS if ALS providers were dispatched to patients with greater unobserved illness severity. Interviews we conducted with 45 state emergency medical service representatives, however, indicate that, if available, ALS would routinely be dispatched for many of the conditions that we investigated. As a result, the decision to dispatch ALS providers may plausibly be uncorrelated with unobserved illness severity for conditions other than trauma; for trauma, we controlled for severity. Moreover, BLS patients were older and had more comorbidities than ALS patients, which suggests that any unobserved differences in severity may actually have biased our results against BLS. The instrumental variable analysis could be confounded if counties with poorer quality hospital care had higher ALS penetration. Our falsification tests found no association of ALS penetration with nonemergent surgical mortality or nonemergent intensive care unit mortality at the county level. *Although these tests increase confidence in our results, we had no way of directly assessing the quality of care for emergency patients that was not susceptible to potential confounding by characteristics of ambulance services. Estimates and significance tests under the propensity score analysis could be subject to bias if ALS providers evaluated a patient and then selectively provided care and billed at the BLS level for less acute cases. Given substantial reimbursement differences between ALS and BLS, it is unlikely that ALS providers billed at BLS rates because Medicare allows billing at the ALS level if assessment by ALS-trained providers was considered necessary at dispatch. Further, analysis of survival differences in 2005 claims, which distinguish ALS claims billed at the BLS level, showed little sensitivity to whether this small group was categorized as ALS or BLS (Appendix 15 of the Supplement). Finally, significance tests under the instrumental variable analysis would still be valid in this case as long as higher rates of ALS claims reflect higher utilization rates of ALS providers, although estimates of the effect magnitude might be biased. Because our sample included only patients with hospital claims, another potential limitation may be that more BLS patients died at the scene or en route to the hospital. In sensitivity analyses that considered these cases, however, the direction and significance of our findings were unchanged (Appendixes 10 and 11 of the Supplement).


----------



## DPM (Oct 13, 2015)

They say with AMI that BLS is better when they use instrumental variable analysis, but that ALS is better when propensity score analysis is used. You even bolder that section. These two analyses contradict each other. 

Likewise, propensity score analysis found better outcomes with BLS for respiratory failure, yet instrumental variable analysis found no survival difference.

So far I've only been able to read what is published for free, but I'm hoping to get a full copy shortly.


----------



## Summit (Oct 13, 2015)

This might be a seperate thread... 

Does your employer give you access to key resources like journals, pharm db, and other ebp resources like uptodate?


----------



## EpiEMS (Oct 13, 2015)

Comparable to OPALS results (except for respiratory distress) and to the primary author's prior paper, I think...

I cannot say I'm entirely surprised about trauma & stroke, but respiratory distress is surprising. However...consider my conjecture:
 1) ALS providers may be using interventions unsuccessfully/inappropriately 
or
 2) Key interventions could be performed at both ALS & BLS levels
or
 3) Incremental inerventions are being performed at ALS level that just don't work
or any combination of 1, 2, and 3...


----------



## chaz90 (Oct 13, 2015)

Summit said:


> This might be a seperate thread...
> 
> Does your employer give you access to key resources like journals, pharm db, and other ebp resources like uptodate?


No. I believe we have access to journals as needed if requested for a specific research/special project we're working on, but for the most part, no. 

In all fairness, most wouldn't be interested. Some even complain about the pre-hospital applications of some of the con-ed sessions we do get. We paramedics tend to be a little narrow minded and shortsighted at times.


----------



## DPM (Oct 13, 2015)

chaz90 said:


> No. I believe we have access to journals as needed if requested for a specific research/special project we're working on, but for the most part, no.
> 
> In all fairness, most wouldn't be interested. Some even complain about the pre-hospital applications of some of the con-ed sessions we do get. We paramedics tend to be a little narrow minded and shortsighted at times.



...and the Annals of Internal Medicine isn't exactly the most applicable journal to our field


----------



## chaz90 (Oct 13, 2015)

DPM said:


> ...and the Annals of Internal Medicine isn't exactly the most applicable journal to our field


Well, I don't quite know how this article found a home in this specific journal, but I'd certainly say this subject is relevant.


----------



## Carlos Danger (Oct 14, 2015)

Just a few comments, observations, and predictions:

1.  Assuming the methodology employed here is sound (and the safe bet is that it is), this is a study that absolutely should not be ignored, if for no other reason than its sheer size. However, many will still ignore it.

2. The findings are roughly in agreement with previous studies - we all know that most ALS interventions have never been shown to positively impact outcomes - which means that no one should be surprised by this. It is not breaking news.

3. People are always quick to play the "poorly conducted" card - often before they even know how it was conducted - when the stated conclusions don't support their own biases. It's always fascinating to see people who don't know the first thing about statistical methods and who never even read clinical research suddenly become experts in how research should be conducted when the findings threaten one of their sacred cows.

4. I doubt anyone is going to use this study to support a claim that ALS is worthless and never brings any value. That isn't what this study says. For instance, the effects of ALS analgesia were not even addressed, so the "but what about analgesia!?!?!" argument that is always thrown out in response to any criticism of ALS has no meaning here.


----------



## EBMEMT (Oct 15, 2015)

Somone started 2nd thread.  their link is to an article that descrines the study and includes video presentation.

http://emtlife.com/threads/als-increases-mortality-bls-cheaper-and-better-outcomes.42496/


----------



## triemal04 (Oct 15, 2015)

BLUF:  Don't hit the panic button, there are most likely methodology flaws in this study although the question raised is valid, and they are right to a certain extent.

This is the same group that wrote a paper (last year?  maybe early this year?) about outcomes after cardiac arrest when comparing ALS and BLS.  Although* I don't have full access to the current study*, given that it is the same group, using the same raw data and looking at the same question, I'm confident in saying that they did the same thing and made the same mistake.  Yes, I know the first response will be to blow this off without thinking.

The problem is that they are using medicare billing codes to group people into groups for comparison.  Great idea, except it goes by the belief that a cardiac arrest is always a cardiac arrest and always the same, or in this case, a stroke/trauma/MI/respiratory failure is always a stroke/trauma/MI/respiratory failure and always the same.  This is patently not true; the simple act of using a medicare code to indicate what was wrong with the patient (especially when done by EMS providers) and possibly how severe the problem is does not allow the true comparison of 2 similarly coded people without actually looking at the individual patient.  To put it another way; one group might say that patient X had a stroke, while another says patient Y also had a stroke and use the same codes...except patient X had a mild CVA with almost full resolution, and patient Y had a severe cerebral hemorrhage.  Or, very likely given that it's EMS, patient X didn't even have a stroke but was coded that way by the ambulance company.  If all that is looked at is medicare codes and who transported the patient, not the actual patient severity, this leads to a false comparison.

Before anyone says it, in the first study they did look at some of the initial hospital medicare codes as well and I bet they did the same here; unfortunately this does not validate the whatever was chosen by the ambulance companies.  Medicare allows billing and coding if the problem was "present at any time" (or words to that effect), and given the problems that were looked at (cardiac arrest, MI, CVA, major trauma, respiratory failure) it would be very unsurprising if many hospitals and doctors coded these encounters in a specific way due to the initial concern and reception.

At least in the first study (and again, I don't have access to the full version of the current one) the way they analyzed the numbers to "prove" their validity also showed the flaws in their reasoning, although this was not recognized by the authors.  It was recognized by several other doctors who were nice enough to write in to the Annals of Internal Medicine about it.  While not meant as a disparagement towards AIM in any way, shape or form, I think there may have been a reason that both studies were published there and not in any of the emergency medicine journals.

So, is the authors conclusion wrong?  Well...I don't think so, though it isn't really fully right either.  I do think they reached their conclusion in the wrong way and are using a broad brush (even a spray gun one might say) to paint a picture that needs a finer touch.  In reality, paramedics are very much misused in America, and even though we do tend to treat a vast number of patients (in most places) the majority of those people don't NEED any treatement; they would have the same outcome if they got a quick ride to an ER and waited for a bit longer.  And when I say majority, I mean about 95% or more.  The times when a paramedic will have a real impact (and in this setting comfort and symptom relief don't come into play) on a patient's outcome are very few and far between.

The sooner this is recognized the better of EMS will be.


----------



## Summit (Oct 15, 2015)

Triemal, I have read the whole study and supplement. In a few moments you will also have that ability 

The major methodology problems you predict:
1. I didn't see them. They looked at hospital codes. They looked at ISS. They performed tests aimed at identifying confounding effects.
2. If they were there, the effect should amplify ALS positive outcomes, not worsen them! SOB that turns out to be anxiety would group to the ALS sample.

Sure, no study is perfect, and I see minor flaws. They admit potential flaws as well and try to limit the conclusions in the discussion based on these potential problems, but like you said, this study is saying something that we should listen to.

We should always ask: is this really something we should listen to?
I think so.
The questions now should be: why is this happening and what should we do about it?


----------



## Noncreative (Oct 15, 2015)

Summit said:


> 1. I didn't see them. They looked at hospital codes. They looked at ISS. They performed tests aimed at identifying confounding effects.


I too, don't have full access to the study, but in the editorial published 10/13/15 http://annals.org/article.aspx?articleid=2456126, It does state that the study used billing codes explicitly, and the only clinical information included was their adjustment for ISS.


----------



## triemal04 (Oct 15, 2015)

Summit said:


> Triemal, I have read the whole study and supplement. In a few moments you will also have that ability
> 
> The major methodology problems you predict:
> 1. I didn't see them. They looked at hospital codes. They looked at ISS. They performed tests aimed at identifying confounding effects.
> ...


Thanks for that, I'll take a look when I have time today or tomorrow and give some more feedback.

1.  If they did take the ISS into account for trauma patients then that does alleviate some of my concern for that specific subset, and, to be honest, that's one that I don't have much doubt about being correct anyway.  For real trauma patients, the things that can be done prehospitally at the paramedic level are often a) done poorly, which makes the situation worse, or b) the wrong thing to do in the first place.  While I think there are exceptions to that, taken as a whole I'd say it's a pretty accurate blanket statement.

1.5  The tests that they performed to see if there were confounders are what gives me pause; if it's similar to what was done in the cardiac arrest study it actually lends credence to their interpretation being off; I'll look.

2.  I'm not sure what you mean here:  "_SOB that turns out to be anxiety would group to the ALS sample_"  No, it would group to whichever group brought them in and how it was billed; if billed as ALS it would go to the ALS group no matter the true illness/severity, and the same for if it was billed BLS.  The issue would be if enough of the BLS calls were coded as something that was more severe than they actually were; if that's the case the outcome of the patient would be better because the problem was less.

I don't know that I would go so far as to say that this is something that we should LISTEN to...but it absolutely is, hands down, without a doubt something that we shoulding be TALKING about, and something that does need to be answered.  Like I said, I think they are likely more correct than not, just that the reached that conclusion in an erroneous way that could lead to the wrong things being done.


----------



## Summit (Oct 15, 2015)

triemal04 said:


> 2.  I'm not sure what you mean here:  "_SOB that turns out to be anxiety would group to the ALS sample_"  No, it would group to whichever group brought them in and how it was billed; if billed as ALS it would go to the ALS group no matter the true illness/severity, and the same for if it was billed BLS.  The issue would be if enough of the BLS calls were coded as something that was more severe than they actually were; if that's the case the outcome of the patient would be better because the problem was less.



Per the Study:
If dispatched as ALS then downgraded to BLS, the call can still be billed to _Medicare _as ALS. Since doing so is perfectly acceptable, it is standard practice and these downgraded patietns are still grouped in the ALS sample, which should work in the ALS sample's favor, yet the ALS results down benefit enough from this bias in their favor to flip the results to what we would expect, which is that ALS interventions save more lives than when not present.

Also:


> *Moreover, BLS patients were older and had more comorbidities than ALS patients, which suggests that any unobserved differences in severity may actually have biased our results against BLS.*


Yet, the BLS sample fared better.

