Do we make a difference?

My illustrious training captain has sent out a link to the following article. I found it quite interesting, even though most of this is stuff we already know. Might this mean we don't need to abolish ALS programs, but rethink them entirely? We at Paramedicine 101 preach evidence-based medicine quite often. I believe every treatment, every procedure, and all outcomes should be researched and reviewed frequently. If I could add anything to the EMS 2.0 movement, it would be a universal online archive for QI/QA. Compliant with all privacy policies of coarse. I just think every agency should have some sort of review team, that not only reviews protocol compliance, but patient outcomes compared to treatments received as well. Let's progress!

If you are not familiar with the Eagles conference, you should be. I have yet to have the chance to attend, but I hear it is the most impressive clinical-oriented prehospital conference out there. You may not get to play with all the new toys and gadgets, but you would have heard about post-arrest therapeutic hypothermia about two years before everyone else. Maybe the EMS 2.0 movement should implement a similar gathering for those of us actually doing the work. Imagine Rogue Medic with a microphone and a room full of people.

Insights from the Gathering of Eagles - 2010

Shattering the Myths

Once again, Dr. Paul Pepe and the team of illustrious medical directors from the 50 largest municipalities in the United States, Canada and the United Kingdom met in early February to share their insights with over 700 of their closest friends.

As has become tradition at the Eagles Conference, the crowd of mostly pre-hospital EMS professionals was intrigued and oft times confused by the paradigm shifts proffered as a result of the research findings presented during the two day event.

In addition to the startling discovery that most of us who thought we resided in the United Stated were informed that we actually live in "Southern Canada" (during the peak of the Winter Olympic Games in Vancouver), the most startling themes to much of the information presented were:

-ALS care does not really make a difference in patient outcomes in almost all life threatening patient conditions
-Response and transport times in pre-hospital medical emergencies really don't make a difference in patient outcomes
-Many of the things we thought helped people may not!

In his opening presentation, Dr. Corey Slovis from Nashville reviewed the most important research papers published in 2009. Dr. Slovis' opening comments brought a hush over the crowd and set the stage for many of the presentations to come...

In the early 1970's the nationwide survival to discharge rate for out of hospital cardiac arrest was about 5.5%...

Today, the survival to discharge rate for out of hospital cardiac arrest is about 5.5%.

Blasphemy you say? How can that be? We have spent billions of dollars in advanced emergency medical service systems - certainly we have had a HUGE impact in patient outcomes - right!(?)

Consider the following ACLS study findings presented by Dr. Slovis...

Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask Ventilation for Witnessed Ventricular Fibrillation Out-of-Hospital Cardiac Arrest (AnnEmergMed 2009;54:656-662) . Bobrow, et. al. found that for adult, witnessed, ventricular fibrillation/ventricular tachycardia, out-of-hospital cardiac arrest (OHCA) resuscitated with minimally interrupted cardiac resuscitation, adjusted neurologically intact survival to hospital discharge was higher for individuals receiving initial passive ventilation than those receiving initial bag-valve mask ventilation.

Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest ( N Engl J Med 2004;351:647-56) done by Steil, et. al. as part of the OPALS study conducted in 17 cities with 5,638 patients included found that the addition of advanced-life-support interventionsdid not improve the rate of survival after OHCA in a emergency-medical-servicessystem previously optimized with rapid defibrillation. BCLS patients had a 5.0% survival rate and ACLS patients had a 5.1% survival rate.

Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial ( JAMA 2009 Nov 25;302(20):2222-9), by Olasveengan, et. al. analyzed the admission and discharged alive rate for 851 cardiac arrest and found that there was no significant difference in survival to hospital discharge for the intravenous drug group vs. the no intravenous drug group.



Ok, Ok, we get it, but certainly modern EMS systems and protocols make a difference in trauma care and airway management! I mean, paramedics have been doing intubation for decades, and we have Level I and Level II Trauma Centers and numerous aeromedical systems. Certainly that matters, right?

