ALS for the BLS Provider -- Assisting ALS

[Christopher]

To be fair, anybody with ALS-level education can do an ALS assessment. You're a BSN, you can certainly do a medic-level assessment, even if your EMT cert says you can't do ALS treatment.

Assessment isn't something that scope of practice limits, other than perhaps the tools you are allowed to use.

Agreed, most paramedic textbooks repeat the same chapters as the EMT textbooks for Patient Assessment.

I provide no advantage in patient assessment outside my ability to read a 12-Lead and having had more education.

 

[Brandon O]

I provide no advantage in patient assessment outside my ability to read a 12-Lead and having had more education.

Capnography?

 

[Christopher]

Capnography?

EMT-B skill in my state

 

[Brandon O]

EMT-B skill in my state

Fine... then my reply is:

You can read 12-leads?

 

[EpiEMS]

To me, an "ALS assessment" includes diagnostic devices only a medic carries and is trained to use, such as the ECG. When people use it to mean "a competent assessment," I understand what they mean, but I find it vexing.

I have to say, though, in full disclosure, my thoughts on this matter have been shaped a lot by the EMS Basics posts. Always great stuff on the blog!

 

[Brandon O]

I have to say, though, in full disclosure, my thoughts on this matter have been shaped a lot by the EMS Basics posts. Always great stuff on the blog!

Hey! Thanks a ton.

 

[Tigger]

I chuckle when I hear people say this... you should see how bad it can get. BLS responsibilities in Mass (at least potentially -- I can't defend any specific service you may hang your hat at) are far greater than in many other areas.

Much of which is done through waivers, or at least till recently. The basic state scope is no better than most.

 

[Brandon O]

Much of which is done through waivers, or at least till recently. The basic state scope is no better than most.

The mere fact that there are many urban systems here running a truly tiered response (BLS 911 units with ALS available per EMD or BLS unit request) is more and more unusual in the current era of all-ALS-all-the-time.

 

[Tigger]

The mere fact that there are many urban systems here running a truly tiered response (BLS 911 units with ALS available per EMD or BLS unit request) is more and more unusual in the current era of all-ALS-all-the-time.

I would rather see ALS all the time frankly.

The only reason the metro Boston area system can be be considered less of detriment to patients than other tiered systems is that there are so many hospitals around. My thought is that everyone is entitled to an assessment better than that of the average EMT (not you certainly), so at least they are getting it in about 15 minutes after we show up.

I would much prefer to run P/B, but that's not going to happen where I am.

 

[Brandon O]

I would rather see ALS all the time frankly.

The only reason the metro Boston area system can be be considered less of detriment to patients than other tiered systems is that there are so many hospitals around. My thought is that everyone is entitled to an assessment better than that of the average EMT (not you certainly), so at least they are getting it in about 15 minutes after we show up.

I would much prefer to run P/B, but that's not going to happen where I am.

I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.

I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.

In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).

 

[Tigger]

I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.

I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.

In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).

I would much prefer to see the way Boston EMS trains its EMTs move into the rest of EMS. Until then however...

At least in the city where I go to school (Colorado Springs), AMR runs all P/B and from what I understand they have few issues with burnout. They also properly split calls, and most shifts the basic can expect to attend at least half of the calls.

 

[Brandon O]

I would much prefer to see the way Boston EMS trains its EMTs move into the rest of EMS. Until then however...

At least in the city where I go to school (Colorado Springs), AMR runs all P/B and from what I understand they have few issues with burnout. They also properly split calls, and most shifts the basic can expect to attend at least half of the calls.

I think that's a reasonable approach as well, as long as the BLS scope is adequate that the medics don't feel like they need twelve hands to get everything done when a patient actually needs it.

I started in an all-PB system in California where the medic had to tech all calls. The EMTs were glorified drivers and didn't need to practice any clinical decision-making, the medics spent all the time managing BLS patients... not good. Even that seemingly small difference is significant.

 

[medicdan]

I think this just comes back to the usual issue, then. Most patients need good BLS care with ALS available for special considerations, which supports a tiered system; however, if you don't believe that the typical EMT can provide good BLS, then you have to have medics providing BLS instead.

