Is anyone afraid that Evidence-Based Medicine will kill EMS?

[thegreypilgrim]

It seems like there is a growing movement among EMS physicians and researchers to just cut their losses and bring EMS back to the "scoop and run" method of days gone by. No real interventions...maybe some oxygen and an IV at TKO/KVO but the real intervention is just diesel therapy. As justification for this would be the very real possibility of study after study on EMS practices demonstrating or "interpreted as demonstrating" that pre-hospital ALS confers virtually no effect on overall patient outcomes.

Please don't take this as a rant against evidence-based medicine or research in general. If this is what research ends up indicating (I doubt it, but I don't doubt that some people will interpret it as demonstrating such), then so be it...I guess I'll find another career.

Is this something anybody is afraid will happen?

Or do you see EMS going the other direction and continuing to advance as a profession?

 

[Aidey]

It is a distant concern that I have that I think has a much higher chance of happening if we don't increase the education standards and start requiring college degrees.

As I mentioned in the thread about multiple Bicarb doses, it may be that some of the stuff we do is only effective in very select cases, but we try it on everyone. The whole when you have a hammer, everything is a nail issue. This results in the "evidence" showing that treatment X statistically doesn't work.

If we keep diluting the sample pool by using treatments on patients that probably aren't appropriate eventually all the statistics are going to show that nothing works.

I think that education will save us because it will enable us to have more treatment options available. This means we can use more appropriate treatments which will result in more patients successfully treated and statistics that aren't as diluted.


Dealing with statistics gives me a huge headache, there are just so many variables, especially when dealing with medical statistics. So much is subjective, and there is really no way to restrict a lot of the variables that affect outcomes. There is also almost no way to have control group to compare pts who received treatment vs patients who didn't.

For example, you mentioned the statistic that ALS has been shown to have negligible affect on patient outcome. Look at the total number of ALS ambulances in the US, and the number of transports they do, and then look at how many of those transports are ALS level transports. If you compare the total number of transports vs the patients that ALS interventions made a difference in numbers are going to be dismal since there are so many transports and only a very very small fraction of them receive ALS intervention during transport.

 

[MrBrown]

I do not see the future of the ambulance service in the emergent realm and this is a radial shift away from what has been the norm.

The ambo of the future will not simply look at scoop and run vs stay and play with the ultimate goal being transport to another facility. It will change to where transport may be an option but not necessarily to a hospital nor will soley responding to 911 (111) "emergencies" be thier mainstay.

A hybrid RN/PA/Paramedic model is needed with people out in 4WDs whose specturm is "out of hospital" care as opposed to "prehospital" and I think the words "prehospital" and "emergency" should be removed from ambulance.

Scope of practice adjustment are not really needed but referral pathways and dispositions to other than an emergency department are required. The hospital is not the only place to recieve care so why make everybody go there?

Medical emergencies will continue to happen and these require a certian level of response however we must go beyond the traditional "ALS" skillset and include a much broader base of education on public health, complex assessment and management and include the ability to Rx certian meds and tests eg x-rays.

Future demand will not be met by traditional ALS/BLS/emergency response but moving beyond that to encompass the ability to manage patients other than transporting them to the hospital.

 

[firetender]

My vote is things will not go back to load and go as long as it's easier to document death through neglect than it is to determine the efficacy of any one approach.

When all is said and done we must, at the very least, APPEAR to be doing something to prevent useless deaths, even though everyone must die.

The impetus to improve rather than curtail the availability of advanced services would be furthered any time an individual of high prominence would get caught in an area of sub-standard care and die.

The Medical/Legal/Corporate Complex, first and foremost is designed to protect its own and will respond accordingly. Going back to load and go would withdraw some of that protection.

(Hmmm...that's pretty cynical, ain't it?)

 

[BLSBoy]

STEMIs, CHFers.
You just pick them up and go to the closest facility, you fail your patient.

 

[Smash]

No. No more frightened of that than of EBM killing medicine in general.

STEMIs, CHFers.
You just pick them up and go to the closest facility, you fail your patient.

