"EMS is a hoax"

[docB]

In the most recent issue of Emergency Physicians Monthly Greg Henry, MD throws out 9 areas he says need changes to help cut costs in healthcare.

Here's his issue #1:

#1 The EMS Mess

As a so-called necessary health care expenditure, I think EMS is the largest hoax ever foisted on the American people. There is no data, not one study, which shows that anything beyond the intermediate level – basic EMT with defibrillator capabilities – does anything in the long run to change the health care of the United States. The problem is this: it’s a hidden cost. Do you realize what it costs for a fire department to simply keep everyone current with their ACLS cards? This is what Casey Stengel would call a long run for a short slide. This has become a local government power base and the numbers aren’t even figured in to the overall health care costs in the United States.

He has some points. The costs of EMS are sometimes hidden as they can be rolled into municipal spending. More frequently though they are front and center as the agencies involved bill patients for services. He's also right in that the data behind EMS and particularly ALS is poor. Most of us in the field however recognize this as an impetus to do better research rather than curtail services. Casey Stengel would hopefully call dumping services at the present time "Throwing the baby out with the bathwater."

In any case this type of attack, similar to others examined in recent threads here, shows that if EMS is to survive we will need to be more involved in research and more attuned to the changes and pressures on healthcare at the macroeconomic and public health levels.

Here's the article in its entirety:
Greg Henry, MD article in EP Monthly

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[leviathan]

That's a pretty dramatic statement that I don't really agree with. Is he basing that on information from studies like OPALS, or data on cardiac arrest survivals? Those areas may not show a significant difference with ALS care, but there are still individual cases where I have seen ALS has made a significant difference for patient care which wouldn't alter overall statistics. What about trauma patients with major airway issues, or the post-arrest patient who is hemodynamically unstable, or patients with severe pain who need narcotics, to name a few examples? I guess you could argue that it doesn't really matter if ALS only makes a difference in 1/1000 patients, but I'm sure that 1/1000 patient would beg to differ.

 

[howelljolly]

Dr Henry should stop using Mannitol. There isnt any good data out there that proves that it decreases mortality.

 

[leviathan]

Danger Will Robinson. Danger.

Shall we discuss the concept and significance of statistical power?

 

[howelljolly]

Does mannitol cost billions of dollars?

I guess not.

 

[howelljolly]

Only if we can also discuss the definition of anecdote.

are we to assume that you are in favor of canning pre-hospital ALS?

 

[leviathan]

Only if we can also discuss the definition of anecdote.

Anecdotes are usually only reserved to situations where we are unaware of the effects of the independent variable. I think we can all think of countless situations where ALS paramedics are able to *prevent* impending cardiac arrests where a BLS crew would be stuck with their thumps up their asses. We understand what the effects would be if only BLS were available on a call where you have a patient with a crap airway that you're unable to ventilate, or where you have a symptomatically bradycardic patient who is about to arrest on you, or a patient in anaphylactic shock who needs epinephrine, or a hypoglycemic diabetic who is unresponsive, etc. etc.

The only thing that research shows is that these "anecdotal" cases are some combination of being too rare, or of the studies not having enough statistical power to show this difference.

And by the way, although broad-sweeping studies such as OPALS do not show an overall benefit with ALS care (in ALL patients of ALL varities), if you look at studies that investigate isolated medical conditions as I've listed above, ALS care shows a statistically significant reduction in mortality vs. BLS.

 

[leviathan]

What I do know is this: no matter how strong the evidence is in favor of ditching a practice, we will always fall into the trap of saying, "Well I saw this one guy who it really worked for! Are you saying we should tell his family that he should die just because it doesn't work for most people?"

As I said, I think you're confusing the research which compares outcomes in ALL patients of ALL varieties between BLS and ALS.

If you look at that patient who you "saw one guy who it really worked for", it actually works for all of them, and not just a few rare cases. As I said, there are a LOT of data to support the benefit of ALS in patients with many specific medical conditions.

 

[howelljolly]

What? I didnt say that.

 

[pseudoknot]

And even if we accept that you know for sure what would have happened, you don't know that you ultimately changed the outcome for the patient beyond that prehospital setting (maybe they died anyway).

I think this is an extremely important point.

I think that the editorial made some a lot of good points and wasn't really singling out EMS.

Certainly we are getting a bit carried away in many areas of medicine, including EMS. Does it help to have a paramedic for a small subset of EMS calls? I think so. Do we need five of them onscene for every single call, most of which need only a taxi? Absolutely not. I was on a shift in LA where 5/6 firefighters were paramedics. That's insane.

Why do we have this cult of CPR in this country? Why do we respond code 3 to most calls, putting the public at risk for no benefit most of the time?

Also, I think Leviathan needs to be a little more careful with his quoting, lest he put Tired's words into someone else's mouth again

 

[docB]

What? I didnt say that.

Also, I think Leviathan needs to be a little more careful with his quoting, lest he put Tired's words into someone else's mouth again

Sorry. Some kind of error in the script. Fixed.

 

[nsx]

Getting back to the original point...

