"Advanced Life Support" Ambulances May Lead To More Deaths 112
HughPickens.com writes Jason Kane reports at PBS that emergency treatments delivered in ambulances that offer "Advanced Life Support" for cardiac arrest may be linked to more death, comas and brain damage than those providing "Basic Life Support." "They're taking a lot of time in the field to perform interventions that don't seem to be as effective in that environment," says Prachi Sanghavi. "Of course, these are treatments we know are good in the emergency room, but they've been pushed into the field without really being tested and the field is a much different environment." The study suggests that high-tech equipment and sophisticated treatment techniques may distract from what's most important during cardiac arrest — transporting a critically ill patient to the hospital quickly.
Basic Life Support (BLS) ambulances stick to simpler techniques, like chest compressions, basic defibrillation and hand-pumped ventilation bags to assist with breathing with more emphasis placed on getting the patient to the hospital as soon as possible. Survival rates for out-of-hospital cardiac arrest patients are extremely low regardless of the ambulance type with roughly 90 percent of the 380,000 patients who experience cardiac arrest outside of a hospital each year not surviving to hospital discharge. But researchers found that 90 days after hospitalization, patients treated in BLS ambulances were 50 percent more likely to survive than their counterparts treated with ALS. Not everyone is convinced of the conclusions. "They've done as much as they possibly can with the existing data but I'm not sure that I'm convinced they have solved all of the selection biases," says Judith R. Lave. "I would say that it should be taken as more of an indication that there may be some very significant problems here."
Basic Life Support (BLS) ambulances stick to simpler techniques, like chest compressions, basic defibrillation and hand-pumped ventilation bags to assist with breathing with more emphasis placed on getting the patient to the hospital as soon as possible. Survival rates for out-of-hospital cardiac arrest patients are extremely low regardless of the ambulance type with roughly 90 percent of the 380,000 patients who experience cardiac arrest outside of a hospital each year not surviving to hospital discharge. But researchers found that 90 days after hospitalization, patients treated in BLS ambulances were 50 percent more likely to survive than their counterparts treated with ALS. Not everyone is convinced of the conclusions. "They've done as much as they possibly can with the existing data but I'm not sure that I'm convinced they have solved all of the selection biases," says Judith R. Lave. "I would say that it should be taken as more of an indication that there may be some very significant problems here."
Training? (Score:3)
like the article says, they would get rushed to the hospital and just received these exact same stabilizing treatments there instead of in the field 10 minutes prior. The only major difference of in the field, than in a hospital room, if you have all the equipment in the field, is the people using the equipment. It is understandable that doctors who have been doing this for decades are better than people newly trained, but it seems to me that obvious for cardiac arrest victims, the absolutely best solution definitely does involve stabilising them right away in the field.
Re:Training? (Score:4, Insightful)
Hospitals have teams. They have ample room to work. Field ambulances have two people. They are extremely cramped. Only one person can work the patient when driving. Finally hospitals have far more advanced equipment than advanced life support ambulances. There is simply no comparison.
Ambulance's job is to stabilize the patient just enough so he can survive the trip to the hospital. Nothing more, nothing less. The conclusions drawn in the article are extremely obvious to everyone in the field, except those who like to get paid for getting the equipment. The main factors in patient's survival in most life threatening conditions that require operation are time to operating table and basic life support. Everything else is just a distraction that threatens patient's life.
The only argument for ALS over BLS is that ALS offers a significant survival chance improvement to offset lost time. This study clearly shows the opposite is true.
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Field ambulances have two people.
Only 2?
When the Sapeur-pompiers premier secours truck turned up the last time I called them they had four people onboard.
If I ever needed a SMUR they'd turn up with a doctor, a nurse, a paramedic and a driver.
(This is in France).
Re:Training? (Score:5, Insightful)
I think living in a country with sane health care practices has colored your perception.
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Different models:
http://www.ncbi.nlm.nih.gov/pm... [nih.gov]
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But the so called "ALS" thingy seems to be an attempt to use the Franco-German model, and if they're doing it with only two people I think they're doing it wrong.