Or TBI's, DKA, Sepsis, Strokes, even multi-system trauma, or indeed pretty much any of our patients.

EMS is medicine. It has to be evidence based or we will both fail our patients and our industry and become increasingly irrelevant. If evidence suggests that in some circumstances minimal intervention is required, or that interventions that we used to rely on are no longer appropriate, then so be it. The motivation should be to provide the best care possible to your patients, not to use the shiniest, most interventionyest toys we can, just because we can.

What we need to do is to stop being afraid of change, and stop having change thrust upon us, but to take the lead and drive the change ourselves. [oprah] Own the change![/oprah]

In many countries EMS has taken on this challenge and have a degree as the minimum entry level; are represented on committees at local, state and national levels; instigate change in protocols/procedures based on EBM themselves; carry out research that benefits their patients, EMS and medicine in the short and long term and adds to our pool of knowledge.

If we fail to meet these challenges, then I suppose EMS will be 'killed', but it won't be EBM that kills it, it will be us.

 

[DrParasite]

BLS saves lives. ABCs, bleeding control, oxygen and defib. That and making good decisions on where to take the patient

ALS prolongs living, makes the situation better, and improves quality of life.

I'm sure people will say "but on this call, ALS saves the life" and "BLS can't do anything, they don't know enough." and you are right, there are times when BLS can't do anything and ALS did save a life.

but the evidence as a whole says that most of the time under most situations, ALS procedures don't save lives, BLS ones do.

 

[John E]

Don't tell that...

to any of the Paramedic students who think they're all going to go save the world...

One wonders how people who think that getting more training so they can do more procedures will deal with facts that show that simply getting their patient to a properly equipped hospital will do more for them than all the in-field 12 leads and IV's ever will.

How long before the usual suspects start crowing about more education solving every problem facing EMS...?

3, 2, 1...

John E

 

[Aidey]

I don't know about where you are, but a 12 lead in vitally necessary in getting the patient to the properly equipped hospital in my area.

 

[John E]

Well at the risk of being obvious...

my location is in both my profile as well as in whatever you call that little block of text that appears with my name.

I take your point but ask yourself this, what are the statistics for long-term patient survival using ALS in the field now vs say 10 years ago? More people may be surviving the trip to the hospital but are they surviving beyond that and if not, would limiting in-field ALS procedures increase that survival rate?

The point that I think was being made was that there is mounting evidence that suggests that delaying transport in order to let field personnel do more and more procedures in the field is not necessarily leading to better long-term patient survival. And if that isn't the overall goal of any branch of medicine, then what's the point of any of it?

At the risk of stirring up another hornet's nest, the OPALS study indicated just that. I'm not going to go into more detail as some people here will start shouting about the location of cities in Canada and the difference between ALS modalities of treatment in Canada and the U.S. which is of course, not the point of the study in the first place. It showed that using more and more advanced in-field ALS procedures did not always correlate to longer patient survival rates. I'm paraphrasing obviously but that's the gist of it. I won't be getting into any arguments with Paramedic students about OPALS again.

Sometimes more education teaches us that fewer procedures may be better for the patient, even if the Paramedic doesn't get to use the newest gadgets all the time.

John E

 

[JPINFV]

The key with OPALS is sperating the trauma portion from the medical portion. Heck, I can post a study that shows that transport by POV saves more lives than BLS ambulance in trauma patients.

 

[Veneficus]

It never ceases to surprise me that every population in the world values education except the US. People in poor nations beg for and risk their lives for education. Could it be education is the road from poverty? That it creates opportunity? Oh well, ignorance is bliss I guess.

Why is it that the same educated people so passionately encourage education for others? Perhaps a perspective others do not see?
What is the motive behind such support? Altruism or personal gain?

Will education solve all the problems of EMS? Probably not. But why is it that the only people who argue against education are the uneducated?

Hubris?
Envy?
Self importance?

