Rethinking EMS: Don’t Knock ‘Homeboy Transport’ an article from Emergency Physicians Monthly

In some cases, the fastest way to get someone to the emergency room is by POV or Private Owned Vehicle. 

 

Apple pie and motherhood. That’s how EMS systems have come to be viewed in this country. While in some locations this is a well-deserved perception, in many others, local EMS systems have become out of step with medical evidence.

 

As the Associate Director of Paramedic Training for Los Angeles County several decades ago, I remember the extensive classroom and practical training provided to the students. If I recall correctly, the total number of hours of education was about 1,800. You can envision the level of detail that was achieved given this extensive amount of time. 

In retrospect we covered a huge amount of material that was essentially irrelevant to field care. But the goal was to ensure a comprehensive level of training. The esprit de corps was high and being selected for the training was considered an honor.

 

 It was generally assumed that paramedic-level care was the gold-standard for EMS. The huge popularity of the TV show, “Emergency!” which focused on three imaginary LA County paramedics in the 70s, catalyzed the nation’s interest in developing paramedic programs.

 

Yet, since those early days there has been a growing body of evidence suggesting we need to challenge many of our assumptions about the best ways to provide prehospital care. 

From issues like the decreasing need for prehospital drug therapy (especially in the setting of a cardiac arrest) to evidence that little is gained by lights and sirens transport (and that it is associated with about 12,000 ambulance collisions annually in the U.S. and Canada) to the demonstrable overutilization of helicopter transport, the list of EMS practices that are worthy of scrutiny continues to grow.

But a much more fundamental question is arising. Perhaps less is more. Perhaps in some settings EMT-based rapid transport can result in better outcomes than ALS care. The next four papers challenge EMS agencies to look careful at the status quo.

1. BLS trumps ALS in some cases...

ALS transport and care were associated with decreased survival in patients with penetrating injuries and ISS scores below 30, and provided no significant benefit for patients with more severe injuries. It appears that speed of transport (ie, BLS care) is more important than the level of care provided.

 2. Private Vehicle Transport Trumps EMS Transport

The authors acknowledge the methodologic limitations of their analysis, but note that these findings are consistent with a significant survival advantage of transport of GSW patients by private vehicle rather than EMS.

3. Cardiac Arrest better outcomes with BLS

In this large study, BLS care for prehospital cardiac arrest appeared to be associated with better outcomes than ALS care.

4. Endotracheal Intubation ETI vs Bag Valve Mask BVM

Rates of survival to hospital discharge were similar in the ETI and BVM groups (26% and 30%, respectively), as were rates of discharge with good neurologic outcome (20% and 23%).

Rethinking EMS: Don’t Knock ‘Homeboy Transport’

Truth is in some cases; patients have a better chance of survival with an EMT rather than a paramedic

Television and movies tell us that paramedics are the be all and do all of emergency medicine, and in some cases that's true. 

But in many cases the use of Basic Life Support, BLS skills like loading the patient and rapidly getting them to the definitive care of physicians have better survival rates than paramedics. 

Read the research links at bottom.

When I posted about using EMR's to respond to medical calls to give Dolan and Meadview a second ambulance, someone close to the fire district said, "Actually, there is less liability if nobody shows up than if somebody shows up and does something wrong". 

That is true.

It's also true that the more invasive procedures you do, the more chance for mistakes. So there's more chance that a paramedic will "do something wrong" because they do invasive procedures like endotracheal intubation or starting IV's. 

EMT's and EMR's use basic BLS skills like airway, breathing, and circulation. They secure an airway, give 02, support respirations, and rapidly transport the patient to the definitive care of a physician. 

My experience...

I was fortunate to take my paramedic training in Los Angeles during the 1984 Olympics. I trained as a Mobile Intensive Care Unit Paramedic at one of the first paramedic schools in the country, the Daniel Freeman Hospital Paramedic School. It was started by Dr. Walter Graf who's known today as one of the founding fathers of EMS.

We attended class 8 hours a day, 5 days a week for 8 weeks. Then 4 weeks rotating through various hospitals like Cedar Sinai, Martin Luther King, and the USC Medical Center. 

We didn't know it at the time, but we were training in the birthplace of emergency medicine as we know it today, the emergency department at the USC Medical Center's General Hospital. 

I spent time in C-Booth, and I really don't know how to describe C-Booth. It was a 10'x10' area with 4 beds, at least 2 always filled with someone who was about to die. It looked more like a MASH unit than today's emergency room.