*The authors make a compelling argument that their data, if biased, is biased against BLS and in favor of ALS, yet, despite this, the data do not show the expected benefit from ALS. The data show the opposite.*


----------



## Akulahawk (Oct 15, 2015)

This appears to be an article that discusses the same journal article discussed here, but perhaps has restated things for easier comprehension. http://sciencelife.uchospitals.edu/2015/10/13/advanced-ambulance-care-increases-mortality/


----------



## EBMEMT (Oct 16, 2015)

chaz90 said:


> E
> The percentages are small, but in a sample this large even a small change is compelling.


They were percentage points, not percentages.   If we compare 3% mortality to 7% mortality (or survival), that is 4 percentage points difference but a 133% increase or 57% decrease.    4 percentage points difference in absolute risk looks like a small difference but can actually be a large relative risk (or odds ratio).

This next example is based on the study lead author's own estimates about 4 minutes into the video.   

Consider 100 severe trauma patients
  63 survive with BLS or ALS
  15 die with ALS care but survive with BLS care.
  22 die whether they get ALS or BLS care.
Thus, this 15 percentage point improvement is a 24% higher survival rate going from ALS to BLS or a 19% lower survival rate going from BLS to ALS.   
And this 15 percentage point improvement is actually a 40% lower mortality rate with BLS (vs ALS) or a 68% higher mortality rate with ALS (vs BLS).
This is not a small percentage, this is a mass casualty.

I would also point out that the study lead author points out that ALS took twice as long (27 vs 13 minutes) from arrival on scene to arrival at ER, though this was from a different study, and considers this the most likely cause of the difference in outcomes.    

Also, scoop and run by police instead of waiting for EMS did not hurt patient outcomes (after adjusting for patient accuity) for GSW/stab wounds; it appears speed and skill/equipment were running neck and neck there with speed having a slight edge.  In an urban environment with multiple trauma centers and short transport times, where the difference in transport times could be a pretty substantial portion of the total.
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00948.x/pdf


----------



## SandpitMedic (Oct 16, 2015)

http://www.ems1.com/research-review...not-determine-whether-ALS-is-better-than-BLS/

A rebuttal to the OP's cited study.


----------



## Summit (Oct 16, 2015)

SandpitMedic said:


> http://www.ems1.com/research-review...not-determine-whether-ALS-is-better-than-BLS/
> 
> A rebuttal to the OP's cited study.


How is that a rebuttal? He doesn't refute any claim nor claim the study is flawed. He points out that no study can control for everything, that the study is worthy of consideration.

His point is well taken. If you cannot control for everything, you can either decide:

1. One cannot know anything with enough certainty to change practice based on evidence.
2. One can use the best evidence available to inform practice and further inquiry.

What one absolutely cannot do is choose option 1 when a study says something undesirable and option 2 when it matches a preconceived desirable position. There are some around here who are willing to do exactly this.

EMS has too many problems to use such mental gymnastics to road block potential progress.

Similarly, anyone who thinks this study supports eliminating ALS is also missing the point.


----------



## SandpitMedic (Oct 16, 2015)

Well that's a rebuttal. He is rebutting the presentation that BLS is better for patients than ALS. That is what a rebuttal is, his counter point is that the study is inconclusive with too many variables to decide a "winner."


----------



## Bullets (Oct 16, 2015)

I really think the results are due to time. Since BLS has options less for clinical management, their scene times are probably going to be shorter than ALS. I would think that this quicker delivery to definitive care would result in improved patient outcomes. Due to the variety of diagnostic tools, increased education and treatments, i would think ALS tends to remain on scene and do ALS things, even if its stuff like ET over a King, multiple attempts at venipuncture ect. Granted this is my conjecture but i think it seems logical that with more tools, the providers will just spend more time doing even a basic (to their level) assessment.


----------



## SandpitMedic (Oct 16, 2015)

I mean... I'm just sharing the article as it relates to the topic. I'm not arguing for or against. I don't really care- nothing will change regardless of what this study finds or doesn't find. To me, we should be placing our intelligence and efforts elsewhere, but that's just my opinion.


----------



## Summit (Oct 16, 2015)

SandpitMedic said:


> Well that's a rebuttal. He is rebutting the presentation that BLS is better for patients than ALS. That is what a rebuttal is, his counter point is that the study is inconclusive with too many variables to decide a "winner."


That is not what your link said!

And the study I posted didn't say that BLS is outright better than ALS.

It says that ALS  has worse outcomes in non-urban environments for some types of patients where we think that ALS should have had better outcomes.

There is no "winner."

ALS is not worthless or bad.

*The study suggests that something about the way we are doing ALS is doing more harm than good for these patient types in non-urban environments, and we should take a close look for the causes and change practice to correct the issue.

There is a "loser": THE STATUS QUO!*


----------



## Carlos Danger (Oct 16, 2015)

This study probably isn't going to change any practice anywhere, and it shouldn't. What are we doing to do based on it, just stop sending ALS? Of course not. "ALS" is not a procedure or a drug that we can stop using. In the context of this discussion, ALS should not even be viewed as a "level" that is distinct from BLS. ALS is simply an arbitrary point on the continuum of clinical care that is provided to sick and injured people. It is an artificially delineated set of skills, and it isn't even the same from place to place. What even makes a skill "ALS" vs. "BLS"?

So, because this study didn't provide any information on what _exactly_ it was that ALS personnel were doing differently from BLS personnel that appears to negatively affect outcomes, there's no way that we can use this study to change our practice.

That doesn't mean it isn't important information. The value in this study is that it will hopefully get folks thinking about the things that we do and whether or not they are actually helpful to our patients. History is full of all sorts of things that seem so glaringly obvious that no one bothers to question it for years and years. The earth being flat and the center of the universe, MAST pants, intracardiac epi, spinal immobilization - the legitimacy of all these things once appeared so self evident that to suggest they were wrong was heresy. So what's next? What will paramedics in 20 or 30 years sit around laughing at the thought of us doing way back in 2015? Is a normal SP02 perhaps bad in the long-term for a COPD or CHF patient? Is hypotension actually protective in trauma patients? Which co-morbidities require a different approach to management, which we don't do now? Which chemical mediators are actually helpful in stroke, but we are wiping them out with our treatments?

One of the problem with research in EMS is that paramedics tend to identify on a personal level with their scope of practice, and this makes it hard for them to accept that maybe some of the skills that make them feel worthwhile as a professional are actually not good for patients. So even when the methodology of a study is impeccable, people still find an excuse for why that finding isn't applicable where _they_ practice. That's no more obvious anywhere that in the airway management debate. "But things are different here. We have a 99.99% first pass success rate with our intubations. Those medics where that study was done must just suck". On some level there is some truth to that - and this is another one of the problems with EMS research - from place to place, paramedics have different competency levels, different drugs and protocols, and different logistical needs. So that add a level of complexity to the generalizing of research findings.


----------



## EpiEMS (Oct 16, 2015)

More randomized trials are the best outcome of a study like this. This kind of study is like John Snow and the pump handle -- we have no idea (playing fast and loose with phrasing here, I know) why ALS isn't showing better outcomes when we have plausible reason to expect that it would. What we need now is to run more OPALS-type studies...


----------



## SeeNoMore (Oct 17, 2015)

I think the truth is that the vast majority of people don't know or care what type of ambulance they get. They want to go to the hospital. If enough press is generated  about how ALS is delaying this without benefits , it could be towns and cities will decide to abandon Paramedics in favor of cheaper BLS. And maybe that's a wise decision. If not we need some focus on hown ALS can be made more effective and we need to stop lashing out as those who question our usefulness.

I don't know if it would make a difference but I work part time in a system with a small number of ALS units and often arrive on scene as the pt is being loaded into the rig. The delay in transport is often a handful of minutes with interventions being performed en route (average transport times of 15 minutes.) I don't have any proof but I feel like fewer Paramedics with more experience  might be part of the answer.


----------



## SandpitMedic (Oct 17, 2015)

Summit said:


> There is no "winner."
> *There is a "loser": THE STATUS QUO!*


Touché.
You are correct.


----------



## medicsb (Oct 17, 2015)

Interesting study, it raises good questions.  But I'm skeptical of its validity, though it appears they really worked hard to control for confounders.  This is based on billing data, and I'm not too confident that billing is going to capture patient acuity or level of care provided as well as we'd like.  (Anecdotally, emergency physicians often under-bill for services.  I had met with a semi-retired EM physician that did consulting work for practices and health system for physician documentation. She would compare the billing codes to the actual charts and often found that patients were usually much sicker than billing codes indicated.  EMRs have changed this somewhat, which has raised alarms with insurance companies, so now they want to decrease payment since they are now having to reimburse for actual services provided, which is more than it has been historically.) They do make the point that if ALS is dispatched because of perceived need for ALS that ALS can be billed.  But, I'm not so sure, unless they are referring to billing for "ALS assessment".  I actually question whether all EMS' actually do this (I worked for a service that did not bill for ALS assessment).   Considering that the majority of EMS systems are "all-ALS", it's really kind hard to know if BLS is really just BLS.  Also, we don't know if if all the BLS was really part of the "true" EMS system, as in are many of these BLS transport done by private ambulances that are not actually part of the local EMS system.  One thing that makes me think this is so is that the SNF transfers were far and away more frequently performed by BLS.  Its tough to know how this could skew things since SNF patient are older with more comorbities and have the potential to be very sick.  To some degree (I know we all have our stories about the staff of SNFs), patients are eval'd by someone with medical training and often with consultation with a physician, so it would be hopeful that when the EMS is activated it is because the patient is sicker.

Will this change practice?  Maybe (big maybe).  If this research is used by CMS to justify decreasing billing for ALS or for further scrutinization of ALS billing, I could see some systems struggling to continue ALS at the present level.


----------



## SeeNoMore (Oct 17, 2015)

I would be curious to know whether folks here believe that the difference in pt outcomes is primarily related to decreased on scene to ED time for BLS. This makes sense in the case of serious Trauma and perhaps Strokes, though I would hope that no matter who is responding every effort would be made to not stay on scene for these patients.

I would have expected that ALS would provide some benefit for the sickest respiratory patients, and that early intervention with meds, CPAP and possibly well done intubation would improve outcomes vs BLS.


----------



## TomB (Oct 18, 2015)

Here's my question. EMS responds to a patient with difficulty breathing with trouble speaking between breaths. The patient has a cardiac history. S/he is hypertensive with adventitious breath sounds. Initial SpO2 in the high 70s. The patient gets a 12-lead ECG, nitroglycerin, and CPAP. By arrival in the ED the patient is doing much better. Respiratory rate is now 24 (down from 40) and SpO2 is 98. Does it get "coded" at the hospital as "respiratory failure"? If not this entire study needs to be thrown in the garbage.


----------



## Akulahawk (Oct 18, 2015)

TomB said:


> Here's my question. EMS responds to a patient with difficulty breathing with trouble speaking between breaths. The patient has a cardiac history. S/he is hypertensive with adventitious breath sounds. Initial SpO2 in the high 70s. The patient gets a 12-lead ECG, nitroglycerin, and CPAP. By arrival in the ED the patient is doing much better. Respiratory rate is now 24 (down from 40) and SpO2 is 98. Does it get "coded" at the hospital as "respiratory failure"? If not this entire study needs to be thrown in the garbage.


If this is the case, I would tend to agree. If such a patient showed up in my ED and we did the same care, that patient would be coded as "respiratory failure." It very well could be the case that the "respiratory failure" patient gets coded as some sort of "respiratory insufficiency" and not failure because the patient is no longer in frank failure upon arrival at the ED. 

You make an excellent point about a huge problem that may just lie at the heart of the study.


----------



## Summit (Oct 18, 2015)

TomB said:


> Here's my question. EMS responds to a patient with difficulty breathing with trouble speaking between breaths. The patient has a cardiac history. S/he is hypertensive with adventitious breath sounds. Initial SpO2 in the high 70s. The patient gets a 12-lead ECG, nitroglycerin, and CPAP. By arrival in the ED the patient is doing much better. Respiratory rate is now 24 (down from 40) and SpO2 is 98. Does it get "coded" at the hospital as "respiratory failure"? If not this entire study needs to be thrown in the garbage.



