Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Our current ambulance system is based on little scientific evidence

 

Our current ambulance system is based on little scientific evidence.

This is one comment by Prachi Sanghavi that has some paramedics very upset.

The video of her short speech at Harvard was posted on EMS1.com[1] and the responses suggested that there is something horribly wrong in the statement, or in any of what followed. There isn’t.
 


 

The problem is with the attitude of those who think that they know everything.

The problem is with the people who oppose finding out if treatments work.

The problem is with people who oppose protecting our patients from harmful treatments.

Prachi Sanghavi discusses the difference between BLS (Basic Life Support) treatment and ALS (Advanced Life Support) treatment. BLS includes all of the prehospital treatment that have evidence of benefit. All of them. ALS includes all of the cool things that paramedics and doctors do before getting to the hospital based on a wish and a prayer, but not on any valid evidence.
 


 

This is a comparison of cardiac arrest outcomes between two similar counties looking at the lack of expected benefit with ALS. There are more variables than just ALS vs. BLS, but we do need to ask Why are these cardiac arrest outcomes so bad with ALS?

Prachi Sanghavi is incorrect about a few things. Paramedics generally use a manual defibrillator, not a semi-automatic defibrillator. Taking longer at a cardiac arrest scene is probably not a problem. Those patients transported without pulses can be expected to end up in the morgue. Moving the patient with ineffective compressions, rather than staying on scene to do compressions well, is not recommended, because it is not supported by evidence. Rushing the patient to the hospital is just rushing the patient to ALS in a building. Yes, there is more ALS available at the hospital, but nothing that has good evidence of improving outcomes. Therapeutic hypothermia, is part of post-resuscitation treatment, not resuscitation treatment. That may change.[2]

Prachi Sanghavi also looked at trauma, stroke, and heart attack. The results were the same. Patients had better outcomes with Basic Life Support.

Our response should be to ask questions.

Are we doing something wrong?

What evidence do we have that ALS treatment improves outcomes?

The problem is that we ignore evidence and make excuses for our willful ignorance.

We are slow to adopt ALS treatments that have good evidence of improving outcomes and much, much slower to get rid of treatments that have only the weakest evidence of benefit – expert opinion. Expert opinion is the basis for all treatments that are later demonstrated to be harmful, so expert opinion isn’t worth bragging about. Real experts understand and learn from the evidence.

Should we trust the people criticizing the message that Maybe more is not better, or should we examine what we have been doing to find out what works?

Why are we opposed to providing the best care we can?

Footnotes:

[1] Researcher: Is BLS better than ALS?
EMS1.com
November 13, 2015
Article

[1] Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial).
Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM.
Resuscitation. 2015 Jan;86:88-94. doi: 10.1016/j.resuscitation.2014.09.010. Epub 2014 Oct 2.
PMID: 25281189

Free Full Text from Resuscitation.

This is a tiny study that suggests a grouping of treatments that may work (or that may include a treatment, or two, that may lead to improved outcomes. The results are good, but it is just one tiny study that needs replication and each of the treatments should be studied individually.

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Comments

  1. The comments on the EMS1 article remind me of something I first heard from Art Hseih. It is easy to latch on to or make change when research affirms our pre-existing beliefs (such as ditching backboards). And it is equally easy to dismiss research that challenges our pre-existing beliefs (ALS better than BLS).

    Thanks for the mention and post.

    • In this case, though, the research IS easily dismissed, because it is very poorly done. I don’t have access to the full article, but from what I understand from the summary and from others that do have access:

      – ALS vs BLS was determined from billing codes, not actual interventions
      – “Except in cases of AMI, patients showed superior unadjusted outcomes with BLS despite being older and having more comorbidities.” More comorbidities than who? What are they using for a comparison group?
      – Non-rural systems are more likely to have EMD. Was EMD dispatching a factor, and how was it accounted for? (This may be in the full article, but I haven’t seen it addressed anywhere else.)

      I’d hit more points, but work is calling. I’ll try to come back to this.

      To paraphrase one commenter at the EMS1 article, “The most accurate summary of her study would be “Medicare patients in non-rural counties whose tripsheets qualify for ALS-level billing have worse outcomes than patients whose tripsheets qualify only for BLS-level billing.””

      • I am not interested in the study itself. I have not read the study, either. I wrote about her talk, not about the study.

        We have no good reason to believe that ALS improves outcomes.

        Rather than admit that, we look for reasons to attack people who point out this flaw in our understanding and in our ethics.

        .

        • “We have no good reason to believe that ALS improves outcomes.”

          That statement is so broad as to be entirely meaningless. Which ALS intervention for which condition?

          Adenosine or Verapamil for converting stable PSVT has a ~90% success rate. Both are “ALS”. (http://www.ncbi.nlm.nih.gov/pubmed/20926952)

          Cardioversion of unstable SVT is successful at a rate of ~99%. That’s “ALS”. (http://www.ncbi.nlm.nih.gov/pubmed/20159384)

          Those are just two examples.

          You are correct that much of what we do in EMS – at all levels, not just ALS – has little to no support beyond “expert opinion” (which should not justify anything more than controlled experiments). Our treatment of cardiac arrest is a prime example of this. But that cannot be extrapolated into “no good reason to believe that ALS improves outcomes”. Some ALS interventions are supported by good evidence. Many are not. We need to focus on fixing the ones that are not (i.e., stopping them until there is supporting evidence).

          • Your first study only compares efficacy of one drug with another drug, so that doesn’t tell us what the placebo rate of conversion would be. The other appears to be a study of stable patients.

            My apologies for not being more specific.

            We have no good reason to believe that prehospital ALS improves outcomes in cardiac arrest.

            Of course, you know that I write about ALS treatments that do work, especially prehospital ALS treatments that work. However, there aren’t any that apply to the topic of this discussion.

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