Our colleagues across both Oceans have embraced education and while they are not without problems, they have enviable systems that progress as the knowledge of man does. Their systems respond to the changing needs of the community. Their societies value their services enough to pay wages higher than working at McDonalds. Getting paid as an EMT-B by anyone is one of the biggest cons ever in the US. Even Bernie Madoff would be envious of the money spent for a horizontal taxi ride with a person who spent 120 hours studying step by step instructions printed on the inside lid of a first aid kit.

While you are reaing your OPALS study, maybe you should look at the ones showing the harm and ineffectieness of long boarding. That calls into question probably 1/2 of EMT Basic education.

Feel particularly useful yet?

Not to worry, I won’t make you suffer through any more on why EMS providers should get an education.
But I will leave you with this question: “What will you do when the US cannot or will not pay for EMS service?”

Maybe one more question:
“You want fries with your hero burger?”

 

[John E]

If you could please...

just point out a single instance in which I or anyone else that's posted in this thread has done any of the things you're complaining about, I'd greatly appreciate it.

This thread is asking if evidence based medicine might end EMS as we know it.

It's not about any of the things you wrote about. Perhaps you sent your message to the wrong thread?

As for not making any of us suffer any longer, you could do that if you actually addressed the topic of the thread instead of going off on some imaginary anti-education rant based on something you obviously read elsewhere.

Just for the record, not that you'll bother to read it and not that I particularly care about your opinion but I for one am one of the most pro-education people I know. If I wasn't, I wouldn't have gone back to college in my 40's to continue my own education. You seem to think that debating topics relating to the way things are done in EMS is an attack on medical education, where you get this idea from I'm not sure, perhaps you've been reading some of the other people on this forum who's reply to a question as innocuous as "what's the weather outside?", is to start ranting about EMT's not having a 4 year college degree. Also for the record, I'm strongly in favor of EMS workers being required to have more education, not training but real education. But this thread isn't about that topic and I don't want to further derail it as you've attempted to do.

As for your last 2 questions, if you want to start a thread about who's going to pay for EMS in the future, you should do that and let those of us who are discussing an all-together different topic continue to do what we're doing.
I have to admit I have no idea what you're referring to with your final question. I have noticed a tendency of people who have failed to make an otherwise legitimate point in an argument using the "burger flipper" as some sort of last ditch effort to make their point but in this case, your use of it in this case is not only silly, it doesn't serve to illustrate anything.

And lastly, it seems I was incorrect about one thing, it took 4 posts for someone to try and derail this thread with a misguided and inaccurate rant about EMS education, not 3. My bad.

John E

 

[Veneficus]

allow me


to any of the Paramedic students who think they're all going to go save the world...

One wonders how people who think that getting more training so they can do more procedures will deal with facts that show that simply getting their patient to a properly equipped hospital will do more for them than all the in-field 12 leads and IV's ever will.

How long before the usual suspects start crowing about more education solving every problem facing EMS...?

3, 2, 1...


I didn't want to deny the response of the usual suspects with this antagonism.

Over the last 20 years there has been a constant struggle to increase the "training" and education of US EMS providers so that more procedures and decisions that do make a difference could be performed rather than just trying to come up with one size fits all algorythms that are not statistically effective. Pick a treatment, long boarding, fluid challenges, oxygen therapy. None of them seem to hold up to scrutiny.

But the same treatments are used in the hospital where they are effective on smaller patient populations. It is not the treatment that is the problem, it is which patients getting it. (Goes back to education) By being educated enough to select appropriate treatments the statisitics on effectiveness should match that of the hospital.

EMS and its destruction is directly dependant on its value. OPALS is not the only study calling into question the value of EMS. It is not a far jump from a study showing ineffective EMS practices to a populous in today's political climate coupled with a pressing need to reduce medical costs, to decide too much is being paid for EMS with too little benefit. (cost vs. perceived benefit)

Perhaps I give too much credit to the average American, but generally when they figure out they are not getting their money's worth they stop paying. (Which would end US EMS as we know it)

I have also posted in a similar thread about the care that must be taken when basing decisions off of studies that have not been reproduced or have biased methodology. Particularly given the "publish or perish" academic environment. Moreover it is important not to superimpose or extrapolate a cohort where one does not exist. (Like with OPALS)

The Future of EMS is inexorably connected to funding, education, and effectiveness. Trying to seperate them even in discussion is folly.