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The difference is sometimes called 'ALS' vs 'Doc-ALS' : http://www.ncbi.nlm.nih.gov/pu... [nih.gov]
There are a lot of tradeoffs in the system, based on things like how many ER physicians you have, population density, and a bunch of resource allocation issues; the differences in outcomes vs expenses is pretty murky.
As this article notes, there are a lot of 'selection biases' that get in the way of studying the topic - basically, apples-to-apples comparisons are tough to come by.
Re:Training? (Score:4, Interesting)
In most cases around here (Finland, one of the better healthcare systems in Europe) we have standard ambulance which is medic/emergency care specialized nurse, driver who is also medic. This is typically a van. There's fairly many of these spread in the region to minimize response times. Then you have specialist doctor unit that typically is called to assist the former when necessary. This is typically a fairly powerful sedan that can drive at much higher speeds. It usually has an MD with training in ER medicine. There's only a few of those, and they are called to assist in more serious cases.
The problem with French model is that you have a lot of resources allocated to a single unit, which means you have a lower unit density for the same cost. That means initial response time goes up, and that tends to have severe negative effects on survival rates.
Re: Training? (Score:2)
Diana Spencer (Score:2)
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President Reagan was being transported to the ER within seconds of being shot; Diana had to wait for both response time and extraction time before treatment could commence. Just not comparable.
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The whole thread is about whether "Advanced Life Support" ambulances are the correct thing. Yes, there ar
Re:Training? (Score:4, Interesting)
I live in a rural area. Rural areas were specifically excluded from the study.
This time of year always reminds me of a call I went on the day before Thanksgiving
I have personally gone on a cardiac call, where the person was asystole when we arrived on scene. I was an EMT-basic. The other two guys were a 20 year EMT-I, and a 20 year Paramedic. A police officer beat us to the scene by 2 minutes and started CPR. The paramedic 2 rounds of cardiac drugs and we got a shockable rhythm. Shocked, good rhythm, packaged her up and took her to the local ER. In the meantime, the hospital had ordered up a helicopter and it was standing by when we get there. 45 minute ride to the nearest cardiac center.
The lady walked out of the hospital 7 days later. She lived another 2 years.
The Paramedic assured me that was the first time he had ever recovered a cardiac patient, in 20 years, who was flatline when he got on scene. The Gods of EMS were with us that night.
Why did she live?
1. Quick effective CPR by the police officer was probably critical. He was less than a block away when he got the call.
2. Quick effective arrival of the ambulance. She lived 4 blocks from the ambulance station. We happened to be in the garage, inventorying the ambulance when we got the call
3. Local ER quickly mobilizing air assets, so that she got to a cardiac center as fast as possible.
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This is why San Diego is trying out two-person crews in pickup trucks [voiceofsandiego.org] as a way to cut costs and response times:
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I live in a rural area. Rural areas were specifically excluded from the study. ... I have personally gone on a cardiac call, where the person was asystole when we arrived on scene...
I was on Ariel [wikipedia.org], which was also excluded from the study, and we applied the cortical electrodes but were unable to get a neural reaction from either patient.
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I remember a doctor telling me the same thing years ago. He said that EMTs are trained to do a fixed list of things, but aren't sufficiently trained to determine which ones will be beneficial for a given patient. Therefore, they always do all of them, whether they're needed or not. This is good for the ambulance companies, since they can charge the maximum amount for every call. It's bad for patients, because it then takes much longer to get to a hospital. In a minority of patients, one of those things
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but it seems to me that obvious for cardiac arrest victims, the absolutely best solution definitely does involve stabilising them right away in the field.
Especially if they don't have one of the fancy forms of health insurance that ensure they won't simply get shipped off to another hospital on a busy night.
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There are lots of other factors as well. Two guys in the back of a van can't work as effectively as an ER team with as many people and as much space as needed. If it's a choice between maintaining continuous chest compressions and figuring out whether the patient's blood potassium is too low or high, which do you do? In a hospital you can do both at the same time. In an ambulance, particularly one that's moving, probably not.
