ALS reduced to first aid.

[LondonMedic]

Brown is an huge proponent of Paramedic RSI.

So am I.

But I think that the answer, in the UK, is to have physicians do it until we can identify a small sub-group of paramedics who can be properly trained, properly supervised and sent to jobs where they're anaesthetising enough people in a week that they're maintaining their skills.

One of the big problem with paramedic RSI in the UK is that the average paramedic in London meets a patient who might benefit from the procedure less than once a month, and usually (hopefully) there will be more than one paramedic on scene, outside of the cities that drops even further. How can you maintain proficiency in anything like this if you do less than 10 a year?

 

[MrBrown]

This is about anaesthetising someone safely; understanding why you would do it, why you wouldn't do it and what to do when things go pear shaped. And that's much more complicated and, in my world, takes a long time to train for, to practice and to truly understand.

All very valid points which Brown agrees with 100% ... but aren't you a cardiologist?

But I think that the answer, in the UK, is to have physicians do it until we can identify a small sub-group of paramedics who can be properly trained, properly supervised and sent to jobs where they're anaesthetising enough people in a week that they're maintaining their skills.

That is what we have done here; identify a small sub-set of Intensive Care Paramedics (ALS practitioners) who have proven themselves capable of being trusted with RSI.

In time it may expand to all Intensive Care Paramedics, but it may not. Given the very strict controls on our RSI program it would be reasonable to assume that it will not.

One of the big problem with paramedic RSI in the UK is that the average paramedic in London meets a patient who might benefit from the procedure less than once a month, and usually (hopefully) there will be more than one paramedic on scene, outside of the cities that drops even further. How can you maintain proficiency in anything like this if you do less than 10 a year?

Between HEMS and BASICS it shouldn't be much of a problem getting this bloke his ketamine and tube.

Now, it would be interesting to see if the SECAMB CCP idea is to go national or not.

 

[LondonMedic]

All very valid points which Brown agrees with 100% ... but aren't you a cardiologist?

Not any more. I'm back in an Emergency Medicine rotation for the next six months, then off to Acute Medicine, then off to Anaesthetics, then off to Critical Care, then off to...

Now, it would be interesting to see if the SECAMB CCP idea is to go national or not.

Maybe not after they :censored::censored::censored::censored:ed up their promo literature. :unsure: http://emj.bmj.com/content/28/8/642.full

 

[MrBrown]

Not any more. I'm back in an Emergency Medicine rotation for the next six months, then off to Acute Medicine, then off to Anaesthetics, then off to Critical Care, then off ...

... off of House Officer runs and onto the big bad world of being a Registrar?

Maybe not after they :censored::censored::censored::censored:ed up their promo literature. :unsure: http://emj.bmj.com/content/28/8/642.full

Since Brown has graduated university Brown lost access to full text journals for free ... oh tragic :sad:

 

[LondonMedic]

... off of House Officer runs and onto the big bad world of being a Registrar?

People expect me to know what to do! (But I'm actually an SHO - you don't have that grade over there do you? Straight from HS/HO to Reg?)

Since Brown has graduated university Brown lost access to full text journals for free ... oh tragic

The upshot of it is that some people think;

• The conclusions are unsound given the methodologies used.
• Some of the data sources and conclusions are unsupported by the facts it presents.
• It has set back the cause of critical care paramedics in the UK by some years.
• Although the research is poor it does not mean that critical care paramedics themselves are - but this conclusion will be drawn by some.
• It will promote rivalry and tension between the relevant medical and ambulance professions.
• The economic analysis and the 'costs per life saved' argument are unsound.
• The document does not seem to have been peer reviewed; why was an academic publication route not followed?

(Reproduced from EMJ)

 

[MrBrown]

People expect me to know what to do! (But I'm actually an SHO - you don't have that grade over there do you? Straight from HS/HO to Reg?)

We do, but it is uncommon. Technically anybody who has a medical degree can apply for Speciality training here, you don't even have to do a HO/SHO tenure, but nobody does that in practice.

The upshot of it is that some people think;

• The conclusions are unsound given the methodologies used.
• Some of the data sources and conclusions are unsupported by the facts it presents.
• It has set back the cause of critical care paramedics in the UK by some years.
• Although the research is poor it does not mean that critical care paramedics themselves are - but this conclusion will be drawn by some.
• It will promote rivalry and tension between the relevant medical and ambulance professions.
• The economic analysis and the 'costs per life saved' argument are unsound.
• The document does not seem to have been peer reviewed; why was an academic publication route not followed?

