Can less ALS mean better BLS?

[DrParasite]

Sure, more patients may receive ALS care faster with more medics, but are those patients better off if BLS providers are no longer proficient in actively assessing and treating patients?

There is scant evidence that more than a few critical interventions make a difference in the first one or two minutes of care; most of these can be performed effectively by well-trained BLS providers.

Critical ALS interventions, on the other hand, while still time-sensitive, can often wait a minute or two. Some research also suggests that health care providers benefit from seeing critical patients more frequently and performing procedures more often.

read the rest here: http://www.ems1.com/als/articles/1932766-Can-less-ALS-mean-better-BLS/

 

[yowzer]

I've only ever worked in areas with tiered ALS and BLS setups where medics aren't dispatched to the majority of calls. Lowly EMTs can easily handle most minor issues, and we're expected to know how to recognize things that turn out to be more serious looking than they appeared to dispatch, and request medics if need be (Or cancel them before arrival if it's the other way around).

Some research also suggests that health care providers benefit from seeing critical patients more frequently and performing procedures more often.

This is a big part of the justification for such a set up. Aren't their all-ALS departments that can't do 12-leads or intubate because they sucked so much their protocols got revised downward? When you're only doing something a few times a year, it's hard to keep the skills up.

 

[ExpatMedic0]

This is quite a system specific issue. In Portland, Oregon every 911 ambulance is staffed with double paramedics, and every fire engine has 1 paramedic. In London (from what I have been told) every ambulance has a paramedic. I think we need to drop this whole BLS/ALS EMS mindset and look at things from an outside the box healthcare perspective. If you went to the hospital would you be ok with ONLY a CNA doing your entire health visit, assessment and check up? If your in a system with dual BLS providers possibly responding and transporting with out any paramedics present what kind of care are the patients receiving; or more so, what kind of care and assessment are they not receiving? Where else in the world can someone with maybe 3 weeks of full-time training staff and ambulance and care for the sick and injured? The article is correct when it states things are being ignored... but I think it goes even beyond what is discussed. Patient care is not only measured in psycho-motor skills which can be applied (although EMS loves to think this way). I think were going to see a paradigm shift within EMS and pre-hospital healthcare along with it being integrated more into the overall healthcare system. As this happens were going to see a shift towards many things, including patient assessments and treat and release options which defer transports to the ED, this will require providers with more than 3 weeks of training to staff an ambulance, in theory.

 

[DrParasite]

If your in a system with dual BLS providers possibly responding and transporting with out any paramedics present what kind of care are the patients receiving; or more so, what kind of care and assessment are they not receiving?

The vast majority of calls I have been on typically need EITHER a ride to the hospital, a comfortable ride to the hospital, or reassurance that their kid isn't doing to die after doing something stupid (fall off the bed, cut themselves, etc). They are usually not suffering a life threatening condition.

The VAST majority (something like 80%) don't need ALS, and will not die if they don't recieve ALS care in the next 2 hours (translation: you can do an ALS intervention if you want, but it won't affect the persons mortality). But they do need to be evaluated by an MD in the near future.

Paramedics are great at cardiac and respiratory emergencies. But the majority of EMS calls aren't cardiac or respiratory emergencies.

Also, the main focus of the article is that a paramedic who only sees sick people and doesn't spend every day deal with not sick people will be a better provider when they deal with sick people (with the evidence to back it up)

 

[EpiEMS]

If we're going to have a well-designed system, yes, a system, we cannot be tossing resources at all patients. In the emergency room, there aren't physicians for each patient -- some get treated by midlevels, for example. Not everybody needs a paramedic.

 

[46Young]

I'm 150% with DrParasite and Michael Gerber on this issue. I've worked in the NYC 911 system which is tiered, Charleston County EMS which is 100% all-ALS third service, and for a fire department which is now all-ALS on every ambulance, every engine company, and soon to be eight trucks and eight heavy rescue squads.

I can say with absolute certainty that I would I would be a much weaker medic had I not worked in the NYC 911 system, three years as a basic, and two years as a medic. When every unit is ALS, that means that medics are also running every BLS call. This makes it very difficult to gain any appreciable experience with critical patients. As an example, over the last six months, I haven't had the need to use the CPAP, I've only run six respiratory distress calls, three good traumas, tow or three true chest pain calls, one V-tach with a pulse, four cardiac arrests, and the rest was all stuff that a basic could handle. In NY, I would typically see those calls in 2-3 weeks depending on what neighborhood my CSL was at.

I've gone whole tours (nine day rotation, three 24 hour shifts worked) without even opening my drug box. With all-ALS, the medics remain inexperienced, and the BLS never learn any critical thinking skills.

I can understand the desire for there to be a single certification level, and doing away with BLS and such, but I don't feel that this is necessary. I agree with DrParasite - 80% of patients don't need ALS. The medic is learning little to nothing by running these 80%. I see no benefit to making everyone medics, when the vast majority of your calls are minor MVA's, sick/flu calls, falls and injuries (call for ALS if pain management is needed). If you're not performing ALS interventions (beyond IV access) on at least one patient out of every four, you have too many ALS transport units. Where I work, that ratio is probably 1:15.

