STUDY: BLS better than ALS for trauma, stroke, respiratory distress

[ExpatMedic0]

I am still waiting on access to the full article so I can look into it further. Its really hard for me to argue in either direction by simply reading the abstract. However, some questions that come mind immediately would be how "advanced" was the ALS. Prehospital doctors, paramedics, flight nurses, ect. Did the ALS have a full array of things that could have changed outcomes in cases such as CVA and trauma like access to thrombolytics and blood products for example. I see the outcomes where worse for respiratory arrest, but what about respiratory distress? Also, Did the study measure mortality only and not morbidity in anyway? However, my biggest question would be was the ALS responding to more critical cases which would have had more negative outcomes regardless and was this accounted for in some way? Not trying to argue for any side here, just curious about these factors while I wait for access so I can review the methodology.

 

[DPM]

To add to the previous post, what is the level of BLS? There are many places in this country where EMT-B can give meds, start lines etc.

 

[sir.shocksalot]

Ems providers are always saying " we need evidence based medicine" then when we have multiple studies proving certain things ems providers want to ignore it and say it's "flawed".

We do not have multiple studies proving certain things. Shoving a bunch of data into SPSS and mathing the **** out of the data does not prove much of anything. Regression analysis are not magic equations that create truths. Evidence based medicine needs to be based on good evidence and expert consensus. No medical director would use the data from this study to turn every ALS ambulance or (god forbid) fire department vehicle into a BLS one. Medical directors in Florida are being sued because they won't let ALS firefighters on engines work as paramedics, there is no way on earth you could use this study to prove you don't need paramedics on the ambulances either.

It would be a huge mistake to trust every study that is published as an absolute truth and not be critical of it's methods or results. How many have died and will die from one completely horrific study that claimed a link between autism and vaccines? Statistics is a tool to find answers, it is not the answer. Besides, changes in accepted practices should be done slowly in measured steps to ensure the changes accomplish the desired goals.

 

[Summit]

We do not have multiple studies proving certain things.

We do have multiple studies showing that something(s) about ALS lead are ineffective to negative for some patient populations.

No medical director would use the data from this study to turn every ALS ambulance or (god forbid) fire department vehicle into a BLS one.

Nobody, I repeat, NOBODY, is arguing for that.

Keep trotting that strawman argument around though...

 

[SeeNoMore]

I imagine the crucial factor to examine will be transport distance. I know further studies are warranted , but it seems very clear ALS is unnecessary in an urban setting. We may only need a very small percentage of current medics , maybe only those in systems where advanced care is 45 minutes or an hour away. What will all the other medics do? But then again, maybe nothing will change and we'll keep up the status quo .

 

[DPM]

...but it seems very clear ALS is unnecessary in an urban setting...

I don't like nit-picking, but this study doesn't show that. It shows that when we use Medicare codes as a guide, a selection of Medicare patients between 2006 and 2011 might have benefited with BLS over ALS in 3 specific areas. This is one of the flaws of the study.

 

[SeeNoMore]

Ok but they are 3 important areas. And this is not the only study that has called ALS outcomes into question. Believe me I'm not happy about it , but I think there are huge changes on the horizon if the public and government figures out what many of us suspsect.

 

[DPM]

They are important areas, but it's hard (for me) to take this study seriously. Respiratory failure, but not distress or breathing difficulty is very specific, yet trauma is all encompassing.

Likewise, though this is claiming that in some cases BLS > ALS, there is a lot of variation in what BLS actually is across the country.

 

[NomadicMedic]

Its not the field treatment by ALS, but in the amount of time it takes to initiate treatment and then transport. Perhaps if all of the "stay and play" protocols (with the exception of post ROSC) were eliminated and treatment was ONLY given en route, we'd see less of a issue?*



*this goes against everything I feel is right, BTW.

 

[SeeNoMore]

I imagine the best results you would achieve in urban areas would be "no difference in outcomes" but perhaps you are correct. It would be interesting to see a study done where half the time patients were loaded and immediately transported without anything but BLS measures performed prior to departure.