Consider these findings regarding trauma and advanced airway care...
Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort (Ann Emerg. Med. 2010 Mar;55(3):235-246.e4. Epub 2009 Sep 23) by Newgard, et. al. analyzed trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. The study looked at call processing, activation, response, scene and overall task times for the response. The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

A Prospective Multicenter Evaluation of Pre-hospital Airway Management Performance in a Large Metropolitan Region ( Prehosp Emerg Care 2009 ; 13:304-310). This is the latest in a series of studies evaluating the efficacy of paramedics doing endotracheal intubation. The study evaluated 1,200 paramedics in 34 EMS transporting agencies. 58% were fire-based, 30% private and 12% were single agency systems. The procedural success rate for the 825 attempted intubations was 74.8%. This is consistent with the findings by others such as Dr. Wang in Pittsburg. Most of the Eagles agreed that intubation, if performed at all, needs to be limited to a single attempt and many were mandating that King airways be used as the main advanced airway procedure.


That's all fine and dandy, but there must be some time-honored care traditions that DO help - for example, applying cervical collars for suspected spinal trauma, right? Wrong??

Dr. Persse from Houston presented his data from the soon to be published study: C-Collar or De-Collar: Are Cervical Devices Harmful? Dr. Persse demonstrated 3-D CT and MRI scan images of unstable c-spine cadavers after c-collars were applied. In application after application the findings showed that in many cases the patient suffered debilitating spine injuries. Although Dr. Persse indicated that more research is needed, this certainly begins to call into question one of the core processes that we as EMS professionals have performed since essentially the dawning of modern EMS.

So, was there any good news about EMS presented during the conference?? Yep...

There was a lot of discussion about a few emerging trends that most Eagles felt should be studied for presentation next year...

Field Termination of Cardiac Arrest Cases - most systems are aggressively pursuing field termination of CPR cases to prevent unnecessary transports. In one notable quote, transporting a patient who has been systolic for 20 - 30 minutes to the emergency department is simply " relocating a corpse".

Community Health and Advanced Practice Paramedics - preventing EMS calls through a targeted approach to frequent emergency service users that can benefit from home visits and dedicated medical homes when they are transported. Similarly, using APPs to do the high risk, low frequency procedures such as endotracheal intubation, hypothermia in ROSC cardiac arrest cases, and medical clearance of psych patients.

Transport CPR cases Non-light and siren - Speaking to the concept of "relocating corpses", anyone who has been in EMS more than a few minutes realizes that if you have worked a CPR case for 30 minutes in the field, there is little to nothing that the hospital can do for the patient than has not already been done. Further, the recent resuscitation studies prove that the most important procedure in CPR is adequate chest compressions. Why then do we risk out lives and livelihood (and that of the public) screaming across town, weaving in and out of traffic, throwing the rescuers around in the back of the ambulance and diminishing the quality of chest compressions all to save 2 - 3 minutes on the transport time?

Those 2 minutes on the tail end of the call makes virtually no difference in the patient's outcome. Besides, if you want to save those 2 minutes, make a more efficient process for moving the patient from the back of the ambulance to the Code Room at the emergency room. Instead of waiting until the ambulance is in "park" at the emergency room, preparing the patient to be taken from the ambulance right away. Change over to portable O2, move the IVs to the stretcher mounted pole(s), buckle the patient safety harnesses, move the monitor to the stretcher, etc. Having all that done IN ADVANCE will make the unloading process more efficient.

Many of the Eagles felt that the time has come to evaluate non-light and siren transports for CPR cases to see if it makes a difference in the patient's outcome. It would improve CPR effectiveness, reduce rescuer injury, reduce the incidence of emergency medical vehicle collisions (and "wake effect" collisions from cars moving out of the way), and overall makes sense.


In my 30ish year career in EMS, I've had the fortune to attend countless conferences. The Eagles conference continues to be one of the most informative, fast-paced and FUN conferences. If you have not had the chance to attend one yet, you should seriously plan on attending the program next year.