That's a pretty dramatic statement that I don't really agree with. Is he basing that on information from studies like OPALS, or data on cardiac arrest survivals?

It doesn't seem like Henry's basing his statement on anything, the way I read it. He jumps from the lack of data supporting the current system, to the conclusion that EMS is an unnecessary expenditure. It's not logical, but it makes sense from a business point of view It sort of reminds me of the scene in American Beauty where the main guy has to document his worth in order to keep his job.

This article is important because many of us in EMS don't pay attention to articles like this. Stuff like this puts EMS on the defensive, while healthcare administrators are on the offensive...maybe a study coordinated by a neutral organization would yield some answers that could actually improve patient care.

Why do we have this cult of CPR in this country? Why do we respond code 3 to most calls, putting the public at risk for no benefit most of the time?

I agree that is responding code 3 to non-emergency calls and signal jumping are big problems, but I don't think that's what the article was getting at...they're looking at cutting costs. It's not as easy to draw a line from unnecessary code 3 response-->unnec crashes-->property damage/fatalities, as it is to show how many taxpayer dollars are going to "unnnecessary" ALS training in fire departments

 

[leviathan]

I think this is an extremely important point.

I think that the editorial made some a lot of good points and wasn't really singling out EMS.

Certainly we are getting a bit carried away in many areas of medicine, including EMS. Does it help to have a paramedic for a small subset of EMS calls? I think so. Do we need five of them onscene for every single call, most of which need only a taxi? Absolutely not. I was on a shift in LA where 5/6 firefighters were paramedics. That's insane.

I absolutely agree, and the service I work for only has ALS responses to those subset of calls where they make a statistically significant difference. Dispatch is only so perfect, so on most of these calls the BLS crew that responds will cancel the ALS crew when they see that the "SOB" patient is talking in full sentences on her phone and smoking a cigarette.

For an example of EMS research which shows a benefit to ALS care, please see this page:
http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm

Why do we have this cult of CPR in this country? Why do we respond code 3 to most calls, putting the public at risk for no benefit most of the time?

Poor dispatching is the main reason.

Also, I think Leviathan needs to be a little more careful with his quoting, lest he put Tired's words into someone else's mouth again

Sorry about that...don't know what exactly happened there.

 

[Medic MD]

I think it's a little bit foolish to conclude that the practice of EMS is worthless simply because the research data doesn't exist to support it. For whatever reason, over the last two decades or so, accurate research in the field has been difficult to obtain. Blame it partly on the funding required for agencies to conduct large-scale research, and blame it partly on the resistance of (most) paramedics to adapt to major changes in their normal routine. That includes changing their practices or simply changing the way they document for research requirements.

Subjectively though, I think that in parts of the country the desire of some agencies to provide what they consider "Exceptional" service has gotten out of hand. Like the poster above referred to, in some cities and counties here in Florida (particularly South FL), it's not uncommon for more than four or five paramedics to respond to a call. Honestly, in populated areas where transport time is.. say... less than 10 minutes, ALS care probably isn't needed and is probably not economical. But, the fact remains that a majority of our country is suburban or rural and that transport times in those areas are certainly long enough to warrant having someone treat the patient who is trained and certified to perform ALS procedures and administer medicines.

I'm an advocate for paramedics in the field, but going overboard with the concept doesn't benefit anyone. Agencies need to do a better job of evaluating what's needed for their population.

 

[docB]

Subjectively though, I think that in parts of the country the desire of some agencies to provide what they consider "Exceptional" service has gotten out of hand. Like the poster above referred to, in some cities and counties here in Florida (particularly South FL), it's not uncommon for more than four or five paramedics to respond to a call. Honestly, in populated areas where transport time is.. say... less than 10 minutes, ALS care probably isn't needed and is probably not economical. But, the fact remains that a majority of our country is suburban or rural and that transport times in those areas are certainly long enough to warrant having someone treat the patient who is trained and certified to perform ALS procedures and administer medicines.

This is a reasonable hypothesis: that ALS is helpful but maybe it needs to be deployed more strategically. This brings up the big paradox in EMS. From a previous thread:

All of this is impacted by the great EMS paradox (a favorite subject of mine). The rural agencies with long transport times that need the advanced skills and equipment the most are the ones who can't afford it. If you have to transport to a hospital an hour away you need intubation more than the medic who is five minutes away. However, as a rural medic you are less likley to get enough tubes on a regular basis to stay as sharp as your urban counterparts.

Some of this boils down to the fact that rural departments might (again, we need the data) benefit a lot more from ALS than urban areas with short transport times. However, rural departments tend to have much less funding and are usually not as attractive to highly trained medics. They also have less money for cool toys which affects all the other aspects.

 

[chimichanga]

What I do know is this: no matter how strong the evidence is in favor of ditching a practice, we will always fall into the trap of saying, "Well I saw this one guy who it really worked for! Are you saying we should tell his family that he should die just because it doesn't work for most people?"

This is exactly on point. Anecdotal evidence helps inject the "human factor."
It puts a face/identity to said anecdote.

And it's not a trap if the anecdotal evidence is your dad, who received 2 rounds of epi/atropine or a shock, and now is around for another Xmas with the grand kids. (we'll never know if basic cpr only would have saved him)

(how many appys do you really need the CT for, but it certainly won't go away as a diagnostic tool)

This is why it won't go away, no matter how lacking the real proof is (according to Dr Henry.)

 

[leviathan]

This is a reason to buy your local paramedics a six-pack of beer at Christmas.

It is not a basis for public policy.

This actually illustrates my point perfectly.

Did you get a chance to check any of those studies which prove ALS is helpful?

 

[chimichanga]

he did not...

he is too busy:

1) posting here

2) saving medicine from itself and all other interlopers

 

[MacBook]

This is a reasonable hypothesis: that ALS is helpful but maybe it needs to be deployed more strategically. This brings up the big paradox in EMS. From a previous thread:

Some of this boils down to the fact that rural departments might (again, we need the data) benefit a lot more from ALS than urban areas with short transport times. However, rural departments tend to have much less funding and are usually not as attractive to highly trained medics. They also have less money for cool toys which affects all the other aspects.

In most cases you are correct but here anyways, rural services tend to have the money to support the staff and equipment needed to support their protocols BECAUSE they are rural. The term rural tho, out here anyways, is probably more extreme than what you are used where hospitals are A LOT further than one would assume.

 

[jkelly2]

Here is the abstract for a lit review that examined efficacy of ALS over BLS. It is a bit dated but you can interpret it for yourself.

INTRODUCTION: Jurisdictions throughout the United States and some other parts of the world have invested substantial time and resources into creating and sustaining a prehospital advanced life support (ALS) system without knowing whether the efficacy of ALS-level care had been validated scientifically. In recent years, it has become fashionable for speakers before large audiences to declare that there is no scientific evidence for the clinical effectiveness of ALS-level care in the out-of-hospital setting. This study was undertaken to evaluate the evidence that pertains to the efficacy of ALS-level care in the current scientific literature. METHODS: An extensive review of the available literature was accomplished using computerized and manual means to identify all applicable articles from 1966 to October, 1995. Selected articles were read, abstracted, analyzed, and compiled. Each article also was categorized as presenting evidence supporting or refuting the clinical efficacy of ALS-level care, and a list was constructed that pointed to where the preponderance of the evidence lies. RESULTS: Research in this field differs widely in terms of methodological sophistication. Of the 51 articles reviewed, eight concluded that ALS-level care is not any more effective than is basic life support, seven concluded that it is effective in some applications but not for others, and the remainder demonstrated effectiveness. The strongest support for ALS-level care was in the area of responses to victims of cardiac arrest, whereas somewhat more divergent findings related to trauma or non condition-specific studies. CONCLUSIONS: While not unanimous, the predominant finding of recent research into the clinical effectiveness of advanced life support demonstrates improved effectiveness over basic life support for patients with certain pathologies. More outcomes-based research is needed.

Bissell RA, Eslinger DG, Zimmerman L. (1998). "The efficacy of advanced life support: a review of the literature." Prehosp Disaster Med. 13:1, pp. 77-87.

 

[MacBook]

_

Really thoughtful reply, I couldn't agree any more.

 

[docB]

In most cases you are correct but here anyways, rural services tend to have the money to support the staff and equipment needed to support their protocols BECAUSE they are rural. The term rural tho, out here anyways, is probably more extreme than what you are used where hospitals are A LOT further than one would assume.

I have seen the opposite. In town all the rigs are either EMT-P + EMT or EMT-Px2. Out in the rural area "rescues" are often staffed with volly FRs or maybe EMTs who have to call in an ALS unit with extend time enroute.

 

[pseudoknot]

I think this may be another instance where the more centrally managed Canadian system distributes resources more efficiently than we do. Indeed, I think that our lack of rational resource allocation was one of the main overall points of Henry's editorial.

 

[Medic MD]

Some of this boils down to the fact that rural departments might (again, we need the data) benefit a lot more from ALS than urban areas with short transport times. However, rural departments tend to have much less funding and are usually not as attractive to highly trained medics. They also have less money for cool toys which affects all the other aspects.

My thoughts exactly. One extreme way to counter the problem might be to simply take ALS out of the cities. Of course, major, major research would be required before that would ever happen, but you'd have more paramedics expanding out to the rural areas where they're needed the most. And you'd significantly reduce the cost of providing service in areas with short transport times. It doesn't help the funding problems in rural areas, but with such an extreme measure taken to redistribute services, I'm sure the states could come up with something.

 

[leviathan]

The few studies I saw in there (and granted, I didn't look at every one) dealing with the efficacy of the procedures don't specifically address outcome data for interventions when performed in the prehospital setting.

Maybe you could tell me which studies you're looking at that actually support your statement that I quoted here?

Actually a large proportion of the studies are dealing with the efficacy of prehospital interventions. For example just clicking on arrest/unconscoius intubation has:

Adnet F, Jouriles JN, Toumelin PL: Survey of out-of-hospital emergency intubations in the French prehospital medical system: A multicenter study. Ann Emerg Med 1998;32:454-460 - Medline

Jacobs LM, Berrizbeitia LD, Bennett B et al: Endotracheal intubation in the prehospital phase of emergency medical care. JAMA 1983;250:2175-2177 - Medline

Wang HE, Yealy DM (2006). How manyattempts are required to accompllish out-of-hospital endotracheal intubation? Acad Emer Med 13;4:372-7. - Medline

Bochicchio, GV, Obeid, I, Manjari, J, Bochicchio, K, Scalea, T. Endotracheal Intubation in the Field Does Not Improve Outcome in Trauma Patients Who Present Without an Acutely Lethal Traumatic Brain Injury. J Trauma. 2003 Feb;54(2):307-11. - Medline

Garza AG, Gratton MC, Coontz D, Noble E, Ma OJ (2003). Effect of paramedic experience on orotracheal intubation success rates. J Emerg Med 25; 251-6. - Medline

Wang HE, Kupas DF, Paris PM, Bates RR, Yealy DM (2003). Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resus 58; 49-58. - Medline

etc etc etc

 

[Druggernaut]

We understand what the effects would be if only BLS were available on a call where you have a patient with a crap airway that you're unable to ventilate, or where you have a symptomatically bradycardic patient who is about to arrest on you, or a patient in anaphylactic shock who needs epinephrine, or a hypoglycemic diabetic who is unresponsive, etc. etc.

In my state, BLS is able to intubate (though only with a combitube), give epinephrine for anaphylaxis, and give glucagon to the unresponsive diabetic, as well as aspirin, nitro, charcoal, and albuterol when needed. With another 100 hours of training after getting your EMT-B license, you could also put in an IV, run saline, D50, narcan, and a few others that slip my mind at this point.

But it's not the dispatching of an ALS unit when a BLS unit is appropriate that runs up costs. It's the dispatching of an ambulance for something that needs no interventions whatsoever, and the inability to tell that person that they are not going to be taken to the hospital.

 

[howelljolly]

In my state, BLS is able to intubate (though only with a combitube), give epinephrine for anaphylaxis, and give glucagon to the unresponsive diabetic, as well as aspirin, nitro, charcoal, and albuterol when needed. With another 100 hours of training after getting your EMT-B license, you could also put in an IV, run saline, D50, narcan, and a few others that slip my mind at this point.

But it's not the dispatching of an ALS unit when a BLS unit is appropriate that runs up costs. It's the dispatching of an ambulance for something that needs no interventions whatsoever, and the inability to tell that person that they are not going to be taken to the hospital.

I think thats a good point... but what can be done about that?

 

[deleted6669]

I have seen greg henry lecture many times. great lectures. smart guy but lots of bluster.
his style is to make shocking statements that get talked about as we have been doing here. he's also quite the minimalist. the last lecture I saw him give was about diagnosing acute neurologic disorders without the use of a ct scanner.
he came on right after the guy who did the acls update. he started his lecture like this:
"let me summarize the last hr for you...if you shock a pt 3 times and he doesn't respond he's a dead sucker, end of story."

 

[howelljolly]

That settles it. From now on, medics should bring patients with respiratory failure in with a BVM.

Tired should be in charge of a RCT on ETI in the field. When the study is abandoned for efficacy, let me know.

There are some things in medicine that we just dont test (see my initial mannitol comment)

Instead of shooting everyone down, why dont you make some suggestions?

 

[greytmedic]

That settles it. From now on, medics should bring patients with respiratory failure in with a BVM.

Tired should be in charge of a RCT on ETI in the field. When the study is abandoned for efficacy, let me know.

There are some things in medicine that we just dont test (see my initial mannitol comment)

Instead of shooting everyone down, why dont you make some suggestions?

What do you mean there are some things in medicine we just don't test?

Marianne Gausche, Roger J. Lewis, Samuel J. Stratton, Bruce E. Haynes, Carol S. Gunter, Suzanne M. Goodrich, Pamela D. Poore, Maureen D. McCollough, Deborah P. Henderson, Franklin D. Pratt, and James S. Seidel. Effect of Out-of-Hospital Pediatric Endotracheal Intubation on Survival and Neurological Outcome: A Controlled Clinical Trial. JAMA, Feb 2000; 283: 783 - 790.

This was the big pediatric study that pediatric patients were assigned to the intubation group or the BVM group based on calendar day. The criteria were, "if they required airway management based on 1 or more of the following criteria: cardiopulmonary arrest (patient apneic without a palpable pulse); respiratory arrest (patient apneic only, with pulse present); respiratory failure (with respiratory rates >60/min or <12/min) with a nonpurposeful response or no response to pain; complete or severe partial airway obstruction; traumatic cardiopulmonary arrest; traumatic respiratory arrest; closed or open head trauma with a nonpurposeful response or no response to pain; and paramedic assessment that assisted ventilation was necessary."

PS: The study showed there was no difference in survival or neurological outcome of peds between BVM and ETI in an urban system.

 

[howelljolly]

Sure, here's a couple suggestions:

1) If you're going to say you have evidence for something, actually make sure you have it.

2) If you're going to cite a half-dozen studies as evidence for something, read the abstract (or at least the title) to make sure it says what you think it says.