One of the very reasons effectiveness studies are done is to determine the cost/benefit ratio.(evidence based "medicine")

It will be the cost(aka value) that ends EMS as we know it. EMS is extremely resiliant to maintaining practices that have been scientifically called into question. (see above)

Another one of the biggest problems with evidence based medicine in EMS as we know it is new treatments have a large burdon of proof to be determined beneficial. While existing treatments require the same outrageous level of proof they are not effective and even then not discontinuing them. (with cost being a factor)

I am sorry for implying the connections in my earlier post and not pointing them out directly. I keep forgetting that since we have the same discussions for decades not everyone has seen them ad nauseum and may not know the intricacies.

 

[John E]

Well at least...

you tried to connect your thoughts with the subject at hand.

Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.

If you're claiming that you've had discussions with people about the state of education in EMS outside of this forum for decades now, well only you know how long you've been in the EMS field.

Did the thought ever occur to you that maybe the folks who have advocating for fewer ALS interventions done in the field may have had a point after all?

I certainly hope that you're including any studies that support increasing ALS interventions when you bring up studies that can't be reproduced or have biased methodologies

To try and bring this back to the original topic, any system of health care that is as you say, "extremely resilient" to change even when faced with scientific proof is one that perhaps needs to go away. Science did away with the barbers and the leeches, for the most part anyway, maybe the idea that a Paramedic in an ambulance really isn't a substitute for a hospital and a team of health care providers is correct. I don't know where the truth lies, but I do know this, there isn't any magic "education" button that is gonna improve patient survival when it comes to EMS. Unless that includes studying whether the whole premise of what EMS means needs to change.

As for the assertion about my antagonism, you brought it, I only replied to your vitriol.

John E

 

[Jeffrey_169]

BLS saves lives. ABCs, bleeding control, oxygen and defib. That and making good decisions on where to take the patient

ALS prolongs living, makes the situation better, and improves quality of life.

I'm sure people will say "but on this call, ALS saves the life" and "BLS can't do anything, they don't know enough." and you are right, there are times when BLS can't do anything and ALS did save a life.

but the evidence as a whole says that most of the time under most situations, ALS procedures don't save lives, BLS ones do.

This is an outstanding point, and I am happy someone realized it. To say BLS doesn't saves lives is like a plumber doesn't fix a leaky faucet. BLS is intergral to EMS, and there are times when in certain rural areas they are closer then ALS, and if they weren't there there would be no viable patient for ALS to work with.

EMS as an occupation has one very real enemy: a lack in education and as a consequence, accreditation. Many states, including Texas, is considering new standards for both scope of practice, standard of care, and educational requirements. There is currently talk in the state legislature concerning the issuance of prescription drugs; antibiotics, pain killers, and certain others would be allowed for the "Licensed Paramedic", while the Certified Paramedic would be about the same as the current standard.

It is unfortunate the reason why we are far off key in our profession is becasue all too often insurance companies, the government run ones in particular, will not cover certain hospital visits unless an ambulance is called and transports the patient. It is also unfortunate pts. have resorted to the ER as their primary care physician for basic care. The cold reality is our hospitals are no longer ran by doctors, but crooked insurance companies and executives who are only in it to make money. An ambulance ride is sometimes the only way these people can get care, or they believe they will be seen faster if they go this route instead of by POV.

It is not the patients fault, they are simply doing what they must in order to get care. Medicine is no longer driven by the desire to heal the sick and injured, but rather by the need to generate large sums of money. This causes us to have to transport far more patients whose care is not emergent, and is far more expensive to deliver then it would be if they simply went to the local Dr's office; but in some cases this is not an option; when you know we won't turn you down, and the ER can't legally turn you away, you will take the only option you have to get the care you need. Its a matter of survival.

