I had an interesting discussion with an EMS coordinator friend of mine on the issue of enhanced BLS. He conceded that while, it was true BLS could easily be taught to give IN Narcan or put on CPAP, his worry was that allowing Basic EMTs to do so many things, their towns or services would feel they did not have to upgrade to the paramedic level. He then showed me an email he had received from another medic arguing for enhanced BLS in his area because that area could not economically support more paramedics. The phrase “could not economically support” was what upset him. He felt that if a town could support police and fire, they ought to be able to support paramedic level EMS services.
I agreed with him. Most EMS budgets are absolutely paltry in comparision to police and fire budgets. It is shameful. All towns should support paramedic level EMS. But, unfortunately, they haven’t and they don’t, and as unfortunately, in these economic times when town, state and federal budgets are being cut, it is unlikely that additional monies will be found for EMS. And hard economic times are not going away. Taxes are being raised, schools are being closed. Health care funding, particularly for hospitals, is being slashed. Where is the money to support more paramedics? Not around here.
EMS, if it wants to even continue its current level of funding, has to show its worth to the community and to the budget makers. Unfortunately, it can currently be argued that ALS doesn’t improve outcomes in such major areas as cardiac arrest survival and in major trauma. Some would say, and there are studies to back it up, that ALS actually contributes to increased mortality in these areas.
On the other hand, BLS can hardly shine when you consider, in many cases, when BLS shows up at your house, they can’t help you any more than throwing you on the stretcher and taking you to the hospital. If your tib and fib bones are sticking through your skin, ice packs and pillows aren’t much help. If your mother is vomiting profusely, an emesis basin and a kind pat on the back don’t quite cut it. Your daughter, in first time anaphylaxis from eating nuts, is dying in front of your eyes, you better hope the ambulance has an epi-pen. Having chest pain? The cath lab is not going to be activated and ready for you when you arrive at the hospital if BLS brings you in. A visiting neighbor in insulin shock? Sorry EMTs can’t pour oral glucose down his throat. And the list goes on. But we can all, ALS and BLS, drive ambulances.
The day is going to come where EMS like hospitals will have to prove positive outcomes or we won’t be reimbursed. I believe we can prove positive outcomes, but it may require a reinvention of the way we do business. I don’t think the answer is a paramedic in every ambulance and on every street corner. Paramedics are part of the solution, but they need to be used differently than perhaps most systems currently use them. The answer may in fact be fewer, but more experienced paramedics, and more, but better equipped EMTs.
Traditionally in medicine, individual interests groups, whether doctors, nurses, or paramedics fight to maintain their territories and their jobs. They do this by putting down their competition. As I got angered years ago when nurses in our state fought to limit paramedics from working outside the realm of emergency medical services because, according to them, we were not qualified to take care of patients in clean well lit rooms (only in rainy ditches), so I would be angered if I were an EMT and was told by a paramedic I was not qualified to do something simple with such a high benefit as giving a vomiting patient oral Zofran or giving an Epi-pen injection to someone in anaphylaxis, while either waiting for a paramedic to arrive or driving to the hospital because there is no paramedic coming.
If my family member is in need of medical assistance, I don’t care if the person coming through the door went to paramedic school or not, if what my family member needs is something that EMS person can safely give them, then I want them to get it. If the EMT can’t safely give it to them, then I would like to have a paramedic available to respond. The trick is finding out what EMTs can and cannot be giving safely. That alone should be the distinction. Safety and risk benefit should triumph over artificial barriers such as EMTs can’t give any medicine or do any “invasive” procedures.
It has already been proven that BLS can safely save lives with AEDs and defibrillation. I am not familiar with the studies, but I think it is safe to say the same holds true with BLS and Epi-pens. I contend there is more out there for them to do that will benefit our communities and enhance respect and support for EMS, while still maintaing patient safety.
Stay tuned for discussion of this.
Note:In previous posts, I have expressed support for the following BLS medications provided the services have approval of their medical director who has overseen proper training: PO Benadryl, PO Tylenol, Zofran ODT, IN Narcan, IM Glucagon. I will address Combivents, NTG SL, IM Versed, and IN Fentanyl in future posts (note saying yet if I will support these.) I will also be posting about other possible BLS enhancements such as CPAP, supraglotic airways, 12-lead transmission, and discussing their risk/reward ratios.