Did I waste my days as a paramedic? Is low-tech care the answer?

[MillCreek]

http://www.pbs.org/newshour/updates/study-finds-advanced-life-support-ambulances-linked-death/

From a summary of the article:

Basic vs. Advanced Life Support Outcomes After Out-of-Hospital Cardiac Arrest

EMBARGOED FOR RELEASE: 3 P.M. (CT), MONDAY, NOVEMBER 24, 2014

Media Advisory: To contact author Prachi Sanghavi, B.S., call Angela Alberti at 617-432-3038 or email Angela_Alberti@hms.harvard.edu. To contact commentary author Michael Callaham, M.D., call Elizabeth Fernandez at 415-514-1592 or email efernandez@pubaff.ucsf.edu.

To place an electronic embedded link in your story: The link will be live at the embargo time: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.5420 and http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.6590.

JAMA Internal Medicine

Patients who had cardiac arrest at home or elsewhere outside of a hospital had greater survival to hospital discharge and to 90 days beyond if they received basic life support (BLS) vs. advanced life support (ALS) from ambulance personnel, according to a report published online by JAMA Internal Medicine.

Emergency medical services (EMS) respond to an estimated 380,000 cardiac arrests that happen annually out of the hospital. ALS providers, or paramedics, are trained to use sophisticated, invasive interventions (such as intubation – the placement of a breathing tube) to treat cardiac arrest before the patient arrives at the hospital. BLS providers, or emergency medical technicians, use simpler devices such as bag valve masks (hand-operated mask that helps breathe for the patient) and automated external defibrillators. Consequently, ALS paramedics tend to spend more time at the location of a cardiac arrest than BLS personnel.

Prachi Sanghavi, B.S., of Harvard University, Boston, and colleagues used data from a nationally representative sample of Medicare beneficiaries from nonrural counties in the United States who had out-of-hospital cardiac arrest between January 2009 and October 2011 for whom ALS or BLS ambulance services were charged to Medicare. There were 31,292 ALS cases and 1,643 BLS cases. Researchers primarily examined patient survival to hospital discharge, to 30 days and to 90 days.

The results show survival to hospital discharge was greater among patients receiving BLS (13.1 percent vs. 9.2 percent for ALS) and so was survival to 90 days postdischarge (8.0 percent vs. 5.4 percent for ALS). Rates of poorer neurological functioning were lower for hospitalized patients who received BLS (21.8 percent vs. 44.8 percent with poor neurological function for ALS). Results suggest the difference in survival between ALS and BLS is explained by higher mortality in the first few days after cardiac arrest for patients who received ALS.

“Our study calls into question the widespread assumption that advanced prehospital care improves outcomes of out-of-hospital cardiac arrest relative to care following the principles of BLS, including rapid transport and basic interventions such as effective chest compressions, bag valve mask ventilation and automated external defibrillation. It is crucial to evaluate BLS and ALS use in other diagnosis groups and setting and to investigate the clinical mechanisms behind our results to identify the most effective prehospital care strategies for saving lives and improving quality of life conditional on survival,” the study concludes.

(JAMA Intern Med. Published online November 24, 2014. doi:10.1001/jamainternmed.2014.5420. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor’s Note: An author made a conflict of interest disclosure. Authors disclosed funding/support. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Commentary: Evidence in Support of Back-to-Basics Approach

In a related commentary, Michael Callaham, M.D., of the University of California, San Francisco, writes: “In sum, is it possible that basic life support (BLS) – using automatic defibrillators, cardiopulmonary resuscitation and airway management without intubation – could be as good or better?”

“Sanghavi et al provide us with provocative data in answer to this question in this issue of JAMA Internal Medicine. … The study by Sanghavi et al uses a different methodology than most previous studies of prehospital care; the population and analysis were based on billings for level of emergency medical system (EMS) response, rather than from clinical records of presentation and treatment at the scene,” Callaham notes.

“Most ALS interventions are ‘advanced’ chiefly in our expectations, not in evidence-based efficacy. It is time instead to perfect and consistently prioritize all the proven basics, all the time,” the author concludes.

(JAMA Intern Med. Published online November 24, 2014. doi:10.1001/jamainternmed.2014.6590. Available pre-embargo to the media at http://media.jamanetwork.com.)

My paramedic days are long behind me, but this is very interesting data. In King County, we really prided ourselves on our cardiac survival rate and at least some of the patients walking out of the hospital cognitively intact.

[Scout26]

Consequently, ALS paramedics tend to spend more time at the location of a cardiac arrest than BLS personnel.

Therein lies the answer.  While ALS is a great, getting the patient to where there are more and better facilities within the Golden Hour is key.   And it has been shown time and time again, and not just for cardiac cases, but all life threatening cases, that the sooner you can get the patient into a hospital the better the outcome.

[KD5NRH]

Therein lies the answer.  While ALS is a great, getting the patient to where there are more and better facilities within the Golden Hour is key.   And it has been shown time and time again, and not just for cardiac cases, but all life threatening cases, that the sooner you can get the patient into a hospital the better the outcome.

