Trauma Care

[Ridryder 911]

Trauma is a BLS is job when it happens < 3 minutes from a Level 1 Trauma Center.. Believe me, it easier to find a vein for fluid & blood replacement in the stage 1 or 2 than stage 3 or 4 shock...also, I rather have the patient intubated to prevent aspiration than a lung full of vomit...ever seen a head bleed vomit ?... Again, use common sense.. most of these procedures can be done enroute.. (Which I challenge most physicians to attempt to intubate, start a peripheral line in a moving EMS unit) they have enough hard time in a lighted aseptic ER/Trauma center... you know that would be a neat study.. Paramedics vs. Physicians successful performance in procedures while enroute to trauma centers... think they would even take the bait.... naww I don't think so either...

Be safe,

Ridryder 911

[Asysin2leads]

Rid, I agree with you fully. The point I'm trying to make is that an ALS provider providing BLS care to a patient has its merits. While the medic haters will hem and haw at the BLS skills of the ALS provider, in the real true adult world, having someone who has worked as an EMT prior to training, done rotations in the emergency room, operating room, pediatrics, and ICU's, will have a better working knowledge of a patient tht is put before them and what the patient needs. That's why ALS has its place in major trauma, good emergency medicine is about knowledge combined with skill, and while the skills may be similar, the knowledge is far greater in an ALS provider.

[rdenman26]

A study of out of hospital cardiac arrest in scotland showed similar results. I have not seen it so I cant say any more on that. As far as trauma goes we found in the early days of parameidcs in the UK (US has had them a lot longer) trauma patients did worse as paramedics stayed on scene to use all there new skill. Of course we now recognise that trauma patients need a surgeon so are rapidly tranported wit htreatment en route.

I would agree that intubated trauma patients do worse as they ar sicker. It seems that we only get to intubated patients with a GCS of three. We are taught that a patient with a GCS of 8 or below should be intubated, but most I have spoken to are afraid of causing laryngospasm or big rises in ICP. I guess that will change as we are movig forward a such a rapid rate. From what I see we could be helping more patient with procedures such as RSI. A lot of our serious trauma has to wait a long time to get to hospital. Cat A calls should have a response in 8 mins but that could be a BLS first responder who then has to wait 20 or 30 mins for an ambualnce to get to some god forsaken part of the county then just as long to get the patient to hospital. We have only on helicoptor in my service that only flies during the day and cant take really bad patients as there in not room. Although they are getting a new one. I guess in places as big as the US canada and austalia 30 or 40 mins is nothing. But when you have a time critical head injury strapped to a board vomiting like a fountain you want him in hospital ASAP.

[THE_DITCH_DOCTOR]

ALS is a luxury on trauma scenes. Nothing more, nothing less.

How does having someone who "knows more" which is really questionable in many cases, not beneficial? Ever looked at scene times? Paramedics are far more likely to sit on scene and dick around trying to start IV's and secure an airway, etc.

The point is that until such time as we start putting trauma surgeons in the back of ambulances, the ONLY treatment for trauma in the field is and will remain rapid transport with airway management and MAYBE IV access (access, different from fluid resuscitation) EN ROUTE.

Yes, the survival rates for intubated trauma patients are miserable, but that's to be expected because of how bad things have to get before you need to insert an invasive airway- many of those patients have significant head trauma and we all know what the consequences of that are.

And what is wrong with statistics? You only have a problem with these particular statistics because they contradict what you believe. Period.

[Summit]

Paramedics are more knowledgable. There is no question about that. If the statistics show this makes them more apt to stay and play on calls that warrant a load and go regardless of level, then send BLS. I haven't had that problem with ALS, but I could definately see that being a problem.

Depending on the system, especially tiered systems and systems that partner basics with paramedics or use FF/EMTs for first response, you see ALS mostly just doing ALS... so they are rockin the ALS but rusty on some parts of BLS.

BLS ony does BLS because that's what BLS's job is. Consequently, BLS is well practiced at BLS.

You aren't going to convince me that just being a paramedic makes one on average more effective at backboarding or taking a pulse or putting a nonrebreather on a pt.

How is more education goin to help a paramedic hold c-spine?

The last fifteen or so trauma pts I've seen (far back as my tired mind is remembering these last two months), ALS showed but pretty much let me run the entire show because thre was nothing ALS for them to do (except they gave some pain meds in two cases). If they'd seen me do somethin incorrectly of course they would have stepped in, but so would another BLS provider.

Of course, my opinion is slightly skewed by the fact that around here IV's are BLS skill (I can also combitube).

[Ridryder 911]

I believe the problem with the study was the intent not so much what it revealed. Also, what was the sugeestion at the end of the conclussion.. to place more BLS units within a 4 minute response time.. yeah, that will happen. I still would like to see a formal sudy of pre-hospital care of trauma trained physcians vs. paramedics. I believe it would be very interesting, on the diagnostic value.