The recommendations for advanced life support changed in 2010 to suggest that t
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All the EMTs I've known well enough to hear about their job have been knowledgeable and professional; but it's always shocked me how much less training(and how much less money) the EMTs get compared to in-hospital medical st
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EMT certification (BLS) here was a 7 college credit hour class.
I strongly believe that, at the end of it, you should be qualified to do almost nothing.
n.b. Former EMT certification.
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I have a good friend who did EMT training. I think it was a two year certificate program. But in our area, to actually work in an ambulance, especially ALS, you essentially have to be a paramedic, which is a four to five year degree program. Note that med school is also a four to five year degree program. MDs then get specialized training for various lengths of time in residency programs, but they also have a much broader focus than paramedics.
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You forget. The survey was about their survival after 90 days.
So the most obvious conclusion would be that ALS managed to keep alive many patients that otherwise would have perished in a regular ambulance.
These patients would have been more frail, and more of them would be unlikely to survive 90 days after the hospital visit.
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like the article says, they would get rushed to the hospital and just received these exact same stabilizing treatments there instead of in the field 10 minutes prior.
Ten minutes?
Theoretically possible here at the terminus of a river and lakeshore parkway with no commercial traffic and a driver taking to the road like a bat out of hell. But looking at the outer ring of suburbs and rural areas more honestly, 30-45 minutes by chopper would be closer to the truth, weather permitting.
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In the case of a cardiac emergency a BLS ambulance can do a lot, as can CPR-trained bystanders. Early high performance CPR and early defibrillation (assuming a shockable rhythm) are crucial. A patient without circulation can be dead in ten minutes from the onset of the emergency so getting them to the hospital is not the priority. CPR and defibrilation is, no matter where that occurs. It is really difficult to do good compressions in a moving ambulance unless it's equipped with the mobile automatic mach
$1200+ for a 15 min trip! (Score:2)
I'm sure a large reason for this roll-out is the insane amount of money these ambulances can charge. This healthcare system rules! USA USA USA /sarcasm
http://www.nytimes.com/2013/12... [nytimes.com]
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The biggest problem with Obamacare, regardless of what the right wing might say, is that it was afraid to go after those who were knowingly overcharging for things.
It's an understandable fear, of course, because what politician wants to be seen as attacking doctors and other life savers? That's been the core of the American problem. You can't free market magic away the fact that you can't negotiate the price of your life. Especially when you're too sick or injured to negotiate at all.
The idea that only h
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Re:$1200+ for a 15 min trip! (Score:5, Funny)
The President himself sabotaged that possibility by accusing doctors of performing unnecessary amputations, which besides depicting surgeons as being suitable for the leading roles in either "Little Shop of Horrors" or "Sweeney Todd", is nonsensical because amputations actually are relatively inexpensive.
I dunno. I heard they cost an arm and a leg.
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The former would be a bit surprising(even when he's being evil, he usually has a pretty good grasp of staying on message and not providing any juicy gaffes); but the latter is something of a commonplace, and isn't so
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amputations actually are relatively inexpensive.
I'm guessing that modern replacement limbs aren't so cheap over time.
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This is exactly the reason people on the left complained about the ACA. The insurance companies have absolutely no incentive to negotiate low prices, they are and always have been payed a percentage of the costs. The higher the costs the more money that percentage translates too. Private insurance is a boondoggle in this country. We should expand the single payer medicare system to cover everyone and just raise the tax rate (and eliminate the high income cap).
It's about bloody time that people stop pretendi
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The biggest problem with Obamacare, regardless of what the right wing might say, is that it was afraid to go after those who were knowingly overcharging for things.
FYI, the ring wing has been screaming bloody murder about cost since day 1. It was the left who kept saying that ObamaCare would reduce costs. By $2500 per family or some such BS.
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$485 actually... just doesn't seem that bonkers to me, sorry. Two medical professionals, probably 2 hours when all is said and done. Any equipment they used on you must be either disposed of and replaced or sterilized. And you're not just paying for those 2 hours, you're paying for them to be sitting around waiting for you to need them. Now arguably that's an externality that perhaps shouldn't be shoveled onto each individual's bill, but changing that would require a very significant overhaul of the sys
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Anything that touches your skin is disposed of or sterilized. The total service would include 2 minutes to your place, 15 minutes to get you loaded up (I've seen this take up to an hour when my neighbor was unconscious for unclear reasons), 2 minutes back, half hour of wiping down every surface you touched or might have touched, half hour of taking stock of what was used and restocking it, and a half hour of documenting all of that for the insurance costs. I don't think 2 hours is an unrealistic estimate.