I do understand your point, but I would argue that many medics aren't doing great BLS either... and that in areas where everybody is a medic this situation is worse, not better. Their skills are hugely diluted, they're burned out, and when BLS does end up taking sick patients they have no experience to do it. Oh, and the cost of service is wildly higher for everyone.

In the real world, the best practical solution may be to recruit good EMTs and then provide additional training to refine their BLS care (the Boston EMS model).

Couldn't agree more. I think we all need to understand that Boston is truly unique-- not many urban systems can get away with having 3ALS trucks for a city this size. Not many systems can justify doing the training they do with their EMTs (again, realizing many are actually medics). For all the ribbing it gets, I like the Cambridge system. Highly trained basics, higher trained Medics, a few ALS trucks supported by ALS first responders. There are enough skills to go around that all the Pro medics get a tube or two a month, and the fire medics get a few a year each. The PB trucks can quickly become double medic by taking fire along, and there is support on scene if necessary.

The city is augmented by a few BLS trucks, who's patients often get an ALS assessment from fire, and can become ALS quickly by taking fire along.

100% of calls are QA'd, interesting or difficult calls are replayed in sim lab monthly for all staff. Education takes a front burner, as does infrequently used skill retention and clinical decision making.

This seems to be a system where PB EMS works well, BLS care is well delivered, and ALS care is always available.

Thoughts? I know I drink the Kool-Aid, but this seems to meet all the system efficiency and care delivery end points we've talked about.

 

[Brandon O]

Couldn't agree more. I think we all need to understand that Boston is truly unique-- not many urban systems can get away with having 3ALS trucks for a city this size. Not many systems can justify doing the training they do with their EMTs (again, realizing many are actually medics). For all the ribbing it gets, I like the Cambridge system. Highly trained basics, higher trained Medics, a few ALS trucks supported by ALS first responders. There are enough skills to go around that all the Pro medics get a tube or two a month, and the fire medics get a few a year each. The PB trucks can quickly become double medic by taking fire along, and there is support on scene if necessary.

The city is augmented by a few BLS trucks, who's patients often get an ALS assessment from fire, and can become ALS quickly by taking fire along.

100% of calls are QA'd, interesting or difficult calls are replayed in sim lab monthly for all staff. Education takes a front burner, as does infrequently used skill retention and clinical decision making.

This seems to be a system where PB EMS works well, BLS care is well delivered, and ALS care is always available.

Thoughts? I know I drink the Kool-Aid, but this seems to meet all the system efficiency and care delivery end points we've talked about.

I haven't directly dealt with them much, but in principle I think it works. My only concern is that making first responders a truly integral part of the system, particularly as ALS, needs some special attention toward creating the right relationship and culture. There's potential for antagonism and cross-talk if it's not clear who's in charge on scene; for BLS transporting units to feel like taxi drivers ("the nice firemen came and took care of me, then an ambulance showed up to give me a ride"); conflicts between transporting and fire medics; and so forth. And you need to make sure that the local protocols/policies, both explicit and implicit, say it's okay for patients to get an ALS assessment but to get down-triaged to BLS.

It may work better in places where EMS already has a good relationship with fire (or other first responders); if they're somewhat hostile that's a deeper problem that needs to be addressed first. Probably over the course of about ten years...

 

[medicdan]

I haven't directly dealt with them much, but in principle I think it works. My only concern is that making first responders a truly integral part of the system, particularly as ALS, needs some special attention toward creating the right relationship and culture. There's potential for antagonism and cross-talk if it's not clear who's in charge on scene; for BLS transporting units to feel like taxi drivers ("the nice firemen came and took care of me, then an ambulance showed up to give me a ride"); conflicts between transporting and fire medics; and so forth. And you need to make sure that the local protocols/policies, both explicit and implicit, say it's okay for patients to get an ALS assessment but to get down-triaged to BLS.

It may work better in places where EMS already has a good relationship with fire (or other first responders); if they're somewhat hostile that's a deeper problem that needs to be addressed first. Probably over the course of about ten years...

Agreed. It takes the coordination of working together for 30+years, and sharing a medical director, equipment, training, and common goals. Certainly not possible for cities with a different private provider every 3 years, or a turnover of medics every 6 months. What I'm saying is that PB 911 response can work, albeit rarely, perhaps as rarely as a system with as few ALS resources as Boston does, it just takes special circumstances.