For more information visit http://gatheringofeagles.us/

About the columnist:
Matt Zavadsky is the Associate Director for Operations at MedStar EMS, the Ambulance Authority System serving Fort Worth and 14 suburban cities in North Central Texas. In this role, he is responsible for overall system operations covering the 850,000 people and nearly 100,000 EMS responses.
He holds a Masters Degree in Health Service Administration and has 30 years experience in EMS including volunteer, fire department, public and private sector EMS agencies. He is a former paramedic and has managed private sector ambulance services from 10,000 to more than 100,000 annual call volume in locations including Fairfield, Connecticut; Augusta, Georgia; La Crosse, Wisconsin and Orlando, Florida. He has also served as a regulator in Lincoln, Nebraska and Volusia County (Daytona Beach), Florida.

Matt is a frequent speaker at national conferences and has done consulting on numerous EMS issues, specializing in high performance EMS system operations, public/media relations, public policy, employee recruitment and retention, data analysis, costing strategies and EMS research.

He has served as the American Ambulance Association as Chair of the Industry Image Committee and membership on the Professional Standards, Strategic Development and Management Training Institute Committees.

Matt is an Adjunct Faculty for the University of Central Florida's College of Health and Public Affairs teaching courses in Healthcare Economics and Policy, Ethics, Managed Care and US Healthcare Systems.
So how do you feel after reading this? If it is a sense of uselessness, you are missing the point. In the world of medicine, EMS is a neonate. We, the ones working right now, can make a huge difference. Please share your thoughts.



Thanks for stopping by,

Adam Thompson, EMT-P

16 comments:

Timothy Clemans said...

I used to tout OPALS cardiac arrest as evidence against ACLS until I realized two things. First, the bystander CPR rate was only 10.3% in the ALS phase. Second, EMS-witnessed VF survival increased 17.2%. That said I don't think drug therapy is effective. My hypothesis is ALS airway management increases survival. It will be interesting to see the results of a randomized trial of standard CPR with analyze late vs. CCR.

Adam Thompson, EMT-P said...

Timothy,

I doubt ALS airway management increases survival. All recent evidence suggests otherwise. Airway is being proven to be of miniscule importance in the setting of sudden cardiac arrest.

Ambulance Driver said...

Endotracheal intubation isn't the gold standard of airway management.

Adequate ventilation is.

And the sad fact is, way too many people get intubated in the field because a medic thought that intubation was *the* goal, and not just one tool in the continuum to achieve it.

Intubation isn't harmful... unless it interferes with continuous chest compressions.

Positive pressure ventilation is beneficial... unless it results in increased intrathorocic pressure and interferes with venous return/impairment of the bellows system, etc...

Invasive airway management is essential... unless the act of securing one causes even temporary hypoxia, or increased ICP in your head injury patient.

A tube can save a life... unless it was put in someone that could have gotten by with less while he bleeds out internally.

Tim, what I want to know is WHY you think that the figures you cite point toward a benefit from ALS?

Bystander CPR rate was only 10.3% for the ALS group. You seem to blame that for skewing the ALS numbers, yet to me it seems to confirm the importance of bystander CPR.

EMS witnessed VF survival increased 17.2%. So how does that indicate the benefit to ALS, rather than just confirm the value of prompt CPR, and prompt defibrillation in the electrical phase of VF?

At my employer, we have increased our CPA patients' survival to hospital discharge neurologically intact, from 7.5% in 2005 to 20.9% in 2010.

The only things we've done different in those five years is a) work all arrests on scene, to minimize interruptions in compressions, and b) de-emphasize intubation to the role of post-resuscitation airway stabilization - primarily because it interfered with compressions for many our of less-skilled intubators.

Your hypothesis that ACLS is beneficial in cardiac arrest may one day prove to be true, when all other confounding factors have been eliminated...

... but right now, in 2010, it flies in the face of pretty much all available research.

Adam Thompson, EMT-P said...

And the sad fact is, way too many people get intubated in the field because a medic thought that intubation was *the* goal, and not just one tool in the continuum to achieve it.

Well said. I cringe frequently when I watch that 80 y/o COPDer acquire a tube that they did not require. I feel that a follow up on every intubated patient should be done by the paramedic whom performs the procedure. A chance to see these patients never get off their ventilators again may make us think twice prior to shelling out any un-needed tubes.

Rogue Medic said...