An all-ALS system is good for a medic that just wants to run easy calls, and not have to bother with ALS restock most of the time.

 

[RocketMedic]

My only issues with tiered systems is that "niceties" like anti-emetics and pain management are often excluded.

For instance, abdominal pain. In most systems, that's a BLS complaint. But ALS providers can mitigate it.

Or a simple fracture. Splinting works, but splinting + fentanyl works better.

 

[chaz90]

My only issues with tiered systems is that "niceties" like anti-emetics and pain management are often excluded.

For instance, abdominal pain. In most systems, that's a BLS complaint. But ALS providers can mitigate it.

Or a simple fracture. Splinting works, but splinting + fentanyl works better.

This can be fixed (at least partly/mostly) by emphasizing to BLS that we don't resent being called for comfort care. I make a point to mention to BLS that they did the right thing by requesting me every time I'm sent for legitimate pain management or anti-emetic usage. I think the more they see how much more comfortable the patient is during transport the more often they're willing to think slightly outside their normal box and request us for what some perceive to be the more minor complaints that we can truly alleviate.

 

[46Young]

My only issues with tiered systems is that "niceties" like anti-emetics and pain management are often excluded.

For instance, abdominal pain. In most systems, that's a BLS complaint. But ALS providers can mitigate it.

Or a simple fracture. Splinting works, but splinting + fentanyl works better.

The reason that this is a non-issue is the same reason why ALS first response does not improve patient outcomes - The first few minutes of patient contact are pretty much BLS, the assessment, Hx, and vitals. If pain management is needed, call for medics. By the time you have a Hx and vitals, the medics will be there and ready to do pain management or anti-nausea. Sending medics to every call "just in case" is overkill IMO.

We are all-ALS, but a neighboring county is BLS/ALS, and we run automatic aid with them. Their BLS have called us for pain management on several occasions. We're there in a few minutes. If the wait time for medics would be long, that's okay. Pain management and comfort care are nice to have, but not necessarily life saving, and it shouldn't affect the overall patient outcome. The ALS should be available for the diff breathers, MI's, respiratory arrest, APE, choking, unconscious, internal bleeding, that sort of thing. In my opinion, it's appropriate to have the patient wait an extra few minutes for pain management from ALS while in care of BLS, so that ALS can be dispatched on calls like those I've mentioned above.

 

[ExpatMedic0]

The vast majority of calls I have been on typically need EITHER a ride to the hospital, a comfortable ride to the hospital, or reassurance that their kid isn't doing to die after doing something stupid (fall off the bed, cut themselves, etc). They are usually not suffering a life threatening condition.

The VAST majority (something like 80%) don't need ALS, and will not die if they don't recieve ALS care in the next 2 hours (translation: you can do an ALS intervention if you want, but it won't affect the persons mortality). But they do need to be evaluated by an MD in the near future.

Paramedics are great at cardiac and respiratory emergencies. But the majority of EMS calls aren't cardiac or respiratory emergencies.

Also, the main focus of the article is that a paramedic who only sees sick people and doesn't spend every day deal with not sick people will be a better provider when they deal with sick people (with the evidence to back it up)

Over saturated systems with ALS providers can lead to lack of skill proficiency and also many of those ALS skills are not required on most calls or can wait a few extra minutes, that is a fine argument, but what I am saying is lets take it a step further. Lets just forget about who needs what ALS procedure and ALS versus BLS for a minute. The root of this entire discussion goes beyond performing pre-hospital procedures in my opinion. In my humble opinion, many of those %80 people who do not require an ALS intervention don't need a ride to the Emergency Department, or even a ride to the hospital by ambulance. They need to be treated and released or told to go see their PCP. While not as glamorous as cool skills like surgical airways and intubation, they still need an assessment by a clinician at their home. Right now I think this is taking many forms, including the community paramedic concept, but in parts of Australia for example, 911 EMS can refuse transports or treat and release.

In conclusion: In the way the system exist today in most of the U.S. I can see your point, I think its a pretty strong argument regardless of what side of the fence your on. I feel quite rusty on intubation myself lately, itsbeen a while. However, I think if pre-hospital ALS gets the ability to refuse transports anytime soon then I think its all gonna fall apart and every BLS unit will need to call for ALS, not for procedures, but for patient assessment, treat and release, and transport choices.

 

[Carlos Danger]

My only issues with tiered systems is that "niceties" like anti-emetics and pain management are often excluded.

For instance, abdominal pain. In most systems, that's a BLS complaint. But ALS providers can mitigate it.

Or a simple fracture. Splinting works, but splinting + fentanyl works better.

Is there any reason BLS can't do pain management? Analgesia does not always have to automatically mean opioids.

Even if it does require opioids, why can't BLS personnel give metered doses?

 

[Medic Tim]

Is there any reason BLS can't do pain management? Analgesia does not always have to automatically mean opioids.



Even if it does require opioids, why can't BLS personnel give metered doses?

Because 120 hours of training isn't enough for what EMTs already do.... Let alone adding more skills and meds.