(Reproduced from EMJ)

The elimination of Technicians and the move toward "Paramedic on every ambulance" really only adds fodder to the argument for UK CCPs. Australia, NZ and Canada (Alberta) has moved towards a two level model whereby Level 1 can do most things and Level 2 (ALS) people are small in number so they can keep up their high level skills and critical thinking.

Perhaps the UK would have been better served by a model such as this rather than what has been done. With the current trends within the NHS Ambulance Trusts giving your standard UK Paramedic RSI would be inappropriate.

Once they get some combination analgesia (or at least midaz+opiate) and cardioversion we can look at it again

 

[systemet]

The elimination of Technicians and the move toward "Paramedic on every ambulance" really only adds fodder to the argument for UK CCPs. Australia, NZ and Canada (Alberta) has moved towards a two level model whereby Level 1 can do most things and Level 2 (ALS) people are small in number so they can keep up their high level skills and critical thinking.

I just want to point out that that's not the way it is in Alberta. Most of the busy services are running an all-ALS configuration, with only occasional use of BLS resources. In the rural areas, BLS is more common, but even most small rural regions now have at least one ALS ambulance in their immediate area.

Now British Columbia, a (very) little to the west has a very small number of EMA-III ACP medics. To the point that some regions routinely run BLS fixed wing flight crews. Or at least they did a few years ago.

Having an all-ALS service has some advantages. You can guarantee that anyone who calls 911/999/000/112/1800BOOBIES gets 12-lead/field lysis or direct transport to PCI. Or that everyone can get analgesia. But with more paramedics you have less exposure to critical calls. So you need to fill that gap with better initial and continuing training. And even that only works to a point, in my opinion.

I should point out that I think the NZ ICP training sounds fantastic. I apologise if I sounded critical of it earlier. It sounds like you're doing things right.

 

[Melclin]

Bear with me, I'll make my point eventually.

I did a little retrospective "study" recently for want of a better word , using my ePCR data for about a month (because clearly I have too much time on my hands where I'm currently working).

I put each patient into one of the following categories:
1) Reasonable to call an ambulance (based on what I believe a reasonable lay person would call an ambulance for).
2) Needed and ED, reasonable person should have got there by their own means.
3) Selfcare/GP.

Then for each pt I also said whether or not an intervention was performed. (I didn't include "just-in-case cannulas").

I excluded psych transports under police custody and IFT.

I know. Its hardly scientific. Nothing more than a though experiment. But the results surprised me none the less.

RESULTS: n=42, By my reckoning, 66% of jobs involved a pt for whom I would have called an ambulance. This surprised me. I thought it would be lower. Of those that could have gone by their own means, it was often not their fault that an ambulance had been called (home care nurses, nurse on call hot line, call to a specialist physician who refused to consult on the phone and told them to call and ambulance). The second thing that surprised me was that, of the remaining 34%, 74% fit into the "selfcare/GP" category. I thought there would be a lot more people from both "selfcare/GP" and "ambulance" categories that would fall into the "ED by their own means", but as it turns out there wasn't much between, "I legitimately need an ambulance" and "I have had a cough for 2 hours".

We intervened in 28% of pts. Most of whom fit into the "ambulance" category. I didn't count the advice we gave the selfcare/GP people, and the assessment and decision making that lead to them staying at home which I think is pretty important.

This made me feel better about that fact that I was feeling a bit like a taxi driver at the time (which was the purpose of having done it in the first place) and it also re-enforced a reasonably well established idea that quite a few of our pts needs primary care, not emergency care. What my little thought experiment showed me was that, rather than most of our patients being people we couldn't do anything for, many actually required our services as healthcare professionals in the emergency sense, and quite a few more might have benefited from the primary care advice we might have given them. I wondered if we could have done more, had we the expertise and scope and it of the paper I wrote in uni arguing for more primary care education.

The questions of "how much is enough" when it comes to education and scope, isn't just limited to the intensive care end of the spectrum. I think there are a lot of good arguments of the expansion of scope in a lot of areas. The rise of the noctor (to quote some idiot), has some legitimate concerns associated with it but I think there is a good argument for the expansion of scope in a lot of healthcare professions, to fill the gaps, to expedite and streamline healthcare and to improve outcomes in a lot or areas.

Back to Bernard and paramedics "killing" patients. Until such time (or if) some sub-group analysis is done on those patients who suffered cardiac arrest during the RSI trial is done, I don't know that the use of pejorative and emotive language like "killing patients" is useful. There are a raft of reasons why patients may have had a higher cardiac arrest rate in the pre-hospital arm, like survivor bias. We don't know what agents were used in the in-hospital arm of the study for induction: is it possible that hemodynamically unstable patients were inducted with ketamine rather than the fentanyl/midazolam that the paramedics were restricted to, thus sparing their perfusion further insult?

