Yesterday, we spoke of Dr. Graf and his development of HEART cars– but more importantly the training and use of paramedics.  Now, there’s new data that our decision to continually add toys to our ambulances does not yield the best care for our patients.

Drs. Prachi Sanghavi (University of Chicago), A. B. Jena,  J. P. Newhouse and A. M. Zaslavsky, (the last three from Harvard Medical) published their study results in the Annals of Internal Medicine.  The study demonstrated that these advanced-care ambulances create confusion for the paramedics.   The high tech equipment in the ambulances, which the authors termed ‘advanced life support’ (ALS) transport- is what is used in 65% of the trips,  when Medicare patients are transported to the hospital.  The other 35% were handled with basic life support systems (BLS). BLS means the paramedics will only provide chest compressions, basic defibrillation, and employ hand-pumped ventilation bags.

Obviously, the ambulance paramedics have less practice (and knowledge) than clinicians operating in a hospital environment.  So, when a paramedic must administer IV (intravenous) fluids, employ advanced defibrillators, or effect a tube insertion for breathing (you do recall the TV shows demonstrate how tricky that really is), errors are made (the tube is put down the esophagus, for example) or way more time is required to complete the action.

Given this, having the paramedics bag the patient (put a respirator attached to  a bag over the patient;s face) to deal with respiratory distress takes no time and requires little advanced skill.  Compared to the insertion of the tube down the trachea, this is a no-brainer.

The Harvard team (Sanghavi was a research fellow at Harvard when this work was done) had analyzed some 380,000 emergency transports that occurred over the years 2006 to 2001.   They chose to further examine some 1/5 of the cases (major trauma, stroke, AMI [acute myocardial infarction) and respiratory failure) for the Medicare patients in the total census.   The key fact they discerned was that some 90% of those patients with cardiac arrest didn’t survive long enough to be discharged by the hospital in 90 days or less.

These results were, as alluded to above, not very promising.  Those suffering heart attacks had a 5.9% improvement in initial survival rate, should they have been transported in the advanced unit, rather than the basic ambulance.  About the same results were found for stroke patients (4.3% initial improvement).

Now, for major trauma, the results were still not good- but they did have a 12.5 (1 in 8) better chance of initial survival when transported by the advanced ambulance.

It gets ‘better’.  The BLS transported patients were 50% more likely to survive 90 days post hospitalization than those transported via ALS units.   And, those patients have better neurological functioning (that means fewer cases of coma, brain trauma, or being in a vegetative state).

Now, you can complaint that these results are tainted.  Because it is possible that BLS transport was chosen for those patients closer to the hospital.   And, being closer- with a much shorter time before hospital intervention- could lead to this change in outcomes.  Or, maybe you believe that only the sicker patients are transported via ALS.  But, that would require the development and use of  a pretty sophisticated dispatch system; one that most cities don’t provide.

Moreover, previous studies have indicated that these study conclusions are valid.  Ten years ago,  IG Stiell, GA Wells, B Field, DW Spaite, LP Nesbitt, VJ De Maio, G Nichol, D Cousineau, J Blackburn, L Luinstra-Toohey, T. Campeau, E Dagnone, and M Lyver reported similar outcomes for patients within their study published in the New England Journal of Medicine.   While not quite the same circumstances, this older research examined the results of bystander provisioning of basic CPR compared to the administration of basic defibrillation.  Their census involved 17 cities across Canada- comparing basic CPR administration to the results when advanced life support was provided.  And, Stiell et. al. reported that survival was at least as good with BLS as those provided ALS.

A study in Taipei (Taiwan) by Drs. MH Ma, TC Lu,  JCS Ng, CH Lin,  WC Chang, PC Ko,  FY Shih, CH Huang, KH Hsiung, BC Lee, SC Chen, and WJ Chen, published their findings in Resuscitation.  Their research examined the outcomes from ‘out-of-hospital’ cardiac arrest for 1423 cases, with some 1037 of the patients receiving BLS (73%).  The research indicated better immediate patient results better after ALS, but no better overall patient outcomes between the two techniques.

And, then, there’s yet another Canadian study.   Drs. MA Hanff, AH Kajii, and JT Niemann examined whether advanced airway management improved outcomes,  when such techniques were administered ‘out of hospital’. (This study can be found within the pages of the Academy of Emergency Medicine)  Hanff et. al. surveyed some 1294 cases, of which 131 (10%) involved  basic bagging techniques and the rest of the patients were intubated.   And, those with BLS had 4.5X better overall survival rates.

Let’s hope the next phase of the Harvard study provides some more definitive conclusions.   They are examining the outcomes for patients who experienced respiratory failure or stroke.   We’ll have to see what that data yields.  But, I’m pretty sure basic will be the way to go.

Let’s make the paramedics’ jobs simply to keep folks alive- and get them to the hospital ASAP.