EMS has our collective panties in a wad about yet another study showing that BLS has a better survival rate than ALS. This time some researchers from the University of Chicago, including Prachi Sanghavi PhD a medical policy researcher from Harvard, looked back at patient outcomes at 90 days and how they arrived at the ED.
Fair enough. More data that we caregivers ever get.
They then went through and controlled for all sorts of variables that can impact care and found what we all already know: Patients who arrive BLS do better than patients who arrive by ALS.
You can not dispute this data.
You also can not dispute Prachi Sanghavi PhD's comment in a related video that "Our ambulance system is in serious trouble."
Just not for any of the reasons she wants to put forward. Have a look:
Put down your pitchforks and let's wander through a few comments she pulls from the larger data set. The first one I'll take issue with/agree on is when she alludes to EMS's inability to properly perform an endotracheal intubation. Data on this skill ranges from incomplete to confusing. For example, am I a success if I have a 100% first pass rate but do so on patients who did not need the procedure? What if I have zero attempts, but a higher ROSC and discharge in tact rate? What if my last 3 misses were on the same crashing CHF patient?
"Delivery quality problems with intubation" as mentioned in the video is a stab while the ref isn't looking. The research may not differentiate ALS or BLS placement of esophogeal airways.
In addition, let's start addressing all the post ROSC care required by many systems. I'm talking about cooling, serial 12 lead ECG, fluid management...all things that take time to establish in the field to meet a pre-determined level of care the local regulatory agency thinks will work.
We have all known that the ambulance system is broken far longer than Prachi Sanghavi PhD has been studying it. We also know that placing blame for a patient's death solely on the time between the scene and the hospital is foolish to say the least.
Response times generally don't impact patient outcomes. Most cardiac arrest survivors had interventions prior to EMS arrival. Many patients who die in hospital are still dying from hospital acquired infection. If a patient dies of a GSW to the chest, that's one thing. No amount of BLS or ALS can save them and I'd argue that a thoracic surgeon gowned up and standing in the street as it happened won't make a difference either, but let's not let that get in the way of the true drive behind this research:
Hospitals save lives, not Paramedics.
Can't argue that. It is hard to argue that a person alive in a hospital for 56 days following cardiac arrest, then dies, is the fault of 14 of the first 21 minutes of that person's insult.
We can control for variables and I don't doubt that the researchers did just that, but we must also remember that focusing on the blood and guts and CPR alone will not give an accurate picture of an EMS system.
ALS exists to assess and treat at a level far above what the Chicago folks want you to understand. "Scoop and Run" and "Stay and Play" haven't been uttered since the early 90's as far as I can tell and we've learned our lesson about pausing compressions for intubation and pulse checks (In the middle of this research no less). ALS exists to intervene in respiratory cases, allergic reactions, tachycardias, bradycardias, mental disorders, minor infections and illnesses and a whole host of other cases that are treated and redirected away from an ED when appropriate.
If the researchers follow their conclusions to a logical end, their data will support only BLS ambulances and a universal "Scoop and Run" policy for each and every 911 call.
Did they miss where we only transport about 60% of our patient contacts? Think the EDs are overcrowded now? Wait until each and every patient hits the doors lights and sirens (shortening arrival to ED time) with an incomplete assessment, no interventions prehospital and an increase in volume of nearly 50%.
The numbers are nothing new. Don't get upset because this data contradicts your 3 years observations on an ALS truck. This is a wake up call for EMS.
The data say ALS isn't helping, heck it is hurting. Methodology aside, would you rather address this study or make sure the next one has different results?
If all we do is reclined cot transport to the ED, I'm 100% behind the Chicago study. Load'em all up, staff the ambulance with a driver and EMT-Basic and haul ass to the ED.
If we want to make a positive impact in the community, agree that ALS patients are more often sicker, more complicated and require more assessment and intervention skills to be delivered viable to the ED.
Agree that the ED CAN NOT be the only destination for all patients.
Agree that BLS and ALS CAN NOT be the only services provided in your community.
Agree that regardless of response times and scene times, good care sometimes takes time to get right.
Agree that endotracheal intubation is not the gold standard in airway management.
Agree that most of what we do is based on anecdotal observation, past practice and, in some cases, voodoo (LSB, epi, Bicarb).
Agree that the American ambulance system is broken and that all the bells and whistles we want to add to the prehospital area need to be researched and proven successful before being widely implemented.