I agree, trauma is a surgical disease. Needless interventions should be decreased as much as possible, however; the risk of aspiration, venous acess to infuse blood, can be treated & obtained enroute. Let us not throw the baby out with the bathwater yet.

Even with Level 1 trauma centers there still has not been a great reduction in trauma deaths. So could we argue these are futile also ? Of course not.. but let us learn also how studies are conducted, the perimeters around, the pre-cursor why the need of a study or sponsors of a study. the number & type of patients involved, length etc...

Just because it is a "scientific study" .. not everything should be taken literally. There are skewed studies. Just wait a few months there will be one to dispute it...then hopefully, we can decide with a rationale mind on what is best for the patient.

Be safe,

Ridryder 911

[Asysin2leads]

>How does having someone who "knows more" which is really >questionable in many cases, not beneficial? Ever looked at scene times? >Paramedics are far more likely to sit on scene and dick around trying to >start IV's and secure an airway, etc.

Okay, let me say ditch, with no hesitation, that that is a LOAD OF CRAP. This is the arguemnt I get all the time from BLS providers, "medics want to 'play' on scene". Yeah, right, because you know, sticking a tube down someone's throat gets my jollies off. That's why I do it.

The truth of the matter is that trauma protocols for paramedics DO NOT CALL FOR STARTING of IV'S or SECURING OF ADVANCED AIRWAY ON SCENE UNLESS THERE IS A DELAY TO TRANSPORT I.E. EXTRICATION. As for "knowing more" the fact that I knew that and YOU DIDN'T, pretty much proves my point. Get your head out of your ass, a good paramedic is first and foremost an excellent EMT. It's uninformed and ignorant opinions like yours that make my job just that much harder.

[THE_DITCH_DOCTOR]

Jeez, Asys, I agree with your statement that protocols say that- our protocols as EMT-I's say the same thing (seeing as we deliver basically paramedic level trauma care (intubation, IV, needle decomp when called for, etc). Don't treat me like some dumbass BLS provider, because I'm not. I'm sorry if I caught you on a bad day but damn, I didn't need my ass excoriated because of it. I hope the rest of your day goes better.

[ERDoc]

Just so everone is on the same page as to the background and purpose of the OPALS study, here is a bit from their web page:

In this era of health services fiscal restraint, policy makers require quality evidence to support decisions to initiate or continue funding for expensive programs. Prehospital Advanced Life Support (ALS) programs cost considerably more than community-wide defibrillation programs, yet evidence is not convincing for the effectiveness of ALS programs for critically ill and injured patients (ALS includes advanced airway management [intubation] and intravenous drug therapy by ambulance officers). This study should provide valuable evidence to Ontario communities and elsewhere, about the relative effectiveness of prehospital programs on the survival and morbidity of cardiac arrest, major trauma and respiratory distress patients. Such information is much needed for the cost-effective planning of emergency health care services.

Background

Survival for prehospital victims of cardiac arrest remains relatively low in Ontario communities compared to many U.S. and European communities.

Optimal survival rates according to the American Health Association depend on four strong links in the "chain of survival". The relative importance of the third link, rapid defibrillation, and the fourth link, full ALS is not clearly distinguished in the scientific literature.

Prehospital ALS measures are also commonly applied to trauma and other critically ill patients in U.S. centres.

The Ontario Ministry of Health (MOH) was reluctant to commit the millions of dollars required for the widespread implementation of prehospital ALS programs without further research demonstrating the effectiveness of such programs in Ontario.

In 1994 - OPALS Study funded by the Ontario MOH.

In 1998 - OPALS Study funded by the Ontario MOH and the Canadian Health Services Research Foundation (CHSRF).

Objectives

To assess the incremental benefits in cardiac arrest patient survival and morbidity that results from the sequential introduction of rapid defibrillation programs.

To assess the incremental benefit in survival, morbidity and processes of care that results from the introduction of prehospital ALS programs to multiple Ontario communities for patients with cardiac arrest (primary objective), major trauma and respiratory distress.

To conduct an economic evaluation of ALS programs for the same patient groups by estimating the incremental cost per life saved and per quality-adjusted life year.

Design

This multi-phase before-after study (see OPALS Research Protocol) is being conducted in multiple communities in 11 base hospital regions and has three distinct phases involving a total of at least 10,000 cardiac arrest patients, 6,000 major trauma patients and 8,000 respiratory distress patients.

Phase I represented the baseline survival status in each study community and was based on retrospective data for the most recent 36 months prior to Phase II.

Phase II assessed the survival for 12 months after the introduction of rapid defibrillation and demonstrated that relatively inexpensive community rapid defibrillation programs increase survival for cardiac arrest patients.

Phase III will assess survival outcomes months after the introduction of full ALS programs for 36 months for cardiac arrest patients and major trauma patients, and for 6 months for respiratory distress patients.

The actual research protocol is on the website also, but is much too big to post here (insert your own size joke here).