Pretty much my guess.  I'd also expect that starting such procedures in the field is more traumatic for the patient at a highly sensitive time.

[SADShooter]

Therein lies the answer.  While ALS is a great, getting the patient to where there are more and better facilities within the Golden Hour is key.   And it has been shown time and time again, and not just for cardiac cases, but all life threatening cases, that the sooner you can get the patient into a hospital the better the outcome.

Not necessarily about rapid transport. Immediate application of effective treatment, specifically CPR and AED, can make the difference. Consistent, quality chest compressions are what is going to improve outcome. Airway seems to be less critical. Circulating the existing oxygen in the blood is more beneficial than adding more via ventilation. So, time spend on an advanced airway may be less worthwhile than compressions and rhythm check/shock, then transporting when CPR routine is established.

[MillCreek]

King County EMS has been one of the world leaders in researching and pushing aggressive care to outside the hospital setting, with administration of thrombolytics, hypothermia and long-duration chest compressions.  I will be interested to see if the article has any results classified by geography or EMS system.

[SADShooter]

Pretty much my guess.  I'd also expect that starting such procedures in the field is more traumatic for the patient at a highly sensitive time.

The patient is clinically dead. It can, however, be very traumatic for family & loved ones on scene. The issue if finding the besta pproach to keeping the victim alive and functional

[SADShooter]

King County EMS has been one of the world leaders in researching and pushing aggressive care to outside the hospital setting, with administration of thrombolytics, hypothermia and long-duration chest compressions.  I will be interested to see if the article has any results classified by geography or EMS system.

MillCreek, Seattle/King County is a participant site in the ROC (Resuscitation Outcomes Consortium) https://roc.uwctc.org/tiki/tiki-index.php?page=roc-public-home

You might enjoy noodling around the information on current and completed studies.

[zahc]

Is there any chance that cases which appear "more serious" tend to get the more advanced care? That would bias the results right quick.

[MechAg94]

We just had a CPR/First Aide class at work with a Red Cross guy.  I thought he said two of the most critical things for heart problems was starting CPR quickly and getting to a hospital quickly.  I can't remember if he had a step for paramedics in there, but paramedics can do CPR or something like it better than I can.  I can understand paramedics trying to do more for the patients, but I wouldn't think they would do that if it meant delaying the trip to the hospital. 

The surprising thing to me about the class was they don't teach you to check pulse anymore.  Apparently if an adult it not breathing with no other apparent injury, the likelyhood of a heart issue is high. 

[Neemi]

The surprising thing to me about the class was they don't teach you to check pulse anymore.  Apparently if an adult it not breathing with no other apparent injury, the likelyhood of a heart issue is high. 

If you do regular person CPR classes, then yes, don't bother checking a pulse. If you're taking healthcare level provider CPR classes, then you check a pulse.

Long story short - if you can't breathe properly (or at all), your heart's gonna stop. Go ahead and start CPR.

We just had a CPR/First Aide class at work with a Red Cross guy.  I thought he said two of the most critical things for heart problems was starting CPR quickly and getting to a hospital quickly.  I can't remember if he had a step for paramedics in there, but paramedics can do CPR or something like it better than I can.  I can understand paramedics trying to do more for the patients, but I wouldn't think they would do that if it meant delaying the trip to the hospital. 

I'd say there are really 3 important aspects for surviving a heart-related complication: 1. Good CPR 2. Using an AED immediately 3. Getting to the hospital ASAP.

Any advanced techniques beyond those three things really require a cath lab and a heart surgeon. In the ER we try to get these types of patients to the cath lab ridiculously quickly - I think the goal is under 15 minutes. My coworkers are pretty amazing at nursing skills, but even we know our limits. Get 'em to the cath lab and get that heart working right again.

I don't think any paramedic or advanced training is a waste of time. Those are important skills - I wish more people knew them. It's just that, in this kind of situation, getting to the cath lab quickly is huge. Other situations will be different.

[KD5NRH]

If you do regular person CPR classes, then yes, don't bother checking a pulse. If you're taking healthcare level provider CPR classes, then you check a pulse.

Long story short - if you can't breathe properly (or at all), your heart's gonna stop. Go ahead and start CPR.

Seems to me that everything else is sort of pointless if you don't take the couple of seconds to check airway and pulse, and just start compressions on someone who won't be able to start breathing again due to choking on an object or throat swelling resulting from an allergic reaction.

[Scout26]

When I had my second heart attack, I walked out to the Ambulance as it was backing into the driveway.   (and climbed into the side door.  All of which, apparently, is a no-no.)  They got me hooked to the 12 lead machine and started doing a bunch of other stuff.  I kept asking "Why aren't we moving?"  They kept futzing around more and more.  We probably sat there for 10 minutes.  When in that time I could have been in the ER.  It seemed like they diagnosed the Heart Attack in the 'blance and then once again in the ER.  That's 10-15 minutes that could have been saved.  I could have been in the Cath lab 10-15 minutes sooner.

There's nothing that says you have to be motionless to hook up leads or do CPR.  So why are they sitting there?

