EMS Research

[tniuqs]

Is someone proposing that every pt needs a min. level of care equal to that of ALS?

YES:

I do in fact from prior posts YOU were an advocate of improved diagnostic abilities to lighten up the load for ALS providers, or am I missing something ?

If there has been such a study where can I find the data?

I the majority of communities across north america there is no fully ALS system to give a comparison so your asking a subordinate level to triage patients without anything but the basic diagnistic kit .... this in itself is flawed arguement, just how to you propose a study be be even considered ... ?

I could only assume that any such study would show the opposite that of which I think has been proposed. Most Pt's I encounter don't need ALS. For the percentage that do we make every attempt to have that provided prior to arrival at a acute care facility.

ALL chest pain calls require ALS a little thing called a 12 lead and early intevention does make a difference we just have to prove it,yet again how would YOU know the difference between a surgical belly and a stuck fart , are we following here ?

I am not proclaiming that any pt could or would not benefit from further assessment, but more so that more educated basics could provide better assessments along with appropriate interventions.

The futher education level is quite clear called REMT-P, step up to the plate, its were the rock stars get separated from the groupies .... ps heard that on TV somewhere ?

Has anyone done any research on the cost of treating and transporting every Pt as a ALS Pt? I don't think that from a cost standpoint it would be justifiable. Lastly, I apologize for derailing the research topic and turning it in to a ALS-BLS skills debate.

The tread was derailed by someone perhaps do get back on tracks shall we ? Its called EMS RESEARCH and it almost appears that your trying .... So just how many EMT-B out there would do not want more education? an improved skill set to provide better care? and a better paycheck ? .... I dare say NONE on EMT city thats why I dare to believe they ARE HERE, so shoot me for believing in this membership....ps better have an elephant gun.

I propose a study based on treatment to door outcomes, BLS compared to ALS ... lets say rural with greater than 40 minute transport times, better yet HEY the response time TO the patient, call to patient contact time should be the determining factor, not cost effective, is it your Mom their coming to treat ? Inclusion criteria proposed "Medical calls only" R/r has provided excellent documentation in previous threads on the poly trauma patient, so exclude those for now.

Just for giggles include this question to the survivors in the study: Did you feel confident in the providers care and knowledge ..... hmmm interesting spin is it not?

I have found this data in our reporting system for this month.

62.23 % BLS transported (ALS never requested)

37.77 % ALS (requested at time of disp.)

11.2 % ALS treated and transported to destination.

What call volume ? huh... numbers svp, 62 % of 5 or 5000 calls ?

These are the only stats our system tracks. So I could extrapolate that of the 37 % of ALS calls that we responded to they were either not available or were cancelled 26% of the time they were requested. We dont differentiate between not available and cancelled. This is from a urban area if someone else has similar or wildly diffrent stats I would like to see.

Ok again Triage by a subordinate level....pointless, and again what call volume are we basing this on ... a year, a week or a day in downtown NYC, out of the bronx burrough (sp) sorry guys never understood that ?

cheers

[Ridryder 911]

Is someone proposing that every pt needs a min. level of care equal to that of ALS?

Okay, let's take EMS out of the equation. Let's pretend a family member or even yourself has became ill. Would you go or take someone to an ER knowing that your family member would be triaged by an nurse aide or CMA? All the nursing care, would be provided by no higher level? ... No RN ever to assess or administer treatment?

Would you be satisfied with that? Again, knowing that the basis of when and initial treatment will be solely based upon that nurses/medication aide assessment and informing their higher level medical personal upon what they found is either life threatening or not. Now, would you feel safe?

See the EMS dilemma?

Even nursing homes have a staff member that is higher level licensed, that is supposed to be able to provide a better assessment and provide medical care, yet EMS does not require such?

Yes, we have a long way to consider EMS competent in delivering medical care.

R/r 911

[BVESBC]

Tnuiqs Wrote,

What call volume ? huh... numbers svp, 62 % of 5 or 5000 calls ?

These % are from YTD stats, 2943 calls as of yesterday.

[katbemeEMT-B]

Okay, a couple of quick replies to BVESBC and then I will get to the original post.

As an educated EMS provider, you should be well aware of the proposed Agenda for The Future and the new National Education Standards which in no way dismiss the EMT-B. In these documents they are setting the education requirements and skills available for each level of care: EMR, EMT, AMT, and Paramedic. Along with these new requirements, those EMT-Bs with so many variances will no longer be able to perform the skills they currently do without further education to an advanced level. So guess what, there goes your theory that the EMT-B will be no longer. Now that's not to say most services won't require their providers to be educated at the advanced level, leaving a very minimal amount of basics out there. That wouldn't be such a bad thing.

