Studies on ALS first response and tiered vs. all-ALS

[denadog]

Cops arrive first on scene for all Cardiac arrest here and start CPR, they are usually there for about 2-3 minutes before us and FD, wouldn't that be splended if they had an AED, BVM, and maybe some basic meds.

Where is this?

 

[medicsb]

I don't think that there's much research that clearly shows better outcomes with tiered response ALS versus all-ALS.

I think the "dumbing down" of our occupation has been done at the educational level, by a lack of demanding enough standards, a willingness to accredit programs with minimal clinical and academic hours, and a general lack of any concerted efforts by paramedics and EMT to demand better education.

I don't think having more paramedics is necessarily a bad thing. But we do need to identify which skills are most critical and vulnerable to deterioration over time, and develop strategies to either limit these skills to a select group of practitioners or provide adequate training to keep them competent.

While there is little evidence to help answer the tiered response vs. all-ALS response (the the very little that exists supports tiered response). There is a lot of research that shows that a physician, nurse, PA, etc. who performs certain procedures or sees certain patients more often see fewer complications, shorter lengths of stay, and lower mortality. There is evidence that medics who intubate more frequently and more likely to be successful. There is evidence that frequent experience with cardiac arrest is associated with improved survival. The only way to increase sick patient contact in the prehospital setting is to limit the number of paramedics. Based on evidence from other areas of medicine, it isn't hard to imagine that paramedic experience influences patient outcomes.

 

[Tigger]

Where is this?

All over the country...

 

[systemet]

While there is little evidence to help answer the tiered response vs. all-ALS response (the the very little that exists supports tiered response).

Can you point me in the direction of this?

There is a lot of research that shows that a physician, nurse, PA, etc. who performs certain procedures or sees certain patients more often see fewer complications, shorter lengths of stay, and lower mortality.

And I agree that this is intuitively reasonable. One example could be the operator-dependence of PCI. But whether this extends to improved outcomes in EMS, and whether the benefits of having limited number of more skilled paramedics outweighs the benefits of having every patient assessed by someone with more than 100 hours of training doesn't seem to be clear.

There is evidence that medics who intubate more frequently and more likely to be successful.

Yep, I've read that. But that was based on a surrogate outcome, e.g. intubation success, not on a measure of mortality / morbidity from a condition sensitive to poor airway controlled, e.g. closed head injury.

There is evidence that frequent experience with cardiac arrest is associated with improved survival.

If you have a reference for this, I'd also be interested. I'm not trying to attack you, in any way. I'm just looking for more resources.

I have seen an association in one trial between the time to intubation and ROSC at the hospital, but nothing in terms of real survival. If there's something out there I've missed -- and it's quite possible there is -- I'd be interested in seeing it.

The only way to increase sick patient contact in the prehospital setting is to limit the number of paramedics.

Pretty much, or decrease cycle time.

Based on evidence from other areas of medicine, it isn't hard to imagine that paramedic experience influences patient outcomes.

I agree that this is intuitively reasonable for some conditions. But I question whether the research has shown this yet.

An all ALS model does offer the benefit of pain control for everyone, a better assessment, a higher incidence of 12-lead screening, etc. This may outweight the benefit gained from improvements in airway management. Or it may not. It's hard to know for sure at this point. Lots of ideas that were intuitively reasonable have been questioned once the research has been done.

 

[Fish]

Where is this?

I was under the impression that this happened all over the Country, It has happened in the 3 system I have worked in. PD has to arrive anyway to every death, so why would they not arrive code 3 first and start compressions?

 

[JPINFV]

PD has to arrive anyway to every death

No... they don't. Not every death is a coroner's case.

 

[Fish]

No... they don't. Not every death is a coroner's case.

Yes they do, because it is up to PD to decide if it is going to be a Coroner's care or not. I have never been on any type of death that PD did not arrive at. Even the 102 y/o who died in their sleep, PD shows up does an investigation and determines if a Coroner needs to be invovled.

 

[JPINFV]

Yes they do, because it is up to PD to decide if it is going to be a Coroner's care or not. I have never been on any type of death that PD did not arrive at. Even the 102 y/o who died in their sleep, PD shows up does an investigation and determines if a Coroner needs to be invovled.

So you've never seen a death in a health care facility.

 

[Fish]

So you've never seen a death in a health care facility.

Yes, and PD shows up. Last month we had a Code out of a Nursing home, We arrive on scene first because we happened to be eating at a Resturant that was apprx. 0.2 miles away from the nursing home, next to show up was One officer, next to show up was the engine, and the next three people who showed up were two cops and a battlion chief(who happened to be in the area so he swung by.) We got pulses Back, pakaged for transport, lost pulses again, and tansported anyway since we were already on the way to the ambulance, First officer on scene said he would follow up at ER, but did not see a need for a Coroner since it was an elderly lady with a long Medical History.

