# The Jig's Up, Kiddies!



## firetender (Mar 30, 2010)

According to this article, (which was sent me by an EMS County Upper Echelon-type guy), in a major, Major Conference, attended by EMS researchers from Great Britain, US and Canada, they concluded it doesn't much matter what I did, or what you do, there's been no real improvement in the outcome of morbidity and mortality from EMS intervention since load and go!

Another lifetime shot to hell!

http://www.emsnetwork.org/artman2/publish/article_40992.shtml


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## atropine (Mar 30, 2010)

Guess we really don't need four year degrees or pay increases.


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## JPINFV (Mar 30, 2010)

atropine said:


> Guess we really don't need four year degrees or pay increases.





> Community Health and Advanced Practice Paramedics - preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported.   Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.



You've average 9 month paramedic wonder isn't an APP. Also, there's another component that no one wants to talk about. If you're having an asthma attack, even if it doesn't change the final outcome, would you rather be treated by paramedics to relieve symptoms or wait for transport to be complete and for however long it takes to get an order (if there isn't a standing order) and treated in the ER?

If you have a traumatic injury, would you like pain control sooner or later? 

If you're hypoglycemia, would you rather have IV glucose solutions sooner or later? 

If you're having trouble breathing because of pulmonary edema, would you rather have symptom relief sooner or later?

Medical care isn't just about getting that high school in life expectancy.


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## LucidResq (Mar 30, 2010)

But without ambulance drivers, how would I get to the ER when I think I might be pregnant and just can't afford a home UPT because I needed to buy my cigarettes?! 

Thank God for Medicaid!


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## CAOX3 (Mar 30, 2010)

Now that we have this figured out we can use the EMS budget to buy more fire trucks.


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## mycrofft (Mar 30, 2010)

*Buy more firetrucks! Gevulht!*

HAHAHAHAHAHAHAHA!!!!!!!!!!!
Dear sir or Madam,
EMS is what's keeping FD's afloat now.

I do not believe the study represents some of the strong results of EMS...the feeling someone has your back, and the alleviation of pain and terror.

Yes, those who are clinically dead mostly can't be brought back to life, and there is only so much you can do for abruptio placenta, dissecting aortal aneurysms or esophageal bleeds in any setting, let alone an ambulance or squatting in someone's living room.

Field EMS, when statisticsadjusted for categories of patients, will be the first people addressing the most fatal problems; therefore, the statistics will reflect a high morbidity and mortality anytime. What happened in the old days was the pt was declared dead at the scene and never made it into the statistics...just a morgue.

I'm not ranting, just reflecting that those who take the risks get the worst press.


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## Bloom-IUEMT (Mar 30, 2010)

JPINFV said:


> If you have a traumatic injury, would you like pain control sooner or later?
> 
> If you're hypoglycemia, would you rather have IV glucose solutions sooner or later?
> 
> ...



Exactly! What a restrictive false dichotomous measurement: being dead or not dead.  What about post condition quality of life? What about patient comfort?


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## JPINFV (Mar 30, 2010)

Bloom-IUEMT said:


> What about post condition quality of life? What about patient comfort?



Those cost too much and won't get us a high score above Sweden. Hence of the reasons why the current health care reform is nothing but a sham.


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## Foxbat (Mar 30, 2010)

The nice thing about evidence-based medicine is that you can prove _anything_.

http://www.ncbi.nlm.nih.gov/pubmed/3367399
_Resuscitation and ALS in MVA appears to be beneficial in the treatment of multisystem trauma in a rural state._

http://www.ncbi.nlm.nih.gov/pubmed/19499469
_We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions._

http://www.ncbi.nlm.nih.gov/pubmed/16036833
_A top-level type of prehospital care had significantly more chances to resuscitate blunt trauma victims found in CA as compared with a simpler level. No significant benefit on long-term outcome was found, but more cases might be needed in future studies because of the inevitably low number of survivors._

http://www.ncbi.nlm.nih.gov/pubmed/10573491
_A two tier BLS and physician staffed ALS system is associated with good long term outcome of patients suffering from out-of-hospital cardiac arrest of cardiac aetiology in a midsized urban/suburban area. Further studies, however, are required to assess whether having a physician in the ALS unit is an independent determinant for improved long term outcome._

http://www.ncbi.nlm.nih.gov/pubmed/9766360
_An improved outcome in children with severe blunt trauma has been demonstrated when prehospital care is provided by physician-staffed ALS units compared with BLS units._