We need to consider why we are using ALS treatments during cardiac arrest.

Where are the studies showing improved outcomes?

Yes, epinephrine will lead to significantly more ROSC (Return Of Spontaneous Circulation), but that does not mean that we should make this a routine treatment, until after there is good evidence of improved neurologically intact survival to discharge.

The same is true for airway management. We should not intubate in the absence of evidence that intubation leads to significantly improved neurologically intact survival to discharge.

The evidence on intubation shows that it leads to interruptions in one treatment that does lead to improved outcomes. With the study by Dr. Ewy showing that a mask is more effective than an invasive airway, we have dramatic evidence that intubation is not good for cardiac arrest patients.

Maybe we will find limited indications for epinephrine, intubation, or other ALS treatments. We do not have any evidence that regular use of ALS treatments improves meaningful outcomes in the treatment of cardiac arrest.

We seem to be trying to do what is best to improve the chances of survival of our favorite hypotheses, rather than the survival of our patients.

My favorite hypotheses are all disposable. Some hypotheses turn out to be good for patients. Other hypotheses turn out to be bad for patients.

The hypotheses only exist to assist us in providing the best care for our patients. The patients do not exist to improve the survival of the hypotheses.

Timothy Clemans said...

"Bystander CPR rate was only 10.3% for the ALS group. You seem to blame that for skewing the ALS numbers, yet to me it seems to confirm the importance of bystander CPR."

My point is OPALS was not a test of ACLS in an environment similar to that of King County where survival (bystander witnessed VF cardiac) prior to the introduction of BLS-D and telephone CPR was 30% (1978 - 1982).

Here are some observational studies from King County suggesting the need for a trial of intubation in an environment similar to KC: Time to intubation and survival in prehospital cardiac arrest., Prompt advanced life support improves survival from ventricular fibrillation., The effect of paramedic experience on survival from cardiac arrest.

"With the study by Dr. Ewy showing that a mask is more effective than an invasive airway, we have dramatic evidence that intubation is not good for cardiac arrest patients."

OK I just read that paper, Passive Oxygen Insufflation Is Superior to Bag-Valve-Mask
Ventilation for Witnessed Ventricular Fibrillation
Out-of-Hospital Cardiac Arrest. My hypothesis is wrong. OK I'm back to believing ACLS is ineffective... Still wonder about those KC papers though...

Rogue Medic said...

Obviously, I misquoted the study. It was not examining the use of advanced airways, but of BVM vs. oxygen mask. However, do we have any good reason to believe that the result would be different, if the comparison were between advanced airway and oxygen mask?

We have a lot to learn about resuscitation. We have not found evidence to support the regular use of ALS. That may change, but until it does, is it appropriate to regularly use ALS treatments?

Yes, there is a big difference in bystander CPR between where Dr. Cobb and Dr. Eisenberg have done so much to encourage bystander CPR and the rest of the US - where administrators have come up with the usual excuses for not even trying.

The rest of the US has relied on ALS theory - theory that has repeatedly failed experimentation.

Dr. Cobb and Dr. Eisenberg relied on being creative in BLS - encouraging people to perform bystander CPR.

Dr. Cobb and Dr. Eisenberg have produced results.

The rest of the US has produced protocols. Generally ineffective protocols.

Timothy Clemans said...

My hypothesis for a while now has been that eliminating pauses for BVM ventilations by intubation or passive oxygenation improves survival. That's why I mentioned it will be interesting to see a randomized trial of CPR vs. CCR.

I wrote about the importance of bystander CPR a while back, see Is Bystander CPR the Ticket to 50% Survival?.

"The rest of the US has relied on ALS theory - theory that has repeatedly failed experimentation."

Calling ACLS a theory is giving it too much credit.

Rogue Medic said...

Timothy Clemans,

Tonight I have been putting my foot in my mouth, as far as terminology. The idea that ALS improves meaningful outcomes from cardiac arrest is only hypothesis.

You did cite some papers that do suggest that ALS does something to improve outcomes. Unfortunately, we do not know what about ALS might be improving outcomes. There is another study that shows the same thing.


