There has long been the suggestion that pre-hospital care can be an industry of diminishing returns when it comes to clinical outcomes. Sometimes, the more money and greater effort you throw at extending clinical practice, the positive effects are more difficult to prove.
We have known for decades BLS saves lives, and this is reinforced by hard evidence. Then, at some stage, someone started to move ALS skills into the pre-hospital field. One of the first was defibrillation.
What was previously an in-hospital, cardiac procedure suddenly entered the ambulance domain- and the results were fantastic. As demonstrated by Anne Holland in her book, early defib (particularly community-initiated defibrillation) has powerfully positive outcomes. Defibrillation started to appear in BLS ambulance vehicles as late as the 1990s and it is hard to believe that before that time, it was an ALS ambulance intervention. Yet now, members of the general public are using defibrillators!
We also know the effect of diminishing returns on the “Chain of Survival”. That is; if someone has not responded to BLS (including defib) and needs ALS interventions, you know they are pretty darn unwell.
Two recent videos by Dr Aaron Carroll (You can watch them here and here) again question the effectiveness of ALS care. Time and again, he presents solid, evidence backed, data from international studies that show patients who receive ALS interventions (…. for most things, trauma, cardiac arrest, MI- the list goes on… ) have worse clinical outcome than those who receive BLS only. Carroll’s language on the topic is exceptionally strong.
While it may seem that the sky is falling for pre-hospital ALS, I would counter by suggesting we take a good hard look at the data and work out what works and what does not. Where can we find clear benefits to pre-hospital ALS? What actions are clearly poor?
Here is something else to consider: Is on-scene ALS delaying transport to hospital? If so, is that operational action a key part of the negative clinical outcomes? It is not unknown for “stay and play” to take over from the “load and go” approach (The best approach is somewhere in between. Have a listen to Dr Cliff Reid talk about it here).
Let’s take a breath and take a detailed look at the research. Examine which ALS clinical interventions show the greatest effectiveness or, at least, greatest promise. At the same time, a review of scene management and interventions is probably timely as well.
Let’s uncover what doesn’t work well. Those are the interventions that need to cease. It is time to respond to the claims of negative patient outcomes- and we should respond rapidly.
But let’s ensure we see what works - and keep those.
Craig Hooper is a health management consultant who specialises in emergency and pre-hospital healthcare operations. He has over 25 years industry experience; strengthening health and ambulance services in the public and private sector of 10 countries. His book "Time to Respond- Pre-hospital Leadership and Operational Management" is scheduled for release in March 2016.
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