As for giving patients better care; well, I am a basic and I agree that the patient deserves the best care available to them. That means EDUCATED providers that have the knowledge to go along with the skills. How can ANYONE provide proper care to a patient if they have no clue the correlation between the anatomy of the body and the physiological processes involved. The more I work as a basic, the more I realize how incompetent I really am and how much my patients suffer because of that lack of education. I personally have decided to increase my knowledge and am currently attending an nationally accredited college and will have an associates degree in Emergency Health Services.

My advice to you is ride with an ALS service some time and see exactly what medics can do for their patients and the knowledge that goes along with that ability to provide care.

Now, on to the original post.....

I would love to see some data on how care provided by ALS services compares to BLS services. Specifically, patient outcomes where an ALS provider can perform interventions BLS can not.

I would also like to see a study done on the difference in ability to properly care for a patient at a basic level with 120 hours of education compared to that of a basic with a minimum of a year of school including: general biology, A&P, basic cardiology, ambulance operations, medical terminology, english, communications, psychology, and whatever else might be fitting.

So, that's my two cents

[Spock]

Spock:

You mentioned that the five who adhered to your study's protocol improved their success rates by 100%. What were their success rates pre and post study? And was that improvement based on non-lab, real-life intubations?

How would it work if you offered an incentive for those who agree to participate yet fail to follow the guidelines? I suppose buying participation could be questionable. But if colleges/universities can compensate for study participation why couldn't you? (Or you could just threaten to remove their ability to intubate in the field for failing to live up to their end of the bargain;) ).

Sounds interesting.

-be safe

The medics that improved went from around 40% to 80% on real patient intubations. Yes 40% wasn't very good to start with but the only variable that I could see was the mannequin intubations. The medics that did not participate showed no improvement. One medic was participating but stopped half way through for an unexplained reason (I suspect peer pressure.) His states went into the tank as he then missed his next four tubes. Not sure if stopping the mannequin intubations was the cause but it was interesting.

The power analysis showed we needed 48 tubes in order to show a 15% improvement which we met with 54 tubes for the study period. Yes the comparisons were based on the study year and the preceding year.

Incentives may be a problem for future studies but paying subjects to participate in a study has been done before. I'm not sure if it will make a difference here.

The current issue of JEMS has a brief article on OR intubations and RSI success. It suggests that OR intubations do not make a difference in success rates. I didn't like their definition of intubation attempt (passing the tube beyond the teeth) and they didn't require capnography.

Certainly an area for further study. Frankly one of the reasons for the lack of participation was no support from administration. We have two supervisors that had a ZERO success rate over two years! Go figure.

Ago porro quod prospicio. Thanks scott33--I love it.

Spock

[paramedicmike]

Forty percent? Really? Some of these guys had a 40% success rate? How is that possible? That just blows my mind!

This is just something I can't figure out. There has been discussion of poor paramedic intubation rates but I never could quite get behind it. Perhaps the strong emphasis in the places where I work on airway management affect local success rates. But I find it amazing that anyone out there only gets four out of every ten intubations attempted. And how can you not identify a misplaced tube?

This just really makes me wonder...

Thanks, Spock, for the follow up.

-be safe

[towheadedmule]

Tnuiqs Wrote,

What call volume ? huh... numbers svp, 62 % of 5 or 5000 calls ?

These % are from YTD stats, 2943 calls as of yesterday.

As of yesterday, the last run number I had was XXX35043

thats 35043 Calls

100% ALS assessed, treated and transported or released per their request.....with the vast majority being what could be classed as a BLS run. In fact I have run hot back the hospital with more non life-threatening dispatched calls than those with life-threatening dispatch criteria. To be fair, our system is completely ALS. We use basics on the trucks, and most are critical elements of the team. Some you have to watch like a hawk, but i have had paramedic partners that were the same way.

The last statistics I saw for our system in my division was a intubation success rate of 92% for the previous month. We do not RSI, so only cardiac arrests, respiratory arrests, unresponsives without a gag, and with CPAP, the rare flash edema gets a tube.

Anyway, I think that the basic premise of practice is good. I ran so many immediate actions drills in the service that i can still do, ie SPORTs on a rifle. You cant do a skill once or twice (even in a year) and consider yourself proficient when placed UNDER stress. Its muscle memory. You can read all about in a book called On Combat, by LTC Dave Grossman. Yes it is mainly about combat, but much of the stresses he refers to is applicable to EMS. Well worth reading, if for no other reason to understand some the actions/antics/concerns of veterans.

