Study: Paramedics must avoid too much care

DrParasite

DrParasite

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Study: Paramedics must avoid too much care
The research showed that the longer patients stayed in the field the worse their chances of survival.

NEW YORK — Researchers have found that paramedics who devote too much care to patients at the scene rather than "scooping and running" may do more harm than good.

The research, detailed in a Reuters Health article, showed that the longer patients stayed in the field the worse their chances of survival, especially for those patients who do not require advanced life support.

The study found that basic life support — CPR and the use of a defibrillator — helped both patients who had been injured and those whose heart had stopped beating, according to the report.

for the entire article, click http://www.ems1.com/research-reviews/articles/1035573-Study-Paramedics-must-avoid-too-much-care/
 
So, with just reading the news article about the study, stay and play works for cardiac arrests, but not for trauma. This shouldn't be earth shattering news.
 
I haven't had time to read it thoroughly (have to run off and do stuff), but the most interesting paragraph to me, is:

"Our analysis presented that ALS care in non trauma cardiac arrest patients increases the 243 probability of survival at hospital discharge almost by 47 % than BLS care (OR 1.468, 95% CI, 244 1.257-1.715). It was noticed that in cases where ALS care is provided by physicians, the 245 probability of survival at hospital discharge is almost two folded (OR 2.047, 95% CI 1.593-
246 2.631). Further research is unlikely to change our confidence in the estimate of the effect."

This completely flies in the face of conventional wisdom. I'll have a better read and come back with some opinions.
 
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Unless they defined "ALS care" and "BLS care" the usefulness of this study is very limited.
 
I don't have access to the full study, but as JPINFV notes, the results don't exactly look earth shattering. Other than the helping "EMTs save paramedics" crowd try to validate themselves, it means almost nothing in the level of care debate.

The increase in survival to discharge (especially with physicians running the resucitation) tells me two things. Post arrest care matters, and blindly following an ACLS algorithm is stupid, resuscitation requires an actual thought process to be really effective.
 
usalsfyre said:
I don't have access to the full study, but as JPINFV notes, the results don't exactly look earth shattering. Other than the helping "EMTs save paramedics" crowd try to validate themselves, it means almost nothing in the level of care debate.

The increase in survival to discharge (especially with physicians running the resucitation) tells me two things. Post arrest care matters, and blindly following an ACLS algorithm is stupid, resuscitation requires an actual thought process to be really effective.
Click to expand...

I keep mentioning that in order to really affect the numbers in "saves" identifying and treating underlying causes needs to be the primary goal.

The very idea of a cookbook in order to bring people back from the dead at a functioning level sounds ridiculously stupid to me. (and I hope others)

Here is some food for thought:

The cardiac arrest algorhythms are based off of the idea that lethal arrhythmia is the cause of sudden death.

In the patho books it lists this as the most common complication of MI. So why are the treatments for MI not a part of this algorhythm instead of EPI and the other drugs?

It really seems like a half assed attempt at resuscitation even based on epidemiology.

If anyone is going to save people with skill, we really must abandon treatments based on "most likely if" but not so commited in case of "what if?"

Despite years of trying to find evidence on common cardiac arrest medications effectiveness, which has never been able to show definitive effect of, maybe we should come up with a new mix?

Doesn't anyone else see these practices as beating a dead horse?
 
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DrParasite said:
Study: Paramedics must avoid too much care

The research, detailed in a Reuters Health article, showed that the longer patients stayed in the field the worse their chances of survival, especially for those patients who do not require advanced life support.
Click to expand...

Which patients in the field don't require ALS yet die? So many of these studies have been conducted in big cities within minutes of a major hospital that the whole BLS is superior to ALS has just become hollow sounding in my ears.

Unless someone purchased the study, which I didn't, there is nothing in the articles at all that even makes them worth reading. Ahhhh...but to be able to get that 10 minutes back....

What is ALS?
What is BLS?
It's a study of studies by Greek researchers. Who validated the previous studies?
Which country(ies) were the source studies obtained from?
What is a normal scene time for those countries?
The level of education for providers?
And on, and on, and on...

My guess is that the answers didn't come from the United States as if they did there would be no data for success rates of out of hospital arrest with physician involvement?

Yeah...someone got a grant and created another document that, at least as reported, created some more compost material.

Dwayne
 
DwayneEMTP said:
Which patients in the field don't require ALS yet die? So many of these studies have been conducted in big cities within minutes of a major hospital that the whole BLS is superior to ALS has just become hollow sounding in my ears.

Unless someone purchased the study, which I didn't, there is nothing in the articles at all that even makes them worth reading. Ahhhh...but to be able to get that 10 minutes back....

What is ALS?
What is BLS?
It's a study of studies by Greek researchers. Who validated the previous studies?
Which country(ies) were the source studies obtained from?
What is a normal scene time for those countries?
The level of education for providers?
And on, and on, and on...

My guess is that the answers didn't come from the United States as if they did there would be no data for success rates of out of hospital arrest with physician involvement?

