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

[sir.shocksalot]

We have various studies which show:

• ALS outcomes worse than BLS for severe trauma, trauma, stroke, respiratory distress.

Are you referencing the study that we are currently debating? Even if you are, one study is not sufficient evidence to draw a conclusion from.

• 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.

That data comes from one study that the author referenced that was done out of Ontario, Canada. http://www.ncbi.nlm.nih.gov/pubmed/15306666
Also, that study was focused on OHCA after implementation of ALS in Ontario and found no difference in outcomes between ALS and BLS (meaning survival to discharge, hospital admission increased according to the study). Saying that ALS doubles on scene time without adding a number of caveats to that is meaningless. Further, it really only applies to cardiac arrest in Ontario since other systems may operate differently.

• Mentioned by current study author as a probable cause for the results.

Authors are not experts in emergency medicine or prehospital care. Two of the authors have vested interests in healthcare economics with one being the director of an insurance company and the other a senior consultant for Precision Health Economics http://www.precisionhealtheconomics.com/about-phe

• ALS outcomes worse than BLS for cardiac arrest (Mentioned in link posted criticizing current study)

Other studies have found no difference or some benefit in ROSC rates but either some or no difference in survival to discharge. AHA has said multiple times that good CPR and early defibrillation saves lives (BLS), so we know that BLS is good but there is no definitive evidence that ALS is bad (on the average it seems to make no difference on outcomes). Latest AHA review of evidence for you: http://circ.ahajournals.org/content/132/18_suppl_2.toc

• 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.

Trauma care by EMS in the US is atrocious. Almost everything you are taught in EMT and Paramedic school is detrimental to sick, hemorrhaging trauma patients. We know that the only thing that saves sick trauma patients are surgeons. We know that IV fluids (IMO in any amount) is bad. Trauma naked is bad. Anything that slows that patient from seeing a trauma surgeon is bad. However a car is only better when used in urban settings so this study is not all encompassing. BLS should be slightly better than ALS for sick trauma in urban settings too unless EMTs can start IVs in that area in which case either one is awful.

• 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/

To your first example here, please cite your sources. We know that transport times are important for some things and not for others; this creates an important distinction when talking about outcomes. To the second example you are once again citing something that uses the study we are debating. The article also cites data about ALS intervention efficacy from OHCA studies, which again we know that anything other than CPR and defib are of dubious benefit at best. To be clear, this means that giving Epi seems to be of no benefit in OHCA, just like it does in the hospital. That cannot be extrapolated to other areas.

• 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

Yes, trauma care is terrible. Also, PHTLS and ITLS don't recommend the routine application of back boards to penetrating trauma. I think that back boards are bad in general and they are on their way out in many areas. But I've already talked about the trauma thing so I won't repeat myself.

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, ...

Machines create unacceptable gaps in chest compressions IMO and have no demonstrable efficacy on patient outcomes. Also, stay and play for cardiac arrest exists to stop from crowding ERs with dead people. Transporting patients in cardiac arrest is dangerous, expensive, and gives no benefit with very rare exceptions. The dangers of going code three with dead people to the ER far outweigh benefits and AHA continues to recommend against routinely transporting cardiac arrest patients. Helicopters are crazy dangerous and are usually guilty of some of the largest delays in transport times so should be used only when the transport times are going to be exceedingly long.

I think there is a big misunderstanding in things we "know" about prehospital care. We actually don't know much. There is hardly any data available to be examined and getting data that is comprehensive enough is exceedingly difficult. Time is important in some things, but not for others and we have no real idea where this cut-off exists. Severe trauma is very time sensitive, less severe trauma may not be. Stroke? Maybe, but not in the measure of minutes (difference between ALS and BLS) since hospitals can create enormous delays while they figure out if tPA is indicated. AMI? Well, STEMI is time sensitive and benefits from early 12-lead EKG and hospital notification (ALS). NSTEMIs? Eh, maybe but again not in the measure of minutes.

Trying to come up with hard and fast rules in medicine is disingenuous. There is a lot of variation in patient presentation, severity, scene dynamics, and EMS system differences that makes the 10 minute rule a moot goal. Multisystem trauma in a car needing extrication is probably going to be longer than 10 minutes. Someone shot on the street corner should have a scene time of a minute or two. Load and go has its place for some things while stay and play has for others, it's not an either-or thing. Good, experienced, well educated clinicians are able to make these decisions based on circumstances and defend their reasoning. Currently, we are a "profession" of technicians (ALS or BLS) that have accepted minimal standards for ourselves and seem to avoid participating in data collecting and research on the work we do.