So, when you take the rising cost of heath care, the lack in education of Paramedics, the dwindling number of qualified professionals in EMS, the corporate take over of medicine, and nearly 1/3 of our nation uninsured; all this coupled with rising transports and rising transport costs, you have a system which is no longer making the difference it was intended to make, and you have a system being asked to do more then it was intended to do and which it not what its job is designed for. Right tool for the right job, but it is a major and complex problem, and one we need to get a grip on quickly before we find ourselves in an archaic profession.

 

[Veneficus]

Since you yourself have pretty much decided what you've decided and since this isn't the place to do so I won't get into it with you other than to point out that it would be hard for you to have been having these discussions here for decades give that you've only been posting here for less than 2 years.

If you're claiming that you've had discussions with people about the state of education in EMS outside of this forum for decades now, well only you know how long you've been in the EMS field.

Clearly it would then seem logical that my participation in these discussions did not start here.

Did the thought ever occur to you that maybe the folks who have advocating for fewer ALS interventions done in the field may have had a point after all?.

Certainly, but it is not globally applicable. In an urban environment with short transport times, a plethora of ALS treatments delays the time to the hospital. I stipulate in a rural environment the outcomes of just transporting will not be as positive. But as I pointed out, BLS interventions are equally in question. As well the benefit of an ALS intervention is not always life saving. But it can be life altering. Everyone likes to talk about pain control, and I could add perspective about that on neuropathic pain, but to be original, hypoglycemia causes cell death, and while oral glucose absorbs faster than IV glucose, it is not always the best idea to start adding a gel to the mouth of an unconcious person.

I certainly hope that you're including any studies that support increasing ALS interventions when you bring up studies that can't be reproduced or have biased methodologies

I was refering to interventions not done in EMS currently because they require more precise selection of patients, that may have a positive impact. I am not able to produce studies to show the effectiveness or lack of with treatments that have not been part of EMS in the past. But I would be more skeptical of somebody who could.

To try and bring this back to the original topic, any system of health care that is as you say, "extremely resilient" to change even when faced with scientific proof is one that perhaps needs to go away.

Best of luck implementing that. A great many experts have not managed to remove spine boards from everyday use on patients.

Science did away with the barbers and the leeches, for the most part anyway, maybe the idea that a Paramedic in an ambulance really isn't a substitute for a hospital and a team of health care providers is correct..

I don't think anyone disputes EMS is not a substitute for a hospital. Leeches do work quite well for microvascular surgery, as well as maggots for wound debriding. Goes back to better selecting who gets what treatment.

I don't know where the truth lies, but I do know this, there isn't any magic "education" button that is gonna improve patient survival when it comes to EMS. Unless that includes studying whether the whole premise of what EMS means needs to change.

I disagree. An increase in education makes selecting the treatments for indvidual patients more accurate. If selecting the most appropriate treatment for a patient doesn't have a benefit then we need to close the hospitals too.

There are several current threads that deal with what EMS needs to change into. Not surprisingly, those same arguments have been played out before this forum.

Are you studying nursing?

 

[Jeffrey_169]

It never ceases to surprise me that every population in the world values education except the US. People in poor nations beg for and risk their lives for education. Could it be education is the road from poverty? That it creates opportunity? Oh well, ignorance is bliss I guess.

Why is it that the same educated people so passionately encourage education for others? Perhaps a perspective others do not see?
What is the motive behind such support? Altruism or personal gain?

Will education solve all the problems of EMS? Probably not. But why is it that the only people who argue against education are the uneducated?

Hubris?
Envy?
Self importance?

Our colleagues across both Oceans have embraced education and while they are not without problems, they have enviable systems that progress as the knowledge of man does. Their systems respond to the changing needs of the community. Their societies value their services enough to pay wages higher than working at McDonalds. Getting paid as an EMT-B by anyone is one of the biggest cons ever in the US. Even Bernie Madoff would be envious of the money spent for a horizontal taxi ride with a person who spent 120 hours studying step by step instructions printed on the inside lid of a first aid kit.

