Paramedic level care (ALS) of no help, may be harmful

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Alan L Serve

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I just watched this video
and let's just say this is really disheartening! I've been in this game a long time and always thought I was helping my patients. It seems ALS harming our patients. The doctor who concluded this video even ended with a suggestion to rethink ever using ALS-level care.

Can someone rebut him and the many studies he cited?

I feel miserable.
 
It seems to me like he spent at least half of that video talking about how bystander initiated CPR and how it is BLS helps increase survival....which, yes, of course it would and yes they are basic skills. However bystander initiated CPR helps for both. The county I live in (dual medic) has somewhere around a 40% survival rate I think when they have bystander initiated CPR. That isn't bad considering where the numbers have been. I think the best point he made is how all these skills we are taught can be distracting and take away time when it isn't always needed, but he made that at the very end.
 
I found it to be very interesting that he says the things that work are already incorporated into BLS and that ALS is the stuff that is just a distraction and only delays delivery to a hospital where they can try to effect a reverse.
 
Alan L Serve said:
I found it to be very interesting that he says the things that work are already incorporated into BLS and that ALS is the stuff that is just a distraction and only delays delivery to a hospital where they can try to effect a reverse.
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Huh? What are you trying to say here?
 
I think there are little details the video doesn't consider in its presentation. Like the airway management with BVM vs. Intubation. Well, EMT's have airway adjuncts too and some ALS folks have this handy little thing called an I-gel that is rather simple and much faster than intubation. I don't know. I remember hearing about that research that came out, but I never looked at it. I just don't think this video does a good job of going into detail about it and explaining it in greater detail. Its like 5 minutes of "bystander CPR is BLS hurr durr" and a brief mention of a point that can have some validity. Maybe I need to watch it again, but that was my initial impression.
 
Sound to me like this person thinks we stay and play but we swoop and scoop Seriously LOL. Maybe time for a new research with a lot more of people than just one or two county's eg: Ontario or in Japan. Don't sweat the small stuff and he needs to maybe stop increasing his fibre in his diet some points were valid others not so much.
 
This doctor is overlooking the large, large segment of the patient population that does not present to us in arrest or a clearly-evident stroke, massive cardiac emergency or traumatic injury and he overlooks essentially everything that can be done for them in a prehospital environment.
 
I don't know if he thinks we stay and play too much. I'm not sure. I wonder if that's in the studies or not. BLS is way more load and go while ALS definitely spends more time on scene.
 
I think "harmful" not the right term overall, it's just not efficacious, and frankly that has been known for decades.

There is certainly potential for harm if you compromise CPR or defibrillation to gain IV access, give adrenaline (or amiodarone if indicated), intubate or do something else rather than focussing on what we know works. There is also a volume of evidence adrenaline in primary cardiac arrest is harmful however there is not yet enough clear evidence to remove it. The large, multi-centre, randomised PARAMEDIC-2 study in the UK should hopefully finally say one way or another.

The two, and only two, interventions which have ever proven effective in cardiac arrest (i.e. by increasing neurologically intact survival) are CPR and defibrillation. That was the case five decades ago when Pantridge first hit the streets of Belfast, it's true now, and it will probably always be so!
 
Doczilla said:
Every time this debate comes up, I wonder why no one considers that patients who NEED ALS generally carry higher morbidity/mortality rates by default.
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Because any study that gets published in a peer-reviewed journal controls for that.
 
Remi said:
Because any study that gets published in a peer-reviewed journal controls for that.
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The counter argument to the ALS vs. BLS morbidity/mortality rates in the video was that dispatchers send different units based on the limited information they have, which of course doesn't account for how resources are utilized when the boots hit the ground.

Taking data about ACLS interventions impacting survival rates in cardiac arrests and extrapolating that to the efficacy of ALS as a whole is unscientific.
 
I took a look at the two JAMA papers and the NEJMed paper referencing the OPAL study. The take home message of those papers seem to be that bystander CPR and early defibrillation are the only factors that significantly improve patient outcome in cases of cardiac arrest. That conclusion doesn't seem controversial to me. But, as Doczilla and others have pointed out, extrapolating that finding to the incremental improvement due to ALS in general greatly overreaches those studies. For example, how is patient outcome improved when an ALS provider is able to get an ECG on a potential MI patient and use the results to inform a transport decision? If the paramedic recognizes an MI and transports to a center with a cath lab, it seems like the patient is likely to be better of than if a bystander or first responder without ALS capabilities drives the patient to an urgent care clinic.
 
My great concern is knowing I will be performing interventions that are more likely than not to harm my patient instead of helping.
 
Which guidelines make you feel concerned that is the case? Just because he makes a video about it, doesn't necessarily make it so. Like I said, my county has about a 40% success rate with their new cardiac arrest protocols. Their protocols are saving more patients than they have before, so locally for me his video is kind of a crock of ****, at least for cardiac arrest. If I was able to work here at the BLS level, I doubt I'd be doing significantly better than the county medics.
 
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