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It is amazing how many peope can't figure out this simple stuff. What you said is of course true, plus the cost of the equipment, buildings, staff, etc.
It is very simple - figure out how much it costs to run an ambulance service for a year (all costs, including debt service, etc). Divide that by how many calls you expect to respond to. There is your 'per call' price (minimum). Now add in the actual costs of disposables,etc.
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I have personally been billed $485 for an ambulance ride that was literally 6 blocks down streets with no traffic. And, though I was unconscious, I'm fairly certain that fee did *not* include hookers and blow.
Would you have preferred waiting to regain consciousness and walking their yourself? Yes, ambulances can be expensive, but you are paying for depreciation, salaries, benefits and ongoing training of the staff, fuel, maintenance, liability and malpractice insurance and various other costs.
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I can't tell if you're joking, or you're as stupid as any random right-wing loon, like the folks that drove all the smart people out of the Republican party.
All insults aside, whoever pays for your healthcare commands your destiny. Currently my health insurance seems better than say, the VA hospital.
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Sometimes, $3,400 in medical bills later, you find out that you averted serious head trauma.
Cayenne Pepper (Score:1)
Cayenne Pepper [suntimes.com]
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You didn't get that maybe it was nonsense when it was a treatment recommended by people whose expertise is stabbing other people?
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Alright, I went and prepared an article just for you [rationalwiki.org], with cites.
My conclusion: don't use cayenne without a real medical doctor recommending it for you.
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Stupid.
Rather than modern, go to older. (Score:3)
Just put large nets on top of hospitals and equip ambulances with catapults.
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I was joking. Medipults would be ridiculous.
The correct system is to have an underground vacuum tube distribution system so anyone can take the patient, throw him into the accessibly placed MediTube and let compressed air move the poor sod to the nearest hospital.
You will believe I'm also joking in this post, but this is how it's actually going to be in the future I come from.
There was just one ailment that required calling an ambulance instead of using the MediTubes: explosive diarrhea.
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Kids playing doctor. (Score:3)
You have lesser trained individuals using more interesting medical equipment.
What could possibly go wrong?
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You have lesser trained individuals using more interesting medical equipment.
What could possibly go wrong?
Usually the staff of ALS ambulances have more training than regular ambulances. Obviously, they have less than an emergency room physician. What needs to be studied is locality and transit time. Does an ALS make sense in rural areas, where the nearest hospital is 30 minutes away? Does it provide a better mortality rate than a helicopter (which costs significantly more)? Or maybe, it's just the opposite where ALS is more effective in metropolitan areas where heavy traffic congestion can make a relatively s
Princess Diana all over (Score:2)
Here, the general rule is scoop and go whereas in France the idea is perform treatment on the spot then get the person to a hospital.
This difference was used to explain why she died (bled out from internal injuries). The idea was, and as others on here have already commented, had she been taken directly to a hospital she had a better chance
I really thought this a few years ago. (Score:2)
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Article and Summary are Baseless (Score:4, Interesting)
Firstly, my bias is I'm a paramedic (and software engineer) who works in a progressive cardiac arrest system with survival numbers roughly twice the national average for all arrest etiologies and three times the average for witnessed VF/VT arrests. We use community Hands-Only CPR campaigns, dispatcher assisted CPR, BLS first response, aggressive ALS care, and specialty cardiac arrest receiving centers to achieve these outcomes.
Secondly, this study adds nothing to the existing literature except to confirm what we already know about variable outcomes across the US. The methodology is shaky at best to make such lofty causality claims as retrospective registry data spanning such a wide swath of the US is bound to obscure the better systems from the worse systems. Retrospective reviews of data from the Resuscitation Outcomes Consortium (ROC) group has found extremely variable resuscitation quality even among study sites. What is crazy is that Sanghavi is consciously ignoring the fact that the high performers in his dataset all come from systems with ALS care!
