Slashdot Mirror
"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."
Hospitals have teams. They have ample room to work. Field ambulances have two people. They are extremely cramped. Only one person can work the patient when driving. Finally hospitals have far more advanced equipment than advanced life support ambulances. There is simply no comparison.
Ambulance's job is to stabilize the patient just enough so he can survive the trip to the hospital. Nothing more, nothing less. The conclusions drawn in the article are extremely obvious to everyone in the field, except those who like to get paid for getting the equipment. The main factors in patient's survival in most life threatening conditions that require operation are time to operating table and basic life support. Everything else is just a distraction that threatens patient's life.
The only argument for ALS over BLS is that ALS offers a significant survival chance improvement to offset lost time. This study clearly shows the opposite is true.
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.
Field ambulances have two people.
Only 2?
When the Sapeur-pompiers premier secours truck turned up the last time I called them they had four people onboard.
If I ever needed a SMUR they'd turn up with a doctor, a nurse, a paramedic and a driver.
(This is in France).
Watch this Heartland Institute video
I think living in a country with sane health care practices has colored your perception.
I live in a rural area. Rural areas were specifically excluded from the study.
This time of year always reminds me of a call I went on the day before Thanksgiving
I have personally gone on a cardiac call, where the person was asystole when we arrived on scene. I was an EMT-basic. The other two guys were a 20 year EMT-I, and a 20 year Paramedic. A police officer beat us to the scene by 2 minutes and started CPR. The paramedic 2 rounds of cardiac drugs and we got a shockable rhythm. Shocked, good rhythm, packaged her up and took her to the local ER. In the meantime, the hospital had ordered up a helicopter and it was standing by when we get there. 45 minute ride to the nearest cardiac center.
The lady walked out of the hospital 7 days later. She lived another 2 years.
The Paramedic assured me that was the first time he had ever recovered a cardiac patient, in 20 years, who was flatline when he got on scene. The Gods of EMS were with us that night.
Why did she live?
1. Quick effective CPR by the police officer was probably critical. He was less than a block away when he got the call.
2. Quick effective arrival of the ambulance. She lived 4 blocks from the ambulance station. We happened to be in the garage, inventorying the ambulance when we got the call
3. Local ER quickly mobilizing air assets, so that she got to a cardiac center as fast as possible.
Different models:
http://www.ncbi.nlm.nih.gov/pm...
Te choice of model seems to be based on how recently the systems were developed, how costs are allocated, and population density.
Trying to find an article I read a while ago that was critical of the cost/benefit ratio of the French model ... will post if I do.
But the so called "ALS" thingy seems to be an attempt to use the Franco-German model, and if they're doing it with only two people I think they're doing it wrong.
Watch this Heartland Institute video
In most cases around here (Finland, one of the better healthcare systems in Europe) we have standard ambulance which is medic/emergency care specialized nurse, driver who is also medic. This is typically a van. There's fairly many of these spread in the region to minimize response times. Then you have specialist doctor unit that typically is called to assist the former when necessary. This is typically a fairly powerful sedan that can drive at much higher speeds. It usually has an MD with training in ER medicine. There's only a few of those, and they are called to assist in more serious cases.
The problem with French model is that you have a lot of resources allocated to a single unit, which means you have a lower unit density for the same cost. That means initial response time goes up, and that tends to have severe negative effects on survival rates.