[ERDoc]

Here are parts of the results from Phase II and III. These are not the actual articles that appeared in the literature, but a synopsis taken from the OPALS website:

Phase II Results

Phase II results of the OPALS Study have been published in the April 1999 issue of The Journal of the American Medical Association (JAMA)! The manuscript entitled "Improved Out-of-hospital cardiac arrest survival through the inexpensive optimization of an existing defibrillation program (OPALS Study Phase II)" created a lot of media attention with it's publication in this prestigious medical journal.

This study compared cardiac arrest survival from Phase I (communities with existing ambulance defibrillation programs) to Phase II (rapid defibrillation) in 19 Ontario communities.

These communities implemented various strategies to optimize their EMS systems to achieve the target response criteria of call received to vehicle stopped with defibrillator in eight minutes or less for 90% of cardiac arrest cases. Many of these communities implemented fire fighter defibrillation programs, along with base paging, tiered response agreements, and roving. Provincially, changes were made to dispatching policies and procedures.

The outcome of these interventions demonstrated that rapid defibrillation increases the chance of survival from prehospital cardiac arrest! In the largest prehospital cardiac arrest study ever conducted, involving over 5,000 patients, survival increased from 3.9% in Phase I to 5.2% in Phase II. This represents a 33% increase in survival. Or, to look at this another way, it represents additional 21 lives saved each year. Increased survival was also associated with bystander and first responder CPR.

The results of Phase II provide evidence for communities considering the cost of CPR training and equipment ambulance services, fire departments and other agencies with defibrillators. In doing so, thousands of lives could be saved in a very cost efficient manner.

For more information on media coverage, check out these web sites:

JAMA - April 7, 1999

Phase III Results

The first of several Phase III results have been published in the August 12, 2004 edition of the New England Journal of Medicine. The manuscript entitled “ Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest†has created a whirlwind of media attention in our national newspapers as well as several international newspapers . These results conclude that CPR, and rapid defibrillation increase cardiac arrest survival, but ALS does not. Over 5,600 patients were studied across 17 urban Ontario centers to reach this conclusion. Of those patients, 1391 were enrolled during the rapid-defibrillation phase, and 4247 during the subsequent advanced life support phase.

Advanced Life Support training was introduced in Ontario several years ago as one part of a comprehensive approach to strengthening community response to cardiac arrest and improving survival rates. This training provides the paramedics with the skills to perform advanced life saving procedures such as airway management, and the administration of intravenous drug therapy. Other parts of the approach include CPR training for police officers and firefighters as well as the installation of public access defibrillators.

Previous OPALS Phase I and Phase II research concluded significant improvement in survival from cardiac arrest if first responder be it citizen, police officer, or fire-fighter performs CPR, and if rapid defibrillation occurs within 8 minutes. Although ALS training does not demonstrate a change in survival rates for cardiac arrest patients, indications from our soon to be published Chest Pain and Respiratory research studies suggest ALS significantly impacts the number of lives saved each year for these patients. The underlying message from the OPALS Cardiac Arrest research is for health officials and planners to place an emphasis on citizen CPR training, and the rapid availability of defibrillation devices.

And, just for completeness, here is the absract from the NEJM:

ABSTRACT

Background The Ontario Prehospital Advanced Life Support (OPALS) Study tested the incremental effect on the rate of survival after out-of-hospital cardiac arrest of adding a program of advanced life support to a program of rapid defibrillation.

Methods This multicenter, controlled clinical trial was conducted in 17 cities before and after advanced-life-support programs were instituted and enrolled 5638 patients who had had cardiac arrest outside the hospital. Of those patients, 1391 were enrolled during the rapid-defibrillation phase and 4247 during the subsequent advanced-life-support phase. Paramedics were trained in standard advanced life support, which includes endotracheal intubation and the administration of intravenous drugs.

Results From the rapid-defibrillation phase to the advanced-life-support phase, the rate of admission to a hospital increased significantly (10.9 percent vs. 14.6 percent, P<0.001), but the rate of survival to hospital discharge did not (5.0 percent vs. 5.1 percent, P=0.83). The multivariate odds ratio for survival after advanced life support was 1.1 (95 percent confidence interval, 0.8 to 1.5); after an arrest witnessed by a bystander, 4.4 (95 percent confidence interval, 3.1 to 6.4); after cardiopulmonary resuscitation administered by a bystander, 3.7 (95 percent confidence interval, 2.5 to 5.4); and after rapid defibrillation, 3.4 (95 percent confidence interval, 1.4 to 8.4). There was no improvement in the rate of survival with the use of advanced life support in any subgroup.

Conclusions The addition of advanced-life-support interventions did not improve the rate of survival after out-of-hospital cardiac arrest in a previously optimized emergency-medical-services system of rapid defibrillation. In order to save lives, health care planners should make cardiopulmonary resuscitation by citizens and rapid-defibrillation responses a priority for the resources of emergency-medical-services systems.