My column on the fuzzy line between ALS and BLS capabilities raising the impertinent question of whether ALS capabilities are necessary anymore must have hit a few nerves. From the standpoint of an author, hitting any nerve at all is good thing because it means people are reading. (I should mention that hitting a nerve is different than getting on one. A sign posted in the med room of an ED where I used to work proclaimed, "I've got one nerve left, and you're stepping on it!" I hope we don't get to that point.)
In this column, I'll try to address some of the clinical points raised by readers. I'll tackle some of the more philosophical considerations in a later piece.
External hemorrhage control
A.J. Heightman, the editor of JEMS, questions my contention that prehospital care has been proven to save lives in only two situations: the provision of electrical therapy to patients with pulseless cardiac arrhythmias and the provision of airway management. "What about external hemorrhage control and fluid resuscitation?" Heightman asks.
The key term here is the word proven. If one looks at the literature of EMS, I don't think any studies demonstrate that external hemorrhage control saves lives. There are probably a number of reasons for this. We've been doing it for years; it's so much a "common sense" maneuver that no one would disagree with it; and it would be hard to do a formal study in which volunteers offer to not have their wounds treated. It's of interest that in the "2000 ACLS Guidelines," the chapter on first aid considers external hemorrhage control a Class IIb intervention (an "acceptable, safe, useful treatment, considered as an optional or alternative intervention" not necessarily the "intervention of choice"). The use of pressure points in the elbow or groin falls within Class "Indeterminate" (research doesn't support a final classification). I think, and the rest of the world probably thinks, that external hemorrhage control works, but can we prove it? Probably not.
The other thing to consider is that, by and large, bleeding that causes death in the field often comes from noncompressible sites ruptured aortas, abdominal injuries or gastrointestinal bleeding that are probably not amenable to EMS care. Even so, BLS or ALS providers can perform external control of bleeding by direct compression equally well.
Does fluid resuscitation of trauma victims save lives?
There's a fair amount of evidence to suggest that in the majority of cases it makes no difference, and it may even be detrimental to certain patient groups. Studies of aggressive fluid resuscitation have shown that patients with blunt chest trauma tend to do worse when administered large volumes of fluids. As a result, some EMS services no longer administer high-volume fluids to trauma victims, but simply establish IV access and give fluids in smaller doses.
I don't know that I'm mentally at that stage. I'm probably still too fixated on numbers to abandon the pleasure of seeing a blood pressure rise above 100 mmHg. But I would agree that restoring blood pressure to normal is probably not necessary or desirable before establishing definitive control of bleeding. This is a larger topic for another time. In reference to this discussion, I think the research sheds doubt on fluid resuscitation as a "proven" concept.
Heightman also raises the issue of decency. Would an EMT want to use rectal diazepam (Valium) under the public's eye in a department store? Probably not, but the same would be true of a paramedic. However, the paramedic has a more socially acceptable option in starting an IV.
The deeper issue: Does the BLS provider's inability to perform the more modest procedure result in a lack of optimal on-site patient care? If we have to move the seizure patient from the second floor of Sears to the ambulance to provide a measure of privacy, does that brief delay cook a few extra neurons? Good question. I scurried to the literature for an answer.
There are a lot of ways to give anticonvulsants. Although we address only IV and rectal administration of diazepam in EMS, intramuscular injection (IM) is an alternative, but absorption is somewhat erratic. The most promising noninvasive means for anticonvulsant administration seems to be nasal. There is literature indicating nasal midazolam (Versed) can be used to halt seizures in children up to 14 years old. Although no data yet exists on the efficacy of diazepam by this route or on midazolam use in adults, logic would dictate that the same effect would occur in patients given nasal Valium. More studies are necessary to determine optimal dosing, but it seems like a promising avenue of investigation. If validated, the use of nasal Valium or Versed in the entire EMS patient population would be a valuable modest adjunct to the BLS provider.
While we're on the subject of routes of drug administration, I wondered if any work had been done with diazepam administration through a laryngeal mask airway (LMA). I could find only two works that addressed the concept of drug use via the LMA. As you may know, the LMA fits over the glottis, but does not directly cannulate the trachea. To ensure intratracheal drug delivery, you have to place a long, flexible plastic catheter through the LMA into the trachea. In one study, this passage was successful only 27% of the time. Another study looked at lidocaine levels in patients who received the drug via an endotracheal tube or an LMA. Plasma drug levels were much lower when given via the LMA. The LMA is a great airway adjunct, but probably not very good as a drug delivery route.
Protocols vs. education
I also received an interesting e-mail from Paul Misasi of Wichita, Kan. He indicates up front that he's a conservative, which automatically puts him at odds with me. I'm not sure that's really true.
His understanding of my article is that I think prehospital care should be exclusively protocol-driven and that paramedics are a luxury we can do without. He illustrates his point with an aviation analogy. You can take monkeys and teach them to fly airplanes, pay them in bananas, and they'll be happy. His contention is that I'd be happy regressing EMS to a protocol-adherent, poorly educated troop of lower primates.
I don't think a totally protocol-driven system is possible or desirable. No matter what level of technical service it provides, the very nature of prehospital care is unpredictable. A high level of clinical suspicion, accompanied by original, imaginative care, is occasionally required. It's impossible to be an effective caregiver when functioning by protocol alone. Accomplishing this task requires a high level of education, no matter what technical devices or care techniques are rendered.
To use a very simple analogy, it doesn't matter if prehospital providers give the diazepam via IV or rectally as long as it's an appropriate situation with an awareness of the proper dose, cautions and side effects. In fact, I would argue that a move toward simpler technology paradoxically requires more education (especially at what we now see as the BLS level). Thought processes must be expanded from the specific to the general, and more mental effort must be expended. Prehospital providers must learn to look at overall patterns of pathophysiology to determine optimal care rather than focusing on a single complaint or physical finding. Further education also results in the ability of paramedics and EMTs to better evaluate treatment options, conduct EMS research and advance the profession of prehospital care.
You can take monkeys and teach them to fly airplanes, and you could also take a roomful of monkeys and typewriters and eventually get Shakespeare. But you get hollow, ineffective performance lacking nuance, meaning or understanding.
In EMS, it's far too easy to be reactionary rather than progressive. It's my hope that Misasi and others like him will take the energy and enthusiasm engendered by this debate to critically examine the local practice of prehospital medicine and become true contributors to patient care.