 

[Carlos Danger]

I imagine the best results you would achieve in urban areas would be "no difference in outcomes" but perhaps you are correct. It would be interesting to see a study done where half the time patients were loaded and immediately transported without anything but BLS measures performed prior to departure.

That would be a truly fascinating study. Unfortunately RCT's like that are almost unheard of in the US.

 

[SeeNoMore]

Does anyone know of any recent studies on the effect of ALS on rural patients? I cant find anything. It's very frustrating we are not better able to evaluate our practice. It also occurs to me that those who post here are likely not representative of the average EMS provider. I feel many providers are fairly apathetic about whether their care reduces mortality. They are not uncaring , but rather take it as a matter of faith that ALS is superior medicine regardless of the situation.

 

[Bullets]

Its not the field treatment by ALS, but in the amount of time it takes to initiate treatment and then transport. Perhaps if all of the "stay and play" protocols (with the exception of post ROSC) were eliminated and treatment was ONLY given en route, we'd see less of a issue?*



*this goes against everything I feel is right, BTW.

Here in NJ our medic patches say "MICU" on them, and i have reminded them on multiple occasions that "M stands for Mobile". Yes this patient needs treatments that you can provide, but this is what we trained for, this is why we can hold a source of pride over other healthcare providers. That we have the ability and hopefully the expertise to start the treatment process in austere and less than ideal condition. We still hold this mindset that we treat out here then we "give" the patient to them in the ED. We need to think more that what we do out here is just doing the same thing they would do, sooner and more local to you the patient. I believe that the stay and play model is detrimental to many of our patients.

 

[SeeNoMore]

I am not convinced the answer is simply to transport more quickly. I don't know if we have good evidence that ALS care (as it is currently employed) is beneficial to many patients no matter when it is initiated. I believe that ALS care in suburban/urban areas is reasonable for seziures, hypoglycemia, pain management and possibly respiratory distress. This would be heavily influenced by what BLS can do (nebs, epi pens etc). I would guess that a small number of highly experienced and educated Paramedics employing evidence based care MIGHT reduce mortality in some cases (Chest pain/MI, Resp Distress/failure, TBI). I fear this will never come to pass and things will stay as they are until a tipping point is reached, and ALS care is drastically reduced.

 

[EBMEMT]

We have various studies which show:

• ALS outcomes worse than BLS for severe trauma, trauma, stroke, respiratory distress.
• ALS averages double the on scene to hospital time. 27 minutes ALS, 13 minutes BLS. Which means that ALS, on average, spent longer stabilizing for transport than the time it takes to package and transport.
• Mentioned by current study author as a probable cause for the results.
• ALS outcomes worse than BLS for cardiac arrest (Mentioned in link posted criticizing current study)
• Scoop and run of GSW/stab victims by police (Philadelphia) improves outcomes over waiting for ambulance (recently posted on this site) after correcting for the fact that police transported the more acute patients.
• Scoop and run of GSW/stab victims by lay people in POV dramatically improves outcomes over waiting for ambulance or police. Greater time savings, greater improvement vs police.
• ALS provided by doctors rather than paramedics in field in canada detrimental to patient outcomes. Again, attributed to time.
• studies of individual ALS interventions suggest they don't improve or hurt the outcome in of themselves but they increase on scene time and that has detrimental effects on patient outcome. Based on link posted in this thread:. http://epmonthly.com/article/back-to-basics/
• In cases of penetrating trauma, spinal motion restrictions kills 16 patients for every one who might avoid paralysis. This appears to be largely (but not entirely) due to delay. http://www.ncbi.nlm.nih.gov/pubmed/20065766

Overall, the gist of it is don't waste time on scene playing doctor (even if you are a doctor), get critical patients to the hospital where you have specialists, medical imaging, operating rooms, cath labs, interventional neuroradiology, etc.