*THIS PATIENT WOULD BE PUT IN THE RESPIRATORY DISTRESS ALS SAMPLE*

From their supplement on sample construction and diagnosis codes:



> We linked ambulance claims to the nearest in time hospital claims using the beneficiary's
> identification number and the date of service. This allowed us to use diagnosis codes that
> described the medical emergency rather than any subsequent developments. Our algorithm
> prioritized linking to the nearest in time hospital claim (up to two days after the ride) and to
> ...



*The study RESPIRATORY FAILURE sample includes*

1. Acute respiratory failure

Disease Synonyms

Acute hypercapnic respiratory failure
Acute hypercapnic respiratory failure due to obstructive sleep apnea
Acute hypercarbic respiratory failure secondary to obstuctive sleep apnea
Acute hypoxemic respiratory failure
Acute respiratory failure from obstuctive sleep apnea
Alveolar hypoventilation
Hypercapnic respiratory failure
Hypoxemic respiratory failure
Postprocedural respiratory failure
Respiratory failure
2. Other pulmonary insufficiency, not elsewhere classified

Disease Synonyms

Acute respiratory distress
Acute respiratory insufficiency
Pulmonary insufficiency
Respiratory distress, acute
3. Acute edema of lung, unspecified

Disease Synonyms

Acute pulmonary edema
Pulmonary edema (fluid in lungs), acute
Pulmonary edema, acute
http://www.icd9data.com/

So yes that would be 518.81 or 518.82 even if they also get a 428.0 or 428.1 if this was a heart failure exacerbation (would exclude the 518.4). I am not a coding expert.


----------



## TomB (Oct 18, 2015)

Thank you!


----------



## NomadicMedic (Oct 18, 2015)




----------



## SandpitMedic (Oct 18, 2015)

Is ACLS not the same in hospital as it is in the field? Aren't we doing the exact same things? If you collapse in the waiting room of the ER and code they are going to do the exact same thing I am going to do when I get to your house if you are in full arrest. That's the point of ALS, to provide the same level of ACLS care in the field. The drugs are the same, the algorithm is the same, and the survival rates are the same (when everything is done as it is supposed to). Sure in a ER the doc will still give bicarb, whoop dee do.

That's the point. We do all of those things and then we take the patient to the hospital... Mostly a save is a save to discharge. Many times I have seen people code in the ER and the likelyhood of them surviving does not enhance just because that's where they coded. I've seen about the same survive in hospital as out of hospital. For all of our advanced technology and understanding we still cannot save everybody. The national average is under 12% for survival with intact neurological capability to have a normal life. Most become vegetables because we sustained their physical body when they normally should have passed. That, or they do die because they're a train wreck, and their bodies have already been too taxed to live- death occurs, as it has since the beginning of time.

There are times when it is appropriate for life sustaining measures like a young person or a child... But if you are an 89 year old renal failure, diabetic patient, and your heart stops.... Your ticket is punched, no matter what we do or where you collapse.

To me that is why I find these studies flawed fundamentally. It does not take into account those patients which are/were going to expire regardless of resuscitation efforts or level of skill. There is no way to know. If they did the study on say, people under 40, or 50, or whatever arbitrary age you want to throw out there, I think it would give us more of an understanding. If my child has a cardiac arrest, I want an ALS ambulance there... I want PALS started ASAP. (Yes, I know most of the time it's hypoxia related and BLS provides that). Just in case of the worst case I want all the capabilities there and ready to go.

Back to adults:
14 minutes of ACLS in the field is no different than 14 minutes of ACLS in the hospital. That's why we stay on scene and do those measures; because bumping down the highway reduces the efficiency of compressions. Stay and play- in the ER that is essentially what they are doing. The problem is mainly getting folks to not interrupt compressions, which is the latest push from the AHA for the last several years, and that has indeed brought up the stats of survival anywhere from about 3-6% depending on what study you look at.

ALS vs BLS?

If I code, I want ALS.


----------



## SandpitMedic (Oct 18, 2015)

I realize some of you may strongly disagree with me and feel as though we should want to provide life saving efforts for every single living organism on the planet, so I apologize if my slightly morbid opinion offends some of you. 

There is a line between common sense, giving someone the dignity of an honorable and natural death, and being in a field in which you are bound to provide efforts even if you morally object. I get that. I have no problem with palliative care, and giving someone a morphine pump with an all access VIP button to do with as they wish. I just don't think we ought to be doing full ACLS on 90 year old people who have lived a full life and haven't contemplated a DNR. 

And before someone says, what about your family- my grandma is 96... And if she died in front of me I would call my family to come say goodbye, not beat up her chest just so she could be taken and connected to machines, in a coma, for an extra 7 days of what some people consider "life."

Sorry for the derail.


----------



## SeeNoMore (Oct 18, 2015)

But the question is do you need ALS on that code or just CPR and defib. I'd like to imagine that ALS would provide some benefits post ROSC , but I don't think any studies show that. If we can't show any benefit to ALS it's fair to consider getting rid of it , as much as that would mess up my prospects. Although who knows maybe helicopters would be called more if there was no ALS at all for certain high acuity patients.


----------



## Carlos Danger (Oct 18, 2015)

SandpitMedic said:


> To me that is why I find these studies flawed fundamentally. *It does not take into account those patients which are/were going to expire regardless of resuscitation efforts or level of skill.* There is no way to know.



Sure it does.

Those propensities (the statistical likelihood of a given outcome) are taken into account and controlled for, if the statistical analysis is done correctly. It's not perfect in a retrospective study such as this one, but generally the larger the sample size the more reliable the findings, and this one was huge.

A good clinical statistician is a wizard.


----------



## SandpitMedic (Oct 19, 2015)

Yeah, I think you can say that all day long... 

But if you aren't Jesus, from the future, a wizard, or whatever diety you prefer - there is no way to say who would live and who dies anyway in a matter of fact way. 

Math me all day long, but this point is another thing we will permanently and desicively disagree on. Stats class be damned.


----------



## cruiseforever (Oct 19, 2015)

SeeNoMore said:


> But the question is do you need ALS on that code or just CPR and defib. I'd like to imagine that ALS would provide some benefits post ROSC , but I don't think any studies show that. If we can't show any benefit to ALS it's fair to consider getting rid of it , as much as that would mess up my prospects. Although who knows maybe helicopters would be called more if there was no ALS at all for certain high acuity patients.


 
What would the benefit of a helicopter be?  Unless if ground transport to a Trauma Center is greater than a hour.


----------



## Carlos Danger (Oct 19, 2015)

SandpitMedic said:


> Yeah, I think you can say that all day long...
> 
> But if you aren't Jesus, from the future, a wizard, or whatever diety you prefer - there is no way to say who would live and who dies anyway in a matter of fact way.
> 
> Math me all day long, but this point is another thing we will permanently and desicively disagree on. Stats class be damned.



"Screw you and your big words and fancy science. We don't believe in nun uh dat that book stuff 'round here. Dem numbers iz for heathens!"

Demonize what you don't understand. Why am I not the least bit surprised? Maybe this is why paramedicine is advancing so rapidly as a highly respected clinical specialty.


----------



## jrm818 (Oct 19, 2015)

Remi said:


> "Screw you and your big words and fancy science. We don't believe in nun uh dat that book stuff 'round here. Dem numbers iz for heathens!"
> 
> Demonize what you don't understand. Why am I not the least bit surprised? Maybe this is why paramedicine is advancing so rapidly as a highly respected clinical specialty.



Except that the claim that pure statistical methods can tell us anything about causality is NOT all that well accepted.  As far as I know, conventional scientific wisdom still suggests that it cannot. 

This topic actually seems fairly ill-suited to study using non-randomized study design, given the high number of variables that need to be accounted for with a purely-statistical method (including not only patient factors, but overall system design, stupid things like how aggressive the billing department is (eg often they harass physicians to include higher acuity billing codes), the care provided at the hospital...which may well depend on care provided in the field, etc.).

Here's an interesting little excerpt about these statistical methods:

http://bayes.cs.ucla.edu/BOOK-09/ch11-3-5-revised3.pdf


And personally I still can't get over the fact that someone who appears to be a non-clinician published this in an internal medicine journal.  It's not just that it's weird....there is a lot of perspective that is lacking when someone is reading or writing about a topic they have limited background information on.

Edit: and I will say that sometimes it is appropriate to be skeptical of things that are not easily explained.  I have no shame in saying that this propensity score nonsense is a bit over my head.

Understanding randomized controlled trials is easy; as such that is a very useful trial design because the majority of readers can evaluate the strengths and potential weaknesses of such a trial, and make conclusions about the applicability of the trial to their own practice

Even if this fancy magic-math can indeed prove causality, I simply cannot wrap my head around methods that use such crazy math (and I took stats, calculus x2, etc. at one point).  As such, when I approach such a paper I have no clue if the methods were used appropriately, what the potential pitfalls of the methods are, and how to apply the research to my own practice.  Even if it's right, there is no way for the majority of even well-informed clinicians to be confident about the information.  Not helpful....


----------



## SandpitMedic (Oct 19, 2015)

I didn't say demonize science or things one does not understand- I said the math is not going to give you accurate enough information. There are to many random unknowns... And even unknown unknowns (thanks Donald Rumsfeld).

You are making this a matter-of-fact issue, and the reality is it is anything but that. I am not completely discounting the universal language, but I am saying it may not be as applicable here as you'd like it to be. There is no way to tell who would have benefitted from BLS over ALS or ALS over BLS after the fact of death in too many situations. Some, sure they are generally easy to hypothesize; most though, is just grief and emotion getting in the way of logic. No one could know for certain.

If anything, I'd like someone to present a study of survival to discharge after cardiac arrest from say, the 1950's, to today. I'll bet my bottom dollar it is better now then it was then, right?

NOPE! http://www.healio.com/cardiology/vascular-medicine/news/print/cardiology-today/{9e0f9dd0-f2b5-4a6f-9505-bc34043540c1}/out-of-hospital-cardiac-arrest-survival-rates-stable-but-not-improved-after-30-years

They had BLS efforts then, and ALS efforts came... But look, the numbers don't lie according to you...

Statistical analysis can be skewed and variables tweaked to come up with just about any kind of finding one would hope to see. That is my point.

We can not save every one. That is it... BLS, ALS, meat wagon, flight team, in-hospital arrest. It doesn't matter. We just do what we are trained to do and adjust and adapt to the latest science based evidence - not math based probabilities. Maybe that is too simple for a wizard like you.


----------



## SandpitMedic (Oct 19, 2015)

The real issue is who we let be paramedics, and the speed at which one can obtain the patch. There needs to be more barriers to entry, more experience required, more education, more clinical time, and more maturity before we turn anyone who wants loose to "practice medicine." There are many medics out there who don't even want to be medics.... It's just a stepping stone, one which they may not take as seriously as folks on this forum. That also has an impact on the way in which they perform their duties. 

That is a derail, but that is evident in most systems. Most can point to one or more of "those guys" that they work with.


----------



## Carlos Danger (Oct 19, 2015)

jrm818 said:


> Except that the claim that pure statistical methods can tell us anything about causality is NOT all that well accepted.  As far as I know, conventional scientific wisdom still suggests that it cannot.



I've never suggested - or even seen anyone else suggest - that pure statistical methods can show causality.



jrm818 said:


> This topic actually seems fairly ill-suited to study using non-randomized study design, given the high number of variables that need to be accounted for with a purely-statistical method



There is no way to do an RCT on a sample of tens of thousands of patients on BLS vs ALS. So retrospective studies like this are done to identify new research questions. Again, they are not intended to show causality or to change practice.



jrm818 said:


> I have no shame in saying that this propensity score nonsense is a bit over my head.



The nuts and bolts of it are well above my head, too. It's high level stuff for statisticians, not for most clinicians. But the basic concept is simple: if X condition is known to have Y probability of a given outcome, then the outcomes of patients who have that condition can be predicted mathematically and compared to the actual outcomes of the sample to ensure that they are representative.

