Ont realizes Advanced paramedics save lives

[Armymedic]

comments to follow:

http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20070523/paramedics_070523/20070523?hub=TopStories

CTV.ca News Staff
 
Updated: Wed. May. 23 2007 10:55 PM ET

Providing paramedics with more training and the ability to perform more advanced medical procedures could save 20,000 lives a year in North America, finds a new study conducted in Canada.


The Ontario Prehospital Advanced Life Support (OPALS) Study was a controlled clinical trial conducted in 15 cities before and after the implementation of a program to provide paramedics with advanced life support (ALS) training on how to help patients with out-of-hospital respiratory distress.


"If you want to save more lives, we need to provide advanced life measure to any patient having trouble breathing," lead author Dr. Ian Stiell, a senior scientist at the Ottawa Health Research Institute, and Emergency Department physician at the Ottawa Hospital, told CTV News.


The study looked at 8,138 Ontarians in 18 urban communities attended by paramedics for respiratory distress either before or after implementation of ALS training in Ontario in 1998. During the first phase, no patients were treated by paramedics trained in advanced life support; during the second phase, 56.6 per cent of patients received this treatment.


They found that patients in the ALS phase were more likely to arrive at the hospital in improved condition (45.8 per cent compared to 24.5 per cent); were more likely to achieve the highest score in a test of brain function (62.5 per cent compared to 52.3 per cent); and were more likely to survive overall.


"We found that training paramedics to provide advanced care to people in respiratory distress decreased the rate of death from 14.3 per cent to 12.4 per cent," said Stiell.


"Although this may seem like a small amount, when you consider that more than 2 million Canadians and Americans are transported by ambulance each year for this condition, the impact is substantial."


Stiell estimates that at least 2,000 Canadian lives would be saved if more paramedics across the country were trained in ALS.


The study also found that patients in cities with a population of more than 100,000 were more likely to benefit during the second phase of the trial.


The results of the study -- the largest of its kind - will be published Thursday in the prestigious New England Journal of Medicine.


One in every five ambulance calls is to help someone having trouble breathing. The most common causes of respiratory distress in this setting include congestive heart failure, pneumonia, chronic obstructive pulmonary disease, and asthma.


Paramedics with ALS training can insert breathing tubes and administer intravenous drugs -- treatments that are usually given in emergency rooms. Those without are limited to giving oxygen, and in some cases providing inhalers and medications that dissolve under the tongue, such as nitroglycerin.


Advanced Life Support (ALS) training for paramedics was introduced throughout Ontario in 1998, but plenty of paramedics still don't have the training. Some provinces have no advanced paramedics.


But as studies such as this one demonstrate how effective well-trained paramedics can be in saving lives, interest in ALS is growing. At the few colleges that offer the advanced training, there's usually a waiting list for the three-year training programs.


"There is a demand out there," said Dr. Josh Ip of the Paramedic Academy of the Justice Institute of B.C. "I would encourage people with an interest in pre-hospital care medicine to perhaps choose this as a career."


As well, more towns and cities are looking to hire ALS-trained paramedics. The City of Ottawa wants at least 50 to 60 per cent of its paramedics to have advanced training but has discovered they are a hot commodity.


"We're not able to have advanced care paramedics on every life threatening call because they're just not there. We're not able to attract or recruit them," says Anthony Di Monte of the Ottawa Paramedic Service.


"This study proves that advanced care paramedics can make an important difference for those suffering from life-threatening respiratory difficulties."


With a report from CTV medical specialist Avis Favaro and medical producer Elizabeth St. Philip

 

[Armymedic]

I put this article up to highlight a couple fundamental differences between a civilian paramedic, and a military medic.

At the QL6 level a military med tech should have the same knowledge and skill as the paramedics highlighted in the article. The largest difference you will see is that civilians deal with a large majority of medical conditions (breathing and cardiac problems) with occasional trauma. Where as our military prehospital role is primarily trauma, with the rare breathing and cardiac condition occasionally. 

For anyone joining the military who thinks that being a civie paramedic is what they want to do, then I hope you enjoy your QL3 course, cause that is where the similarities end.

 

[herseyjh]

I was struck by the glowing praise of pre-hospital ALS.  For a while now there has been a few mixed messages regarding the effectiveness of ALS interventions in the field.  I will have to track down the study and take a look.

