Too Much of a Good Thing?
By Kelly Grayson
"Yeah, but these go all the way to 11," Nigel Tufnel, Spinal Tap
In the rock mock-umentary "This Is Spinal Tap," Nigel and his bandmates took special pride in their special Marshall amplifiers that went all the way to 11 when every other band's topped out at 10. If they couldn't top their peers in musicianship, at least they could take comfort in being louder than everyone else.
I've often thought of EMS as the healthcare equivalent to the members of Spinal Tap. If there is a single healthcare profession most likely to crank their metaphorical amplifiers all the way to 11, that profession is us. Even if we can't do it better than everyone else, we can say with certainty that we can do it louder. Just ask any waitress or bartender at an EMS convention hotel.
For years, we immobilized everyone, content to let the radiologists sort 'em out. A generation of EMTs since 1993 were taught to start oxygen therapy with the non-rebreather mask. Entire departments made it policy to run lights and siren to every call. When it came to IV access, we had macho sayings like, "Go big or go home."
We hyperventilated head injury patients for years, clung to PASG application long after it was proven ineffective, and still regard endotracheal intubation as the next step in airway management after oral airways.
EMS rarely does anything by half-measures. Heck, even when we do adopt half-measures, we go totally overboard with it. If you don't believe it, take a look at some of the restrictive treatment protocols out there. They're usually restrictive about everything, not just the areas where caution and circumspection make sense.Changes in clinical practice have come — albeit slowly. Adherence to the tenets of evidence-based medicine has substantially changed the way we practice prehospital medicine. Ken Mattox's studies have shown us a different approach to fluid resuscitation in trauma. Henry Wang has pointed out our flaws at advanced airway management.
More and more systems are turning a critical eye toward the type of calls they respond to with lights and siren. In March, I listened to Bryan Bledsoe at EMS Today point out that our most sacred of cows — oxygen therapy — might not be as beneficial as we had thought, and may in fact be harmful for some of our sickest patients.
New American Heart Association guidelines have radically changed the way we perform resuscitations, with promising improvements in resuscitation rates by doing — now here's the shocker — less. Less emphasis on medications and advanced airway management, and increased emphasis on effective compressions, has already begun to improve outcomes, almost tripling the survival hospital discharge rates at my employer since 2005 in fact.
The PASG, for the most part, has been relegated to the dustbin of EMS history. Spinal clearance protocols are becoming increasingly popular. Supraglottic airways are becoming widely recognized as a safe, viable alternative to endotracheal intubation. More and more systems are using CPAP for their CHF patients.
We're learning to question tradition, and how to critically evaluate research and implement changes in clinical practice based upon research we deem valid. If you look closely enough, the changes in the practice of prehospital medicine are obvious and plentiful.
It's actually within our service delivery model that so many major EMS systems still subscribe to the "more is better" philosophy, despite a dearth of evidence to support the practice. Indeed, studies such as OPALS — still the primary benchmark in most EMS system — proved that EMTs do it better than paramedics when it comes to cardiac arrest outcomes.
Recently, we learned that Columbus, Ohio, is considering a return to BLS-only EMS care, citing a demonstrated lack of benefit of ALS care in improving patient outcomes. Perhaps not surprisingly in the current economy, it is money and politics that are driving the debate, not science.
Predictably, the current EMS administration disputes the committee's recommendation. "A paramedic is vital in saving lives; there is a huge difference," said Battalion Chief Doug Smith, spokesman for the Columbus Division of Fire, in a previous interview.
Never mind that Battalion Chief Smith has nothing other than tradition and conjecture to back up his assertion, whereas a search of the available medical literature can provide a number of studies that prove otherwise.
Even the fire officials' argument that their current system works — with cardiac arrest survival rates nearly twice the national average — is a red herring. Cardiac arrest survival overwhelmingly depends upon effective and timely CPR and defibrillation — both BLS interventions. Evidence of the benefit of ALS is scant, at best.
The fact is, more paramedics are not necessarily better. Let's take Volusia County, Fla., for example. Volusia County contains a number of major tourist destinations such as Daytona Beach and the Daytona International Speedway. With a permanent population of roughly 500,000, swelling to many more during peak tourist season, Volusia runs about 70,000 EMS responses a year with EMT/Medic-staffed transport ambulances and an all-ALS fire department first response. Calls with multiple paramedics on scene are a commonplace occurrence there.
Normally, one wouldn't think you could ever have too many paramedics. That is, unless you have too many paramedics vying for too few intubation attempts. From 2004-2005, Volusia County's intubation success rate hovered at only 45 percent for the ALS first responders, and 88 percent for the transport medics.
Skill rust-out for endotracheal intubation lead them to take the radical step of making Combitubes the primary ALS airway for the ALS first responder paramedics. Now, the King Airway is their current invasive airway of choice, not the endotracheal tube.
The advisory committee that recommended Columbus Fire return to a BLS-only system based its recommendation on a 2005 meta-analysis of 22 previous studies that concluded that ALS care provided no significant improvement in patient outcomes over BLS care. What doesn't appear in the story is the evidence that ALS care does improve outcomes in a number of non-arrest patients -- diabetic emergencies, respiratory distress and acute coronary syndromes, to name a few.
Yet the city officials in Columbus seem intent to swing the pendulum as far as possible in the opposite direction, rather than allow the gravity of current system needs to center it squarely in the middle, such as a tiered BLS/ALS system.
It's not like Columbus hasn't done such a thing before. As little as 10 years ago, they ran BLS/ALS tiered response, and no one has come forward to say that system didn't work. Although it may not be the best choice for every EMS system, tiered response does work.
For example, Boston EMS runs such a system and their medics boast intubation success rates and STEMI recognition on par with their ER doctors. And Boston EMS, as a whole, boasts a cardiac arrest survival rate more than twice that of Columbus.
Ten years ago, the desire for more paramedics led Columbus Fire to switch to an all-ALS system. Now, the more they stretch to stay ALS-only, the more the city seems to recoil in the other direction, in some sort of perverse Frank Starling mechanism.
Seems to me that both sides could find a balance between the extremes by heeding Mark Twain's advice:
"All things in moderation, including moderation."