Opals

[CAOX3]

This article is not meant to start a World War 3. Its a study on the benefit of ALS on signifigant trauma.

Do I believe everything written in this column, study? No

I believe that pre hospital ALS, does benefit pts. As explained in these articles, we are still yet to determine how many.

Decide for yourself, or at least give it a read it raises some interesting points.

Please intelligent comments only, if this turns into a pissing match I will ask the administrators myself to shut it down.

http://www.insidermedicine.com/arch..._than_Basic_Support_(April_22_CMAJ)_2422.aspx

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2292763

Let me reiterate again for people that will question me. I am a strong proponent of the benefit of ALS in the pre-hospital setting. However the full benefit is still yet to be determined.

 

[VentMedic]

Before we get carried away here, there must be a clarification of the Canadian system of "BLS" compared to the U.S.

BLS and ALS is defined in the study:

For the basic-life-support phase, "primary care" paramedics is BLS. These paramedics had previously graduated from a 10-month program at a community college and were trained to provide all basic-life-support measures, including oxygen, bag–valve–mask ventilation, and automated external defibrillation.

The study intervention consisted of an advanced-life-support program in which primary care paramedics were trained to perform endotracheal intubation, insert intravenous lines, and administer intravenous medications. After this training, they were called "advanced-care" paramedics. The Emergency Medical Technician Level III training program of the Canadian Medical Association involved 6 weeks of didactic instruction, 6 weeks of clinical instruction, and 12 weeks of preceptorship training in the field.

In the U.S., BLS is an EMT-B with 110 hours of training.

The Canadians' idea of BLS education is more along the lines of what the U.S. training should look llike. The "BLS" Canadians spend more hours being educated and trained than many of the U.S. Paramedics.

This BLS and ALS line that has been drawn distracts from the medicine. Over 40 years EMS and hospitals have all changed to go with evidence based medicine. The early years were "scoop and run". Then, "stay and play" was accepted because at that time it was felt that maybe more intervention in the field was beneficial.

We could review the changes over the years for everything in medicine and some reflects on EMS. MAST is out but at one time it was the standard. Tourniquets were in, then out and now are back. The Golden Hour is controversial as it has many interpretations for the reasons as to how it is used. Studies should not be made to determine whether it is a "BLS" or "ALS" provider responding but for different thoughts on the way things are done and protocols changed to reflect the changes in medicine.
If you review the other studies done, you will find there is a need for "ALS" also.

Even surgeons in hospitals have had to change their practice to reflect the changes in medicine. Before, they may have cut immediately and now some injuries or disease processes may be treated successfully by medicines or other interventions. It doesn't mean their educated and skilled ASSESSMENT is not needed nor can they be eliminated from the picture entirely and replaced by the M.D. who is a General Practitioner. It just means medicine is constantly changing. One has to be educated enough to process these changes and adapt. Next week might bring a different study. More studies will follow and then more decisions to make on how it applies to MEDICINE in your area.

 

[Outbac1]

Just to add to what Vent said about Canadian medic training. The Primary Care and Advanced Care Paramedic levels have only come out since 2001. The Paramedic Assosiation of Canada developed new national levels and requirements that were meant to standardize things accross the country. While there is room for interpretation on how to achieve the various levels requirements. The goal of standardized levels with required knowledge has been largely obtained.

If I've read it right the OPALS study finished in 2002 just after the new national levels and requirements came out. Prior to that it was a bit of a mish mash of levels, names and the amount of training that went with each. It also varied as you went accross the country. A popular title in the 1990's was to have P1, P2, and P3. The training for these levels was not standardized. A level P1 for example would have about a 5 month course and a P3 an additional 10. A P2 was usually a P1 with some add on skills and meds. I believe,(and could be wrong) that it was these P1s that were bumped up to a P3 level.

 

[downunderwunda]

Just to throw a spanner in the works, there is also some debate as to limiting the uses of ETT in the field. There is some conjecture that some are taking too ling to insert when an alternative airway would be as appropriate.

Not necesarrily my personal feelings, but food for thought.

 

[VentMedic]

Just to throw a spanner in the works, there is also some debate as to limiting the uses of ETT in the field. There is some conjecture that some are taking too ling to insert when an alternative airway would be as appropriate.

Yes. It is very controversial for Pediatrics and a few EMS agencies have eliminated ETI for kids.

Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome

http://jama.ama-assn.org/cgi/content/abstract/283/6/783

The references at the end of the article are good reading also.

For adults, ETI may be controversial for a variety of reasons including education/training and continued training and/or experience. If a Paramedic only gets 1 - 5 tubes per year, they may not be able to stay at a high level of competency for this skill. That has been a concern in some areas where we send 4 - 6 Paramedics to each call.