Impact of advanced cardiac life support-skilled paramedics on survival from out-of-hospital cardiac arrest in a statewide emergency medical service.
Woodall J, McCarthy M, Johnston T, Tippett V, Bonham R.
Emerg Med J. 2007 Feb;24(2):134-8.
PMID: 17251628 [PubMed - indexed for MEDLINE]


The free full text is available here, with a link to the free PDF.


The idea that ALS improves outcomes is still only hypothesis. A theory has plenty of evidence to support it. Currently, there is little more than speculation. In discussing scientific studies, the scientific definition of theory would be the appropriate definition to use. This does not meet the level of evidence to be called a theory.

A randomized trial of MICR (Minimally Interrupted Cardiac Resuscitation) is important. However, the results so far have been dramatic. The only thing surprising would be if randomized MICR did not show significant improvements over conventional CPR. The second study (below) does seem to include the patients from the first study (below).


Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest.
Bobrow BJ, Clark LL, Ewy GA, Chikani V, Sanders AB, Berg RA, Richman PB, Kern KB.
JAMA. 2008 Mar 12;299(10):1158-65.
PMID: 18334691 [PubMed - indexed for MEDLINE]


The free full text is available here, with a link to the free PDF.


Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest.
Bobrow BJ, Ewy GA, Clark L, Chikani V, Berg RA, Sanders AB, Vadeboncoeur TF, Hilwig RW, Kern KB.
Ann Emerg Med. 2009 Nov;54(5):656-662.e1. Epub 2009 Aug 6.
PMID: 19660833 [PubMed - indexed for MEDLINE]


The free full text is available here, with a link to the free PDF.

Adam Thompson, EMT-P said...

Now this is an educated debate. I would like to turn the discussion in a different direction.

Whether ALS Tx changes outcomes for the cardiac arrest patient or not, how do we find out and change direction based on the results?

Do we just sit back and wait for the AHA to come out with it's new updates? Because that is the norm. That is most likely what is going to happen. That is what we will be talking about five years from now. We will be going over the research found after implementation of the next set of AHA guidelines.

Anyhow, great discussion guys, and great citations as well.

Duke Powell said...

Just a couple of random thoughts after a quick read of both the article and the comments.

1. "The study found that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field."

I would posit that a 2 hour (or 2 day) response time would result in less than desirable outcomes for victims of multi-system trauma. If this is true, and I think all would agree, then it follows that at SOME point response times do make a difference. The question is whether or not current mandates are cost effective, realistic and result in better outcomes. I think that an 8-12 minute response time requirements should be loosened to some extent. It would save an awful lot of money and not effect outcomes.

2. I understand that survival rates in out of hospital cardiac arrests have not met expectations over my 39 year EMS career. However, when we put so much emphasis on this fact, we risk leaving a public impression that Paramedics have no impact on pre-hospital care generally. Nothing can be further from the truth.

We do ourselves great harm in putting so much stock in studies whose patient population make up just a small percentage of our work load.

Anyhow, great discussion and I'm glad I dropped by....

Timothy Clemans said...

The two CCR before and after trials in process aren't convincing to me because they are comparing not the 2005 guidelines but the 2000 guidelines to CCR. Also they are before and after trials which are almost always positive. I am aware of the positive randomized trial of AHA 2005 to CCR using animals.

Look at the ASPIRE trial of the ZOLL AutoPulse. Dramatic increase seen in the before and after trial but the ASPIRE trial demonstrated no benefit and tenancy for worsening.

I don't want to see CCR adopted until a positive randomized trial has been conducted partly because once something has been adopted getting a randomized trial done is pretty hard.

Rogue Medic said...

Duke Powell,

I would posit that a 2 hour (or 2 day) response time would result in less than desirable outcomes for victims of multi-system trauma. If this is true, and I think all would agree, then it follows that at SOME point response times do make a difference.


Yes.


The question is whether or not current mandates are cost effective, realistic and result in better outcomes.


I think that one important message from all of this is that we should not be endangering the community, or ourselves, in a mad dash to beat some arbitrary time limit.

We need to pay more attention to being reasonable, than to satisfying a QA/QI/CYA check list.