http://www.ncbi.nlm.nih.gov/pubmed/1474627
_This study identified a number of significant predictors of per capita county trauma mortality rates: rurality, percentage nonwhite population, percentage unemployment, and Advanced Life Support (ALS) versus Basic Life Support (BLS) status. Of these, ALS versus BLS status is not only the most significant independent predictor, it is the only predictor readily amenable to change. The aspects of ALS clearly associated with decreased trauma death rates should be identified and, if possible, undergo widespread implementation._

http://www.ncbi.nlm.nih.gov/pubmed/6694231
_The TS on arrival at the hospital increased significantly more for patients receiving field ALS care than for patients transported by BLS ambulances (p = 0.01). ALS resuscitation had most influence on patients with TS 4-13 and did not delay transport time. Furthermore, a positive change in prehospital TS was significantly related to an increased chance of long-term survival for any given severity of injury (p = 0.0002). From these data we conclude that the TS is useful for prehospital triage and that appropriate field ALS resuscitation results in more favorable outcomes following major trauma._


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## Bloom-IUEMT (Mar 31, 2010)

JPINFV said:


> Those cost too much and won't get us a high score above Sweden. Hence of the reasons why the current health care reform is nothing but a sham.



Agreed?  Some  progressives such as mine-self only like the bill because of what it represents as oppose to its manifest content which is actually private market based.  If I have a choice between the current bill and nothing, I chose the bill because I know public option government-regulated healthcare system is not going to happen in my lifetime.  BTW, thanks for the reply to my PM:glare:
If the market found a way to control prices and give universal access to healthcare, don't you think it would've happened by now?  
ANd I prefer the term "placebo" to "sham." THe 2010 Placebo Bill. Has nice ring to it.


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## JPINFV (Mar 31, 2010)

Bloom-IUEMT said:


> BTW, thanks for the reply to my PM:glare:


Um, what PM?


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## Bloom-IUEMT (Mar 31, 2010)

JPINFV said:


> Um, what PM?



It's from an old thread I started about Healthcare reform circa 9-24 of last year. The mods closed it before I had chance to reply. I'll resend it.


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## Veneficus (Mar 31, 2010)

*and yet people haven't figured it out*

You mean I am not Jesus Christ, raising people from the dead? What a let down. Somehow my ego will recover, but it will be difficult.

Sometimes I really think this kind of study is targeted at the providers who haven’t caught on yet. All it does is affirm what has been known in educated professional circles for ages.

Lights and sirens response and transport risks outweigh any benefit.
Measuring effectiveness by response time doesn’t correlate to outcome. Other than the general public, a bunch of dinosaurs running EMS agencies, and the occasional specialty NP that has to take time out to go on a transport, who could possibly think it would? 

Think about it. Less than 8 minute response goal is going to do what for a cardiac arrest patient w/o bystander intervention? You are going to meet this outstanding goal 90% of the time? Even if you got there in 6 minutes… Best of luck in your efforts to raise somebody from the dead after 6+ minutes and get them out of the hospital to any place other than a vegetable garden. 
Prehospital intubation isn’t showing outstanding success in improving outcomes where a OPA and a BVM would do? Another devastating blow… (pay no attention to the sarcasm)

Immobilization techniques not working? I guess all those posts I spent time typing pointing out basic anatomy characteristics of immobilization weren’t wasted?

“Life saving medications” (the people over in Naples, Florida may want to tune in here) doesn’t matter in cardiac arrest? The AHA has been saying for years they have no evidence it helps and an equal amount that it doesn’t hurt. In layman’s terms, “We can find it does anything one way or another.”  In fewer words: “It couldn’t really matter.”

Trauma: This really burns me. EMS providers walk around with utterly stupid statements like “a trauma requires surgery.” What it requires is a trauma expert. (usually a surgeon, but not always EM often does a fine job) Even in surgery low grade liver and splenic lacs don’t automatically mean removal or surgical correction anymore. The very concept of “damage control surgery” is you are going to make some repairs to keep as much viable function as possible. If a patient is not in irreversible shock or has some other condition incompatible with life, chances are they will live to the hospital. There are even accounts of Roman Legion Soldiers in BC surviving open pneumos during battle and returning to fight after recovery. If the patient is in irreversible shock (think about that term) will the surgeon wave his/her magic wand and alter time to prior to that?