Skepticism is healthy and necessary and I support it 100% in every case. But dismissing a study - and any research that doesn't support your biases, really - out of hand because you've never taken the time to learn even basic research methods and terminology and because "only Jesus knows who is going to die" isn't skepticism, it's ignorance.


----------



## SandpitMedic (Oct 19, 2015)

That was sarcasm... I'm not on the bible jock.
I was illustrating my point in a satirical way.
No one can see the future, in this case who will live or who will die.

Color me skeptical.

Don't try to paint me in the loony column because I made a joke and don't fall in line with your line of thinking.

Nice misdirect.


----------



## jrm818 (Oct 19, 2015)

It's funny...I just got an e-mail that there's going to be a 40 minute round-table with the author at this years ACEP conference next Monday.  I'm sorry I can't go....



Remi said:


> I've never suggested - or even seen anyone else suggest - that pure statistical methods can show causality.



On a careful re-read, the paper does indeed dance around implying causality.  The author does really heavily suggest she is describing a causal relationship in her presentation posted on youtube, however....she even goes as far as to imply that her primary question is "how does ambulance type _*affect *_survival.

She also says
"if all of these patients instead got basic life support than I estimate that an additional 15 people would live to at least 90 days."
"This is a big problem, because currently if we call 911 we get the advanced ambulance."
"so how is it that advanced is worse than basic ambulance."
*"Using data and statistics we can study causality in real world settings that are otherwise difficult to replicate in experiments"*

Very heavy on the implying that ALS is the cause of the bad outcomes....





Remi said:


> There is no way to do an RCT on a sample of tens of thousands of patients on BLS vs ALS. So retrospective studies like this are done to identify new research questions. Again, they are not intended to show causality or to change practice.



Fair, if this were a question generating piece of research.  I'm sorry, but I really see the author's presenation of the work as implying causality, and implying that the work implies that we need to start hacking away at ALS level care.  The author's responses to critical letters after their first paper suggest the same.

The more I think about this piece of research, the more I dislike it.  There is no good research question that comes out of this.  It isn't an attempt to establish equipoise to justify an RCT of ALS vs BLS.  It has too many topics to really evaluate any patient population or intervention, so we end up with a poorly elucidated skim job.

My other problem is that I get heavy overtones of financial savings in the papers and her presentations (and her CV); and the quality of the science here is nowhere good enough to make money-saving (aka resource slashing) decisions. 

I get a bit too much of a feeling that the author is happy she found the results that she did.  It seems likely to me that a career would get more mileage out of demonstrating to medicare how they can save money, so I really start to wonder about the underlying biases of the author.  I suspect there is more incentive to generate research which finds expensive interventions not useful, which makes me a bit more skeptical from the get-go.


----------



## Carlos Danger (Oct 19, 2015)

jrm818 said:


> On a careful re-read, the paper does indeed dance around implying causality.  The author does really heavily suggest she is describing a causal relationship in her presentation posted on youtube, however....she even goes as far as to imply that her primary question is "how does ambulance type _*affect *_survival.
> 
> She also says
> "if all of these patients instead got basic life support than I estimate that an additional 15 people would live to at least 90 days."
> ...



OK. So what? This is where skepticism comes in. If you think the authors conclusions are wrong, then fine. But if you want to convince others that this study is BS, then you need to define specifically _why_ it's BS.

Something other than "I don't understand it, so it must be wrong."


----------



## Summit (Oct 19, 2015)

SandpitMedic said:


> more experience required, more
> education, more clinical time, and more maturity before we turn anyone who wants loose to "practice medicine." There are many medics out there who don't even want to be medics.... It's just a stepping stone, one which they may not take as seriously as folks on this forum. That also has an impact on the way in which they perform their duties.


I agree with what you said in the above quote. But, that is just my opinion.

But are you proposing this as an explanation and potential solution that addresses the results of the study that you say we cannot trust? Upon what evidence do you base your claims?



			
				SandpitMedic said:
			
		

> We just do what we are trained to do and adjust and adapt to the latest science based evidence - not math based probabilities.


This statement, however, makes it clear you fundamentally do not understand how evidence based medicine works... but you think you do...



> Is ACLS not the same in hospital as it is in the field? Aren't we doing the exact same things? If you collapse in the waiting room of the ER and code they are going to do the exact same thing I am going to do when I get to your house if you are in full arrest. That's the point of ALS, to provide the same level of ACLS care in the field. The drugs are the same, the algorithm is the same, and the survival rates are the same (when everything is done as it is supposed to).


Many if not most hospitals do not stick to the ACLS algorithm. ACLS is a starting framework. Also, hospital inpatients are a different population than out of hospital arrests.



SandpitMedic said:


> If anything, I'd like someone to present a study of survival to discharge after cardiac arrest from say, the 1950's, to today. I'll bet my bottom dollar it is better now then it was then, right?
> 
> NOPE! http://www.healio.com/cardiology/vascular-medicine/news/print/cardiology-today/{9e0f9dd0-f2b5-4a6f-9505-bc34043540c1}/out-of-hospital-cardiac-arrest-survival-rates-stable-but-not-improved-after-30-years
> 
> They had BLS efforts then, and ALS efforts came... But look, the numbers don't lie according to you...



Look... you don't even have an abstract interest in evidence based medicine. I say that in an overly literal way. As in you lacked the interest to read even the abstract of the study that was poorly summarized in the link you provided. If you had an interest, you'd find that it says something a little different than you imply:
http://circoutcomes.ahajournals.org/content/early/2009/11/10/CIRCOUTCOMES.109.889576.full.pdf+html
If you wanted to read the actual study, you'd realize that they only included studies from 1980-2008 and their generalizations were that there wasn't a worldwide improvement over ~30 years as of 2008. Their biggest conclusion was that bystander CPR is the biggest way to improve outcomes and they speculated that TH could make a difference (and they would have speculated that the 2010 AHA guidelines might as well).


----------



## SeeNoMore (Oct 20, 2015)

I dont have access to the full text , but I found this in a story on ems1.com "The study found that ALS medics take longer than clinicians in hospitals to perform procedures, such as the administration of intravenous fluids and drugs and intubation." and goes on to imply this is part of the reason for better BLS outcomes. Does the study address this? If so it almost would seem to suggest that earlier ALS intervention would be beneficial. I'm not claiming that though. Do you folks think this will actually generate additional studies or just fade into the background?


----------



## SandpitMedic (Oct 20, 2015)

Fade to black.


----------



## SeeNoMore (Oct 21, 2015)

I hope not.  It's in our best interest to attempt to clarify when and why Advanced Life Support is a useful addition to BLS level care. If not it will be done for us by those that may not have any interest in Paramedics remaining a viable profession.


----------



## ExpatMedic0 (Oct 21, 2015)

Summit said:


> How is that a rebuttal? He doesn't refute any claim nor claim the study is flawed. He points out that no study can control for everything, that the study is worthy of consideration.
> 
> His point is well taken. If you cannot control for everything, you can either decide:
> 
> ...



I would say its a rebuttal because a statement is included ""Their premise is flawed," said Howard Mell, a spokesman for the American College of Emergency Physicians and director of emergency services in Iredell County, N.C. He said ALS ambulances transport much more serious patients. "That's why they have much worse outcomes.""


----------



## sir.shocksalot (Oct 21, 2015)

SeeNoMore said:


> and goes on to imply this is part of the reason for better BLS outcomes. Does the study address this?


No, the study does not. On scene and response times were not taken into account as I understand the study. I also do not have access to the full text of the article, which is very frustrating.

This study is crap for a number of reasons. Any retrospective data needs to be taken with a grain of salt and understanding that there are a lot of variables that affect patient outcomes that cannot be accounted for with most data sets available. This study used billing codes and did not account for actual interventions performed which could be a marker for patient severity. I know Summit and others have said that the authors have adjusted for patient severity but other articles have pointed out that the authors only used other billing codes to "adjust" for cormorbidities. While statistics gives more accurate results with larger data pools, the largest data pool on the planet is worthless if the data does not adequately represent the population being studied. I think most would find it difficult to figure out what a patient was going through if the only information they have is a bunch of billing codes. Plus, what was the reason that some of the patients were transported BLS instead of ALS? Knowing how the vast majority of EMS systems work by sending ALS to the sickest or every patient what is different about the BLS population? Were they less sick at the time of dispatch? Was this adjusted for?

This study generates more questions than answers. Statistics and evidence based medicine are very helpful within the constraints of common sense and expert opinion. Statistics are a blunt instrument and will spit out numbers/correlations/associations even if the data going into the equation is crap or the author's interpretation of the data is crap. My issue here is that a non-expert with no experience or understanding of prehospital or emergency medicine is reaching for a conclusion from incomplete data. To be very clear about what this study shows is that patients who receive ALS bills in a non-rural area and have medicare tend to have a higher mortality. I could conclude that ALS medicare bills increase mortality, but we all know that is crazy. Essentially that is what this study is doing, the study should conclude: ALS has higher mortality except for AMI but the causes are unclear and ALS may be a marker for patient severity or some unknown variable during ALS care is contributing to mortality and further study is warranted.

Common sense and other, more rigorous, studies tell us that ALS helps in some situations and hurts in others but is heavily area dependent. Most studies have shown that trauma care is better when it's BLS or no EMS in urban settings. Beyond that there is not much other data, even if there was it would have the caveat of only applying to EMS in the area studied. Paramedic and overall EMS quality varies by zip code and data collection and reporting by EMS is virtually absent. In an article that responded to this study an author cited a mere 14% compliance rate of ALS crews administering epinephrine every 3-5 minutes in cardiac arrest. If the quality of care from paramedics is poor then we need to examine that, a study comparing ALS and BLS bills and outcomes is not an adequate exploration of the topic.

We, as an EMS community, should not be settling for crap studies with insufficient data. We should be advocating for more comprehensive and mandatory data reporting to a state health office. Comprehensive data will let us actually do some higher quality retrospective studies that includes important clinical data points such as vital signs and interventions performed. This study makes an effort to examine something that warrants much closer examination but falls far short of actually providing any meaningful conclusions.

Analysis of the study by Dr Lacocque: http://epmonthly.com/article/back-to-basics/
Editorial in Annals of Internal Medicine by Drs. Sasson and Haukoos: http://annals.org/article.aspx?articleid=2456126
Paramedic compliance with ACLS drugs: http://www.ncbi.nlm.nih.gov/pubmed/16801287


----------



## SandpitMedic (Oct 21, 2015)

See... Someone had the time that I did not. I agree with Expat and Shocksalot.

Where I didn't feel like elaborating to, let's be honest, mostly Remi, because I am tired of debating the color of the sky with him on every topic... Some one else stepped up to the plate.
We just never really agree on much, 'tis the way of the world. I anticipate someone will now delve into every line of text in search of a "gotcha" moment in effort to disprove an entire page long counter point.

I respect all parties, but also side with this study being an ineffective means of measuring patient treatment levels in the field. I feel this will fade to black, and nothing will change regardless of what findings are had. Maybe that makes me the pessimist, but look at EMS... We aren't exactly our own best friends.


----------



## Carlos Danger (Oct 22, 2015)

sir.shocksalot said:


> This study is crap for a number of reasons.
> 
> Analysis of the study by Dr Lacocque: http://epmonthly.com/article/back-to-basics/
> Editorial in Annals of Internal Medicine by Drs. Sasson and Haukoos: http://annals.org/article.aspx?articleid=2456126
> Paramedic compliance with ACLS drugs: http://www.ncbi.nlm.nih.gov/pubmed/16801287



I have read quite a few analyses of this study now, and have not yet seen a single author articulate a problem with the way it was conducted, or point to any methodological or statistical flaws. Aside from the normal disagreement with the conclusions that you find with literally _every_ published paper, the common theme in the commentary about this one - which I completely agree with and have stated at least once on this forum already - is that this paper has the same (gasp!) limitations as every other retrospective study. Primarily, that studies like this can not be used to show causality, because there are way too many unaccounted-for variables. And also, because no specific intervention or practice was investigated, it is impossible to use this study to change practice. Studies like this are foundational in that they cast a broad net and generate questions that can hopefully be researched in a more controlled and focused way. The fact that such a basic thing needs to be pointed out continuously to the prehospital world is a bit worrisome.

The fact that this study cannot show causality does make the study "crap" and is not a flaw. Is the fact that a Honda Accord can't pull a 12,000 pound trailer up a steep mountain grade a flaw? No; that isn't what Accords were designed for. They aren't _intended_ to do that, so the fact that they cannot do that is not a flaw. The things that they are intended for, they are very good at, which is why no one who knows anything about vehicles would refer to a Honda Accord as "crap". The same is true of prospective vs. retrospective studies. They are different types of research that are done different ways and used for different things. Just because one is not the same as the other does not make either one "crap". If you purchase a Honda Accord expecting to use it like a 1-ton diesel and the car fails miserably, that is 100% your fault, not the fault of the Accord or the folks who designed it. A great apple makes a terrible orange.

In the commentary he provided for epmonthly, one almost gets the feeling that Dr. Lacocque views the lack of ability to show causality as a flaw. That misunderstanding (if it in fact exists - I could certainly be wrong) is unfortunate, but it is really irrelevant, because he also writes "While it is tempting to dismiss Sanghavi et al’s findings, they are in line with past research", and concedes that "Numerous studies have even corroborated Sanghavi’s findings, showing the lack of efficacy of out-of-hospital advanced airway use [6,7], vasopressin [8], IV drugs [9] and even ALS care as a whole [10]." He also describes the study as ".......a large, robust study, corroborated by others, and whose authors worked hard to control for every variable they could". Doesn't sound like he agrees with shocksalot that this paper is "crap".

Similarly, in their commentary for AIM, Sasson and Haukoos describe the paper as "well conducted" and write that it "raises important questions about the effectiveness of prehospital care". They then go on to explain - again - the limitations of a retrospective study and why it cannot be used to show a _causal_ link between ALS care and worse outcomes. Even if they don't find this paper particularly useful and even though they disagree with the the authors conclusions, I doubt that, even if pressed to do so, these doctors would describe this study as "crap".

In fact, the only people I've seen referring to this study as "crap" and / or calling for outright dismissal of its findings are a few of the commenters on EMTlife who - and I say this with all due respect - don't know even the very first thing about research, and who's opinion is nothing more than an emotional reaction to the author's conclusions.

The truth is, no one here would be calling this study "crap" if it showed the opposite conclusions. Sandpit and Shocksalot, you would both be jumping for joy, gloating at the skeptics and pointing to this study as "evidence" that ALS works, and you wouldn't care in the least that it is "just" a retrospective statistical analysis and not actual research. It would probably never even occur to you to look into the basic study design.

As I wrote before, the findings of this study are compelling, both because of the sheer size of the study and because in several ways it repeats the findings of previous studies. There is probably something to it - exactly what, I don't know - and anyone who says otherwise is literally ignoring the facts.


----------



## jrm818 (Oct 22, 2015)

Remi said:


> Aside from the normal disagreement with the conclusions that you find with literally _every_ published paper, the common theme in the commentary about this one - which I completely agree with and have stated at least once on this forum already - is that this paper has the same (gasp!) limitations as every other retrospective study. Primarily, that studies like this can not be used to show causality, because there are way too many unaccounted-for variables. And also, because no specific intervention or practice was investigated, it is impossible to use this study to change practice. Studies like this are foundational in that they cast a broad net and generate questions that can hopefully be researched in a more controlled and focused way. The fact that such a basic thing needs to be pointed out continuously to the prehospital world is a bit worrisome.
> 
> The fact that this study cannot show causality does make the study "crap" and is not a flaw. Is the fact that a Honda Accord can't pull a 12,000 pound trailer up a steep mountain grade a flaw? No; that isn't what Accords were designed for. They aren't _intended_ to do that, so the fact that they cannot do that is not a flaw. The things that they are intended for, they are very good at, which is why no one who knows anything about vehicles would refer to a Honda Accord as "crap". The same is true of prospective vs. retrospective studies. They are different types of research that are done different ways and used for different things. Just because one is not the same as the other does not make either one "crap". If you purchase a Honda Accord expecting to use it like a 1-ton diesel and the car fails miserably, that is 100% your fault, not the fault of the Accord or folks who designed it. A great apple makes a terrible orange.
> 
> In the commentary he provided for epmonthly, one almost gets the feeling that Dr. Lacocque views the lack of ability to show causality as a flaw. That misunderstanding (if it in fact exists - I could certainly be wrong) is unfortunate, but it is really irrelevant, because he also writes "While it is tempting to dismiss Sanghavi et al’s findings, they are in line with past research", and concedes that "Numerous studies have even corroborated Sanghavi’s findings, showing the lack of efficacy of out-of-hospital advanced airway use [6,7], vasopressin [8], IV drugs [9] and even ALS care as a whole [10]." He also describes the study as ".......a large, robust study, corroborated by others, and whose authors worked hard to control for every variable they could". Doesn't sound like he agrees with shocksalot that this paper is "crap".



Again, unfortunately this research _is_ being spoken about as if it implies causality - by the lead author herself, posted on YouTube, with the Harvard emblem emblazoned on it.




Remi said:


> And also, because no specific intervention or practice was investigated, it is impossible to use this study to change practice. Studies like this are foundational in that they cast a broad net and generate questions that can hopefully be researched in a more controlled and focused way. The fact that such a basic thing needs to be pointed out continuously to the prehospital world is a bit worrisome.



If this study were more closely tailored to a specific clinical scenario or intervention, it could indeed be question generating.  An example of such a paper would be a retrospective examination of the influence of various factors on the survival of prehospital trauma (or whatever) victims.  One way to use such a study in a question generating way is to examine a multitude of factors and identify associations that deserve further investigation - e.g if ALS care, long extrication/transport time, and field intubation are all _associated_ with bad outcomes, we now have a new impetus to use other methodologies to determine if there is a causal link between any of those three variables and poor outcome.

This paper used a retrospective/purely statistical method to try _answer_ a question, not search for new questions.  I think that is the center of many people's criticism, and seemed to be the center of the criticism of this group's previous paper which used similar methodology.  "Question generating" studies aren't supposed to simply be a less-robust examination of an interesting question.  As far as I can see, the only reasonable follow up to this paper is a more robust study asking _the exact same question_ - "does ALS care lead to bad outcomes?"


----------



## Summit (Oct 22, 2015)

sir.shocksalot said:


> I also do not have access to the full text of the article ... This study is crap



The only thing that is "crap" is your ability to form a valid opinion without reading the study.



> This study used billing codes ... the largest data pool on the planet is worthless if the data does not adequately represent the population being studied.


How do you figure the data is nonrepresentitive? BECAUSE OF THE "BILLING CODES"?

Paramedics have 0 training in coding which makes it a convenient thing to harp on and feel good. The people who do understand think you look foolish for making that argument.

They used ICD9 codes to group patients by malady. ICD9 code assigned by the treating hospital is dependent on the medical diagnosis.

Then they grouped patients by BLS and considered two tiers of ALS care billing and those were based on interventions including presumption of the need for ALS care or assessment. Perhaps you think that billing departments won't bill the government for explicitly allowable reimbursements?

Injury Severity Scores were associated with each patient in the trauma group because the trauma ICD9 codes encompass a much wider range of patient acuity than say Respiratory Failure.



> Knowing how the vast majority of EMS systems work by sending ALS to the sickest or every patient what is different about the BLS population?


*The patient types addressed in this study:
AMI, RESPIRATORY DISTRESS, TRAUMA, STROKE
Every system would send ALS if they had it except possibly minor trauma, but those were controlled by the Injury Severity Score.*

So if the patient got BLS, it is because there was no ALS. Not because of low severity. And this was verified by their data analysis.



> Were they less sick at the time of dispatch? Was this adjusted for?


The study found that BLS patietns were typically older and had more comorbidities.



> Common sense


Common sense used to tell use to give hemmorhagic shock patients infinite NS boluses to keep a pressure even as their blood turned translucent because patients need a pressure to correct hypoperfusion. Now common sense tells us we need to balance hypotension with exacerbating blood loss with too much IVF.



> Other, more rigorous, studies tell us that ALS helps in some situations and hurts in others


That is what this study shows. What studies are you referring to?



> Beyond that there is not much other data


Wait... you just said there were all these other studies?



> Paramedic and overall EMS quality varies by zip code and data collection and reporting by EMS is virtually absent. In an article that responded to this study an author cited a mere 14% compliance rate of ALS crews administering epinephrine every 3-5 minutes in cardiac arrest. If the quality of care from paramedics is poor then we need to examine that, a study comparing ALS and BLS bills and outcomes is not an adequate exploration of the topic.


Here we agree on the frist part of your statement. The second part, you missed the point of this study, which is to IDENTIFY A PROBLEM. The study did not supply a solution (nobody said to eliminate EMS). There was some speculation on cause by looking at other studies, such as the one you reference.

Did the study find a problem? YES

Did the study find a solution? NO

What should we do? DETERMINE THE CAUSES WITH FURTHER STUDY SO THEY CAN BE CORRECTED



> We, as an EMS community, should not be settling for crap studies with insufficient data.


The reduction of your reasoning is that it is literally impossible to study whether an ALS care system benefits the patient.

We shouldn't settle for pundits who don't understand research processes or even read the studies they want to discount for emotional reasons.


----------



## jrm818 (Oct 22, 2015)

Summit said:


> Here we agree on the frist part of your statement. The second part, you missed the point of this study, which is to IDENTIFY A PROBLEM. The study did not supply a solution (nobody said to eliminate EMS). There was some speculation on cause by looking at other studies, such as the one you reference.
> 
> Did the study find a problem? YES



What problem?  This is the crux of the issue; saying they found a "problem" requires accepting that ALS care _caused_ worse outcomes; and that requires accepting that the methodology used here says anything about causality.  

If all the paper did is identify an association between ALS care  and poor outcomes, well then OK, but that's not a _problem_ that requires fixing, just like the fact that patients treated in the ED have worse outcomes than patients treated at an urgent care isn't a problem.


----------



## Summit (Oct 22, 2015)

jrm818 said:


> What problem?  This is the crux of the issue; saying they found a "problem" requires accepting that ALS care _caused_ worse outcomes; and that requires accepting that the methodology used here says anything about causality.



The study didn't conclude: "eliminate ALS."

A proposed causal link doesn't imply the specific causes. As another poster said, ALS isn't a monolithic thing. It is a conglomerate of interventions, providers, care philosophy and systems. The study says there is some thing(s) wrong with it. Both the studies AND THE DETRACTORS have given their opinions or provided studies indicating what some of those specific causes (and potential solutions) may be, whether provider quality, training, or methodology of care and transport!


----------



## jrm818 (Oct 22, 2015)

Summit said:


> The study didn't conclude: "eliminate ALS."
> 
> A proposed causal link doesn't imply the specific causes. As another poster said, ALS isn't a monolithic thing. It is a conglomerate of interventions, providers, care philosophy and systems. The study says there is some thing(s) wrong with it. Both the studies AND THE DETRACTORS have given their opinions or provided studies indicating what some of those specific causes (and potential solutions) may be, whether provider quality, training, or methodology of care and transport!



But that assumes that a nonrandomized retrospective trial with data derived from billing codes is sufficient to conclude that there is a causal link between ALS care and poor outcomes in the first place.  I think you will find that conventional wisdom, especially among clinicians, is that such a methodology cannot completely control for confounders and thus cannot conclude _anything _about causality.


----------



## EpiEMS (Oct 22, 2015)

At the very least, it confirms issues we already knew existed and gives more...evidence, shall we say, to back the argument for more controlled trials.  
It's an elegant study and confirms OPALS et al, so what's the problem?


----------



## Summit (Oct 22, 2015)

jrm818 said:


> But that assumes that a nonrandomized retrospective trial with data derived from DIAGNOSIS CODES AND billing codes AND MUCH MUCH MUCH MORE FROM A HUGE DATASET is sufficient to conclude that there is a causal link between ALS care and poorer outcomes than BLS for some patient types that ALS should have better outcomes for if the patients were comparable... AND THEY WERE



Fixed a few things... and those fixes are *NOT the same* as saying Urgent Care patients do better than ED patients as a generalized statement.



