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January 15, 2015

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.



From → Healthcare

  1. thebikechurch permalink

    I found the evidence cited in that article disturbing, and disturbingly persuasive (I read through some but not all of the studies). I would love to hear criticisms of it, or to hear contrary evidence, or even a broad review of the debate…

    And it’s certainly possible that firsthand experience with ACLS stuff may help shape a defense of it. Though familiarity has its pitfalls, too.

    • thetinfoilhatsociety permalink

      As a former paramedic I might be able to speak to at least some of this. For quite a while ACLS was stressing intubation and advanced interventions like IV’s and medications to the detriment of plain old CPR. Even stopping for the 20 seconds necessary for a good paramedic to put in a tube meant losing pulse pressure/blood pressure that was slowly built up and you have to start from scratch.

      In 2005 after a large scale study done in Tucson with Tuscon Fire the guidelines were completely changed, particularly for EMS providers. No longer was ALS intervention even considered until 200 compressions were completed; ventilating with an oral airway and bag valve mask was promoted if you were not absolutely confident of getting the tube within 15-20 seconds on the FIRST AND ONLY try, and even IV’s were discouraged unless you could get it while doing CPR, or getting an interosseous as an alternative. Now, regular ACLS still says 30 compressions and 2 ventilations maintained over a two minute cycle, but the much better outcomes are coming from ALS providers in the field who are doing the 200 compressions straight through without doing anything else in that two minutes. Those are the people who are coming into the ER with a pulse and blood pressure, getting whole body chilling for 24 hours – 48 hours and making full, or nearly full, recoveries. I predict that at the next revamping of the guidelines the 200 compressions before anything else will become the standard.

      I will say that after working in a large urban trauma center ER for five years it was simply amazing how many doctors are really very attached to their intubations, even when it means disrupting CPR. And of giving drugs that haven’t been in the ACLS algorithm for over a decade.

      • Very interesting. I hadn’t heard about the work in Tucson. You’re saying that although we start with BLS we don’t always give it enough time. Good insight.

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