With the week spent on teaching paramedics to “load and go” and “we do nothing in trauma care” is it any wonder they don’t help any? Of course what they don’t tell you is that most of the trauma you read about in your paramedic text, and divine being forbid, EMT text is on the decline, and not even the norm most places. Most trauma is muscle skeletal in nature, of which compartment syndrome and myoglobinurea are the life threats. (the later a condition that massive fluid and furosimide actually helps with) Of course with the amount of trauma knowledge in EMS, who in their right mind would allow US EMS to make decisions like that?  

I have also written at length here about a public health and prevention role of EMS. Apparently I don’t understand it is about saving lives and “real emergencies.” Even in the hospital most people in the “emergency department” are not. What makes EMS think their patient population would be different and still think they are a part of the same Emergency team? 
In response to this article, I see a lot of the same old arguments about pain control, difficulty breathing, allergic reactions, etc. But here is the rub. The easiest way to bring somebody back from the dead is to prevent them from getting to a life threatening state. Those people don’t show up in morbidity studies.

Since our “patients are customers” some say. (which demonstrates the ignorance of modern medicine) Why don’t we ever base our value on what they think helps, or what might actually help instead of feeding them trash like response times? Makes us look like fools or self serving.

Since before I started, EMS has measured its effectiveness on its ability to raise people from the dead and stop time. Those are quite high benchmarks. 
Something to think about: “If EMS prevents people from going to the hospital, the amount of people who EMS “helps” but don’t die in the hospital will go down. Maybe more realistic measures like lowering healthcare costs, time of return to function for patients, and a response and education to everyone who calls EMS rather than deciding to refuse people for not being a “true emergency” are much more attainable benchmarks?

Clearly undereducated providers tearing down the street to perform the same mindless treatments on every patient hoping the patient falls into the epidemiology those treatments are designed for doesn’t really “help.” (Analyze what you are doing, no international multicenter trial needed to figure it out. It is amazing what you can figure out thinking about something instead of beating your chest and promoting a big heart and good intentions.)


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## Bloom-IUEMT (Mar 31, 2010)

Veneficus said:


> The easiest way to bring somebody back from the dead is to prevent them from getting to a life threatening state. Those people don’t show up in morbidity studies.
> 
> Since our “patients are customers” some say. (which demonstrates the ignorance of modern medicine) Why don’t we ever base our value on what they think helps, or what might actually help instead of feeding them trash like response times? Makes us look like fools or self serving.
> 
> ...



Well said. I would love EMS to become more prevention and education based. I remember reading recently about a small community that required it's citizens to learn CPR and morbidity from out of hospital cardiac arrest dropped to some amazingly low number that I wished I remembered :unsure:


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## Shishkabob (Mar 31, 2010)

Actually, I wont disagree with this 'study'.  It is true.  The vast majority of our calls are NOT changed by what we do... because a vast majority of our calls are NOT emergent and don't require instant intervention, if any intervention at all.

But try telling me that EMS doesnt change outcomes in MIs, analphylatic reactions, respiratory arrest, certain cardiac arrest, and other calls that actually ARE emergent, and I'll buy what you're smoking.


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## MrBrown (Mar 31, 2010)

The notion of "emergency medical service" and "life support" needs to go; it stopped being relevant long ago

Most people who call ambo get a bit of symptom relief (nebules, GTN, pain meds) it doesn't truly fix the problem but that is not the job of the Ambulance Officer.  

There are some very sick people that do need the interventions of an Intensive Care Paramedic but these sort of studies that show they have negatable difference seem to be limited to cardiac arrests or trauma resuscitation


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## dudemanguy (Mar 31, 2010)

During my emt clinicals with an ALS rig, I went on maybe 20 911 calls. Out of those I can only think of one where an ALS intervention probably saved someones life. That was a diabetic with a blood sugar south of 20 who was in dire straits and snapped out of it with an injection of D50. She still might have survived had it just been load and go, albeit with substantially fewer brain cells. 
In most calls that were serious life threatening emergencies it was pretty much just load and go, they may have had an IV started by the time they reached the ER but I doubt that alone affected survival. The closest thing to intubation I experienced was a combitube insertion, which is a BLS skill here. The medics I rode with said they rarely intubated.

Having said that, if I or a loved one needed an ambulance, Id much rather have a paramedic show up at the door then an EMT.


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