I think it's silly that you two will base your entire argument on supposed "evidence" (direct or indirect) to refute the point of this article, then get pissy with me when I point out that you haven't actually offered any. I mean really . . .


What would I like to see done with EMS? Pretty much this (think "glorified taxi service"):
- eliminate all ALS paramedics and EMTs, use only BLS (yes, use BVM only)
- strip EMT "assessments" down to the bare minimum; nobody cares if the EMT thinks it's GERD instead of an MI
- dramatically decrease the time and effort we spend training pre-hospital providers; like I said, you can train a corpsmen in basic assessment and procedures in a few months, there's no reason you need 2 years to train a paramedic
- expand the system of alorithm-based prehospital care that already exists based on the presenting complaint to standardize care
- minimize interventions they are permitted initiate outside the hospital; require physician verbal orders before doing most anything
- along the same lines, start using dedicated physicians to guide EMTs in the prehospital setting; stop pulling ER physicians away from their work to answer calls from the field

Im not using one bit of evidence, and thats my entire point. I think that the idea of switching to an entirely BLS system is almost absurd on the face of it.
Now, with your points....

In 1996 they did strip the BLS assessment down to identification rather than diagnosis. Do you think that this paradigm has worked over the last 12 years? (Im not saying it has or hasn't.... but, your idea was put in place already)

Dedicated on-line medical control physicians. Already in place in the FDNY. Thats about the only place where you are going to find an prehospital/disaster medicine fellowship trained, EM physician who is willing to sit on their bum and talk to EMS for 12 hours straight.

You propose to make EMS providers stupider so that residents like yourself get angrier when they present a patient to you? You forget the EMS providers are human, and will rise to their level of incompetence no matter what you do. By cutting out all of the thinking, you are going to end up with people that do not want to do any thinking. Everyone else will leave the career and go so something else. Thats how it is already, motivated intelligent EMTs become medics, motivated medics become RNs, MDs RTs.... brain drain effect.

I dont mean to be offensive, but theres no other way to say it. I dont see anything novel or useful in your suggestions

 

[leviathan]

2) If you're going to cite a half-dozen studies as evidence for something, read the abstract (or at least the title) to make sure it says what you think it says.

I didn't have time to read through all of those countless studies to see it was looking more at success rate with intubation rather than differences in mortality. I don't know how YOU did have the time as a resident!

I can easily look at one of the countless other protocols on that website to see the research they have found. I am sure there is a lot of data on things like anaphylaxis and cardiac emergencies, but naturally the website is down right now. I will try checking it out tomorrow.

I think it's silly that you two will base your entire argument on supposed "evidence" (direct or indirect) to refute the point of this article, then get pissy with me when I point out that you haven't actually offered any. I mean really . . .

I wasn't the one who responded to you on that, but I personally do not care. I think it is a good idea that you are challenging the cost effectiveness and reliability of the current system. If it really is useless, I agree that we should can it. However, I do not think this is the case.

What would I like to see done with EMS? Pretty much this (think "glorified taxi service"):
- eliminate all ALS paramedics and EMTs, use only BLS (yes, use BVM only)

Would definitely be feasible in an urban area with short transport times. However, do you think a patient with complex medical problems and an ALS crew available to provide immediate care would not make a difference, if the nearest hospital was 45 minutes away?

- strip EMT "assessments" down to the bare minimum; nobody cares if the EMT thinks it's GERD instead of an MI

This is true; however, assessment is still important if the EMT is going to be able to treat the patient. I don't know what area you practice in, but where I work, we simply hand off the patient with a brief history and our assessments, and do not suggest any diagnosis. That is the job of the physician.

- dramatically decrease the time and effort we spend training pre-hospital providers; like I said, you can train a corpsmen in basic assessment and procedures in a few months, there's no reason you need 2 years to train a paramedic

You should see how scary some of the BLS guys are in my area who get 6 months of training @ 40 hours/week....oh man, I couldn't imagine how much worse they would be with even LESS training.

- expand the system of alorithm-based prehospital care that already exists based on the presenting complaint to standardize care

There are definitely pros to algorithm-based systems, but also many cons. I think algorithm-based systems are great as long as there is legroom for paramedics to step outside of the box if they have the intelligence and the justification for doing so, and if they are willing to be held responsible for any deviations they make which were incorrect.

- minimize interventions they are permitted initiate outside the hospital; require physician verbal orders before doing most anything

I'm sure a physician would want to be called every 2 minutes by the paramedic to ask if s/he can give grandma another 50 of gravol.

- along the same lines, start using dedicated physicians to guide EMTs in the prehospital setting; stop pulling ER physicians away from their work to answer calls from the field

As per last comment, it would work if you could find a dedicated physician for this, but show me a system that would be able to recruit physicians to do this kind of work.

 

[leviathan]

Hmm, looks like I can't get access to any of these articles. If other people want to look at this website and prove/disprove for me that there is evidence for efficacy of ALS, let me know.

