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"Advanced Life Support" Ambulances May Lead To More Deaths
HughPickens.com writes Jason Kane reports at PBS that emergency treatments delivered in ambulances that offer "Advanced Life Support" for cardiac arrest may be linked to more death, comas and brain damage than those providing "Basic Life Support." "They're taking a lot of time in the field to perform interventions that don't seem to be as effective in that environment," says Prachi Sanghavi. "Of course, these are treatments we know are good in the emergency room, but they've been pushed into the field without really being tested and the field is a much different environment." The study suggests that high-tech equipment and sophisticated treatment techniques may distract from what's most important during cardiac arrest — transporting a critically ill patient to the hospital quickly.
Basic Life Support (BLS) ambulances stick to simpler techniques, like chest compressions, basic defibrillation and hand-pumped ventilation bags to assist with breathing with more emphasis placed on getting the patient to the hospital as soon as possible. Survival rates for out-of-hospital cardiac arrest patients are extremely low regardless of the ambulance type with roughly 90 percent of the 380,000 patients who experience cardiac arrest outside of a hospital each year not surviving to hospital discharge. But researchers found that 90 days after hospitalization, patients treated in BLS ambulances were 50 percent more likely to survive than their counterparts treated with ALS. Not everyone is convinced of the conclusions. "They've done as much as they possibly can with the existing data but I'm not sure that I'm convinced they have solved all of the selection biases," says Judith R. Lave. "I would say that it should be taken as more of an indication that there may be some very significant problems here."
Basic Life Support (BLS) ambulances stick to simpler techniques, like chest compressions, basic defibrillation and hand-pumped ventilation bags to assist with breathing with more emphasis placed on getting the patient to the hospital as soon as possible. Survival rates for out-of-hospital cardiac arrest patients are extremely low regardless of the ambulance type with roughly 90 percent of the 380,000 patients who experience cardiac arrest outside of a hospital each year not surviving to hospital discharge. But researchers found that 90 days after hospitalization, patients treated in BLS ambulances were 50 percent more likely to survive than their counterparts treated with ALS. Not everyone is convinced of the conclusions. "They've done as much as they possibly can with the existing data but I'm not sure that I'm convinced they have solved all of the selection biases," says Judith R. Lave. "I would say that it should be taken as more of an indication that there may be some very significant problems here."
advanced pay bill?
Most of these patients would likely not have been rushed into advanced surgeries or anything of that kind. And it is not like they are getting infection because of they are getting medical treatments performed in none sterile environments.
like the article says, they would get rushed to the hospital and just received these exact same stabilizing treatments there instead of in the field 10 minutes prior. The only major difference of in the field, than in a hospital room, if you have all the equipment in the field, is the people using the equipment. It is understandable that doctors who have been doing this for decades are better than people newly trained, but it seems to me that obvious for cardiac arrest victims, the absolutely best solution definitely does involve stabilising them right away in the field.
Troll is not a replacement for I disagree.
Howdy all,
Just so we are clear, the industry knows this. BLS before ALS has been taught by the AHA from CPR classes all the way through ACLS for many years. Back around 2000 the emphasis was on the cool toys. Now the emphasis is on chest compressions.
Time to ER care is a factor here. A BLS ambulance can do little, so it will transport, often as quickly as the patient can be moved to the ambulance. An ALS vehicle, on the other hand, will often try to stabilize patients on the scene despite the fact that a crowded vehicle offers little space to work. It'll be later getting to the ER.
I'm sure a large reason for this roll-out is the insane amount of money these ambulances can charge. This healthcare system rules! USA USA USA /sarcasm
http://www.nytimes.com/2013/12...
There is much discussion lately about Cayenne pepper being able to assist someone suffering from a cardiac arrest.
Cayenne Pepper
Political correctness is really just herd psychology pushed by insecure people who desperately seek social conformity.
Just put large nets on top of hospitals and equip ambulances with catapults.
You have lesser trained individuals using more interesting medical equipment.
What could possibly go wrong?
A Pirate and a Puritan look the same on a balance sheet.
For control, they should try refrigerator trucks..
I distinctly remember after the crash there were comparisons between the way ambulance service is done in this country and how it is done in (most of) France.
Here, the general rule is scoop and go whereas in France the idea is perform treatment on the spot then get the person to a hospital.
This difference was used to explain why she died (bled out from internal injuries). The idea was, and as others on here have already commented, had she been taken directly to a hospital she had a better chance of survival than being held at the scene for nearly two hours while they worked on her.
For reference.
We will bankrupt ourselves in the vain search for absolute security. -- Dwight D. Eisenhower
I was watching these two paramedics do all kinds of sort of half assed things on this collapsed old guy when they were literally 2 blocks from a hospital. I would have thought that it would have been far better procedure to just heave him into the ambulance like a sack and then get him to the hospital in the 60 seconds (again literally) that it would have taken. My simple medical thought was that I could hold my breath for the trip to the hospital as opposed to where I would easily be dead in the time it was taking them.
In some cases like this one I even see the stretcher as extraneous and time wasting.
My friend had an even better comment in that it would have been better for one of us to just throw him over our should and run him to the hospital with the over the shoulder resulting in a bit of CPR. We may very well have done this had we not arrived at the same time as the paramedics.
Firstly, my bias is I'm a paramedic (and software engineer) who works in a progressive cardiac arrest system with survival numbers roughly twice the national average for all arrest etiologies and three times the average for witnessed VF/VT arrests. We use community Hands-Only CPR campaigns, dispatcher assisted CPR, BLS first response, aggressive ALS care, and specialty cardiac arrest receiving centers to achieve these outcomes.
Secondly, this study adds nothing to the existing literature except to confirm what we already know about variable outcomes across the US. The methodology is shaky at best to make such lofty causality claims as retrospective registry data spanning such a wide swath of the US is bound to obscure the better systems from the worse systems. Retrospective reviews of data from the Resuscitation Outcomes Consortium (ROC) group has found extremely variable resuscitation quality even among study sites. What is crazy is that Sanghavi is consciously ignoring the fact that the high performers in his dataset all come from systems with ALS care!
Regardless, we already knew that the basic treatments in cardiac arrest care, namely chest compressions and defibrillation, are the true foundation to survival to discharge neurologically intact. OPALS proved this point back in 2006, and it has been confirmed in nearly every large study of cardiac arrest since. High performance CPR--sometimes called Pit Crew CPR--is increasingly common and has been driving improved survival to discharge across the world. In our area you will receive at least one fire engine, two ambulances, and possibly a supervisor vehicle to any cardiac arrest. Why? So we have enough manpower to ensure that high quality chest compressions continue the entire time.
However, focusing on the basics is only part of the success story for out of hospital cardiac arrest. Dr. Bently Bobrow, and others out of Arizona's Sarver Heart Center and the SHARE group, found that implementing a bundle of care including focused BLS care vastly improves survival to discharge. They did this for the entirety of Arizona. And that's the point, that an entire system of care must be in place to realize the largest gains. It starts with early recognition of cardiac arrest by bystanders with dispatcher help, early bystander CPR directed by dispatchers, early BLS care, followed by aggressive ALS care that adds to the basics, resulting in transport only after Return of Spontaneous Circulation (ROSC) to the most appropriate cardiac receiving facility, where the patient will receive the appropriate intensive care with follow-thru to discharge rehab.
If you take the body of knowledge for OHCA you realize that there is no silver bullet. CPR alone is not enough. Defibrillation alone is not enough. No medication alone will change outcomes (the first large RCT of epinephrine started this year in the UK since studies on dogs in the 70's, and the ALPS trial is finally looking at antiarrhythmic medications). You need a silver chain (h/t to Dr. Snyder). You need a system of care. For a look at what we really need to be doing to advance the care of Out of Hospital Cardiac Arrest (OHCA) patients you should read Mickey Eisenberg's book "Resuscitate!" or the recently published commentary by Jeffrey Goodloe, "Optimizing Neurologically Intact Survival from Sudden Cardiac Arrest: A Call to Action". Attempting to use outcome data from a larger, uncontrolled registry (such as this CMS data) to do anything other than form a hypothesis is extremely misleading.
Does Sanghavi's research really prove ALS care is not necessary and the patient should be transported to a hospital? Not at all. Worse still, Alan Zaslavsky's statement that these patients need to be brought, " as quickly as possible to hospital treatment," is patently absurd. Every one of the systems of care they point to which have the highest survival to discharge rates do the exact opposite. In Seattle/King County (Washington) or Wake County (North Carolina) you're not slapped on a stretcher and driven to a hos
The American Heart Association recommends doing quality CPR on the scene for at least 15 minutes before transport. if available, advanced life support can be done without interupting compressions during that time. There is research to prove that doing uninterrupted CPR for the first 15 minutes has a higher rate of return of spontaneous circulation (ROSC). That is NOT the same as surviving 90 days after cardiac arrest. Patients who have a return of heartbeat obviously will have a better chance of survival. Patient movement to an ambulance does interupt compressions, sometimes for relatively long periods. I would be curious how big a study this is and where it was conducted. The statistics in our area are much different. The key to survival is early, quality CPR before all else.
Sigh. Another Slashdot story about a new article published in a scientific journal, another Slashdot story that fails to link to the original published paper. I just noticed that the "News for nerds. Stuff that matters" tagline no longer appears on the Slashdot front page; this sort of omission is probably one of the reasons why.
For people who are interested in the actual data:
Sanghavi, P. et al. "Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support." JAMA Intern Med Published online November 24, 2014. doi:10.1001/jamainternmed.2014.5420.
And here's the JAMA press release.
~Idarubicin
Only more births can lead to more deaths.
Each born person tends to die only once, no more, no less.
Could it be that the on-board equipment they're talking about is simply used more frequently in the more severe cases that would end in deaths anyway?
I don't know for sure, but it's just my thought on the matter.
As a former Firefighter/EMT, I remember being forced to wait for a paramedic unit to arrive FROM THE HOSPITAL for a possible MI patient. This when we could have had the patient in an ambulance and in the ER within 10 minutes. There is a great need for common sense field triage, and very little reason to keep a patient on the ground for an hour when a trauma center is five miles away.
From TFA:
That’s according to a study published Monday in JAMA Internal Medicine, which suggests that high-tech equipment and sophisticated treatment techniques may distract from what’s most important during cardiac arrest — transporting a critically ill patient to the hospital quickly.
The TFA mentions about a study on JAMA but there is NO LINK to the real article/study? Or the author does not know how to properly cite the source he is talking about? I have to dig it out by myself and it is at http://archinte.jamanetwork.co... ... I hope people stop writing an article like this when they don't properly give a proper citation...
Completely meaningless figure; what was the survival rate for all patients, not just those that had already made it 90 days, if there were 3x as many making it to 90 days then that would still be a plus.
Waterfox - a Firefox fork with legacy extension support, security updates and better privacy by default.
...they'll bill like real doctors.
I am a former paramedic, supervisor, and finally EMS director.
There are calls where a paramedic(highest level EMT) is required, we can in those cases do anything an ER doctor could and are indispensable. Unfortunately the private ambulance system in the US is badly abused to make every call possible an ALS call. This is highly profitable especially considering that despite paramedic degree now required too many people are willing to work for peanuts in a job where though we are often abused by management the outcome is literally saved lives.
We have always placed scientific study of our methods at the top for designing new treatment protocols. IMHO best case is a system where fire, volunteer, and police first responders are basic EMTs but unless called special for a simple broken leg transport a paramedic unit on the way especially in rural areas is best for almost any patient care. If scoop and run is called for the ALS protocol just needs to call for that when possible just as we paramedics already do for trauma only treating once we are moving towards a hospital or helicopter LZ.
Was selection bias accounted for?