 

[Donut]

I seem to recall, from the preliminary results presented at the Ontario Paramedic Conference 2005, that ALS had a higher mortality rate when involved in trauma calls.  I should read the article, too.

 

[bisonmedic]

In regards to the ALS Paramedics, it is a fantastic idea to have them, but for the needs of the CF, the PA and senior medics seem to do just fine. It is nice to have all those fancy skills, but in our job it's how fast you plug the hole and how fast you get them to the OR. We as medics have a hard time maintaining our core skills let alone any advanced procedures. :cdnsalute:

 

[Armymedic]

They did have a higher trauma mortality level. Obviously due to the experience level and advanced training. In fact, in a diferent article it stated that after repiratory and cardiac, minor trauma was the next most frequent call.

To those of use who has spent any time on a city amb...well, duh. (Oh, another call to a granny who's fallen and broke her hip. Oh gee, Spring, another kid in a bicycle crash.)

 

[bisonmedic]

Ah yes, the late night calls to the "Lizard Ranch" ( old folks home ). The great majority of calls that are done on civy street are BLS calls. The ALS type of service was drawn up mostly for the rural parts where they did not have the hospitals of the big city. Most time the transport times for the larger centers are short, therefore the advanced procedures done on patients could delay emergency care at the hospital. This is important with cardiac cases that require clot busters ( eg TPA< etc). It is nice to have that large toolbox of tricks, but sometimes BLS with rapid transport trumps stay and play with ALS.

 

[Donut]

They did have a higher trauma mortality level. Obviously due to the experience level and advanced training. In fact, in a different article it stated that after repiratory and cardiac, minor trauma was the next most frequent call.

To those of use who has spent any time on a city amb...well, duh. (Oh, another call to a granny who's fallen and broke her hip. Oh gee, Spring, another kid in a bicycle crash.)

That's true in the majority (all?) of Ontario's system, but not at all true in a targetted EMS system, such as in other parts of North America.  In some systems, ALS do ALS calls, and BLS do BLS calls, according to dispatch criteria (MPDS or similar)...some send both, and the call is handled by the appropriate level. This layered response has yet to be studied with the same academic detail as OPALS is attempting to in Ontario.

The article in the NEJM is related only to SOB calls, and doesn't touch on trauma outcomes.

From http://www.ohri.ca/programs/clinical_epidemiology/opals/protocol.asp (the study protocol outline)

For major trauma and respiratory distress,the evidence for ALS programs is even less compelling. Endotracheal intubation may reduce neurologic sequelae for head injured patients or improve outcomes for other conditions but this has never been clearly demonstrated. Furthermore, there is significant risk of morbidity from increased intracranial pressure or aspiration when spontaneously breathing patients are intubated in the field. Similarly, recent studies have suggested that prehospital IV fluid infusion may exacerbate hemorrhage. Many studies have attempted to determine the value of prehospital ALS for trauma patients by comparing two competing strategies, rapid transportation versus field stabilization with ALS interventions. These studies are all limited by many methodological weaknesses. No studies have demonstrated improved respiratory distress patients survival or morbidity with prehospital ALS and there is some evidence that inappropriate prehospital drug therapy may actually increase mortality.


The latest Annual Report from OHRI shows that in 81.25% of trauma calls ALS made no difference, 11.87% had a worse outcome with the implementation of ALS, and 5.43% had better outcomes with ALS involvement. http://www.ohri.ca/programs/clinical_epidemiology/opals/AnnualStatisticalReport20012002.pdf pp 32-37.

72% of the included patients had "Severe" or "Life Threatening" injuries.  Only 4% were "Minor".  This was a retrospective study of the Ontario Trauma Registry based on 13 Trauma Centers in Ontario...not exactly the kid who falls off his bike or granny with the sore hip.

DF

 

[bisonmedic]

I'm all for the ALS crews, could use them where I live. Although they may not make the greatest difference in some of the trauma, they do help with providing faster tmt of many conditions that usually get looked at in the emerg dept. If they can start faster the patient has a better chance of a good outcome. Just remember PARAMEDICS SAVE LIVES, EMT'S SAVE PARAMEDICS. ( Quote from wise old amb partner from Alberta )