While you are reaing your OPALS study, maybe you should look at the ones showing the harm and ineffectieness of long boarding. That calls into question probably 1/2 of EMT Basic education.

Feel particularly useful yet?

Not to worry, I won’t make you suffer through any more on why EMS providers should get an education.
But I will leave you with this question: “What will you do when the US cannot or will not pay for EMS service?”

Maybe one more question:
“You want fries with your hero burger?”

Well put...very well put indeed.

I only have one more comment to add; if you have education without common sense, all you have is an educated dummy. There needs to more taught on clinical decision making skills, trauma assessment, medical assessment, and most of all PATIENT ADVOCACY. Too many of us in our profession forget to listen to the patient, and too many of us are judging our patients and making fun of them after the call. "I hate transporting bums" I heard a fellow medic say once. I told him. "Then find another job!!!" They are people too, and its important we remember this fact.

 

[fire_911medic]

Evidence Based medicine

I have no problems with evidence based medicine - however I do have the concern that the majority of these studies are conducted within densely populated urban areas with close access to multiple hospitals. I am fairly certain that if moved to a rural area that has extensive transport times (ie like the area I service it is 2 hours via ground L/S to reach definitive care) . I think you may see altered results. Of course understand that research studies can be altered based on the patients chosen to read whichever way they want them to.

I'm not against evidence based medicine, but I would suggest several trials in both urban and rural settings (as I discussed before - 1 hour plus transport times) with consistent results before proposing changes. If evidence is consistant, then by all means change it for the good of the patient, but don't change results based on what you see in an urban setting alone. It may be more convenient for your study, but remember it will affect everyone. Also another concern that this brings up is that patients that do require ALS interventions in rural areas they may say, "well just call a helicopter". That's fine but they can't always fly and I look for safety measures to be tightening flight parameters considerably within the next few years. Something to consider also is do you want to give a patient that requires maybe a little ALS intervention (and codes are tough to work in the HEMS environment many will not fly eminent or working codes due to that) a 16,000 + bill compared to a 600 dollar bill? Something to think about.

 

[Jeffrey_169]

I have no problems with evidence based medicine - however I do have the concern that the majority of these studies are conducted within densely populated urban areas with close access to multiple hospitals. I am fairly certain that if moved to a rural area that has extensive transport times (ie like the area I service it is 2 hours via ground L/S to reach definitive care) . I think you may see altered results. Of course understand that research studies can be altered based on the patients chosen to read whichever way they want them to.

I'm not against evidence based medicine, but I would suggest several trials in both urban and rural settings (as I discussed before - 1 hour plus transport times) with consistent results before proposing changes. If evidence is consistant, then by all means change it for the good of the patient, but don't change results based on what you see in an urban setting alone. It may be more convenient for your study, but remember it will affect everyone. Also another concern that this brings up is that patients that do require ALS interventions in rural areas they may say, "well just call a helicopter". That's fine but they can't always fly and I look for safety measures to be tightening flight parameters considerably within the next few years. Something to consider also is do you want to give a patient that requires maybe a little ALS intervention (and codes are tough to work in the HEMS environment many will not fly eminent or working codes due to that) a 16,000 + bill compared to a 600 dollar bill? Something to think about.

This is very true. I worked for such an agency in NM, and we had a ground transport time of almost 2 hours, and this was on a good day. They think a blanket solution is a cure all, when in reality different populations in different areas require a different approach. I live 2 miles form both of our hospitals, so yes ALS or even BLS probably wouldn't make a difference in the long run in most cases, but in other areas it couldn't be more different. It really falls on us; we need to speak up and defend our occupation, and consequently our patients. We need to tell the WHOLE story, not just the part which is convenient for the profiteers and these think tanks who study stats and not medicine. They study medicine from afar, we study up close and personal.

I am not against statistics, but there is far more to medicine then meets the eyes, and far more complicated then a piece of paper can adequately define and explain. A few studies are not conclusive for the entire profession, but our silence has enabled this mentality. We need to speak up!