I think if you are an ALS agency, providing "better care" is all you can hope to do.
It seems like this is what we should be doing everywhere in healthcare. For some reason there's a segment of the EMS population that seems to think that providing non-acute care is beneath them.
If you are talking about outcome based care, ALS has almost no place in it. People talk about allegery attacks and epi, etc, but in they are a very small minority of cases. People with such allergies who do not have their own, access to epi pens, etc are an even smaller minority.
However, one could argue rationally that the patients with a first anaphylaxis event, or those who have had a severe enough prior reaction to require an epi-pen prescription but don't have access to it, represent a high-risk group. I realise this is rational conjecture versus anything evidence-based.
I agree that this represents quite a small percentage of EMS patients.
A hypoglycemic patient, while benefitting from ALS, will probably survive a few more minutes with a BLS ride to the hospital. With more or less deficit dependant on the case.
True, but for a healthcare system what's a better utilisation of resources -- sending an ambulance with a provider with 3 years of education, costing around $1,000, and perhaps directing this patient to a nonurgent family MD consult at a later point, or, using a provider with a year of education, costing about $1,000, transferring that patient to a hospital, and then having them assessed by an attending, a bunch of RNs, lab techs, etc., trying up scarce resources, and then getting a nonurgent family medicine referral.
I think that if we look at this from a systems perspective, there's some value to throwing a paramedic on an ambulance. The incremental cost isn't that high when you start looking at other healthcare system costs.
If you consider glucometry, states where BLS is permitted to start an IV or admin a neb, it is far more economical and practical to supply these BLS providers with a few simple things like an epi pen, albuterol, dextrose in water, and protocols to administer them with or without medical control contact.
It's cheaper, for sure. In my region, around $10/hr cheaper, with a lower capital cost for equipment. But it's not really that much cheaper, is it?
It has been a while, but I will restate, ALS is a want, not a need. Nobody "needs" ALS.
So if you are going strictly off of want, ALS providers may want to provide better care. If their rank and file value their jobs and have any brains, they would demand it.
This may be what I'm doing here, and I appreciate that you're being deliberately inflammatory. I think there are some areas where ALS has positive impacts:
* Control of pain
* Control of nausea
* Augmenting palliative care resources
* Referring patients away from the hospital, e.g. low-risk hypoglycemia
* CHF treatment (I recognise that much of this is in the process of being downloaded to BLS)
* Respiratory distress (see OPALS subgroup analysis --- I might be cherrypicking)
* STEMI recognition, PCI bypass, field thrombolysis
* CVA identification and stroke center bypass (admittedly, potentially very BLS)
* Psychiatric / Agitated patient transport (rather benzodiazepines than a taser or two and a few broken limbs).
* Seizure control
* Tranexamnic acid in trauma (I know that you don't like CRASH-2 and you're far more educated than me in this area).
Granted there's little evidence (or none) for most of this. But I'd also argue that the cost of ALS care is relatively low. There's already going to be an ambulance -- unless we're going to replace them with a taxi service, which I guess we could. I don't think many people would find that acceptable, but that would be an option. There's already going to be a bunch of equipment on that ambulance, and a couple of providers drawing salary.
Sure, there are cheaper monitors than an LP12/15/X-series that BLS can use -- although the options dwindle if we provide BLS 12-lead, which realistically we should. Some of the disposables, like adenosine, or TNK, are pretty expensive. But it's not that great an incremental cost between running a BLS response and running an ALS response. Is it really that much to ask that when I call 911, the representative of the health care system that arrives has a couple of years of education, and can move someone with a long-bone fracture without a whole ton of unnecessary screaming?
With respect.