 

[triemal04]

After reading this thread all I can say is sweet bleeding jeebus there are some people here with utterly closed minds. I'm shocked.

No wait...I'm not.

If anyone has one of those "beating a dead horse" gif's, now is the time to put it up.

 

[triemal04]

Oh, and I forgot to mentio; this study, like the previous one, is a waste of time. The more I think about it, the more my brain hurts. I retract all my previous statements except to say that, while these people are just plain ignorant, the question they ask is valid, and needs to be answered.

 

[ExpatMedic0]

I just skimmed over the full study. Unfortunately I have final exams for over the next 10 days, so I won't be able to really dig into until after then. Although I will say I am gonna really dig into their methodology at some point. For now, it appears the authors did take a lot of things into consideration and I don't think the data from the study should just be dismissed or written off like some here are suggesting. This data could lead to further explorations of ALS care and lead to a marked improvement in the way ALS is delivered. However, it would appear we need a lot more information on the regional level and protocols of the ALS and the BLS before we can really understand some of these results. For example for respiratory failure, what where the majority of causes, and what was the ALS capabilities. Did the ALS have CPAP, RSI, mechanical ventilators, and a full array of pharmaceutical interventions? What are the protocols and education/training levels of the ALS and the BLS? For AMI, did the ALS have STEMI activation procedures, tools, and training? For CVA where prehospital thrombolytics available for ALS? How much protocol and training variation for levels of ALS and BLS was there? Unlike a medical doctor in the ED at a major hospital, ALS and BLS providers vary wildly in scope of practice and education, as do their protocols and interventions. I don't think the results should be ignored, but researched further as to why the results are the way they are, because the authors do not provide that information (which is fine, because it was not the goal of this particular study). Perhaps some sub-cohorts of ALS performed 10x better than BLS, we don't know because we're grouping these variables together as if they are the same. Lastly, there is also no mention of morbidity, only mortality. Perhaps all the BLS patients that are neurologically intact have other lifelong disabilities and the ALS ones do not, we don't know. What did the BLS patients receive in definitive care that reduced mortality levels, is it something we have the capabilities to deliver pre hospital with ALS? It is a good study in a sense as it shows a possible problem, but for me it raises more questions than answers in exploring why the results are the way they are and how can we conduct more research to discover that? Just some food for thought for now.

 

[Carlos Danger]

Unlike a medical doctor in the ED at a major hospital, ALS and BLS providers vary wildly in scope of practice and education, as do their protocols and interventions.

That is exactly true. There is a huge diversity in paramedic education, experience, protocols, drugs, equipment, transport times, and even receiving facility capability from state to state and county to county, and all of those things can potentially affect outcomes. Even among two different services in the same town, one might be a much better place to work for various reasons, and thus more selective about the paramedics they hire, taking on only more experienced ones. Then the better service provides their (likely better to begin with) paramedics with better going education, better equipment, and better protocols than their competition.

All of that makes generalizing and translating to practice almost any EMS research findings difficult, and I think even people who don't read or understand research kind of inherently get that. So when you combine those real challenges with a general lack of respect for or understanding of research to begin with, it's easy to see why people are so quick to dismiss research as unimportant or at least not applicable to them. The icing on this crapcake is the fact that so many in EMS have a lot of their personal identity wrapped up in their ability to "do what doctors do at 90mph", so they take personally any suggestion that some of what they do in the field might not be good for patients.

There are two compelling things about this study: First, it's massive size. Such a huge sample drawn from all over the country would arguably control to at least some degree for some of the variables that exist from EMS service to EMS service. Second, as has been pointed out here several times, this study confirms some of what other studies have already told us. You can make an argument to ignore the findings of one study - even a very large one, perhaps - but it is much harder to argue that we should ignore the findings of numerous studies that are in basic agreement.

So what this study really tells us, IMO, is that we need to be critical of prehospital interventions, and constantly search for proof that what we are doing for our patients is really in their best interest. In order to advance, we really need to be more professional overall - more educated, more critical, and less emotionally invested in what we do.

 

[DrParasite]

ALS vs BLS?

If I code, I want ALS.

