Academic Studies Vs. Real Life In The Field

While flying to Milwaukee recently, cruising at 35,000 feet, I found myself catching up on my professional trade journal reading. My standard practice is to pile the reading materials from fire and EMS professional trade journals that come in during the course of a month into a corner of my office and then catch up on reading them during flights.

While thumbing through a well-known trade journal, there it was - another article talking about a physician who probably got some grant money to do a study on the effectiveness of pre-hospital care by paramedics. The article discussed two studies conducted at the Los Angeles Medical Center and Southern California Medical Center and compared those patients brought in by ambulance and those who arrived by some other means. Unfortunately, both studies are a direct indictment of the Los Angeles Fire Department and the excellent EMS system it operates.

The first study was published in a surgical journal and was titled, "Paramedic Vs. Private Transportation Of Trauma Patients: Effect On Outcome." The study compared 4,856 EMS patients with 926 non-EMS patients and basically said trauma patients transported to hospitals by friends, relatives, bystanders or police had a better survival rate than those transported by paramedics in the Los Angeles Fire Department EMS system.

The second study, "Emergency Medical Services (EMS) Vs. Non-EMS Transport Of Critically Injured Patients: A Prospective Evaluation," was published in the same surgical journal by most of the same physicians involved in the first study. This study compared 103 serious trauma patients and concluded there was no significant difference in mortality between those brought in by ambulance and those who arrived by some other vehicle.

The study, however, also concluded that those brought in by ambulance took twice as long to arrive versus those brought in by private conveyance. Did they really need a study to find that out? Of course it is going to take longer to transport somebody to a hospital by ambulance.

A victim who was transported by a friend, relative or bystander was probably placed in a vehicle within moments after the incident, probably could walk with assistance and the driver probably endangered other lives by driving rapidly to a hospital - probably running some red lights along the way.

On the flip side, with ambulance transports, there is a time lapse from the incident until someone calls 911. The dispatcher must process the call and dispatch the ambulance and any other apparatus; then there is travel time to the scene. Other factors that can delay transport to the hospital include whether the patient must be extricated from a car or from a multi-story building, excited family members, etc. The world of working a code in a dark alley is a little different from the nice, clean, well-lighted, well-controlled environment of an emergency room.

The authors of the studies do not factor any of these "Oh! By the way…" issues and basically conclude that paramedics waste time securing airways, immobilizing patients and starting IVs. One can conclude that the authors of the studies clearly advocate "scooping and running" with the patient to the hospital without worrying about the most basic of basic life support such as airway management.

I am not advocating sitting in the back of an ambulance three blocks from a Level 1 trauma center for 20 minutes trying to get an IV with a patient who has a gunshot to the chest. But these unfair and subjective studies that look at one EMS system, do not calculate other factors and contend that paramedicine is ineffective need to redefine their hypothesis, data and analysis, and experience the real world of working in the field.

Over the last several years, speakers have been stomping through conferences, writing articles or doing studies declaring that there is no scientific evidence for the clinical effectiveness of advanced life support (ALS) level of care in the out-of-hospital setting. The basis of their argument indicates that ALS intervention in the field is actually harmful or has very little benefit to a seriously injured or ill patient.

As I read these articles or listen to these speakers, I cannot help but think we have come full circle. It was a little over 30 years ago when the National Academy of Sciences, National Research Council published its famous white paper, which propelled the formation of EMS systems. The 1966 paper, "Accidental Death And Disability: The Neglected Disease Of Modern Society," said people were dying needlessly because of poor pre-hospital provider training and care, equipment and emergency room care.

Are today's authors, researchers and speakers suggesting we retreat to the pre-1966 method of treating and transporting patients? Are they suggesting we go back to the "ambulance driver" days with one person driving an ambulance and no one tending to the patient in the back of the vehicle? From what I have heard and read, yes, they are saying it without putting into those exact words.

In case you're worried that these are the only studies on the effectiveness of ALS in the pre-hospital setting - fear not! There are plenty of studies showing that pre-hospital care decreases mortality and morbidity. Studies out of Boston and the Chapel Hill, NC, School of Medicine clearly show the benefits of ALS care in the field for trauma victims. In the case of the Chapel Hill study, it was quite comprehensive and exhaustive with a sampling of 12,417 trauma patients.

Another study reviewed all the literature on the efficacy of ALS. The authors did an extensive review of all the applicable and available literature through computer searches and other means from 1966 to October 1995. The results of their study showed the terms of methodological research differed from one study to another. Of the 51 articles reviewed, eight concluded that ALS-level care is no more effective than basic life support. Seven concluded that it is effective in some applications, but not for others. And the remainder demonstrated effectiveness. The strongest support for ALS-level care was in the area of responses to victims of cardiac arrest.

So in closing, just don't get rid of those ambulances and paramedics quite so fast after some number crunchers get some grant money and tell you what you do has little or not benefit to the patient. Maybe they need to leave the confines of their nice, clean offices and do a little riding in the field.