[KD5NRH]

When I had my second heart attack, I walked out to the Ambulance as it was backing into the driveway.   (and climbed into the side door.  All of which, apparently, is a no-no.)  They got me hooked to the 12 lead machine and started doing a bunch of other stuff.  I kept asking "Why aren't we moving?"  They kept futzing around more and more.  We probably sat there for 10 minutes.  When in that time I could have been in the ER.  It seemed like they diagnosed the Heart Attack in the 'blance and then once again in the ER.  That's 10-15 minutes that could have been saved.  I could have been in the Cath lab 10-15 minutes sooner.

There's nothing that says you have to be motionless to hook up leads or do CPR.  So why are they sitting there?

Waiting for your credit check and insurance confirmation so they can decide between the nice hospital or the dump that's not even up to Motel 6 standards.

[Scout26]

Waiting for your credit check and insurance confirmation so they can decide between the nice hospital or the dump that's not even up to Motel 6 standards.

I live in Wheaton, the nice hospital is the county hospital.   There aren't any dumps, unless you go to Cook County and Stroeger Hospital.   That's a dump.

[wmenorr67]

NCIS sort of hit on this last week on their episode.  Former Navy Corpsman, receives same training as Army and Air Force Medics, wasn't National Level EMT certified whereas Army and Air Force are.

Jest of the story was she was in trouble for practicing medicine w/out a license even though she saved two lives, one with a trac.

 

[Neemi]

If they were choking, CPR will fix it. Anaphylaxis? Yeah CPR won't help much. Getting to the hospital quickly will, though.

[KD5NRH]

If they were choking, CPR will fix it.

Quick airway clearing might negate the need for CPR (and the attendant rib damage) though.

[Neemi]

Quick airway clearing might negate the need for CPR (and the attendant rib damage) though.

It *can* but all of the latest data suggested that most of the time that a finger sweep is attempted, the object gets pushed in deeper. Hence the "no more!" recommendation. 

[AmbulanceDriver]

The one thing that in our system is nice is that we have 12 leads that can transmit directly to the receiving hospital.  So taking the extra few minutes on scene can actually save time in the long run.  The cardiologist can be looking at the initial 12 lead while we're still transporting, and recognizing a STEMI in the field means that the cath lab is already manned and ready by the time we arrive at the ER.

[MillCreek]

^^^Or depending on the protocol and the patient's presentation, you need to analyze the 12 lead before administering thrombolytics in the field.

[AmbulanceDriver]

correct, although I don't think we're doing thrombolytics in oregon.  At least not in our system.  But normally, if we call a STEMI in the field, and the receiving cardiologist has had a chance to look at our transmitted 12-lead, we usually bypass the ER and go direct to the cath lab.  Plus not all the hospitals in Portland have a cath lab, so if we catch it in the field, we may bypass a closer hospital that doesn't have a cath lab and go direct to one that does. 

As far as treatment on scene goes, in our service area we do the same ACLS treatments in the field as what they do in the ER.  the only thing we don't have is of course diagnostic imaging, and the cath lab.  Plus if there's ever any question in the field of "did we really try *everything*", we can have a physician consult in less than 30 seconds via the radio. 

[MillCreek]

NCIS sort of hit on this last week on their episode.  Former Navy Corpsman, receives same training as Army and Air Force Medics, wasn't National Level EMT certified whereas Army and Air Force are.

Jest of the story was she was in trouble for practicing medicine w/out a license even though she saved two lives, one with a trac
 

We all know how accurate TV is, but I bet it was doing a crico in the field, not a trach.

[KD5NRH]

As far as treatment on scene goes, in our service area we do the same ACLS treatments in the field as what they do in the ER.  the only thing we don't have is of course diagnostic imaging, and the cath lab.  Plus if there's ever any question in the field of "did we really try *everything*", we can have a physician consult in less than 30 seconds via the radio.

I would expect more on-scene work out of town, but from my block, it's less than three minutes to the ER entrance.  (And that's just timing in my car, stopping for the three stop signs and light, and not speeding.)  I would hope that would be a major consideration for the crew, and they would just focus on loading up quickly and safely, and doing only what's immediately necessary.  The next hospital is another 30 miles and not really more specialized in anything than the one here.  Cases bad enough for direct transport without a local stop tend to be airlifted from the scene, since they're almost always going to one of the bigger hospitals more than a 90 minute drive away.

[Firethorn]

NCIS sort of hit on this last week on their episode.  Former Navy Corpsman, receives same training as Army and Air Force Medics, wasn't National Level EMT certified whereas Army and Air Force are.

Jest of the story was she was in trouble for practicing medicine w/out a license even though she saved two lives, one with a trac.

I'll have to remember to look up that episode.  Did she do it as part of a job where she was paid, or was it that she happened across something and provided emergency first aid?

If the latter, the lack of medical certs should only help her case - she's not a corpsman/EMT anymore, but still had usable, if older skills.  Not being employed or certified, she's not required to keep them up.  Or at least that's my take on it.

[Regolith]

Did she do it as part of a job where she was paid, or was it that she happened across something and provided emergency first aid?

Happened across it.