 

[EpiEMS]

I'd bet that Boston has better ALS, though, as a function of how few ALS providers they have: at peak staffing, they have 3.8 BLS units for each ALS unit, and, in total, they have 3.44 medics for every EMT (http://www.cityofboston.gov/Images_Documents/2011_Boston_EMS_Vital_Stats[1]_tcm3-31009.pdf). This probably means more chances for the medics to practice real ALS skills, leading to more experienced (hopefully, better) medics.

 

[medicdan]

I'd bet that Boston has better ALS, though, as a function of how few ALS providers they have: at peak staffing, they have 3.8 BLS units for each ALS unit, and, in total, they have 3.44 medics for every EMT (http://www.cityofboston.gov/Images_Documents/2011_Boston_EMS_Vital_Stats[1]_tcm3-31009.pdf). This probably means more chances for the medics to practice real ALS skills, leading to more experienced (hopefully, better) medics.

I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly.
Skill degradation is real, as you note, and it appears is not a problem for Boston medics.

 

[Brandon O]

I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly.
Skill degradation is real, as you note, and it appears is not a problem for Boston medics.

Actually, I don't think I'm saying that. Having a lot of high-quality hospitals nearby may mean you can have less ALS, but it also means you can do almost anything for EMS; it's a panacea, you could be running a taxi service and people will still get care reasonably quickly.

It's more that -- as you said -- "BLS can handle so much." That's not a function of being close to hospitals, it's a result of putting out competent EMTs with an adequate scope. If you have that, you can acknowledge the reality that most patients don't need anything more than BLS, and then you don't need much ALS on the road. No calling ALS just because a patient is sick, or calling to cover your butt, or calling because the protocol says you can't be trusted -- you call only when a patient needs something they can provide but you cannot.

The only concerns I have with such a system (particularly when transport times are longer) are: 1) BLS usually can't provide much symptomatic relief for pain, nausea, anxiety, etc (of course, in many areas ALS is also reluctant to crack their drugbox for such "wussy" reasons); and 2) It raises the threshold for an ECG, since some patients with ambiguous complaints may initially receive a BLS crew who won't ask for an intercept, whereas an initial ALS crew may have done the "just in case" 12-lead and perhaps caught a STEMI. That's why I like to fantasize about BLS with 12-lead capability (available in some places) and IM/IN analgesia, antiemetics, etc (probably never going to happen).

 

[EpiEMS]

I'm with you, that's part of their success. But I think Brandon is also arguing that having that few medics on the road only works because of the "enhanced" scope the basics have, including Narcan, but also the sheer number and proximity to hospitals in Boston. Fairly often, a BLS truck can get to the ED before medics show up from across the city, or stabilize and cancel. The can get away with staffing so few trucks and having so few medics because BLs can handle so much, so quickly.
Skill degradation is real, as you note, and it appears is not a problem for Boston medics.

Makes good sense. Though, as one of my favorite blogs says (and I don't 100% agree), the life-threatening problems caused by opioid overdose can be managed without Naloxone. Or, to quote: "If you have a BVM (Bag Valve Mask resuscitator), you should not need naloxone. The problem is inadequate respiration, not inadequate naloxonation. Manage the airway first, then, if you have naloxone and desire to use appropriately titrated naloxone, go ahead." (http://roguemedic.com/2010/07/current-drug-shortages-2/) Lots of other problems can be adequately managed by BLS, conditional on prompt transport and short transport times.

That's why I like to fantasize about BLS with 12-lead capability (available in some places) and IM/IN analgesia, antiemetics, etc (probably never going to happen).

BLS should be transmitting 12 leads, for sure. IM/IN medications are tougher...but they're done in some places. Heck, Montana lets EMTs with an "endorsement" give morphine with an autoinjector. Admittedly, they can only give 2.5mg, but, still, they are EMTs and giving a narcotic. Viz.: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf

 

[Brandon O]

Heck, Montana lets EMTs with an "endorsement" give morphine with an autoinjector. Admittedly, they can only give 2.5mg, but, still, they are EMTs and giving a narcotic. Viz.: http://bsd.dli.mt.gov/license/bsd_boards/med_board/pdf/emt_med_endorse.pdf

Awesome.

This would help address the issue of narc control.