Examples of pages with evidence where I think ALS is extremely helpful include:

Treatment of hypoglycemia:
http://emergency.medicine.dal.ca/ehsprotocols/protocols/flowcharts/hypoglycemia.cfm?ProtID=6212.02

Post-arrest care:
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=6311.03

Overdoses (are there studies comparing BLS using a BVM with its complications compared to ALS reversing the overdose with narcan and/or intubating the patient?
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=6213.02

Status epilepticus: (Who can say that a person in status does not significantly benefit from having it terminated with benzos, instead of a BLS crew transporting a seizing patient for an additional 45 mins to hospital?)
http://emergency.medicine.dal.ca/ehsprotocols/protocols/LOE.cfm?ProtID=6214.02

Anaphylaxis: (Can a patient with a rapid onset of anaphylaxis survive without immediate epinephrine administration by ALS? Would the 45 min transport to a rural hospital kill them if there were only BLS?)
http://emergency.medicine.dal.ca/eh...flowcharts/6208Anaphylaxis.cfm?ProtID=6208.03

Conditions I don't think ALS will benefit the patient unless there are extreme circumstances:
Acute coronary syndrome
Cardiac arrest
Trauma

 

[howelljolly]

What about critical care and flight? Nurses all the way?

 

[MacBook]

I have seen the opposite. In town all the rigs are either EMT-P + EMT or EMT-Px2. Out in the rural area "rescues" are often staffed with volly FRs or maybe EMTs who have to call in an ALS unit with extend time enroute.

Both posts were fair. It's very service dependent. Our pre-hospital system here is going provincial so I'm not sure how that will all play out.

 

[leviathan]

Both posts were fair. It's very service dependent. Our pre-hospital system here is going provincial so I'm not sure how that will all play out.

Hopefully you will change to a two-tiered system...that will do great things for your ALS providers.

 

[jkelly2]

OBJECTIVE: To determine whether firefighter/emergency medical technicians-basic (FF/EMT-Bs) staffing basic life support (BLS) ambulances in a two-tiered emergency medical services (EMS) system can safely determine when advanced life support (ALS) is not needed. METHODS: This was a prospective, observational study conducted in two academic emergency departments (EDs) receiving patients from a large urban fire-based EMS system. Runs were studied to which ALS and BLS ambulances were simultaneously dispatched, with the patient transported by the BLS unit. Prospectively established criteria for potential need for ALS were used to determine whether the FF/EMT-B's decision to cancel the ALS unit was safe, and simple outcomes (admission rate, length of stay, mortality) were examined. In the system studied, BLS crews may cancel responding ALS units at their discretion; there are no protocols or medical criteria for cancellation. RESULTS: A convenience sample of 69 cases was collected. In 52 cases (75%), the BLS providers indicated that they cancelled the responding ALS unit because they did not feel ALS was needed. Of these, 40 (77%) met study criteria for ALS: 39 had potentially serious chief complaints, nine had abnormal vital signs, and ten had physical exam findings that warranted ALS. Forty-five (87%) received an intervention immediately upon ED arrival that could have been provided in the field by an ALS unit, and 16 (31%) were admitted, with a median length of stay of 3.3 days (range 1.1-73.4 days). One patient died. CONCLUSION: Firefighter/EMT-Bs, working without protocols or medical criteria, cannot always safely determine which patients may require ALS intervention.

Cone DC, Wydro GC. (2001). "Can basic life support personnel safely determine that advanced life support is not needed?" Prehosp Emerg Care. 5: (4) 360-5.

 

[pseudoknot]

That study is so full of holes as to be totally worthless. It's a good example of when crappy research is worse than none at all.

 

[MedicFL]

There sample size was 69 pt of convenience that is a pretty crappy sample size and population. They may have cherry picked there cases, who knows but to make a generalization after only 69pt's is kind of a joke.

 

[pseudoknot]

Yes, the convenience sample was a big problem for me. Also the fact that there was no real outcome data. You'd need a lot more than 70 patients to know if there was a significant difference in mortality, and I don't particularly care if stuff happened in the ED that could have been done in the field, UNLESS it can be shown to have affected the outcome.

 

[leviathan]

There sample size was 69 pt of convenience that is a pretty crappy sample size and population. They may have cherry picked there cases, who knows but to make a generalization after only 69pt's is kind of a joke.

The main flaw is that the study doesn't say whether BLS did anything detrimental. Abnormal vital signs? Abnormal physical findings? If they were taking in healthy patients to the hospital, then who exactly is BLS supposed to be taking? Interventions were performed immediately upon arrival to the hospital? What interventions...IV starts? Is that going to alter their outcome? The study is full of holes.

 

[howelljolly]

Im not really that keen on using mortality as an endpoint, in this case, or in a lot of cases actually. Sure, that is a good, solid outcome... but what has it got to do with most of these patients? (My assumption is that most patients wont die with or without ALS, so why see if they are dying?)

Why does the research have to revolve around EMS justifying its own existence? Will anybody really change their regional systems based on data that says "Nah, paramedics dont make a difference in overall mortality."

Are they really going to make their BLS simply drive faster with priority-1 patients?

Who's going to pronounce at the home? Are we really going to take everyone who is long dead to the hospital for pronouncement?

