ALS Versus BLS

BLS outperforms ALS in terms of patient mortality outcomes. This from a study, Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies, published in the October Annals of Internal Medicine authored by Prachi Sanghavi (and team) of Harvard University. The study includes cardiac arrest, trauma, stroke and MI care.

The authors looked at a large random sample of Medicare data compiled between 2006 and 2011 from nonrural areas. They were looking at survival and neurological functioning at 30 days, 90 days, 1 year, and 2 years.

You can see the abstract and results here;

Abstract

Their conclusion: Advanced life support is associated with substantially higher mortality for several acute medical emergencies than BLS.

Go to this link to watch the author of the study present her case.

You Tube Presentation

The video is instructive because it lets you know that her view of EMS is simple. She believes that care is best achieved by getting people quickly to the hospital because the hospital is better and quicker at performing life-saving interventions. This is important as her unnuanced view of EMS may influence the assumptions and formulas her team used to compare the data between the two groups.

It is easy to dismiss this study because it is so difficult to understand. I am not a statistician and am frustrated that I have to take her word that the comparison between BLS and ALS is a fair one and that her propensity scores and variable analyses all mean an even playing field. I can understand a blinded randomized controlled study where a patient either gets Drug-A, Drug B or Drug-C- the placebo, and the results show a clear benefit to either A, B, or C. I simply don’t have the statistical training to comprehend how Sanghavi and team arrived at the results they did.

But until this study is clearly refuted by statistical experts with a better understanding of EMS, the study and its conclusion will haunt me. What if she is right? It is not out of the range of possibility particularly for cardiac arrest or trauma patients. As Sanghavi points out other studies, such as the OPALS studies in Canada, have shown ALS makes no difference and may cause harm. What if we as ALS practitioners are harming our patients while trying to do good? What if the problem is not with ALS, but with our ALS interventions? Is it not unheard for medicine to inflict harm on patients in the interests of doing good. Medicine is constantly evolving as we study our interventions. Sometimes we find better interventions, sometimes we discover out current interventions are harmful.

There is no research that epinephrine produces meaningful outcomes in cardiac arrest. (ROSC is not a meaningful outcome if it you die in the ICU). There is no research that advanced airways improve outcomes. ET intubation, while “securing an airway,” can also give responders the avenue to kill their patients through hyperventilation. Not all paramedics are experienced intubators. How many tubes in the esophagus in a population of 1000 cardiac arrest patients does it take to wipe out the gains of a secured airways in the same group? Capnography, which can help prevent unrecognized esophageal intubation, is still not universally used, and certainly wasn’t in widespread use during most of this study.

I have been to many cardiac arrests in my 26 years on the street. I have seen CPR delayed for intubation. For years, getting the tube was clearly more of a focus for many paramedics than today’s mantra of push hard, fast and deep and limit hands off chest time. We had to get that tube then, had to get the IV to give the life-saving epi. I have no doubt there are patients ALS lost who could have been saved with better BLS.

This ALS/BLS study covers a time period when likely not all ALS systems were practicing permissive hypotension in their trauma patients. When I started as a medic in 1993, we pounded our trauma patients with fluid resuscitation even after research was showing it was likely killing them. The better the medic — two large bore IVs running wide open (until the patient bled clear)– the worse the outcome.

MAST trousers, steroids for head injury, high dose lasix for suspected CHF, routine bicarb for cardiac arrest, spinal immobilization for penetrating trauma not to mention all trauma, High-Flow oxygen for all MI patients. Where was the evidence for these harmful procedures? I wonder what else we might be doing that may be harmful that we are not yet fully aware of? The new study mentions stroke care. A medic I respect greatly thinks our entire system of stroke care is bad for the patient –that tPA does more harm than good. Even tPAs supporters acknowledge it may kill 1 in 100, and harm 1 in 20 patients. My friend is a bit out there at times, but he is very smart,and can point to the big pharma money trail behind the research and the flaws in the research. He would postulate that a rapid stroke identification with notification to the hospital might get the patient a better chance at getting a drug that could kill them. As I said, I don’t necessarily agree with him, but like this study, he gives me pause to wonder.

I have the hardest time making sense of the MI doing worse with ALS care, but I can make an argument that it could be true. I can think of several ways paramedics could cause harm to MI patients: 1) We give them NTG which doesn’t make a difference in MI outcome. The NTG, drops their pressure to the point at which the patients cannot receive an ACE Inhibitor or Beta Blocker that does make a difference in their outcomes. 2) We give them morphine. A study a number of years ago said Morphine in NSTEMI was linked to greater mortality. People weren’t certain why it might have caused harm, but they speculated it either affected the cortisol level, which is protective or by taking away the patient’s pain, they made them less urgent as pain is often the prime factor in whether or not a NSTEMI goes to the cath lab. 3) Medics either fail to do a 12-lead ECG or fail to accurately interpret it. In our hospital our worse door to balloon times are in these cases. When EMS recognizes the STEMI and field activates our times are right to the cath lab awesome. When EMS misses with patient and downplays the patient’s condition, their times are longer than the walkin patient with a similar complaint who gets a 12-lead within 10 minutes of coming through the door, and longer than the BLS patient who comes in without a 12-lead.

