More Studies on Advanced and Basic Life Support

ALS still doesn't appear to be better than BLS. This is Healthcare Triage News.


John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics

And the housekeeping:

[dersitzpinkler]

HCT and scishow are my favorite channels. Hooray for actually being able to back up your claims with scientific evidence!

[minwang]

Why last year? I saw the last ALS vs BLS video came out 3 days ago.

[sohailmunir]

One of the criticism I have is patients who received BLS got care quicker than those who received ALS.

[dan]

For those interested here's a critique of the article cited in the video

[michmash]

As always, a thought-provoking video. My favorite point that you made is that sometimes RCT are not ethical/viable, so we need to use the evidence that we can gather.

This is similar to the flack that the dietetics community has received lately about nutrition research. Yes, studies that rely on subject's memory and self-reports will be flawed. But it is REALLY difficult/expensive/possibly unethical to run a long-term RCT on human diets! What the critics fail to recognize is that nutritionists (the ones with good training in science) will also look at other types of research: short-term RCTs, population studies, animal trials, etc. and try to piece the puzzle together from there.

Your tobacco analogy is exactly the one I have been using to explain this...we know cigarettes cause cancer even with a lack of RCTs. So unless someone can come up with a practical way to improve the quality of non-RCT studies so that they are "worthy", we might just have to work with what we have!

[mdkc]

What about conversion of BLS to ALS? We've looked at whether dispatchers screen calls - could it just be that less sick patients are adequately treated by the BLS provider, but with the sicker ones the BLS provider will call for ALS backup?

[deriamis]

Thank you, +Healthcare Triage, for answering the further research concerns. I'll admit, I am still all for ALS, but my mind has definitely been changed on its proper role. I think what the research might be saying is that the it takes to transport the patient to the hospital has much more of an effect than ALS in the field does. I do wonder, though, what the research says about patients that were farther from the hospital versus ones that are closer. The original role of ALS in the field, after all, was that it was supposed to reduce the time to critical care for patients that were a significant distance from the hospital, and therefore outside the "golden hour" treatment window. If ALS doesn't have a role to play in urban areas where the time to the hospital is relatively short, what about longer transports? I would love to know if there's been any research done on that question.

[stephend]

what I don't understand here is what is meant by getting ALS. in the pulseless VT, VF, and PEA BLS and ACLS are almost identical with the exception of pressors and advanced air ways in ACLS. ACLS also includes treatment for afib, a flutter, VT with a pulse, ACS, and stroke / CVA.

Maybe it would be more precise to say that in cardiac arrest (VF, pulseless VT, PEA) BLS performs better than ACLS, but ACLS is more than cardiac arrest.

[donfolstar]

With statistical research (and everything else) don't let the perfect be the enemy of the good.

[poplawsj]

I think it would be more interesting and helpful to try and assess which interventions have better outcomes than comparing ALS to BLS.

I mean, what does that comparison even mean? In the US the interventions ALS can perform compared to BLS vary widely by state and even county! Yes we have the national certifications but state and local laws tend to either narrow or widen what Interventions BLS can perform. Is a BLS with an I-tech certification still considered as giving BLS? In some states BLS are limited to only being able to "assist" with administering 3 medications after consulting with an ER doctor. While in others BLS may be able to give 12 or more medications without consultation from an ER doctor.

Seems any comparison of ALS and BLS wouldn't be granular enough to be meaning full.

[JohnSmith]

I have a question if that is the case then why does it say in the NREMT-B book if having an MI coordinate with ALS before arriving in scene????

[Kaalyn_HOW]

So much love for this. As someone who received ALS in my teens, I cant help but wonder if my dysautonomia (autonomic nervous system dysfunction) and neurological problems that began soon after and have completely disabled me today weren't strongly influenced by that. I've also been revived by standard BLS. No additional complications after other than those to be expected with the main health complication.

[nraynaud]

do you have a proposed mechanism for the worse faring of the ALS? could it be failing on a limited aspect?

[DanielleFromMI]

I'd be curious to know more about the differences in the counties that this study worked with. I know some cities/counties that use BLS more often than ALS do so because they have a privatized and more cheaply run ambulance system that relies on Basic EMTs. In these cases I've generally noticed that the main control of a response to trauma or whatever medical emergency isn't the ambulance but the first responders/firefighters who supposedly have more training? This is just an understanding I've gotten from what I've heard talking to the EMTs that show up to the hospital I work in. So, I could be crazy, but maybe the cities/counties that send a BLS in the study that another city would send an ALS for do so because their first responders are more trained and that affects the outcomes. Cause I agree, it sounds weird that ALS causes more problems than less. Then again getting someone quickly to a hospital is THE most important thing. Very interesting studies.

[ShadowDrakken]

Sounds like if you want a RCT, you're going to have to remove the equipment needed to perform ALS from half of the ambulances entirely, forcing BLS. Then rotate where all the ambulances setup camp every day so that every area gets reasonably equal instances of ALS and BLS ambulances.

[Brounstein]

If me or my loved ones is in this situation, how do ensure/request that only BLS is performed?

[avoisin]

The evidence is compelling. I'd still like to see more thought about WHY ALS is causing problems. From the last video, the guess about ALS meaning longer times to arrive at hospital is a good thought, and it might be possible to get the data on that for a study to help root cause things.

[johngill]

I just want to throw out there, in my rig we have both a basic and a medic on board. At the scene we decide if it deserves als or bls, if it requires bls, I take the pt, if als, my partner does. so I know I get the easier and less complicated pt's, and my partner gets the more difficult ones. this is anecdotal, but it has been that way in every system I've worked for. 4 systems, 9 agencies.

we also have what's called intercepts, where bls care givers will call in an als rig to continue care if cases get to difficult.

I am curious what practices you'd eliminate from als, or add to bls to make it better?

this us not meant to be a decent voice, just right now I've not seen one clue of evidence from the field. of course my pts live they weren't going to die in the first place. my partners however are always in worse condition. that doesn't mean I'm right, but right now these studies are to removed for me to understand the trend they are pointing out, and how it will help, or how to help.

[etchasketcher]

There is actually a trial being conducted right now looking at whether adrenaline is helpful or harmful in the treatment of a cardiac arrest. It is an individually randomised, double blind, controlled trial,
conducted by the University of Warwick in the UK.

[dm_nimbus]

Given the outcomes of these studies, would more paramedics be willing to attempt an RCT?