Only then can you challenge the research. Only then can you try to stand up to defend what you do, what I do, what we do.
Fair enough. More data that we caregivers ever get.
They then went through and controlled for all sorts of variables that can impact care and found what we all already know: Patients who arrive BLS do better than patients who arrive by ALS.
You can not dispute this data.
You also can not dispute Prachi Sanghavi PhD's comment in a related video that "Our ambulance system is in serious trouble."
Just not for any of the reasons she wants to put forward. Have a look:
Put down your pitchforks and let's wander through a few comments she pulls from the larger data set. The first one I'll take issue with/agree on is when she alludes to EMS's inability to properly perform an endotracheal intubation. Data on this skill ranges from incomplete to confusing. For example, am I a success if I have a 100% first pass rate but do so on patients who did not need the procedure? What if I have zero attempts, but a higher ROSC and discharge in tact rate? What if my last 3 misses were on the same crashing CHF patient?
"Delivery quality problems with intubation" as mentioned in the video is a stab while the ref isn't looking. The research may not differentiate ALS or BLS placement of esophogeal airways.
In addition, let's start addressing all the post ROSC care required by many systems. I'm talking about cooling, serial 12 lead ECG, fluid management...all things that take time to establish in the field to meet a pre-determined level of care the local regulatory agency thinks will work.
We have all known that the ambulance system is broken far longer than Prachi Sanghavi PhD has been studying it. We also know that placing blame for a patient's death solely on the time between the scene and the hospital is foolish to say the least.
Response times generally don't impact patient outcomes. Most cardiac arrest survivors had interventions prior to EMS arrival. Many patients who die in hospital are still dying from hospital acquired infection. If a patient dies of a GSW to the chest, that's one thing. No amount of BLS or ALS can save them and I'd argue that a thoracic surgeon gowned up and standing in the street as it happened won't make a difference either, but let's not let that get in the way of the true drive behind this research:
Hospitals save lives, not Paramedics.
Can't argue that. It is hard to argue that a person alive in a hospital for 56 days following cardiac arrest, then dies, is the fault of 14 of the first 21 minutes of that person's insult.
We can control for variables and I don't doubt that the researchers did just that, but we must also remember that focusing on the blood and guts and CPR alone will not give an accurate picture of an EMS system.
ALS exists to assess and treat at a level far above what the Chicago folks want you to understand. "Scoop and Run" and "Stay and Play" haven't been uttered since the early 90's as far as I can tell and we've learned our lesson about pausing compressions for intubation and pulse checks (In the middle of this research no less). ALS exists to intervene in respiratory cases, allergic reactions, tachycardias, bradycardias, mental disorders, minor infections and illnesses and a whole host of other cases that are treated and redirected away from an ED when appropriate.
If the researchers follow their conclusions to a logical end, their data will support only BLS ambulances and a universal "Scoop and Run" policy for each and every 911 call.
Did they miss where we only transport about 60% of our patient contacts? Think the EDs are overcrowded now? Wait until each and every patient hits the doors lights and sirens (shortening arrival to ED time) with an incomplete assessment, no interventions prehospital and an increase in volume of nearly 50%.
The numbers are nothing new. Don't get upset because this data contradicts your 3 years observations on an ALS truck. This is a wake up call for EMS.
The data say ALS isn't helping, heck it is hurting. Methodology aside, would you rather address this study or make sure the next one has different results?
If all we do is reclined cot transport to the ED, I'm 100% behind the Chicago study. Load'em all up, staff the ambulance with a driver and EMT-Basic and haul ass to the ED.
If we want to make a positive impact in the community, agree that ALS patients are more often sicker, more complicated and require more assessment and intervention skills to be delivered viable to the ED.
Agree that the ED CAN NOT be the only destination for all patients.
Agree that BLS and ALS CAN NOT be the only services provided in your community.
Agree that regardless of response times and scene times, good care sometimes takes time to get right.
Agree that endotracheal intubation is not the gold standard in airway management.
Agree that most of what we do is based on anecdotal observation, past practice and, in some cases, voodoo (LSB, epi, Bicarb).
Agree that the American ambulance system is broken and that all the bells and whistles we want to add to the prehospital area need to be researched and proven successful before being widely implemented.
Only then can you challenge the research. Only then can you try to stand up to defend what you do, what I do, what we do.
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