I don't know how man Codes I have been on, I would guess over 150? I can't tell you how many we transported and how many we didn't and how many required a Corone because I can't remember. But what I can tell you, is whenever I have been at a Code, so has law enforcement. Usually they are first to arrive and last to leave if we pronounce on scene,

 

[Fish]

So you've never seen a death in a health care facility.

Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.

 

[DrParasite]

Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.

No, but PD does need to respond to every unattended death. at a home with a hospice nurse, for another example, typically does not get a cop either.

but 99 year old granny who is found dead in her bed in the AM does need a cop, to determine if she died of natural causes or because her husband smothered her with a pillow because he wanted a divorce and she wouldn't give him one.

Nursing homes/SNF's are a gray area. I've been involved in investigations at them (detectives called me while i was on vacation in vermont), and others where they didn't. but I would wager 99% of unattended deaths, with the person being unattended by a health care professional (RN or higher) should require a PD presence.

BTW, lots of volunteer/rural/suburban EMS systems have PD as the first responder; it typically makes more sense than the FD, since PD is already on the road, usually closer to the scene, and can initiate CPR and Defib in less than 8 minutes. Not so much for the urban areas though.

 

[Fish]

No, but PD does need to respond to every unattended death. at a home with a hospice nurse, for another example, typically does not get a cop either.

but 99 year old granny who is found dead in her bed in the AM does need a cop, to determine if she died of natural causes or because her husband smothered her with a pillow because he wanted a divorce and she wouldn't give him one.

Nursing homes/SNF's are a gray area. I've been involved in investigations at them (detectives called me while i was on vacation in vermont), and others where they didn't. but I would wager 99% of unattended deaths, with the person being unattended by a health care professional (RN or higher) should require a PD presence.

BTW, lots of volunteer/rural/suburban EMS systems have PD as the first responder; it typically makes more sense than the FD, since PD is already on the road, usually closer to the scene, and can initiate CPR and Defib in less than 8 minutes. Not so much for the urban areas though.

Yeah every unattended Death has LE respond

 

[JPINFV]

Now obviously PD does not respond to Codes in Hospitals, not unless the Hospital request them for a criminal investigation.

...so PD doesn't always show up for all codes...

 

[Fish]

...so PD doesn't always show up for all codes...

Leave it up to you,

Be logical, did I really need to clarify by saying every out of hospital code? I truely thought that was something you would have figured out on your own. next time I will be more specific for you.

 

[JPINFV]

The reason I brought it up is every prehosptial code I've seen brought into the ED where resuscitation failed had the ED staff make the decision based on preset criteria on whether they could release to a funeral home or had to call a coroner.

 

[Fish]

The reason I brought it up is every prehosptial code I've seen brought into the ED where resuscitation failed had the ED staff make the decision based on preset criteria on whether they could release to a funeral home or had to call a coroner.

Sure, but on scene before the patient was brought into the ER, PD was on scene. Then when they find out the patient is being transported and to what hospital they follow up with the Doc to see what his opinion is along with the Medics opinions. The Dr alone cannot decide this, he was not at the original scene.

 

[JPINFV]

Again, it depends on the circumstances. Not every original scene is going to occur on the street, and I highly doubt that the average cop knows enough about medicine to make even an uneducated guess as to whether a patient at a non-hospital health care facility was suspicious or not unless the staff beat the patient to death. So, again, the police routinely show up to cardiac arrests at health care facilities outside of the hospital?

 

[Fish]

Again, it depends on the circumstances. Not every original scene is going to occur on the street, and I highly doubt that the average cop knows enough about medicine to make even an uneducated guess as to whether a patient at a non-hospital health care facility was suspicious or not unless the staff beat the patient to death. So, again, the police routinely show up to cardiac arrests at health care facilities outside of the hospital?

Like I said before, I have never been to a Cardiac arrest(mind you I only go to arrest outside of the hospital, and also not a hospice patient at home with hospice on scene.) That the Heat did not also show up to, I can't ever think of a time that I have responded to a Code and the 5.0 didn't respond with us.

 

[46Young]

The question is, how many hats can one person wear especially if EMS is to become a profession? There's a reason you don't see many neuro-cardio-thoracic-orthopedic surgeon psychiatrists around.

A paramedic course doesn't take too much brain power to get through, compared to other medical degrees. It's not rocket surgery. The didactic material in the fire academy, or even the fire science curriculum isn't exactly challenging either. The FF/medic has to have completed both before being qualified as a FF/medic. A four year degree in just about anything would take more effort than learning the basics of what a FF/medic is responsible for. OTJ drills and field experience reinforce their education. It isn't too difficult to keep proficient in both sides. After being OTJ for a few years, some of us can go TROT or Hazmat. TROT is six weeks of class and practicals, aazmat is two weeks. After that class, you'll get in station training on cut jobs before being cleared to ride the Heavy Rescue. After that, I'll agree that you're spreading yourself a little thin, but the material collectively isn't as much as a four year degree, let alone a Masters.

 

[usalsfyre]

Perhaps everyone would be better off if paramedic did require some brain power...

:deadhorse: