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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."
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.
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.
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 President himself sabotaged that possibility by accusing doctors of performing unnecessary amputations, which besides depicting surgeons as being suitable for the leading roles in either "Little Shop of Horrors" or "Sweeney Todd", is nonsensical because amputations actually are relatively inexpensive.
I dunno. I heard they cost an arm and a leg.
Slow down, cowboy! It has been 4 hours since you last posted. You must wait another few hours.
Anything that touches your skin is disposed of or sterilized. The total service would include 2 minutes to your place, 15 minutes to get you loaded up (I've seen this take up to an hour when my neighbor was unconscious for unclear reasons), 2 minutes back, half hour of wiping down every surface you touched or might have touched, half hour of taking stock of what was used and restocking it, and a half hour of documenting all of that for the insurance costs. I don't think 2 hours is an unrealistic estimate.
And like I said, most days those guys are probably sitting around, getting 1 or two calls per day. Your bill covers that waiting around time also. If it didn't, they wouldn't be waiting around. And if they weren't waiting around, you wouldn't get treatment for half an hour or more when you need it.
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