I think you've hit the nail on the head. Survivor bias.

To add to this is a further example of what I was saying about adding to scope and not subtracting. The addition of a paralytic probably improved prehospital intubation. Survivor bias aside, if the results of this study actually reflect some small "kill rate" on our part, I would hazard a guess that it might have something to do with a lack of induction options, not too many.

 

[Melclin]

So am I.

But I think that the answer, in the UK, is to have physicians do it until we can identify a small sub-group of paramedics who can be properly trained, properly supervised and sent to jobs where they're anaesthetising enough people in a week that they're maintaining their skills.

One of the big problem with paramedic RSI in the UK is that the average paramedic in London meets a patient who might benefit from the procedure less than once a month, and usually (hopefully) there will be more than one paramedic on scene, outside of the cities that drops even further. How can you maintain proficiency in anything like this if you do less than 10 a year?

Another nail, hit squarely on the head. I was ganna address this issue in an earlier post, but you're onto it.

The important thing here (systenet take note, its not ALS or nothing), in my mind, is to have 2nd tier providers with enough education/scope that they don't constantly have the top tier providers out to every job. It seems a real problem in America. If your basic providers have to call their top tier providers for pain relief or because of a HR >100 or the complaint of SOB etc, you've got problems. I think, relative to a lot of other systems, we've achieved a nice balance here where our basic providers have considerable education and reasonable scope such that they can deal with most patients. This means obviously that you have less advanced providers seeing a greater proportion of sick people (as a very rough estimation about 1 per 140,000; you might only fill a small room with the Intensive Care providers covering a city of over 4 million). What's more is that a doctor in the same position will be limited in exposure in the same ways.

I'm not really the person to ask. There are MICA paramedics on here, but I believe I was once told by a MICA bloke, while discussing skill retention that he averages a little over a tube per week (he'd done 3 in the past four days, 2 RSI and one cardiac arrest), this might not reflect other's experience. I suppose you have to make some kind of informed choice about what constitutes 'enough' and I think that has to be based on outcomes. We're never going to tube as many trauma pts as a specialist trauma anaesthetist but that doesn't mean there isn't a role for paramedic advanced airway management, as long as its supported with good quality data. As it happens, I don't think the Bernard paper accurately reflected the education/experience involved in, or the success of, the RSI trial. From memory it only focused on the trauma aspect. Anecdotally, I have heard of the considerable success of RSI in other patient populations since its expansion beyond TBI pts. Again, anecdotally, I have heard that the RSI program, in TBI alone is saving the health system somewhere between $30-60 million a year in terms of reduced cost of ongoing care due to improved outcomes.

Take the exact figures I have quoted with a grain of salt, but I think general gist of what I'm saying is clear. I think, when all of this data is put together formally, there will be more literature to come out our RSIs and I think the results will be overwhelmingly positive.

 

[MrBrown]

I just want to point out that that's not the way it is in Alberta. Most of the busy services are running an all-ALS configuration, with only occasional use of BLS resources. In the rural areas, BLS is more common, but even most small rural regions now have at least one ALS ambulance in their immediate area.

True, but what Brown meant was that an EMT in Alberta has a good scope over and above that of the standard Primary Care Paramedic (e.g. cannulation, intravenous fluids, ECG interpretation).

Your service may choose to have an all EMTP configuration however Alberta is an example of a jurisdiction which has gone with the more-is-better-lower idea and moved beyond the traditional mix of what was BLS/ALS, as we have done here in New Zealand, as Australia and South Africa have also done.

 

[SeeNoMore]

I firmly believe that some prehospital providers in some situations really can make a difference with the wide array of interventions that exist in the prehospital realm. The problem as others have pointed out is making sense of that given how varied education, call volume etc is by area.

Unfortunately given the current state of EMS we are likely to see a move towards reducing rather than extending the scope of practice of many ambulance services.

It seems to make sense for aeromedical and critical care paramedics and nurses to continue to make use of interventions like RSI, chest tubes etc. Who knows maybe with the increase in ultrasound tech there will even start to be better study outcomes for the use of pericardiocentesis.

But I'd say for ground based ambulances it makes sense to limit procedures and new technology unless there is real solid evidence it makes a difference for pts. This can be done through studies and pilot programs with specific services.

 

[DrParasite]

But I'd say for ground based ambulances it makes sense to limit procedures and new technology unless there is real solid evidence it makes a difference for pts. This can be done through studies and pilot programs with specific services.

But unless I am mistaken, the studies have shown that ALS (in general) makes little statistical difference in patient outcomes.

That and ALS fire trucks make no difference in patient outcomes.

but too many people will ignore studies and real solid evidence when it doesn't support their point of view.

 

[JPINFV]

But unless I am mistaken, the studies have shown that ALS (in general) makes little statistical difference in patient outcomes.

Define patient outcome. Is patient survival the best outcome, or just the easiest to measure. IIRC, according to OPALS some interventions (specifically IV dextrose) reduces time to discharge. What about other interventions. Does pharmacological pain management reduce mortality? If it doesn't, is it worth having around because it reduces patient suffering ?

Is the only thing EMS worth is saving lives, or is there more to patient care, including and especially emergency medicine?

 

[DESERTDOC]

But unless I am mistaken, the studies have shown that ALS (in general) makes little statistical difference in patient outcomes.

That and ALS fire trucks make no difference in patient outcomes.

but too many people will ignore studies and real solid evidence when it doesn't support their point of view.

Provide links to the studies, thanks.

 

[usalsfyre]

Provide links to the studies, thanks.

I think he's referring to the (in)famous OPALS doccument.

 

[DESERTDOC]

I think he's referring to the (in)famous OPALS doccument.

I am unaware, tell me more.

 

[DrParasite]

http://www.ohri.ca/emerg/research_archive/opals/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2292763/

and the most unreliable source on the web:

http://en.wikipedia.org/wiki/Ontario_Prehospital_Advanced_Life_Support_Studies

 

[Melclin]

For everybody's consideration.

Abstract
Background
The scientific evidence of a beneficial effect of ALS in pre-hospital treatment in trauma patients or patients with any acute illness is scarce. The objective of this systematic review of controlled studies was to examine whether ALS, as opposed to BLS, increases patient survival in pre-hospital treatment and if so, to identify the patient groups that gain benefit.

Methods
A systematic review of studies published in the databases Medline (PubMed), EMBASE, Cochrane Library and Scopus up to July 31st, 2010. Controlled studies comparing survival after the pre-hospital ALS treatment versus BLS treatment in trauma patients or patients with cardiac arrest were included.

Results
We identified 1081 studies of which 18 met our inclusion criteria. In nine of 18 studies including 16,857 trauma patients in the intervention group, ALS care did not increase survival compared to BLS treatment (pooled OR 0.892, 95% CI, 0.775–1.026). In nine of 18 studies including 7659 patients with cardiac arrest in the intervention group, ALS care increased survival compared to BLS treatment (OR 1.468, 95% CI, 1.257–1.715). Most subgroup analyses revealed no significant interactions, but data from six trials, where ALS was provided by physicians, increases the probability of survival at hospital discharge even more (OR 2.047, 95% CI 1.593–2.631).

Conclusion
Implementation of ALS care to non-traumatic cardiac arrest patients can increase survival and further research is unlikely to change our confidence in the estimate of the effect. On the contrary, in trauma patients our meta-analysis revealed that ALS care is not associated with increased survival. However, only few controlled studies of sufficient quality and strength examining survival with pre-hospital ALS treatment exist.

http://www.resuscitationjournal.com/article/PIIS0300957211002401/abstract?rss=yes

 

[systemet]

The two discussed above are:-

(1) ALS in major trauma and:
(2) ALS in cardiac arrest

The evidence to support either of these is very weak. Obviously, as we're debating, there's some suggestion that RSI in major trauma may be harmful/neutral or beneficial -- as we started discussing. Therapeutic hypothermia in VF arrest, initiated prehospitally has been shown to improve neurologic outcomes / survival in separate studies.

OPALS subgroup analysis showed that paramedic care reduced death, hospital admission and ED intubation in respiratory distress patients (Stiell et al.) This was pre-CPAP.

There's data out there that shows prehospital 12-lead reduces door-to-needle time. Some data supporting ER bypass to cathlab and for prehospital lysis.

I think there's strong evidence that ALS care is beneficial. It just may be that this benefit is most clearly seen outside of the areas we've traditionally focused on, e.g. major trauma and cardiac arrest.





Stiell et al. Advanced Life Support for Out-of-hospital respiratory distress NEJM (2007) 356:2156-164.

 

[JPINFV]

The two discussed above are:-

(1) ALS in major trauma and:
(2) ALS in cardiac arrest

The evidence to support either of these is very weak. Obviously, as we're debating, there's some suggestion that RSI in major trauma may be harmful/neutral or beneficial -- as we started discussing. Therapeutic hypothermia in VF arrest, initiated prehospitally has been shown to improve neurologic outcomes / survival in separate studies.

Just because I'm feeling nit picky, therapeutic hypothermia leads to better outcomes. Whether it has to be initiated prehospitally or in the ED is still up for debate.