I think that an 8-12 minute response time requirements should be loosened to some extent. It would save an awful lot of money and not affect outcomes.


I agree.


2. I understand that survival rates in out of hospital cardiac arrests have not met expectations over my 39 year EMS career. However, when we put so much emphasis on this fact, we risk leaving a public impression that Paramedics have no impact on pre-hospital care generally. Nothing can be further from the truth.


I agree.

It has been customary to pay more attention to this very dramatic part of EMS. This is what created the need for paramedics, even though what paramedics did, back then is done by basic EMTs today.


We do ourselves great harm in putting so much stock in studies whose patient population make up just a small percentage of our work load.


While I do not think that paramedics contribute to good cardiac arrest outcomes, I think it would be a mistake to conclude that paramedics do not contribute to good outcomes for certain prehospital patients.

In respiratory distress, chest pain, agitated delirium, pain management, anaphylaxis, and other conditions, the patient can receive significant benefit from treatment by a paramedic. None of these conditions depend on paramedics being able to raise the dead.

We continue to define ourselves by our treatments, rather than by our ability to contribute to good outcomes by the use of critical judgment.

This is an example of a failure of critical judgment.

As with cardiac arrest, some of the treatments I used as examples may no longer need to be delivered by a paramedic. Expanding the scope of the basic EMT does not diminish the value of the good paramedic. There has been plenty of recent discussion of that particular example of faulty judgment. No, I am not suggesting that you make that suggestion.


Anyhow, great discussion and I'm glad I dropped by....


I'm glad you dropped by, too.

Rogue Medic said...

Timothy Clemans,

The two CCR before and after trials in process aren't convincing to me because they are comparing not the 2005 guidelines but the 2000 guidelines to CCR.


some of the non-MICR fire departments were following the 2000 AHA Guidelines while others were following the 2005 AHA Guidelines.

From the Comments section of Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest.

This is a valid concern, but even if the tripling of survival is not any better than what we would have with the new guidelines, passive oxygen insufflation is less invasive than forceful oxygen insufflation.

I know, it is not very nice to describe BVM ventilation as forceful oxygen insufflation, but is it in any way inaccurate?

Even a little bit?

In choosing between major surgery and minor surgery, and no apparent difference in outcome, which would you choose?

In choosing between a drug with a lot of side effects and a drug with minor side effects, and no apparent difference in outcome, which would you choose?

William of Ockham would not have to think about this for long. A very interesting guy. His bio includes possible charges of heresy. I'm a little jealous.


I don't want to see CCR adopted until a positive randomized trial has been conducted partly because once something has been adopted getting a randomized trial done is pretty hard.


I do not want to see forceful oxygen insufflation during cardiac arrest adopted as the standard, until it can be demonstrated to improve outcomes in a randomized controlled trial.

Unfortunately, this experimental treatment has been adopted. Now it may require extraordinary evidence to remove the treatment, that may be very harmful.

You are correct that we should demand evidence before we adopt a treatment.

The treatment is forceful oxygen insufflation, which has already been adopted without adequate research.

Withholding ventilation/passive oxygen insufflation is not the active treatment. This is just less of the active treatment.

Duke Powell said...

Rogue Medic

You and I are on the same page.

Just a couple more observations:

1. On the cardiac arrest topic the question should be turned around. It's not that the medic has failed but it is those who have determined what the proticols that have failed. After all, I am ready, willing and able to jump thru just about any hoop the physicians put in front of me. Whenever I hear an august group of academics pontificate on poor outcomes, I hear "blame."

Well, they'd best look in the mirror.

2. But, on the other hand, they don't always get it wrong. STEMI diagnosis in the field, coupled with cath lab activation by medics while standing in the patient's living room, has had the biggest impact on EMS since defibrillators were put on ambulances.

We now have plenty of studies showing the efficacy of this new standard of care.

Did the Eagles have anything to say about this?

Timothy Clemans said...

"I do not want to see forceful oxygen insufflation during cardiac arrest adopted as the standard, until it can be demonstrated to improve outcomes in a randomized controlled trial."

OK fair enough.