Regardless, we already knew that the basic treatments in cardiac arrest care, namely chest compressions and defibrillation, are the true foundation to survival to discharge neurologically intact. OPALS proved this point back in 2006, and it has been confirmed in nearly every large study of cardiac arrest since. High performance CPR--sometimes called Pit Crew CPR--is increasingly common and has been driving improved survival to discharge across the world. In our area you will receive at least one fire engine, two ambulances, and possibly a supervisor vehicle to any cardiac arrest. Why? So we have enough manpower to ensure that high quality chest compressions continue the entire time.
However, focusing on the basics is only part of the success story for out of hospital cardiac arrest. Dr. Bently Bobrow, and others out of Arizona's Sarver Heart Center and the SHARE group, found that implementing a bundle of care including focused BLS care vastly improves survival to discharge. They did this for the entirety of Arizona. And that's the point, that an entire system of care must be in place to realize the largest gains. It starts with early recognition of cardiac arrest by bystanders with dispatcher help, early bystander CPR directed by dispatchers, early BLS care, followed by aggressive ALS care that adds to the basics, resulting in transport only after Return of Spontaneous Circulation (ROSC) to the most appropriate cardiac receiving facility, where the patient will receive the appropriate intensive care with follow-thru to discharge rehab.
If you take the body of knowledge for OHCA you realize that there is no silver bullet. CPR alone is not enough. Defibrillation alone is not enough. No medication alone will change outcomes (the first large RCT of epinephrine started this year in the UK since studies on dogs in the 70's, and the ALPS trial is finally looking at antiarrhythmic medications). You need a silver chain (h/t to Dr. Snyder). You need a system of care. For a look at what we really need to be doing to advance the care of Out of Hospital Cardiac Arrest (OHCA) patients you should read Mickey Eisenberg's book "Resuscitate!" or the recently published commentary by Jeffrey Goodloe, "Optimizing Neurologically Intact Survival from Sudden Cardiac Arrest: A Call to Action". Attempting to use outcome data from a larger, uncontrolled registry (such as this CMS data) to do anything other than form a hypothesis is extremely misleading.
Does Sanghavi's research really prove ALS care is not necessary and the patient should be transported to a hospital? Not at all. Worse still, Alan Zaslavsky's statement that these patients need to be brought, " as quickly as possible to hospital treatment," is patently absurd. Every one of the systems of care they point to which have the highest survival to discharge rates do the exact opposite. In Seattle/King County (Washington) or Wake County (North Carolina) you're not slapped on a stretcher and driven to a hos
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Amen, brother. Comparing survival rates of in-hospital cardiac arrest cases and pre-hospital cardiac arrest cases is an absurd comparison. The are not the same population, at all. Given the mean response time for ALS to reach the arrest patient in the field, a 10% number is impressive. Definitive care is definitive care and the sooner it is delivered, the better the outcome, period. Adding the transport delay the time to definitive care will drive survival rates down. This has been well-e
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I'm a 10+ year medic myself in a Northern rural EMS system with an average response time of 10 minutes and an average transport time of 20-25 non-emergency and 15-20 emergency. That being said we had a large coverage area and were the last ALS service on the rural fringe of a large metro area so had outlying areas as well as mutual aid calls for neighboring BLS services. So 20+ minute response times were common and my personal longest 911 (not transfer) was 52 minutes. The transport time to a definitive
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Another problem is urban environments with Fire based non-transport ALS where theres an additional transfer of ALS care on scene to the transport crew invariably burns time. In a well coordinated system that should be minimal and the fire based EMS often provides a 3-5 minute jump on scene arrival time for EMS (typically these systems then have a somewhat lower density of transport ALS units than a pure transport only service).