An article by Intermountain Health Care described C-Booth this way, "the most critical, traumatic injured patients arrived in the trauma bay, called C-Booth, where “more people have died and more people have been saved than in any other square footage in the United States,” according to physician and director Dr. Ryan McGarry"

It was a teaching hospital; we were young paramedics, PA's, and physicians, it was an exciting place to learn, but one of the first things we learned was that mistakes happen, and patients die.

Back in Spokane

As part of my training, I spent 480 hours training with a Spokane Fire Department paramedic unit. On our first run, the first day of my training we got a shortness of breath call about two miles away at a bowling alley. 

A 40-year-old male who was bowling with his son was having an asthma attack. It only took us a few minutes; it was a straight shot down Division St from Station 10. 

He was in respiratory distress in the tripod position when we arrived using accessory muscles to breathe. 

I started an IV as another paramedic was assessing the patient. As he was assessing breath sounds the patient progressed into respiratory arrest. The paramedic intubated the patient using an endotracheal tube, I attached an ambu-bag to the ET tube bagged the patient as he auscultated each lung and saying he had breath sounds in both.

The patient quickly progressed into cardiac arrest as firefighters were bringing in equipment. I continued to bag the patient as firefighters started CPR. We loaded the patient and ran code to Sacred Heart Hospital a couple of miles away. 

One of the first things they do in the emergency room when you arrive with an intubated patient is do an x-ray to confirm the ET tube in the trachea and not the esophagus. As soon as they got the x-ray back, they called the code. 

The endotracheal tube had been placed in the patient's esophagus rather than the trachea and I had been bagging oxygen into his stomach rather than his lungs giving him no chance of survival.

The ER doc went out and told his family he was sorry that they did everything they could, but he had suffered a severe asthma attack.... 

He never said he was sorry, but the paramedic had accidentally placed the breathing tube in his esophagus rather than his trachea. If it had been placed in his trachea and he received lifesaving oxygen, he may not have progressed into cardiac arrest. 

Talk about a learning experience for a paramedic trainee, did I help kill a guy. I always made sure I could see the vocal cords when doing intubations. 

Truth is in some cases, patients have a better chance of survival with an EMT rather than a paramedic, because EMTs use basic life support with rapid transportation to get the patient to the definitive care of a physician.

These are excerpts from EMS articles about survival rates when being transported by a paramedic vs EMT. The results may surprise you..

I love this article Rethinking EMS: Don’t Knock ‘Homeboy Transport’ because in Dolan many times we transport friends or family in private vehicles (POV) because of long response times. 

Article; BLS is more than basic, it’s fundamental to good care

Advanced Life Support vs. Basic Life Support for Patients With Trauma in Prehospital Settings: A Systematic Review and Meta-Analysis "In prehospital settings, the present study showed no advantages of ALS on the outcomes in patients with trauma compared to BLS".

Article; Advanced ambulance care increases mortality

Patients suffering from trauma, heart attack or stroke have a better chance at survival if they are transported by a basic life support ambulance than by an advanced life support ambulance, according to a new study involving data from nearly 400,000 patients in non-rural counties nationwide. NOTE: Some will say this was done in non-rural areas but a nobody survives a cardiac arrest in Dolan Springs or Meadview. A paramedic and EMT alone cannot run an effective cardiac arrest and transport. It takes at least 4 people, someone needs to run the code, someone needs to drive, and you need at least two people to CPR. You can only do effective CPR for 10 minutes.

The study, published in the Oct. 13, 2015 issue of Annals of Internal Medicine, found that:

• For patients suffering from trauma, survival was 6.1 percentage points higher for those transported by a basic life support (BLS) ambulance than those who were transported by an advanced life support (ALS) ambulance. Patients with critical major trauma had a 12.5 percentage point greater chance of surviving for 90 days if transported by BLS.
• Patients with acute myocardial infarction (heart attack) were 5.9 percentage points more likely to survive for 90 days after their ambulance transport if they were transported in a BLS rather than ALS ambulance.
• Patients with stroke had a 4.3 percentage point greater chance of surviving for 90 days, when transported by a BLS ambulance.
• There was no survival difference between BLS and ALS ambulances for patients with respiratory failure.
• Greater use of BLS may also save money..

"But we found that basic life support patients were more likely to survive. They were also more likely to have better outcomes on measures such as neurological functioning."

LINKS USC Medical Center C-Booth

C-Booth Code Black

LA Times 1985 article, Tending to Broken Bodies : Heart of County-USC: the Emergency Room