Yeah...someone got a grant and created another document that, at least as reported, created some more compost material.

Dwayne
Click to expand...

So you can provide us with data to support ALS in the US makes a difference?

Considering the education level of US EMS, I doubt any such study will ever demonstrate anything more than ALS in the US is a want, not a need.
 
I am going to ascert that BLS care would be better if done by better educated providers than people who took 150 hour class.

In NY state where this study was apparently done, albuterol treatments, epi pens, alternative airways and glucometers were all ALS but are all becoming BLS. So we do need to know more about the definitions.

Most ALS treatments could be done enroute. One need not spend alot of time on scene to start a line, push a med, pace someone etc etc
 
firecoins said:
I am going to ascert that BLS care would be better if done by better educated providers than people who took 150 hour class.

In NY state where this study was apparently done, albuterol treatments, epi pens, alternative airways and glucometers were all ALS but are all becoming BLS. So we do need to know more about the definitions.

Most ALS treatments could be done enroute. One need not spend alot of time on scene to start a line, push a med, pace someone etc etc
Click to expand...

I just finished reading the full article.

It was an analysis of all studies done on ALS vs. BLS that were available in English and compared the 2 with the endpoints of survival to discharge.

It included physician and non physician based studies.

In terms of trauma, it demonstrates what we have known for years, that ALS intervention decreases trauma survival. The reasons are not explained in meta analysis.

However, over the years several confounders have come to light, including severity of injury, the deletorious effect of some treatments, and prolonged on scene time. There was an attempt to explain these discrepencies, but nothing new was offered.

In non traumatic cardiac arrest the numbers for ALS look good, at near 45%, but the major confounder I see when comparing BLS is that of the treatment modalities listed, an AED was notably absent. Which I conclude in systems where early defib for non traumatic cardiac arrest is avalable via AED, the BLS numbers would look better.

In the discussion the study authors suggested this as well as some of the studies predated the use of AEDs.

In the handful of studies that included physician systems, the survival was reported almost double the non physician ALS systems.

One of the discussion points was also that the etiology and therefore treatment of sudden cardiac arrest is likely different in different populations around the world. Making some populations more likely to survive resuscitation than others.

Part of the discussion makes mention that the conclusions about ALS submitted here are in contra to both the OPALS and Taipei studies.

There was no attempt at an explanation made as to why.

While I had high hopes for the study to offer something definitive about ALS prehospital, I don't think it met a reasonable burdon of proof to outweigh the prior two studies with not even an explanation of how to account many of the confounders.

I was particularly unimpressed by the assertion that physician based systems saw a survival to discharge of nontraumatic cardiac arrest even more than 46%.

If that were the case I am sure we would be hearing a lot more about where that is happening.
 
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There was a study that was done by Hopkins a while back looking into Baltimore City's EMS and ALS vs. BLS vs. Scoop and Run care levels. Basically they found that EMS providers were spending too much time on scene backboarding and collaring something such as a GSW and in turn pt. were dying upon arrival to the ED. They went as far to say that even in a penetrating trauma to the chest that boarding and collaring is potentially harmful and they hoped local EMS protocols would reflect these changes in the future.

Obviously we know the only thing to fix trauma pt's is cold steel. I am just wondering how many studies must be done before the state protocols follow the recommendations......You can be super knowledgable and up to date on the latest and greatest in medical care but if you are bound by protocols there isn't much you can do.
 
CANMAN13 said:
There was a study that was done by Hopkins a while back looking into Baltimore City's EMS and ALS vs. BLS vs. Scoop and Run care levels. Basically they found that EMS providers were spending too much time on scene backboarding and collaring something such as a GSW and in turn pt. were dying upon arrival to the ED. They went as far to say that even in a penetrating trauma to the chest that boarding and collaring is potentially harmful and they hoped local EMS protocols would reflect these changes in the future.

Obviously we know the only thing to fix trauma pt's is cold steel. I am just wondering how many studies must be done before the state protocols follow the recommendations......You can be super knowledgable and up to date on the latest and greatest in medical care but if you are bound by protocols there isn't much you can do.
Click to expand...

http://prdupl02.ynet.co.il/ForumFiles_2/27677825.pdf - a study published in 2010 from John Hopkins that estimated the number needed to treat to benefit one penetrating trauma spinal cord injured patient is a little over 1000. The number needed to harm with spinal immobilization was a little over 60.

Anyhow, I'd agree with the sentiment that the original study being discussed doesn't offer anything new. But, it should be reiterated that it only looked at non-trauma cardiac arrest and trauma, and only for trauma should one "load-and-go" based on this study and others that have come before it. Cardiac arrests is probably the ultimate "stay-and-play" scenario, even at the BLS level in most situations. I don't believe that there has ever been any research assessing for an association between scene-time and morbidity and mortality for medical emergencies other than STEMI and ischemic CVA; however, I've hardly read every prehospital study, so I could very well be wrong.
 
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