Exception is cardiac arrest (where we are generally required to stay and play) and I suspect that exception is unlikely to bear the test of time now that it is possible to let machines do the chest compressions. You might need to pull over to do the analysis before shocking as vibration can upset AED. chest compressions until defibrilator attached, analyze, shock, chest compressions until mechanical compression device attached, begin mechanical compressions while loading patient, shock again, wheels up, ALS, ...

The "golden hour" is not a deadline, in the sense that the patient will be ok if you get them to the ER by the end of the golden hour. It is more like an hour glass with patient survival declining towards zero continuously over that hour. Assuming patient is really that critical.

Some possible ways of speeding up delivery for time critical patients:

• Do not delay BLS interventions for ALS interventions.
• ALS is ok as long as the wheels are turning.
• Send the closest unit rather than a "better" but more distant unit
• Use the helicopter when it will reduce transport times. Give helicopter advance warning.
• load and go instead of stay and play
• do not wait for ALS to arrive, have ALS intercept in route
• If ALS is likely to be beneficial, dispatch them for assist before BLS arrives
• Consider not waiting for ambulance to arrive. Have police scoop and run, send ambulance to intercept enroute. Have dispatcher give bystanders option to scoop and run (but not break traffic laws) if emergency responders will be delayed.
• conduct portions of the patient assessment before ambulance arrives. I.E. phone patch AIC to patient.
• Don't try to keep on scene times down to 10 minutes, try to eliminate the 10 minutes.
• Give hospital stroke/STEMI/trauma alerts early, even if you don't have all the data yet.
• possibly bypass hospitals that can't offer definitive treatment.
• reduce use of spinal motion restriction

 

[Aprz]

Saw this on Facebook. I didn't look further into it, but it probably pertains to this thread.

http://journals.lww.com/jtrauma/Fulltext/2015/08000/Decreased_mortality_after_prehospital.8.aspx

 

[SeeNoMore]

Very interesting. It's odd that tourniquet use was considered. Isn't that a BLS intervention generally? I wonder how many of the deaths prevented were simply from management of blood loss.

 

[Carlos Danger]

Saw this on Facebook. I didn't look further into it, but it probably pertains to this thread.

http://journals.lww.com/jtrauma/Fulltext/2015/08000/Decreased_mortality_after_prehospital.8.aspx

Interesting read - thanks for posting it.

Too bad though, that it is a retrospective review that relies on fancy voodoo statistics - and therefore worthless.

 

[SeeNoMore]

It's different as it proves I'm still a hero

 

[sir.shocksalot]

Nobody, I repeat, NOBODY, is arguing for that.

Keep trotting that strawman argument around though...

You mean like this:

I believe that the stay and play model is detrimental to many of our patients.

Overall, the gist of it is don't waste time on scene playing doctor (even if you are a doctor), get critical patients to the hospital where you have specialists, medical imaging, operating rooms, cath labs, interventional neuroradiology, etc.

• load and go instead of stay and play

I have quoted the authors a few times who also make the argument that BLS has better outcomes. Having now read the full study and the supplements I am even more skeptical of the results. The authors took a lot of liberties and assumptions about why someone received BLS over ALS. Most specifically, they made the incorrect assumption that the ALS population and BLS population were equal based on the idea that ALS would be dispatched to all these calls in the first place and these patients are getting BLS bills because ALS was not available. They determined this was a fact after interviewing EMS leaders in 45 states. Not to mention the ALS samples were sometimes 5-7x larger than the BLS sample; for AMI there were 100,000+ ALS patients while there was only 14,000+ BLS patients. Plus, all the math they did on the data lends itself to type I errors in the first place.

I appreciate what the authors are trying to do. They are trying to study something which has a complete dearth of data to use in any sizeable population. People are jumping to conclusions using conclusions from this study that also jumped to conclusions. The study is interesting and they really tried to adjust for as many things as possible but the data is just not there to do a thorough analysis. So, for the conclusion the study reached I stand by saying that it is crap. As I said before, we need more studies.