Here the fire department is CPR trained, but CPR should be given only until the AED is connected and running. Then, it's AED only, because if CPR and the AED didn't bring them back (to a stable heartbeat), then nothing the fire department can do. The Ambulances are 5-10 minutes out, and in good cases, the fire department can beat them by 5 minutes or more. Though, in off-times the fire response will be worse. Most areas are covered by multiple overlapping crews, and if the nearest is deployed somewhere
Another /. story that doesn't link to the paper (Score:3)
Sigh. Another Slashdot story about a new article published in a scientific journal, another Slashdot story that fails to link to the original published paper. I just noticed that the "News for nerds. Stuff that matters" tagline no longer appears on the Slashdot front page; this sort of omission is probably one of the reasons why.
For people who are interested in the actual data:
Sanghavi, P. et al. "Outcomes After Out-of-Hospital Cardiac Arrest Treated by Basic vs Advanced Life Support. [jamanetwork.com]" JAMA Intern Med Published online November 24, 2014. doi:10.1001/jamainternmed.2014.5420.
And here's the JAMA press release [jamanetwork.com].
It can't lead to more deaths. (Score:1)
Only more births can lead to more deaths.
Each born person tends to die only once, no more, no less.
Seriously? (Score:2)
From TFA:
That’s according to a study published Monday in JAMA Internal Medicine, which suggests that high-tech equipment and sophisticated treatment techniques may distract from what’s most important during cardiac arrest — transporting a critically ill patient to the hospital quickly.
The TFA mentions about a study on JAMA but there is NO LINK to the real article/study? Or the author does not know how to properly cite the source he is talking about? I have to dig it out by myself and it is at http://archinte.jamanetwork.co... [jamanetwork.com] ... I hope people stop writing an article like this when they don't properly give a proper citation...
Ambulances (Score:2)
Completely meaningless figure; what was the survival rate for all patients, not just those that had already made it 90 days, if there were 3x as many making it to 90 days then that would still be a plus.
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Article clarifies what the summary wrote badly, that the number did indeed refer to all patients and not just those that had made it 90 days.
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Was selection bias accounted for?
If advanced ambulances are sent to the really horrific problems and basic ambulances to the basic problems then a result like "more people die near the advanced ambulances" is going to a consequence of the selection not the service. This conclusion could (in the lack of understanding that makes up the large majority of politicians) result in more harm being done to the general welfare instead of current levels of good.
There seems to be an additional selection bias implied by the article. It appears they are only counting live bodies that make it to the hospital.
ALS should be able to get more borderline patients to the hospital which later die while with BLS they are more likely to be declared dead either
at the scene or before they reach the hospital and therefore not counted towards that number.
JAMA Study and Clickbait Headline (Score:1)
There are several likely reasons why you are seeing these results. First, look at the date of the study period (January 1, 2009, and October 2, 2011). During this time, the American Heart Association standards for CPR called for inserting an airway first, following by establishing breathing (or rescue breaths) and then perform cardiac compressions. We now know that this is incorrect. Recent studies have shown that in cases of cardiac arrest, compressions should begin immediately and should be continuous. Th
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Very surprised to read this. (Score:2)
Thought that was settled. Stabilizing victims for transport has been SOP in Germany, and has been shown to provide worse outcome than the simple get-them-into-the-ER approach previously favored in the states.
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Thought that was settled. Stabilizing victims for transport has been SOP in Germany, and has been shown to provide worse outcome than the simple get-them-into-the-ER approach previously favored in the states.
[citation needed]
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Google it. Scoop and run has much higher survival rates. Paramedics don't have the tools, the training or the ability to do the things a doctor can do in an ER. The only way for a stabilize and transport system to work better would be to have multiple physicians riding around in ambulances that have all the facilities and equipment that an ER room does. The scoop and run system on the other hand will get a patient to an ER with the maximum amount of time for the ER to deliver care.
There is conclusive resear
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See some information lives outside the Internet.
This little factoid was related to me by my sister who is a German M.D. and happened to intern in the US so she got to practice both approaches.
Want to check if this is correct? Then Google is your friend.
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Oxygen administration? (Score:1)
I wonder if there's a link between ALS ambulances and the practice of giving oxygen to heart attack patients?
A recent study in Victoria, Australia found that there was a 20% increase to the damage to the heart [abc.net.au] if given oxygen by ambulance paramedics.
Perhaps, in general, the BLS ambulances don't carry as much oxygen and thus administer it less frequently?