Are we going to take the home-care, bedbound pediatric who dislodged their tracheostomy to the nearest ER, 20 mins away, where the hospital happens not to have a vent thats appropriate for a 6 year old?

What about the patient who has a recent history of cardiothoracic surgery, and the BLS crew who doenst know how to do an appropriate H&P, and doesnt understand the complications of CT surgery, brings the patient with the worlds largest pericardial tamponade to the closest ER, which has no capability to treat the patient? OK, drain the pericardium and put them in an ambulance and send them to an approporate facility. Oh, wait.... silly me, I forgot....the ambulance is staffed by EMTs, not critical care medics...

Its easy to say "Stop spending $96,000 to train a medic (thats what it costs in my area), we just need a glorified taxi service to get people to the hospital." The change to the current infrastructure will cost lives.

Ive been thinking about this for a few days, and I've decided that its the stupidest idea ever.

Where's DocB?

 

[MediumDef]

Im not really that keen on using mortality as an endpoint.

ALS Benefit for Respiratory Distress
Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory distress. New England Journal of Medicine 356(21):2,156–64, May 24, 2007

Results.....The rate of death among all patients decreased significantly, from 14.3% to 12.4% (absolute difference 1.9%; 95% CI, 0.4–3.4; p=0.01)...



You don't have to use mortality as an endpoint someone else already did it. Sometimes it's just easier to start with an absolute and then work your way backwards



And just so no one has to strain themselves coming up with their own rebuttal

http://emergency-medicine.jwatch.org/cgi/content/full/2007/523/1

 

[pseudoknot]

Im not really that keen on using mortality as an endpoint, in this case, or in a lot of cases actually. Sure, that is a good, solid outcome... but what has it got to do with most of these patients? (My assumption is that most patients wont die with or without ALS, so why see if they are dying?)

Mortality and morbidity are things that matter to the patient. If there is no effect on either, why waste money doing something?

Why does the research have to revolve around EMS justifying its own existence? Will anybody really change their regional systems based on data that says "Nah, paramedics dont make a difference in overall mortality."

No, not overnight. However, in medicine we do a lot of things that haven't been rigorously evaluated. When we do get around to scientifically studying our practices, we often find that treatments we thought we great are worthless or harmful. This is because we don't understand very much about physiology or pathphysiology and have almost no predictive models. EMS should have to justify its existence, just like everything else in medicine.

brings the patient with the worlds largest pericardial tamponade to the closest ER, which has no capability to treat the patient?

Someone correct me if I'm wrong, but isn't pericardiocentesis the definitive treatment for tamponade? Isn't that within the capabilities of any functioning emergency department? Isn't that a good example of something where you don't want to delay treatment driving an extra 15 minutes to a trauma center, or screwing around for 10 minutes on scene trying to start an IV that won't benefit the patient?

 

[docB]

Where's DocB?

Why does the research have to revolve around EMS justifying its own existence? Will anybody really change their regional systems based on data that says "Nah, paramedics dont make a difference in overall mortality."

Are they really going to make their BLS simply drive faster with priority-1 patients??

I'm here but I actually really like this debate. I don't agree with Tired. I think that ALS will eventually prove to be of benefit. But, I do think that there is going to be increasing onus on EMS to provide data justifying its existence as well as current practices and training levels.
I think that there would be systems that would go minimalist. The politicians would do anything to save money. The thing we have going for us is that the public really believes in EMS and Paramedics. Problem is going to be that we're going to be pushed more and more to provide data to back stuff up. Stuff we used to take as given. That's the creation of the movement toward evidence based medicine.

Who's going to pronounce at the home? Are we really going to take everyone who is long dead to the hospital for pronouncement??

The bean counters won't really care about the details like that. They're all about the $$$. If they think that the county coroner or some other, cheaper entity can suck up some of the load they'll dump it on them.

This is really similar to the thread where the trauma surgeon said that EMS is bad for penetrating trauma victims. Surgeons tend to think that any layer of healthcare that stands between them and the patient is bad. That's why Dr. Seamon and Tired don’t care much for EMS. In general they also don’t care much for ER docs. That’s why they have been the most vocal in questioning existing practice. The problem is that they sometimes don’t approach these issues in a constructive way.

Here’s where I think we’re going to be going in the next several years. I don’t think there will be any big changes to the current training and staffing levels. I do think that we will have to start producing data that shows we are accomplishing something. That can be better outcomes, better patient satisfaction, better pain control, better assessment coupled with utilization of resources and so on. That means EMTs will need to be involved and leading this research.

I think we will see some changes in the way we do things. For example if the data continues to stack up on better outcomes with less intervention for penetrating trauma patients we will have to address that. One possibility is a protocol that limits interventions in penetrating trauma victims within a certain transport time to a trauma center.

Ultimately though money will drive change more than anything else. If there are reimbursement cuts or increases or if insurers find a way to quit paying for unwarranted transports EMS will change very quickly.

Sorry this is so rambling. I’m writing it in between patients. The big thing is that we’re going to be getting more and more criticism like this in the future. The way to fight it is to do the research, improve the quality and change when indicated. We can’t just refuse to adapt or we’ll get shut out of the decision making process.