> I think you will find that conventional wisdom, especially among clinicians, is that such a methodology cannot completely control for confounders and thus cannot conclude _anything _about causality.


You'll find that they did an excellent job of controlling and discussed what they couldn't, and the preponderance of likely biases were in favor of ALS, not BLS.

So, since you already admit that RCT is not acceptable here, you'll find that medical scientists and clinicians are willing to accept the _suggestion of causality to the extent _of looking for individual causal explanations for the system effect on outcomes found in this study.

Otherwise, you are simply saying, "I think that ALS should be awesome, and there is no way to test this assumption, and anything that says otherwise is inconclusive at best." There is no complimentary way to describe such thinking.


----------



## jrm818 (Oct 22, 2015)

Summit said:


> Fixed a few things... and those fixes are *NOT the same* as saying Urgent Care patients do better than ED patients as a generalized statement.
> 
> 
> You'll find that they did an excellent job of controlling and discussed what they couldn't, and the preponderance of likely biases were in favor of ALS, not BLS.
> ...



Do you speak to people like this in real life?  I don't think I've been anything but polite, and I expect the same from you, although you are an anonymous set of fingers somewhere in the internet.

Enjoy your discussion.


----------



## Carlos Danger (Oct 22, 2015)

jrm818 said:


> What problem?  This is the crux of the issue; saying they found a "problem" requires accepting that ALS care _caused_ worse outcomes; and that requires accepting that the methodology used here says anything about causality.



According to all conventional wisdom, ALS _should _show clearly improved outcomes among the sicker patients.

Considering that the very existence of the paramedic profession as we know it and much of the EMS industry relies on that assumption, I'd say that a large, well put together study showing that such a benefit may not exist - or worse - presents a pretty substantial problem, not to mention a host of potential research questions.

You sound as though you read quite a bit of research. If that is the case, then you are well aware that probably a large majority of published clinical research results in findings that are not immediately actionable but that contributes to the body of scientific knowledge, often forming the basis for further study.


----------



## Summit (Oct 22, 2015)

jrm818 said:


> Do you speak to people like this in real life?  I don't think I've been anything but polite, and I expect the same from you, although you are an anonymous set of fingers somewhere in the internet.
> 
> Enjoy your discussion.


Hey no offense was meant but I definitely was refuting your position by b pointing out your incomplete representation of the study and re-presenting your logic in a way that illustrates its faults which is part of a spirited debate.


----------



## SandpitMedic (Oct 22, 2015)

This is a hostile work environment.


----------



## Carlos Danger (Oct 22, 2015)

SandpitMedic said:


> This is a hostile work environment.



I love you, man.


----------



## sir.shocksalot (Oct 23, 2015)

Summit said:


> The study didn't conclude: "eliminate ALS."
> 
> A proposed causal link doesn't imply the specific causes. As another poster said, ALS isn't a monolithic thing. It is a conglomerate of interventions, providers, care philosophy and systems. The study says there is some thing(s) wrong with it. Both the studies AND THE DETRACTORS have given their opinions or provided studies indicating what some of those specific causes (and potential solutions) may be, whether provider quality, training, or methodology of care and transport!



*“This study demonstrates that in medicine costlier isn’t always better; simply transporting the patient to the hospital as soon as possible appears to have a high payoff"*, states Newman, one of the study's authors.

This is a very bold conclusion to make from the study that was used. I think this is the issue that we have with the study. The methodology limits the studies ability to control for confounders regardless of the use of other billing codes to try and control for confounders (with the exception of the trauma sample which is likely well controlled by ISS). The only logical conclusion this study can reach is the need for more studies.

The lack of mandatory data reporting in EMS is really the biggest problem and makes it almost impossible to drive EMS care forward. Most research in EMS is limited and/or biased. A lot only applies to specific agencies or areas or is biased by voluntary data reporting and study participation (biases towards higher quality care/Hawthorne effect). Things have to change so we can use large data sets to really see where EMS is at across the country and how ALS care effects outcomes and differs between agencies and geographic regions.


----------



## evantheEMT (Oct 24, 2015)

Ems providers are always saying " we need evidence based medicine" then when we have multiple studies proving certain things ems providers want to ignore it and say it's "flawed".


----------



## ExpatMedic0 (Oct 24, 2015)

I am still waiting on access to the full article so I can look into it further. Its really hard for me to argue in either direction by simply reading the abstract. However, some questions that come mind immediately would be how "advanced" was the ALS. Prehospital doctors, paramedics, flight nurses, ect. Did the ALS have a full array of things that could have changed outcomes in cases such as CVA and trauma like access to thrombolytics and blood products for example. I see the outcomes where worse for respiratory arrest, but what about respiratory distress? Also, Did the study measure mortality only and not morbidity in anyway? However, my biggest question would be was the ALS responding to more critical cases which would have had more negative outcomes regardless and was this accounted for in some way? Not trying to argue for any side here, just curious about these factors while I wait for access so I can review the methodology.


----------



## DPM (Oct 24, 2015)

To add to the previous post, what is the level of BLS? There are many places in this country where EMT-B can give meds, start lines etc.


----------



## sir.shocksalot (Oct 24, 2015)

evantheEMT said:


> Ems providers are always saying " we need evidence based medicine" then when we have multiple studies proving certain things ems providers want to ignore it and say it's "flawed".


We do not have multiple studies proving certain things. Shoving a bunch of data into SPSS and mathing the **** out of the data does not prove much of anything. Regression analysis are not magic equations that create truths. Evidence based medicine needs to be based on good evidence and expert consensus. No medical director would use the data from this study to turn every ALS ambulance or (god forbid) fire department vehicle into a BLS one. Medical directors in Florida are being sued because they won't let ALS firefighters on engines work as paramedics, there is no way on earth you could use this study to prove you don't need paramedics on the ambulances either.

It would be a huge mistake to trust every study that is published as an absolute truth and not be critical of it's methods or results. How many have died and will die from one completely horrific study that claimed a link between autism and vaccines? Statistics is a tool to find answers, it is not _the_ answer. Besides, changes in accepted practices should be done slowly in measured steps to ensure the changes accomplish the desired goals.


----------



## Summit (Oct 24, 2015)

sir.shocksalot said:


> We do not have multiple studies proving certain things.


We do have multiple studies showing that something(s) about ALS lead are ineffective to negative for some patient populations.



> No medical director would use the data from this study to turn every ALS ambulance or (god forbid) fire department vehicle into a BLS one.


Nobody, I repeat, NOBODY, is arguing for that.

Keep trotting that strawman argument around though...


----------



## SeeNoMore (Oct 24, 2015)

I imagine the crucial factor to examine will be transport distance. I know further studies are warranted , but it seems very clear ALS is unnecessary in an urban setting. We may only need a very small percentage of current medics , maybe only those in systems where advanced care is 45 minutes or an hour away. What will all the other medics do? But then again, maybe nothing will change and we'll keep up the status quo .


----------



## DPM (Oct 24, 2015)

SeeNoMore said:


> ...but it seems very clear ALS is unnecessary in an urban setting...



I don't like nit-picking, but this study doesn't show that. It shows that when we use Medicare codes as a guide, a selection of Medicare patients between 2006 and 2011 might have benefited with BLS over ALS in 3 specific areas. This is one of the flaws of the study.


----------



## SeeNoMore (Oct 24, 2015)

Ok but they are 3 important areas. And this is not the only study that has called ALS outcomes into question. Believe me I'm not happy about it , but I think there are huge changes on the horizon if the public and government figures out what many of us suspsect.


----------



## DPM (Oct 24, 2015)

They are important areas, but it's hard (for me) to take this study seriously. Respiratory failure, but not distress or breathing difficulty is very specific, yet trauma is all encompassing. 

Likewise, though this is claiming that in some cases BLS > ALS, there is a lot of variation in what BLS actually is across the country.


----------



## NomadicMedic (Oct 25, 2015)

Its not the field treatment by ALS, but in the amount of time it takes to initiate treatment and then transport. Perhaps if all of the "stay and play" protocols (with the exception of post ROSC) were eliminated and treatment was ONLY given en route, we'd see less of a issue?*



*this goes against everything I feel is right, BTW.


----------



## SeeNoMore (Oct 25, 2015)

I imagine the best results you would achieve in urban areas would be "no difference in outcomes" but perhaps you are correct. It would be interesting to see a study done where half the time  patients were loaded and immediately transported without anything but BLS measures performed prior to departure.


----------



## Carlos Danger (Oct 25, 2015)

SeeNoMore said:


> I imagine the best results you would achieve in urban areas would be "no difference in outcomes" but perhaps you are correct. It would be interesting to see a study done where half the time  patients were loaded and immediately transported without anything but BLS measures performed prior to departure.



That would be a truly fascinating study. Unfortunately RCT's like that are almost unheard of in the US.


----------



## SeeNoMore (Oct 26, 2015)

Does anyone know of any recent studies on the effect of ALS on rural patients? I cant find anything. It's very frustrating we are not better able to evaluate our practice. It also occurs to me that those who post here are likely not representative of the average EMS provider. I feel many providers are fairly apathetic about whether their care reduces mortality. They are not uncaring , but rather take it as a matter of faith that ALS is superior medicine regardless of the situation.


----------



## Bullets (Oct 26, 2015)

DEmedic said:


> Its not the field treatment by ALS, but in the amount of time it takes to initiate treatment and then transport. Perhaps if all of the "stay and play" protocols (with the exception of post ROSC) were eliminated and treatment was ONLY given en route, we'd see less of a issue?*
> 
> 
> 
> *this goes against everything I feel is right, BTW.


Here in NJ our medic patches say "MICU" on them, and i have reminded them on multiple occasions that "M stands for Mobile". Yes this patient needs treatments that you can provide, but this is what we trained for, this is why we can hold a source of pride over other healthcare providers. That we have the ability and hopefully the expertise to start the treatment process in austere and less than ideal condition. We still hold this mindset that we treat out here then we "give" the patient to them in the ED. We need to think more that what we do out here is just doing the same thing they would do, sooner and more local to you the patient. I believe that the stay and play model is detrimental to many of our patients.


----------



## SeeNoMore (Oct 27, 2015)

I am not convinced the answer is simply to transport more quickly. I don't know if we have good evidence that ALS care (as it is currently employed)  is beneficial to many patients no matter when it is initiated. I believe that ALS care in suburban/urban areas is reasonable for seziures, hypoglycemia, pain management and possibly respiratory distress. This would be heavily influenced by what BLS can do (nebs, epi pens etc). I would guess that a small number of highly experienced and educated Paramedics employing evidence based care MIGHT reduce mortality in some cases (Chest pain/MI, Resp Distress/failure, TBI). I fear this will never come to pass and things will stay as they are until a tipping point is reached, and ALS care is drastically reduced.


----------



## EBMEMT (Oct 27, 2015)

We have various studies which show:

ALS outcomes worse than BLS for severe trauma, trauma, stroke, respiratory distress.
ALS averages double the on scene to hospital time.  27 minutes ALS, 13 minutes BLS.    Which means that ALS, on average, spent longer stabilizing for transport than the time it takes to package and transport.
Mentioned by current study author as a probable cause for the results.
ALS outcomes worse than BLS for cardiac arrest  (Mentioned in link posted criticizing current study)
Scoop and run of GSW/stab victims by police (Philadelphia)  improves outcomes over waiting for ambulance (recently posted on this site) after correcting for the fact that police transported the more acute patients.
Scoop and run of GSW/stab victims by lay people in POV dramatically improves outcomes over waiting for ambulance or police.   Greater time savings, greater improvement vs police.
ALS provided by doctors rather than paramedics in field in canada detrimental to patient outcomes.  Again, attributed to time.
studies of individual ALS interventions suggest they don't improve or hurt the outcome in of themselves but they increase on scene time and that has detrimental effects on patient outcome.  Based on link posted in this thread:.  http://epmonthly.com/article/back-to-basics/
In cases of penetrating trauma, spinal motion restrictions kills 16 patients for every one who might avoid paralysis.   This appears to be largely (but not entirely) due to delay.   http://www.ncbi.nlm.nih.gov/pubmed/20065766
Overall, the gist of it is don't waste time on scene playing doctor (even if you are a doctor), get critical patients to the hospital where you have specialists, medical imaging, operating rooms, cath labs, interventional neuroradiology, etc.