This is not a slam against EMTs at all. Just the sad state of EMS education.

 

[Carlos Danger]

Because 120 hours of training isn't enough for what EMTs already do.... Let alone adding more skills and meds.

This is not a slam against EMTs at all. Just the sad state of EMS education.

I have mixed feelings about that.

I agree that educational standards in American EMS are low across the board, but I guess I just don't see the harm in implementing non-narcotic analgesic techniques.

I don't think I'm even convinced that OLMC guided, metered-dose fentanyl administration would be hamful.

 

[DrParasite]

Because 120 hours of training isn't enough for what EMTs already do.... Let alone adding more skills and meds.

This is not a slam against EMTs at all. Just the sad state of EMS education.

how much training do you need to give tylenol? or advil? or benedryl?

I'm pretty sure Jon Doe can walk into RiteAid (or your local pharmacy), buy a bottle, follow the directions on the bottle and suffer no ill effects.

Please explain why after Jon Doe becomes an EMT, he is no longer trained enough to give someone an OTC medication, when he was perfectly capable of doing so before?

 

[Chewy20]

how much training do you need to give tylenol? or advil? or benedryl?

I'm pretty sure Jon Doe can walk into RiteAid (or your local pharmacy), buy a bottle, follow the directions on the bottle and suffer no ill effects.

Please explain why after Jon Doe becomes an EMT, he is no longer trained enough to give someone an OTC medication, when he was perfectly capable of doing so before?

x2

I look at it this way: Some companies run P/B trucks with no academy before sending the employee to the field. That crew would be a lot better off if the EMT was trained in more skills and pharmacology. Sadly being an EMTB is a joke in a lot of places and not trusted to do more than be a taxi with lights on top. I like the idea of P/B trucks, spreads the wealth of knowledge throughout the department and gives the EMTB a chance to learn a lot. Medics may feel differently which is understandable.

 

[Brandon O]

Please explain why after Jon Doe becomes an EMT, he is no longer trained enough to give someone an OTC medication, when he was perfectly capable of doing so before?

No axe to grind here, but the answer would be that you can give YOURSELF meds, not somebody else under your auspices as a professional. And even giving them to yourself, if you have comorbidities the formal advice would be to "consult your physician" first.

In other words, in some way or another, a professional capable of assessing the risks and benefits ought to be involved if you're not a healthy and vim young buck.

 

[Akulahawk]

how much training do you need to give tylenol? or advil? or benedryl?

I'm pretty sure Jon Doe can walk into RiteAid (or your local pharmacy), buy a bottle, follow the directions on the bottle and suffer no ill effects.

Please explain why after Jon Doe becomes an EMT, he is no longer trained enough to give someone an OTC medication, when he was perfectly capable of doing so before?

There's quite a bit of learning that goes on before someone can even come close to considering whether or not a given medication is appropriate to give to someone else... especially when it's under the auspices of another medical professional. While someone truly can go to the local store and buy a bottle of the above stuff, read the directions, and probably do OK, they probably also know how much of that medication they've taken and most people won't exceed the dose limits on the bottle.

An EMT doesn't usually have the knowledge necessary to administer most medications outside of what they get in school and even then that's basically stuff that's safe to give per protocol under some very defined conditions.

Paramedics get more knowledge and they do become very familiar with the drugs they administer, but... again, most don't learn to use those drugs outside the protocol limits, though they may learn that many of their drugs have some off-label uses.

I'm very content to make certain medication decisions for myself only but as soon as I have to administer medications to other people, you can be sure that I'm going to know why I'm giving those meds and why they're appropriate for that particular patient.

 

[Av8or007]

" Is there any reason BLS can't do pain management? Analgesia does not always have to automatically mean opioids.

Even if it does require opioids, why can't BLS personnel give metered doses?"


Entonox is used at the EMR level up here in Canada in some provinces and very much so in the UK.

IN fentanyl with strict protocols and a prefilled syringe is also an option for bls/ils severe pain. Most of the complications of opiates can at worst be managed w/ airway maneuvers or ventilation (this is not by any means good, but compared to some other normally als drugs, opiates are relatively forgiving). Titrated naloxone can be used as a last resort and in many areas its already BLS/public access.

 

[Drax]

In Portland, Oregon every 911 ambulance is staffed with double paramedics, and every fire engine has 1 paramedic.

I'd love to work for a department like this. I feel like it would be a great learning experience to be attached to an ALS provider. Especially for inexperienced EMTs, provided that paramedic has the heart of a teacher.

 

[46Young]

x2

I look at it this way: Some companies run P/B trucks with no academy before sending the employee to the field. That crew would be a lot better off if the EMT was trained in more skills and pharmacology. Sadly being an EMTB is a joke in a lot of places and not trusted to do more than be a taxi with lights on top. I like the idea of P/B trucks, spreads the wealth of knowledge throughout the department and gives the EMTB a chance to learn a lot. Medics may feel differently which is understandable.

If the BLS are working there because they want to be there, as opposed to FF/EMT's that see it as a necessary evil, or just using it as a stepping stone job, they should be more apt to learn from the medic.