YMMV

Russell

[UMSTUDENT]

Is someone proposing that every pt needs a min. level of care equal to that of ALS?

If there has been such a study where can I find the data?

I could only assume that any such study would show the opposite that of which I think has been proposed. Most Pt's I encounter don't need ALS. For the percentage that do we make every attempt to have that provided prior to arrival at a acute care facility. I am not proclaiming that any pt could or would not benefit from further assessment, but more so that more educated basics could provide better assessments along with appropriate interventions. Has anyone done any research on the cost of treating and transporting every Pt as a ALS Pt? I don't think that from a cost standpoint it would be justifiable. Lastly, I apologize for derailing the research topic and turning it in to a ALS-BLS skills debate.

I have found this data in our reporting system for this month.

62.23 % BLS transported (ALS never requested)

37.77 % ALS (requested at time of disp.)

11.2 % ALS treated and transported to destination.

These are the only stats our system tracks. So I could extrapolate that of the 37 % of ALS calls that we responded to they were either not available or were cancelled 26% of the time they were requested. We dont differentiate between not available and cancelled. This is from a urban area if someone else has similar or wildly diffrent stats I would like to see.

Actually, there is information to suggest that most patients are not ALS in nature. Only about 20-30% of 9-1-1 requests require ALS interventions.

With that said, there is tons of literature to support EMS systems that are 100% ALS utilizing a flexible production strategy. Whether you agree or disagree with PUM EMS systems, Stout was successful in demonstrating, utilizing real peer-reviewed research, that BLS is basically useless...

For example consider:

Cone and Wydro, in the Oct-Dec edition of Prehospital Emergency Care showed that 77% of ALS cancellations by BLS providers were inappropriate. 87% of these patients required ALS upon arrival at the ER. 31% were admitted and one died.

Schmidt and Atcheson showed in the June 2000 edition of Academic Emergency Medicine that 3-11% of patients determined not to need a ambulance by EMTs had a critical event.

Sasser (1998) demonstrated that Paramedics and Doctors disagreed 52% of the time regarding the level of treatment needed.

Burstein (1996). Study on paramedic refusals. 199 patients refused service. 48% sought care within a week. 13 patients were admitted and 1 died.

The list goes on. I mean I actually have list...this is a hotly debated topic in the world of EMS management and one that gets preached down my throat in lecture after lecture.

I think what the data shows is that 9-1-1 is abused and perhaps used inappropriately by some individuals but that paramedics and EMTs are either:

A) Uneducated to make adequate determinations of the level of care.

OR

Paramedics and EMTs lack the diagnostic tools to make these determinations in the field.

I choose to believe that A is the main cause of poor choices(B is also important) in clinical work-up in EMS, which is why I am hugely in favor of advancing EMS education and working towards the development of a better prepared, advanced prehospital clinician. I honestly believe there is a lot of room for EMS to make a genuine contribution to public health.

[tniuqs]

Check out the Canadian EHS Research Consortium:

http://www.paramedic.ca/cerc/

I don't know if they have specific funding allocated but they do receive it from other sources. It is in the beginning stages but seems to be quickly building momentum.

I have done follow up, thanks for the heads up ! I am so pumped about this Study anyone/everyone in EMS should read the complete pfd, a quick google.

A CAF link, fyi.

http://www.google.ca/search?hl=en&q=RO...trial&meta=

I do have a few queries in regard to the ARDS outcomes, it does not appear from first review that any "guidelines" in so far as the means of ventilation for the patients in this study .... as we have so much research data in that area, ie Small VT (5 to 7ml/kg ideal body wt) as opposed to Conventional VT, (10 to 15) the outcome studies in this multicenter study were very conclusive.

Question remains are set Ventilator parameters or Manuel ventilation guidelines part of the BC study, if ARDS is to become an outcome indicator?

cheers, and I believe I am getting sexually aroused ....;~) j/k

Sure would be lighter to carry in my remote kits ... just in passing.

[triemal04]

Spock-

Got me thinking a bit. When your medics intubate someone, do they (and are they trained to make this determination) document what class of airway if was? (that good old class 1-4 system) And really REALLY (especially if you are using RSI) make the right choice to intubate or not each time?

I don't mean any offence by that, but you aren't the first by a long shot to bring up how crappy some people are at intubating, or how low the national success rate is for paramedics. I've always wonder how much, if any of it, was due to intubations that started out as a lousy shot. If you, or anyone else has any info on that it'd be great.