Exception is cardiac arrest (where we are generally required to stay and play) and I suspect that exception is unlikely to bear the test of time now that it is possible to let machines do the chest compressions. You might need to pull over to do the analysis before shocking as vibration can upset AED.  chest compressions until defibrilator attached, analyze, shock, chest compressions until mechanical compression device attached, begin mechanical compressions while loading patient, shock again, wheels up, ALS, ...  

The "golden hour" is not a deadline, in the sense that the patient will be ok if you get them to the ER by the end of the golden hour.   It is more like an hour glass with patient survival declining towards zero continuously over that hour.    Assuming patient is really that critical.

Some possible ways of speeding up delivery for time critical patients:

Do not delay BLS interventions for ALS interventions.
ALS is ok as long as the wheels are turning.
Send the closest unit rather than a "better" but more distant unit
Use the helicopter when it will reduce transport times.   Give helicopter advance warning.
load and go instead of stay and play
do not wait for ALS to arrive, have ALS intercept in route
If ALS is likely to be beneficial, dispatch them for assist before BLS arrives
Consider not waiting for ambulance to arrive.   Have police scoop and run, send ambulance to intercept enroute.  Have dispatcher give bystanders option to scoop and run (but not break traffic laws) if emergency responders will be delayed.
conduct portions of the patient assessment before ambulance arrives.   I.E. phone patch AIC to patient.
Don't try to keep on scene times down to 10 minutes, try to eliminate the 10 minutes.
Give hospital stroke/STEMI/trauma alerts early, even if you don't have all the data yet.
possibly bypass hospitals that can't offer definitive treatment.
reduce use of spinal motion restriction


----------



## Aprz (Oct 27, 2015)

Saw this on Facebook. I didn't look further into it, but it probably pertains to this thread.

http://journals.lww.com/jtrauma/Fulltext/2015/08000/Decreased_mortality_after_prehospital.8.aspx


----------



## SeeNoMore (Oct 27, 2015)

Very interesting. It's odd that tourniquet use was considered. Isn't that a BLS intervention generally? I wonder how many of the deaths prevented were simply from management of blood loss.


----------



## Carlos Danger (Oct 27, 2015)

Aprz said:


> Saw this on Facebook. I didn't look further into it, but it probably pertains to this thread.
> 
> http://journals.lww.com/jtrauma/Fulltext/2015/08000/Decreased_mortality_after_prehospital.8.aspx



Interesting read - thanks for posting it.

Too bad though, that it is a retrospective review that relies on fancy voodoo statistics - and therefore worthless.


----------



## SeeNoMore (Oct 27, 2015)

It's different as it proves I'm still a hero


----------



## sir.shocksalot (Oct 29, 2015)

Summit said:


> Nobody, I repeat, NOBODY, is arguing for that.
> 
> Keep trotting that strawman argument around though...



You mean like this:



Bullets said:


> I believe that the stay and play model is detrimental to many of our patients.





EBMEMT said:


> Overall, the gist of it is don't waste time on scene playing doctor (even if you are a doctor), get critical patients to the hospital where you have specialists, medical imaging, operating rooms, cath labs, interventional neuroradiology, etc.
> 
> load and go instead of stay and play



I have quoted the authors a few times who also make the argument that BLS has better outcomes. Having now read the full study and the supplements I am even more skeptical of the results. The authors took a lot of liberties and assumptions about why someone received BLS over ALS. Most specifically, they made the incorrect assumption that the ALS population and BLS population were equal based on the idea that ALS would be dispatched to all these calls in the first place and these patients are getting BLS bills because ALS was not available. They determined this was a fact after interviewing EMS leaders in 45 states. Not to mention the ALS samples were sometimes 5-7x larger than the BLS sample; for AMI there were 100,000+ ALS patients while there was only 14,000+ BLS patients. Plus, all the math they did on the data lends itself to type I errors in the first place.

I appreciate what the authors are trying to do. They are trying to study something which has a complete dearth of data to use in any sizeable population. People are jumping to conclusions using conclusions from this study that also jumped to conclusions. The study is interesting and they really tried to adjust for as many things as possible but the data is just not there to do a thorough analysis. So, for the conclusion the study reached I stand by saying that it is crap. As I said before, we need more studies.


----------



## sir.shocksalot (Oct 29, 2015)

EBMEMT said:


> We have various studies which show:
> 
> ALS outcomes worse than BLS for severe trauma, trauma, stroke, respiratory distress.


 Are you referencing the study that we are currently debating? Even if you are, one study is not sufficient evidence to draw a conclusion from.


EBMEMT said:


> ALS averages double the on scene to hospital time.  27 minutes ALS, 13 minutes BLS.    Which means that ALS, on average, spent longer stabilizing for transport than the time it takes to package and transport.


 That data comes from one study that the author referenced that was done out of Ontario, Canada. http://www.ncbi.nlm.nih.gov/pubmed/15306666
Also, that study was focused on OHCA after implementation of ALS in Ontario and found no difference in outcomes between ALS and BLS (meaning survival to discharge, hospital admission increased according to the study). Saying that ALS doubles on scene time without adding a number of caveats to that is meaningless. Further, it really only applies to cardiac arrest in Ontario since other systems may operate differently.



EBMEMT said:


> Mentioned by current study author as a probable cause for the results.


 Authors are not experts in emergency medicine or prehospital care. Two of the authors have vested interests in healthcare economics with one being the director of an insurance company and the other a senior consultant for Precision Health Economics http://www.precisionhealtheconomics.com/about-phe


EBMEMT said:


> ALS outcomes worse than BLS for cardiac arrest  (Mentioned in link posted criticizing current study)


 Other studies have found no difference or some benefit in ROSC rates but either some or no difference in survival to discharge. AHA has said multiple times that good CPR and early defibrillation saves lives (BLS), so we know that BLS is good but there is no definitive evidence that ALS is bad (on the average it seems to make no difference on outcomes). Latest AHA review of evidence for you: http://circ.ahajournals.org/content/132/18_suppl_2.toc



EBMEMT said:


> Scoop and run of GSW/stab victims by police (Philadelphia)  improves outcomes over waiting for ambulance (recently posted on this site) after correcting for the fact that police transported the more acute patients.
> Scoop and run of GSW/stab victims by lay people in POV dramatically improves outcomes over waiting for ambulance or police.   Greater time savings, greater improvement vs police.


 Trauma care by EMS in the US is atrocious. Almost everything you are taught in EMT and Paramedic school is detrimental to sick, hemorrhaging trauma patients. We know that the only thing that saves sick trauma patients are surgeons. We know that IV fluids (IMO in any amount) is bad. Trauma naked is bad. Anything that slows that patient from seeing a trauma surgeon is bad. However a car is only better when used in urban settings so this study is not all encompassing. BLS should be slightly better than ALS for sick trauma in urban settings too unless EMTs can start IVs in that area in which case either one is awful.


EBMEMT said:


> ALS provided by doctors rather than paramedics in field in canada detrimental to patient outcomes.  Again, attributed to time.
> studies of individual ALS interventions suggest they don't improve or hurt the outcome in of themselves but they increase on scene time and that has detrimental effects on patient outcome.  Based on link posted in this thread:.  http://epmonthly.com/article/back-to-basics/


 To your first example here, please cite your sources. We know that transport times are important for some things and not for others; this creates an important distinction when talking about outcomes. To the second example you are once again citing something that uses the study we are debating. The article also cites data about ALS intervention efficacy from OHCA studies, which again we know that anything other than CPR and defib are of dubious benefit at best. To be clear, this means that giving Epi seems to be of no benefit in OHCA, just like it does in the hospital. That cannot be extrapolated to other areas.


EBMEMT said:


> In cases of penetrating trauma, spinal motion restrictions kills 16 patients for every one who might avoid paralysis.   This appears to be largely (but not entirely) due to delay.   http://www.ncbi.nlm.nih.gov/pubmed/20065766


 Yes, trauma care is terrible. Also, PHTLS and ITLS don't recommend the routine application of back boards to penetrating trauma. I think that back boards are bad in general and they are on their way out in many areas. But I've already talked about the trauma thing so I won't repeat myself.


EBMEMT said:


> Exception is cardiac arrest (where we are generally required to stay and play) and I suspect that exception is unlikely to bear the test of time now that it is possible to let machines do the chest compressions. You might need to pull over to do the analysis before shocking as vibration can upset AED.  chest compressions until defibrilator attached, analyze, shock, chest compressions until mechanical compression device attached, begin mechanical compressions while loading patient, shock again, wheels up, ALS, ...


 Machines create unacceptable gaps in chest compressions IMO and have no demonstrable efficacy on patient outcomes. Also, stay and play for cardiac arrest exists to stop from crowding ERs with dead people. Transporting patients in cardiac arrest is dangerous, expensive, and gives no benefit with very rare exceptions. The dangers of going code three with dead people to the ER far outweigh benefits and AHA continues to recommend against routinely transporting cardiac arrest patients. Helicopters are crazy dangerous and are usually guilty of some of the largest delays in transport times so should be used only when the transport times are going to be exceedingly long.

I think there is a big misunderstanding in things we "know" about prehospital care. We actually don't know much. There is hardly any data available to be examined and getting data that is comprehensive enough is exceedingly difficult. Time is important in some things, but not for others and we have no real idea where this cut-off exists. Severe trauma is very time sensitive, less severe trauma may not be. Stroke? Maybe, but not in the measure of minutes (difference between ALS and BLS) since hospitals can create enormous delays while they figure out if tPA is indicated. AMI? Well, STEMI is time sensitive and benefits from early 12-lead EKG and hospital notification (ALS). NSTEMIs? Eh, maybe but again not in the measure of minutes.

Trying to come up with hard and fast rules in medicine is disingenuous. There is a lot of variation in patient presentation, severity, scene dynamics, and EMS system differences that makes the 10 minute rule a moot goal. Multisystem trauma in a car needing extrication is probably going to be longer than 10 minutes. Someone shot on the street corner should have a scene time of a minute or two. Load and go has its place for some things while stay and play has for others, it's not an either-or thing. Good, experienced, well educated clinicians are able to make these decisions based on circumstances and defend their reasoning. Currently, we are a "profession" of technicians (ALS or BLS) that have accepted minimal standards for ourselves and seem to avoid participating in data collecting and research on the work we do.


----------



## triemal04 (Oct 30, 2015)

After reading this thread all I can say is sweet bleeding jeebus there are some people here with utterly closed minds.  I'm shocked.

No wait...I'm not.

If anyone has one of those "beating a dead horse" gif's, now is the time to put it up.


----------



## triemal04 (Oct 30, 2015)

Oh, and I forgot to mentio; this study, like the previous one, is a waste of time.  The more I think about it, the more my brain hurts.  I retract all my previous statements except to say that, while these people are just plain ignorant, the question they ask is valid, and needs to be answered.


----------



## ExpatMedic0 (Oct 31, 2015)

I just skimmed over the full study. Unfortunately I have final exams for over the next 10 days, so I won't be able to really dig into until after then. Although I will say I am gonna really dig into their methodology at some point. For now, it appears the authors did take a lot of things into consideration and I don't think the data from the study should just be dismissed or written off like some here are suggesting. This data could lead to further explorations of ALS care and lead to a marked improvement in the way ALS is delivered. However, it would appear we need a lot more information on the regional level and protocols of the ALS and the BLS before we can really understand some of these results. For example for respiratory failure, what where the majority of causes, and what was the ALS capabilities. Did the ALS have CPAP, RSI, mechanical ventilators, and a full array of pharmaceutical interventions? What are the protocols and education/training levels of the ALS and the BLS? For AMI, did the ALS have STEMI activation procedures, tools, and training?  For CVA where prehospital thrombolytics available for ALS? How much protocol and training variation for levels of ALS and BLS was there? Unlike a medical doctor in the ED at a major hospital, ALS and BLS providers vary wildly in scope of practice and education, as do their protocols and interventions.  I don't think the results should be ignored, but researched further as to why the results are the way they are, because the authors do not provide that information (which is fine, because it was not the goal of this particular study). Perhaps some sub-cohorts of ALS performed 10x better than BLS, we don't know because we're grouping these variables together as if they are the same. Lastly, there is also no mention of morbidity, only mortality. Perhaps all the BLS patients that are neurologically intact have other lifelong disabilities and the ALS ones do not, we don't know. What did the BLS patients receive in definitive care that reduced mortality levels, is it something we have the capabilities to deliver pre hospital with ALS? It is a good study in a sense as it shows a possible problem, but for me it raises more questions than answers in exploring why the results are the way they are and how can we conduct more research to discover that? Just some food for thought for now.