Since you brought it up, Why? What does ALS do that BLS can't? ok, wait, let me rephrase that question: what will ALS do that is shown to have a better clinical outcome that BLS can't? If I remember correctly, in cardiac arrests, the only thing that has been proven through clinical research to make cardiac arrest patient's walk out of the hospital were CPR (push hard and fast) and early defibrillation, both of which BLS can do.

Intubations have no clinical benefit over BVM, ACLS has no statistical benefit, and the heart treats electricity from a lifepak 15 and electricity from an AED the same way.

So, again, if you code, why would you want ALS, if they don't improve your chances of walking out of the hospital?

 

[ExpatMedic0]

I think some people may be lead to believe "ALS is bad" because of the findings. However, I think that's the wrong way to look at this. "How can ALS be improved" is the way it needs to be looked at. As mentioned though, the study raises more questions than answers. It identifies a possible area for improvement. Unfortunately it is not me you need to convince, its stakeholders and policy makers. No one here can state why the ALS had worse outcomes in this study, because no one (including the authors of the study) know. We can speculate, but ultimately further investigation is needed. This study's conclusion is "Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS." Maybe this could lead to further studies to answer the Why's and How's. Once we can identify these unknowns, there is potential to improve ALS and improve these statistics. That may not mean more BLS, it could mean more ALS. For now, its opened up a big can of worms and hopefully a lot more money and interest in prehospital research, I hope

 

[chaz90]

Since you brought it up, Why? What does ALS do that BLS can't? ok, wait, let me rephrase that question: what will ALS do that is shown to have a better clinical outcome that BLS can't? If I remember correctly, in cardiac arrests, the only thing that has been proven through clinical research to make cardiac arrest patient's walk out of the hospital were CPR (push hard and fast) and early defibrillation, both of which BLS can do.

Intubations have no clinical benefit over BVM, ACLS has no statistical benefit, and the heart treats electricity from a lifepak 15 and electricity from an AED the same way.

So, again, if you code, why would you want ALS, if they don't improve your chances of walking out of the hospital?

Locally, I want ALS because we provide more effective compressions, more timely defibrillations with decreased hands off time, and don't throw cardiac arrests into ambulances with manual CPR. I can't argue the ACLS meds point, but we make an effort to work on correctible causes of the arrest as they come up, and we do not pause compressions to intubate.

BLS could provide all of these things just as easily, but unless you get a good BLS crew, they're likely going to have one person doing manual compressions for way too long, transport an arrest in order to get to "definitive care" and do crappy manual compressions the whole way.

 

[DrParasite]

Oh, and I forgot to mentio; this study, like the previous one, is a waste of time. The more I think about it, the more my brain hurts. I retract all my previous statements except to say that, while these people are just plain ignorant, the question they ask is valid, and needs to be answered.

umm why? because multiple studies say something you don't want to hear? Because the evidence doesn't support your opinion? Because it makes you feel a little less important than you think you are?

Just so there is no confusion, i am not anti-ALS, nor do I think we should be getting rid of paramedics. But we do need to go with the evidence, which means there are a select few types of calls where paramedics should remain on scene for extended periods of time. as @Bullets said (and since we are both from the same state, I understand why we both think this way), paramedic should be MOBILE, and often bring the ER to the patient, however the goal still is to get the patient to definitive care, which means an MD.

I'm not saying I don't need or want a paramedic, what I'm saying is ALS can be greatly beneficial, because it's allows those MD like interventions to be provided before the patient gets to the ER, provided they are done while transporting to the hospital, instead of creating an extended time on scene.

Oh, and on a cardiac arrest, I absolutely want a paramedic, maybe even 2. I want them to see what the patient's heart rhythm is, so we know if this patient is saveable or not. And yes, I think BLS crews should be competent and be able to do their jobs without a paramedic there to either hold their hand or tell them step by step what they need to do, but apparently that level seems to leave when you go away from a tiered EMS system.

 

[Bullets]

Machines create unacceptable gaps in chest compressions IMO

Only with poor agnecy training on those machines

and have no demonstrable efficacy on patient outcomes.

Ahh, you're one of these people. You are looking at the science wrong. Its not about being better, its that machines are just as good as humans, but do not tire, do not interrupt compressions once applied and free up a provider to do something else, manage an airway, gain iv access, draw up drugs, ect.

Locally, I want ALS because we provide more effective compressions, more timely defibrillations with decreased hands off time, and don't throw cardiac arrests into ambulances with manual CPR. I can't argue the ACLS meds point, but we make an effort to work on correctable causes of the arrest as they come up, and we do not pause compressions to intubate.

