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’