If advanced ambulances are sent to the really horrific problems and basic ambulances to the basic problems then a result like "more people die near the advanced ambulances" is going to a consequence of the selection not the service. This conclusion could (in the lack of understanding that makes up the large majority of politicians) result in more harm being done to the general welfare instead of current levels of good.
There are several likely reasons why you are seeing these results. First, look at the date of the study period (January 1, 2009, and October 2, 2011). During this time, the American Heart Association standards for CPR called for inserting an airway first, following by establishing breathing (or rescue breaths) and then perform cardiac compressions. We now know that this is incorrect. Recent studies have shown that in cases of cardiac arrest, compressions should begin immediately and should be continuous. The recent switch by the AHA to 'compression only' CPR by the layperson, and changing the healthcare provider sequence to "Compressions, Airway, Breathing" or CAB, is already beginning to show improvements in cardiac arrest outcomes.
But at the time of this study, this was not the case. At the time of the study, the recognized protocol by the American Heart Association was airway was the top priority. As a result, paramedics were taught to secure the airway, and the only way to secure the airway is through intubation - a skill not available on BLS ambulances. It takes time to intubate, it is not easy, and it is especially difficult to perform it in the field. We now know that this should not be done. In fact, both ALS and BLS providers now use minimal invasive techniques to control airway, as the focus is on compressions and defibrillation. The result is that ALS providers are being disparaged for simply following their protocols - protocol standards set by the experts at the AHA.
Secondly, ALS providers tend to respond to the sickest patients. A BLS unit arrives on scene and recognizes the seriousness of the situation and calls for an ALS unit. And yes, some CPR patients are sicker than others. A patient who receives an electrical shock and goes into cardiac arrest is not as 'sick' as the patient with a history of congestive heart failure and asthma that goes into cardiac arrest. Both are in cardiac arrest, but the chances are that the electrical shock victim will have a positive outcome, while the CHF/asthma patient will not.
Not all 'ALS' ambulances have the same protocols or medications. These are typically set by the medical director of the service, with guidance by the state regulatory office. To lump everyone together as 'ALS' is disingenuous.
One thing this study does not look at is the number of patients who might have gone into arrest had ALS not intervened. For example, take our CHF patient mentioned earlier. If we can get to him early enough, we can administer medications to prevent him from going into cardiac arrest. BLS units can't do that. Yet there is little talk or studies about this aspect of prehospital medicine. It is much easier to 'survive' if you never succumb to cardiac arrest to begin with.
There is a lot about medicine that we simply don't know. Studies are done all the time, and we should use these to improve the field of both hospital and prehospital care. There is a place for both BLS and ALS care.
However, sensationalized article headlines such as this ""Advanced Life Support" Ambulances May Lead To More Deaths" are not only inaccurate, but detrimental to improving the field of prehospital medicine. This study looks at one very small aspect of prehospital care, in an area where outcomes are notoriously poor to begin with. Yet the clickbait headline would lead folks to think ALS ambulances and the men and women who staff them are killing people. This is inexcusable.
Over a long enough period, the death-rate is 100%, no matter what you do. It can't be more and it won't be less.
(Disclaimer: I just read the subject.)
Don't fight for your country, if your country does not fight for you.
Thought that was settled. Stabilizing victims for transport has been SOP in Germany, and has been shown to provide worse outcome than the simple get-them-into-the-ER approach previously favored in the states.
I has been said that President Reagan survived the same type of vascular damage that Princess Diana did not.
Does the fact that the Advanced Life support Team attends more serious emergencies have anything to do with this stat?
I have worked in the field and generally ALS isn't even the first on scene for most emergencies. Lots of contributing factors but this one set of numbers does not lead me to conclude the same as this article.
I wonder if there's a link between ALS ambulances and the practice of giving oxygen to heart attack patients?
A recent study in Victoria, Australia found that there was a 20% increase to the damage to the heart if given oxygen by ambulance paramedics.
Perhaps, in general, the BLS ambulances don't carry as much oxygen and thus administer it less frequently?