JC: Is there any point teaching paramedics? St.Emlyn’s

bls or alsOK, so it’s a provocative title, but it reflects my thoughts when I first saw this paper on teaching paramedics and in particular when I saw the conclusion.

‘….the evidence indicates that there is no benefit of advanced life support training for ambulance crews on patient outcomes’

Really? That reminded me of this……

OK, the analogy doesn’t work completely, but it’s a great song!

Anyway, I’m interested in critical care, I LOVE education and I’m interested in pre-hospital care so this paper would appear to be right up my street, but is there really no benefit to education? If so then many of us have wasted an awful lot of time and effort over the years and if it’s true what’s the mechanism here? How can education not lead to any benefits?

Education should lead to better understanding and therefore better outcomes in time critical interventions, or should it? We need to look at this paper in a little more detail to see what we can find.

As always have a look at the abstract below and then go online and have a look at the summary and full paper. I think it is open access (from UK in any case).

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Let’s ask some questions.

[DDET What kind of study is this]
This is a systematic review of all papers looking at educational interventions for paramedics in the treatment of trauma victims. Confusingly for the UK audience they refer to ALS as the educational intervention which over here means the course regarding life support due to cardiac (largely causes) and not trauma. What the authors mean is interventions where ambulance crews had received PHTLS or ATLS training (or equivalent).

This is a systematic review and they have done a good job of looking through a number of databases, references and other data sources in the way that Cochrane reviews do. The search approach is pretty good and I think we can be fairly confident that they have not missed any significant papers. Of note they looked for certain types of study.

Again, these are reasonable restrictions as these types of trial are most likely to give us a good answer to the question.


[DDET What did they find?]
I was surprised. Despite the large number of patient:provide interactions, the large number of services worldwide and the enormous investment in training there were just 3 trials that met the inclusion criteria, of which one was an RCT.

This is a poor evidence base on which to conduct a review and to a large extent this is the major problem with this paper. Reviews can only be as good as the data included in them and significant flaws are evidence in all papers.

Similarly the date of the papers relevant to the current world of trauma care is important. The included studies were published in 1998, 2004 and 2008. So much has changed over that period in terms of taught interventions that we would struggle to link those papers as ‘similar’ interventions.

The authors have looked at the three trials and concluded that in all three there is little evidence to support ALS training. In particular they note trends to increased mortality with ALS in the Arreola-Risa study and in an a-priori subgroup of patients with low GCS in the Stiell paper.


[DDET What are the major problems with the data?]
Apart from the chronological issues we have methodological ones with concerns regarding blinding as only one trial (Nicholl) was randomized.

The Arreolla-Risa study was single centre and the Stiell study as before/after which have a significant bias in educational interventions.

The authors have done a fair job on pointing out al the flaws and this should be recognized and appreciated. Their job is a tough one as the data they are working with (i.e. the source papers) is heavily biased and out of date.


[DDET So why no benefit?]
I can feel the wrath of the prehospital community as they read this review, but let’s pause for a moment and consider what the data may tell us and what it cannot.

Is there a plausible mechanism for no benefit or even a worse outcome for more education? Well possibly. The authors argue that training results in more interventions and longer scene times – thus a mechanism for an increase in mortality perhaps? The mechanism here is that if poor quality, poorly performed, delays or unnecessary interventions take place then perhaps mortality might increase. As a plausible mechanism that is fair, but I’m not convinced that we have the detailed information here for us to explore that.

To be fair the review authors point out a number of confounders regarding systems, geography, injury patterns and staffing models that significantly influence why they have found little evidence for ALS education. This compounded with the methodological biases of the papers makes it pretty tricky to come to a firm conclusion. [/DDET]

[DDET So is this the end of Pre-Hospital Care for trauma patients]


Clearly not as the data and the confounders here make it impssible for us to make any definitive statements on the effectiveness of educational interventions for prehospital trauma care.

In systems with highly advanced prehospital trauma services staffed by advanced PHEM practitioners then this has little or no relevance and even in areas of the world like Virchester with little or no (@obidoc as a notable exception) physician based trauma services then I would like to be cared for by a paramedic who has received more than a basic grounding in trauma care.


[DDET So what about the authors conclusion?]
Good question. The authors conclude…

There is no evidence for the effectiveness of advanced life support training for ambulance crews in injury mortality or morbidity.

Technically this is correct but if I had been the authors I might have concluded differently. The St.Emlyn’s conclusion is…

‘There is insufficient evidence to draw any conclusion on the effectiveness of advanced life support training for ambulance crews in injury or mortality’

I think that’s a more balanced conclusion and whilst it might not meet Cochrane style guidelines, it reflects the evidence available.

In summary my concern here is that the rather definitive conclusion from the highly respected Cochrane group may be misinterpreted as evidence to not invest in improving education in trauma care. That would be a false and unfair action on the basis of the available evidence which simply does not exist in a definitive form.

In answer to our original question we say ‘Yes’ until definitive evidence tells us otherwise we should train our paramedics.




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