 

[pseudoknot]

ALS Benefit for Respiratory Distress
Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory distress. New England Journal of Medicine 356(21):2,156–64, May 24, 2007
...
http://emergency-medicine.jwatch.org/cgi/content/full/2007/523/1

Thanks for that. It reminds us of another point that I think is partly what the original article was trying to get us to think about: cost/benefit analysis. This is currently something that is basically not done in the US healthcare system except here and there by insurance companies who are trying to deny as many claims as possible.

So: maybe ALS helps some patients (I personally have no doubt this is true, although I think it harms others in our system). Is it worth it?

A better example: we've developed a national obsession with CPR and defibrillation, trying to more effectively treat...death? So, how much money do we put into having AEDs on every street corner and every police car, etc.? What if we put that money into vaccines, or preventive care for DM and HTN? Might we not save more lives? Would people care since those things aren't dramatic and sexy like cardiac arrest?

 

[pseudoknot]

Ultimately though money will drive change more than anything else.

Maybe someday, but I think without some kind of national cost/benefit analysis this is another facet of the ALS paradox you've brought up in the past. How many paramedics does Santa Monica, CA need, where the average transport time to the hospital is maybe 5 minutes max? Probably zero. Do you think they care about saving money on what is perceived to be a "life saving" system? No way. The rural areas, on the other hand, probably do need more advanced care during their long transports, but don't have the tax base for it.

 

[nsx]

Maybe someday, but I think without some kind of national cost/benefit analysis this is another facet of the ALS paradox you've brought up in the past. How many paramedics does Santa Monica, CA need, where the average transport time to the hospital is maybe 5 minutes max? Probably zero. Do you think they care about saving money on what is perceived to be a "life saving" system? No way. The rural areas, on the other hand, probably do need more advanced care during their long transports, but don't have the tax base for it.

So: maybe ALS helps some patients (I personally have no doubt this is true, although I think it harms others in our system). Is it worth it?

Huh? Cost benefit analysis is going to determine just that, cost/benefit. The ambiguous term here is benefit. How do you put a price on the save due to having extra resources and training?
I sure as hell wouldn't want ALS wiped out if it was my as* on the line, would you? Would you be for a strictly BLS system if it were proven to be cheaper? 'Cause it's definitely easy to prove that BLS is cheaper than ALS.

I don't understand how a cost/benefit analysis can yield some incredible answer that isn't trumped by bottom line. First you have to define benefit, or rather who benefits.

So: maybe ALS helps some patients (I personally have no doubt this is true, although I think it harms others in our system). Is it worth it?

A better example: we've developed a national obsession with CPR and defibrillation, trying to more effectively treat...death? So, how much money do we put into having AEDs on every street corner and every police car, etc.? What if we put that money into vaccines, or preventive care for DM and HTN? Might we not save more lives? Would people care since those things aren't dramatic and sexy like cardiac arrest?

I don't understand this logic either. It assumes the general public wants to take responsibility for their own health (that doesn't sound grammatically correct).... We already have automatic BP cuffs in the drugstore and free health screenings at the grocery store, does it do anything to prevent HTN? You can lead a horse to water but you can't make it drink.

 

[pseudoknot]

I sure as hell wouldn't want ALS wiped out if it was my as* on the line, would you?

It depends on what's going on. If I'm five minutes from the hospital then I don't care. If I'm ten minutes or more and having an anaphylactic reaction, then I'd probably like to have ALS there.

Would you be for a strictly BLS system if it were proven to be cheaper? 'Cause it's definitely easy to prove that BLS is cheaper than ALS.

I'm not saying we should get rid of ALS, but I think we might be better off scaling it back and redistributing it. As I said in my post above, the issue is not whether EMS is a complete waste of money, but rather are we getting the best bang for our buck or could more lives be saved by putting some of that money elsewhere.

Does proton beam therapy benefit patients? I'm not an expert but I'd guess it might. Is it ethical or rational to build those facilities for $150M or more, instead of putting the money into more cost effective treatments? Absolutely not, IMO.

 

[nsx]

It depends on what's going on. If I'm five minutes from the hospital then I don't care. If I'm ten minutes or more and having an anaphylactic reaction, then I'd probably like to have ALS there.


I'm not saying we should get rid of ALS, but I think we might be better off scaling it back and redistributing it. As I said in my post above, the issue is not whether EMS is a complete waste of money, but rather are we getting the best bang for our buck or could more lives be saved by putting some of that money elsewhere.

Does proton beam therapy benefit patients? I'm not an expert but I'd guess it might. Is it ethical or rational to build those facilities for $150M or more, instead of putting the money into more cost effective treatments? Absolutely not, IMO.

I agree with what you've written here. But if ALS is going to be scaled back on the basis that it's not always beneficial, it needs to be shown that it is beneficial under certain conditions..or else why not cut it out entirely (from the business point of view)?

It sounds a little silly to conduct studies attempting to demonstrate that having epi in the scope of practice improves outcomes in the event of an anaphylactic reaction, but maybe that's the kind of thing we need to be working on.