BLS could provide all of these things just as easily, but unless you get a good BLS crew, they're likely going to have one person doing manual compressions for way too long, transport an arrest in order to get to "definitive care" and do crappy manual compressions the whole way.

This isnt an ALS or BLS issue, this is a overall training issue. YOUR BLS does crappy compression, YOUR BLS loads and gos with a dead person, YOUR BLS doesnt run a code efficiently. Just because youre a paramedic doesnt make you better or worse at running a code, you just need to better educate your BLS providers. If that isnt happening in the classroom then its your responsibility to teach them on the streets or talk to their system directors and medical directors.

My BLS project was the first in the area to adopt and change our OHCA policy in 2009 and it was a fight to get the volunteer EMS, Fire departments and Cops to understand why we were sitting on scene with these patients, why we waited so long and why we left dead bodies at home for PD to deal with. And the first time i did a hands on defibrillation i might as well have pulled the cops gun and shot someone. But over time and with education we have started to bring them around.[/QUOTE]

 

[RocketMedic]

The study misses the point of ALS care, which is to palliative symptoms and stabilize deteriorating patients.

 

[chaz90]

The study misses the point of ALS care, which is to palliative symptoms and stabilize deteriorating patients.

Well, if we were successfully stabilizing deteriorating patients, I would imagine they would survive more frequently than if they were not "stabilized." Again, I'm firmly on the side of seeing that this study has some merit based on size but only justifies the need for further research and does not prove causation.

 

[SixEightWhiskey]

In so many communities, calling 911 means you will get an ALS truck with at least 1 paramedic every single time. I am a firm believer that this makes every individual paramedic less proficient at their job (since medics are inherently doing a higher volume of lower acuity calls and individually seeing less very sick patients) and also causes BLS providers to have less experience with truly sick patients, and furthermore less experience determining who's sick and who's not.

I work in a system that dual responds ALS and BLS to calls that get EMD'd as ALS criteria calls, and it's great, because the BLS folks get to do emergencies and see sick patients, and ALS (ideally) only commits to sick patients and gets cancelled to a lot of the nonsense, therefore being available for when the truly acute call happens. In an urban environment I have found it to be the ideal EMS system model. Typically, the BLS will get to the patient first and assess them, and if its something truly urgent where the patient needs a hospital urgently (trauma, CVA), they are trained to head for hospital with or without medics. If we meet them, great, if not, that patient gets what they need, whether it be a surgeon/tPA/whatever it is that they need. Respiratory calls, cardiac calls, compromised airways; those are the calls paramedics can make a definitive difference with.

 

[RocketMedic]

In so many communities, calling 911 means you will get an ALS truck with at least 1 paramedic every single time. I am a firm believer that this makes every individual paramedic less proficient at their job (since medics are inherently doing a higher volume of lower acuity calls and individually seeing less very sick patients) and also causes BLS providers to have less experience with truly sick patients, and furthermore less experience determining who's sick and who's not.

I work in a system that dual responds ALS and BLS to calls that get EMD'd as ALS criteria calls, and it's great, because the BLS folks get to do emergencies and see sick patients, and ALS (ideally) only commits to sick patients and gets cancelled to a lot of the nonsense, therefore being available for when the truly acute call happens. In an urban environment I have found it to be the ideal EMS system model. Typically, the BLS will get to the patient first and assess them, and if its something truly urgent where the patient needs a hospital urgently (trauma, CVA), they are trained to head for hospital with or without medics. If we meet them, great, if not, that patient gets what they need, whether it be a surgeon/tPA/whatever it is that they need. Respiratory calls, cardiac calls, compromised airways; those are the calls paramedics can make a definitive difference with.

On the flipside of this, BLS and EMT-Basic and equivalents (and EMT-Intermediate and AEMT) are so easy to obtain that the barrier to entry is essentially a test written to the eighth-grade level and local hiring practices. This means that the BLS 911 responses are not necessarily getting seasoned veteran super-providers, but transitory pre-med college students doing their six months of EMT for the resume and the local high school glee club or a few firefighters, to steal a phrase from a friend of mine. Assuming that the BLS component in tiered systems is functionally competent is not a solid thing to do.

 

[ExpatMedic0]

Here's a little update. One of the authors discussing the study in question. http://www.ems1.com/ems-products/ambulances/video/28297187-Researcher-Is-BLS-better-than-ALS