As much as we may disagree with the findings of these studies or think or hope they are wrong, we are kidding ourselves if we don’t at least pay attention to what the studies are saying.

If my family member is sick or in cardiac arrest, do I want the responder to be me on my first day as an EMT? Me on my last day as an EMT (4 years experience before becoming a medic)? Me on my first day as a paramedic? Or me today as a medic with over two decades of paramedic experience? The answer depends on the call.

In all cases I want me today to respond (except if the call involves carrying a heavy patient), but there are some calls where I would not want me on my first day as a paramedic.

For cardiac arrest, I would rather have me on my last day as an EMT than on my first day as a medic. If my leg is broken or I am nauseous or hypoglycemia or in anaphylaxis, I want me on my first day as a medic rather than the world’s best EMT.

We clearly have to consider the quality of paramedic we are putting on the street. Medicare reimbursement has made it in the ambulance companies interests to put as many ALS cars on the street as possible to maximize reimbursement. This can be good in terms of making more ALS interventions available to the patient population, but it diminishes the necessary experience level of those offering the intervention.

If I were king for a day and had a magic wand, here’s what I would do about all of this.

1. No intervention be undertaken without solid research.
2. If there is no research on a considered intervention, then research shall commence.
3. Just because you go to paramedic school and pass should not guarantee you the right to practice paramedicine. All medics should undergo a lengthy apprenticeship — not just be thrown to the wolves.
4. If BLS can do an ALS intervention safely, and that intervention is beneficial, then they should be able to. Just think if defibrillation had stayed an ALS intervention only, then Sanghavi’s study would have been moot, as BLS would have lost a life-saving tool.
5. All in EMS, BLS and ALS, shall be paid at a wage that shall enable them to feed their families, pay their mortgages and with help from loans, put their kids through college so that EMS shall be a career and that responders coming through your door are experienced.
6. I will have full statistical knowledge and will be able to demonstrate all the ways Sanghavi’s study is wrong (if it is).

Make it be so!

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References:

Advanced cardiac life support in out-of-hospital cardiac arrest

The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative

Effects of prehospital epinephrine administration on neurological outcomes in patients with out-of-hospital cardiac arrest

Thrombolytics for Acute Ischemic Stroke

Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest

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3 Comments

  • David Delauter says:

    I believe the most important thing to remember is that it is called practicing medicine. There are advances everyday. And we are constantly hammered with mew drugs and equipment to become familiar with. We become proficient, but not always experts, depending on the frequency of use. ALS vs. BLS? I don’t know. I’ve have work with EMT’s who are very capable and competent. I’ve also worked with a few who I’m not sure I would trust. Same goes for ALS providers. I believe there are occasions when the EMT relies too much on an ALS provider and fails to use critical thinking skills that would enable a BLS transport as opposed to ALS. Each one of us second guess many of the decisions we make in the field. It is the nature of the beast. And, unfortunately, we do not always get feedback once the patient is placed on that ER stretcher. All in all, ALS and BLS do the best we can with what we have. We are all needed in some way. And no matter what study shows what, we will continue to work together to enhance the opportunity for survival to those we serve. Do not allow this study to haunt you. It is one study. We have put years of hard work, education and down right pride to do what we do for everyone. At times, people we may feel do not deserve it. But, we do it anyway. Regardless of race, creed, color, religion, good guy, bad guy, we do not discriminate. We serve all. And always will. Thanks for listening.

  • S. Benson says:

    Medical research is hard; pre-hospital research, VERY hard.
    What I find fascinating about this, and similar, papers is that many of the same ALS interventions done in the field are the same as in the Emergency Department.
    Controlling for the variable is difficult but we need to try and understand when/if the same interventions, when done in the field, are leading to worse outcomes.
    I’ve been doing this for a while and have done countless intubations and observed countless in-hospital intubations.
    Are we really that much slower?
    Are we really over ventilating that much?
    Note: and with the advent of pulse ox, capnography, and prehospital ventilators it’s hard to believe we aren’t doing better at this than 30 years ago!

    Lastly, I must say that this is actually one of the weaker papers I’ve read. There are some rather astounding assumptions and it is obvious, IMHO, that the authors do not understand EMS systems.

  • Brian Rendon says:

    There also factors she can not see using just raw data. most Basic only services are closer to a hospital then an advanced unit. Advanced ALS units bridge the gap for counties with extended transport times and no hospital. I am sure her numbers are correct, however you must consider the backround and reasoning for the numbers and times.

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