Physician-manned ambulances could improve the quality of advanced life support (ALS) given to people who experience traumatic out-of-hospital cardiac arrest (OHCA), suggests a study published April 25 in JAMA Surgery.
The researchers used nationwide registry data from Japan to identify 4,382 patients who were transported to emergency hospitals with OHCA following traffic collisions. In Japan, physicians accompany ambulances in some municipalities but not others.
Given this setup, lead author Tatsuma Fukuda, MD, PhD, and colleagues sought to answer two questions: Is ALS associated with better outcomes than basic life support (BLS)? If so, who should perform it?
About 45 percent of the cohort received only BLS before arriving at the hospital, while 36.3 percent of patients received ALS from emergency medical services (EMS) personnel and 18.9 percent received ALS from a physician. ALS involves invasive interventions and medication administration, whereas BLS includes only noninvasive measures such as cardiopulmonary resuscitation, automated external defibrillators and protection of the breathing pathway to improve the chances of survival.
Prehospital ALS performed by a physician was associated with 94 percent increased odds of one-month survival when compared to BLS, and more than double the odds of survival versus ALS provided by EMS clinicians. There were no significant differences in survival when comparing BLS to ALS performed by EMS practitioners.
After propensity-score matching, patients treated by physicians versus EMS showed a 53 percent greater chance of having a return of spontaneous circulation before hospital arrival and were more likely to have a favorable neurologic outcome.
“Physicians should probably be involved in prehospital ALS in traumatic out-of-hospital cardiac arrest cases; however, further well-designed studies are required to determine the optimal prehospital care for patients with traumatic out-of-hospital cardiac arrest,” Fukuda et al. wrote.
The researchers ventured two guesses for why the outcomes were better with physician involvement:
- Physicians are authorized to trust their own judgment and perform interventions immediately. EMS personnel must receive clearance from medical directors, potentially resulting in delays in treatment.
- Physicians might be more proficient at some procedures and are allowed to conduct more advanced interventions.
“To improve outcomes after traumatic OHCA, increasing physician-manned ambulances may be effective,” the authors wrote. “Another effective option may be to permit EMS personnel to perform ALS based on their own judgment and/or expand the range of available procedures that EMS personnel can learn, practice, and perform.”
Fukuda and colleagues acknowledged it would be tricky to generalize their finds to other nations, which might already have more physician involvement in prehospital care or a wider range of interventions that EMS practitioners are permitted to perform. They also suggested cost-effectiveness analyses would be needed before dramatically changing ambulance staffing models.
The issues of cost and availability would be sticking points in the U.S., “particularly in the current climate of emergency medicine and trauma physician shortages,” wrote the authors of an accompanying editorial.
They pointed out the capabilities of EMS personnel in Japan are more limited than other nations. In addition, EMS in Japan aren’t allowed to terminate out-of-hospital resuscitation the same as physicians, which could have led to a survivorship bias because the physicians’ patients who turned up at the hospital were likely to be in better shape.
“Perhaps the intervention, not the personnel, could be saving more lives,” wrote Sandra DiBrito, MD, and Elliott R. Haut, MD, PhD—both with Johns Hopkins University School of Medicine. “Rather than sending physicians into the field, the Japanese system could consider expanding the scope of practice for EMS clinicians to include routine first-line therapies, such as intraosseous catheter placement. Further training and liberalizing restrictions on EMS clinicians could allow higher-quality, timelier ALS that could affect all patients with injuries, not only those in cardiac arrest.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.