BLS vs. ACLS
A New York Times article caught my eye a few days ago: “Doing more for patients often does no good.” Oh, good, I thought, another voice of reason in an era of hyper-intervention. Everybody who reads this blog knows that I am anti-intervention when it comes to health care. The tired “less is more” phrase definitely characterizes my view of medical treatment. Maybe, I thought, there’s some new research making my argument. Well, there’s new research, but it, and the article, are not helpful
Aaron Carroll, a pediatrician and blogger, brought to his readers attention a new JAMA article in which researchers seemed to have determined that advanced cardiac life support (ACLS) is no better than basic life support (BLS) and that ACLS is being used indiscriminately and ineffectively. Specifically, the researchers looked at the Medicare ambulance billing for patients who had been admitted to a hospital after an out-of-hospital cardiac arrest. They compared outcomes of those who had gotten billed for BLS vs. those who had gotten billed for ACLS. They said in their conclusion “Patients with out-of-hospital cardiac arrest who received BLS had higher survival at hospital discharge and at 90 days compared with those who received ALS [ACLS] and were less likely to experience poor neurological functioning.” Dr. Carroll then mentions similar studies that seem to support this conclusion, then uses these as evidence that “doing more often does no good”.
Wait a minute.
BLS is called basic for a reason. The tenets of BLS are Airway, Breathing, Circulation. If the person is not breathing you breathe for them. If their heart is not beating you do chest compressions or, these days, use a defibrillator if you have one handy. There is plenty of evidence that BLS saves lives. Lives that have a chance of being saved, that is. People who need BLS are, say, a child drowning in a pool, a young man with an undiagnosed cardiac rhythm disorder, an older man with certain types of heart attack. These are all critical events but, with basic intervention in a timely manner, reversible. The timely manner part is critical here. Because a person who could be saved with BLS will, in a very short period of time, progress to needing ACLS. Why? A very short period of not breathing or not having a heart beat doesn’t produce widespread systemic effects like a prolonged period does. Therefore, OF COURSE patient who get BLS do better than those that progress to needing ACLS.
ACLS doesn’t have basic in the title for a reason. ACLS is big medicine. Medicine like you need on TV. It requires big tubes in major vessels, ventilators, powerful drugs, and people who know how to use them. People who need ACLS generally have not responded to more basic measures, or have a disease process that can’t be overcome by basic measures. Therefore, OF COURSE patients who get ACLS do worse.
Writing an article in a major publication suggesting that sending ACLS providers (who also do BLS, by the way) for every emergency is a wasted resource and a cause of overtreatment is misleading at the very least. I don’t know when the last time was that Dr. Carroll was in an emergency room or code situation on the wards or on the street, but health care providers don’t jump straight to ACLS. We do our ABCs first, grab a mask to ventilate if we need to, attach a defibrillator to see what kind of rhythm the patient has if any, do chest compressions or defibrillate. It is only after those things don’t work that we go to ACLS.
Now, if Dr. Carroll had argued that we do too much aggressive resuscitation of patients who are unlikely to get better or who will have poor quality of life afterwards, I’d totally agree. But that is not an assessment out-of-hospital providers can make.