----------



## Carlos Danger (Oct 31, 2015)

ExpatMedic0 said:


> Unlike a medical doctor in the ED at a major hospital, ALS and BLS providers vary wildly in scope of practice and education, as do their protocols and interventions.



That is exactly true. There is a huge diversity in paramedic education, experience, protocols, drugs, equipment, transport times, and even receiving facility capability from state to state and county to county, and all of those things can potentially affect outcomes. Even among two different services in the same town, one might be a much better place to work for various reasons, and thus more selective about the paramedics they hire, taking on only more experienced ones. Then the better service provides their (likely better to begin with) paramedics with better going education, better equipment, and better protocols than their competition.

All of that makes generalizing and translating to practice almost any EMS research findings difficult, and I think even people who don't read or understand research kind of inherently get that. So when you combine those real challenges with a general lack of respect for or understanding of research to begin with, it's easy to see why people are so quick to dismiss research as unimportant or at least not applicable to them. The icing on this crapcake is the fact that so many in EMS have a lot of their personal identity wrapped up in their ability to "do what doctors do at 90mph", so they take personally any suggestion that some of what they do in the field might not be good for patients.

There are two compelling things about this study: First, it's massive size. Such a huge sample drawn from all over the country would arguably control to at least some degree for some of the variables that exist from EMS service to EMS service. Second, as has been pointed out here several times, this study confirms some of what other studies have already told us. You can make an argument to ignore the findings of one study - even a very large one, perhaps - but it is much harder to argue that we should ignore the findings of numerous studies that are in basic agreement.

So what this study really tells us, IMO, is that we need to be critical of prehospital interventions, and constantly search for proof that what we are doing for our patients is really in their best interest. In order to advance, we really need to be more professional overall - more educated, more critical, and less emotionally invested in what we do.


----------



## DrParasite (Oct 31, 2015)

SandpitMedic said:


> ALS vs BLS?
> 
> If I code, I want ALS.


Since you brought it up, Why?  What does ALS do that BLS can't?  ok, wait, let me rephrase that question: what will ALS do that is shown to have a better clinical outcome that BLS can't?  If I remember correctly, in cardiac arrests, the only thing that has been proven through clinical research to make cardiac arrest patient's walk out of the hospital were CPR (push hard and fast) and early defibrillation, both of which BLS can do.  

Intubations have no clinical benefit over BVM, ACLS has no statistical benefit, and the heart treats electricity from a lifepak 15 and electricity from an AED the same way.

So, again, if you code, why would you want ALS, if they don't improve your chances of walking out of the hospital?


----------



## ExpatMedic0 (Oct 31, 2015)

I think some people may be lead to believe "ALS is bad" because of the findings. However, I think that's the wrong way to look at this. "How can ALS be improved" is the way it needs to be looked at. As mentioned though, the study raises more questions than answers. It identifies a possible area for improvement. Unfortunately it is not me you need to convince, its stakeholders and policy makers. No one here can state why the ALS had worse outcomes in this study, because no one (including the authors of the study) know. We can speculate, but ultimately further investigation is needed. This study's conclusion is "Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS." Maybe this could lead to further studies to answer the Why's and How's. Once we can identify these unknowns, there is potential to improve ALS and improve these statistics. That may not mean more BLS, it could mean more ALS.  For now, its opened up a big can of worms and hopefully a lot more money and interest in prehospital research, I hope


----------



## chaz90 (Oct 31, 2015)

DrParasite said:


> Since you brought it up, Why?  What does ALS do that BLS can't?  ok, wait, let me rephrase that question: what will ALS do that is shown to have a better clinical outcome that BLS can't?  If I remember correctly, in cardiac arrests, the only thing that has been proven through clinical research to make cardiac arrest patient's walk out of the hospital were CPR (push hard and fast) and early defibrillation, both of which BLS can do.
> 
> Intubations have no clinical benefit over BVM, ACLS has no statistical benefit, and the heart treats electricity from a lifepak 15 and electricity from an AED the same way.
> 
> So, again, if you code, why would you want ALS, if they don't improve your chances of walking out of the hospital?


Locally, I want ALS because we provide more effective compressions, more timely defibrillations with decreased hands off time, and don't throw cardiac arrests into ambulances with manual CPR. I can't argue the ACLS meds point, but we make an effort to work on correctible causes of the arrest as they come up, and we do not pause compressions to intubate. 

BLS could provide all of these things just as easily, but unless you get a good BLS crew, they're likely going to have one person doing manual compressions for way too long, transport an arrest in order to get to "definitive care" and do crappy manual compressions the whole way.


----------



## DrParasite (Oct 31, 2015)

triemal04 said:


> Oh, and I forgot to mentio; this study, like the previous one, is a waste of time.  The more I think about it, the more my brain hurts.  I retract all my previous statements except to say that, while these people are just plain ignorant, the question they ask is valid, and needs to be answered.


umm why? because multiple studies say something you don't want to hear?  Because the evidence doesn't support your opinion?  Because it makes you feel a little less important than you think you are?

Just so there is no confusion, i am not anti-ALS, nor do I think we should be getting rid of paramedics.  But we do need to go with the evidence, which means there are a select few types of calls where paramedics should remain on scene for extended periods of time.  as @Bullets said (and since we are both from the same state, I understand why we both think this way), paramedic should be MOBILE, and often bring the ER to the patient, however the goal still is to get the patient to definitive care, which means an MD.  

I'm not saying I don't need or want a paramedic, what I'm saying is ALS can be greatly beneficial, because it's allows those MD like interventions to be provided before the patient gets to the ER, provided they are done while transporting to the hospital, instead of creating an extended time on scene.

Oh, and on a cardiac arrest, I absolutely want a paramedic, maybe even 2.  I want them to see what the patient's heart rhythm is, so we know if this patient is saveable or not.  And yes, I think BLS crews should be competent and be able to do their jobs without a paramedic there to either hold their hand or tell them step by step what they need to do, but apparently that level seems to leave when you go away from a tiered EMS system.


----------



## Bullets (Oct 31, 2015)

sir.shocksalot said:


> Machines create unacceptable gaps in chest compressions IMO


Only with poor agnecy training on those machines



sir.shocksalot said:


> and have no demonstrable efficacy on patient outcomes.


Ahh, you're one of these people. You are looking at the science wrong. Its not about being better, its that machines are just as good as humans, but do not tire, do not interrupt compressions once applied and free up a provider to do something else, manage an airway, gain iv access, draw up drugs, ect.





chaz90 said:


> Locally, I want ALS because we provide more effective compressions, more timely defibrillations with decreased hands off time, and don't throw cardiac arrests into ambulances with manual CPR. I can't argue the ACLS meds point, but we make an effort to work on correctable causes of the arrest as they come up, and we do not pause compressions to intubate.
> 
> BLS could provide all of these things just as easily, but unless you get a good BLS crew, they're likely going to have one person doing manual compressions for way too long, transport an arrest in order to get to "definitive care" and do crappy manual compressions the whole way.



This isnt an ALS or BLS issue, this is a overall training issue. YOUR BLS does crappy compression, YOUR BLS loads and gos with a dead person, YOUR BLS doesnt run a code efficiently. Just because youre a paramedic doesnt make you better or worse at running a code, you just need to better educate your BLS providers. If that isnt happening in the classroom then its your responsibility to teach them on the streets or talk to their system directors and medical directors.

My BLS project was the first in the area to adopt and change our OHCA policy in 2009 and it was a fight to get the volunteer EMS, Fire departments and Cops to understand why we were sitting on scene with these patients, why we waited so long and why we left dead bodies at home for PD to deal with. And the first time i did a hands on defibrillation i might as well have pulled the cops gun and shot someone. But over time and with education we have started to bring them around.[/QUOTE]


----------



## RocketMedic (Oct 31, 2015)

The study misses the point of ALS care, which is to palliative symptoms and stabilize deteriorating patients.


----------



## chaz90 (Oct 31, 2015)

RocketMedic said:


> The study misses the point of ALS care, which is to palliative symptoms and stabilize deteriorating patients.


Well, if we were successfully stabilizing deteriorating patients, I would imagine they would survive more frequently than if they were not "stabilized." Again, I'm firmly on the side of seeing that this study has some merit based on size but only justifies the need for further research and does not prove causation.


----------



## SixEightWhiskey (Nov 4, 2015)

In so many communities, calling 911 means you will get an ALS truck with at least 1 paramedic every single time. I am a firm believer that this makes every individual paramedic less proficient at their job (since medics are inherently doing a higher volume of lower acuity calls and individually seeing less very sick patients) and also causes BLS providers to have less experience with truly sick patients, and furthermore less experience determining who's sick and who's not.

I work in a system that dual responds ALS and BLS to calls that get EMD'd as ALS criteria calls, and it's great, because the BLS folks get to do emergencies and see sick patients, and ALS (ideally) only commits to sick patients and gets cancelled to a lot of the nonsense, therefore being available for when the truly acute call happens. In an urban environment I have found it to be the ideal EMS system model. Typically, the BLS will get to the patient first and assess them, and if its something truly urgent where the patient needs a hospital urgently (trauma, CVA), they are trained to head for hospital with or without medics. If we meet them, great, if not, that patient gets what they need, whether it be a surgeon/tPA/whatever it is that they need. Respiratory calls, cardiac calls, compromised airways; those are the calls paramedics can make a definitive difference with.


----------



## RocketMedic (Nov 6, 2015)

SixEightWhiskey said:


> In so many communities, calling 911 means you will get an ALS truck with at least 1 paramedic every single time. I am a firm believer that this makes every individual paramedic less proficient at their job (since medics are inherently doing a higher volume of lower acuity calls and individually seeing less very sick patients) and also causes BLS providers to have less experience with truly sick patients, and furthermore less experience determining who's sick and who's not.
> 
> I work in a system that dual responds ALS and BLS to calls that get EMD'd as ALS criteria calls, and it's great, because the BLS folks get to do emergencies and see sick patients, and ALS (ideally) only commits to sick patients and gets cancelled to a lot of the nonsense, therefore being available for when the truly acute call happens. In an urban environment I have found it to be the ideal EMS system model. Typically, the BLS will get to the patient first and assess them, and if its something truly urgent where the patient needs a hospital urgently (trauma, CVA), they are trained to head for hospital with or without medics. If we meet them, great, if not, that patient gets what they need, whether it be a surgeon/tPA/whatever it is that they need. Respiratory calls, cardiac calls, compromised airways; those are the calls paramedics can make a definitive difference with.



On the flipside of this, BLS and EMT-Basic and equivalents (and EMT-Intermediate and AEMT) are so easy to obtain that the barrier to entry is essentially a test written to the eighth-grade level and local hiring practices. This means that the BLS 911 responses are not necessarily getting seasoned veteran super-providers, but transitory pre-med college students doing their six months of EMT for the resume and the local high school glee club or a few firefighters, to steal a phrase from a friend of mine. Assuming that the BLS component in tiered systems is functionally competent is not a solid thing to do.


----------



## ExpatMedic0 (Nov 17, 2015)

Here's a little update. One of the authors discussing the study in question. http://www.ems1.com/ems-products/ambulances/video/28297187-Researcher-Is-BLS-better-than-ALS


----------

