Enhanced BLS At What Cost?

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.

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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.

12 Comments

  • Tami says:

    “The cath lab is not going to be activated and ready for you when you arrive at the hospital if BLS brings you in.”

    I think you better check some facts on this one as in many states, the STEMI system is in place and BLS will hook you up to a 12 lead, send it, and transport to the nearest cath lab with ALS intercept requested.

    • medicscribe says:

      You are correct Tami. BLS can do this, if they are allowed to. In our state, they currently cannot, although there is a pilot project that will allow several BLS services to do it in one area of the state. That project is currently awaiting approval of the commissioner. I am a big supporter of this pilot project. I will be writing about this in a future post in this series. The point of this particular post was that WITHOUT ENHANCED BLS, BLS cannot do many thing such as tell if someone is having a STEMI. I am in support of enhancing BLS when those enhancements will benefit patients without endangering them. BLS 12-lead aquisition is a nonbrainer for me. AS you know, BLS does not have to interpret, only transmit to a physician who will interpret.

      Thanks for commenting.

  • Darius Sharpe says:

    While I agree EMTs should be allowed to do more in the field, that list you have here is practically halfway to a paramedic. At some point those highly trained EMTs will start demanding more more money for the increased level of care and increased liability. Plus the ambulance ride will cost more because all those new medications and possibly a 12-lead capable monitor will have to be stocked. In the end the cost is barely reduced for the company and possible not rediced at all for the patients.

    Also, I have to disagree with you on the NTG, Fentanyl and Versed. Any medications that can cause a drop in blood pressure or altered mentation should only be given I the patient has an IV or there is at least the ability to give one if something goes wrong.

    • medicscribe says:

      Hi Darius

      I haven’t posted my comments on ntg yet, but I will give a preview. I too am against Sl NTG for Bls. Too much risk, low benefit. I am not revealing my commentary on controlled substances yet. Stay tuned.

      I’ll address rest of your comments later. Thanks again.

  • EMTFreakGirl says:

    In Montana, Basics can take additional training and get “Endorsed” for skills such as Monitoring, Medications (Nitro, ASA, Benadryl, EPI, Albuterol) IV/IO Initiation/Maint.(YES! I did say IO) and Advanced Airways (including ET, Kings, Combi’s and CPAP) Endorsements must be individually approved by the county medical director to be used. It’s worked out well here, in a very rural, lots of volunteers area that truly can’t financially support paramedics “all round.” We also have ALERT (airmed, totally Rockin’ airmed!!!!) that will fly just about anytime, anywhere as ALS support if ground ALS is too far away or just out of resources. It’s not a medic on every ambulance but it works for us in the vast area we cover. Just giving an example!

  • BH says:

    Darius, military medics (trained to the NREMT-B level plus a little more) are handing out Fentanyl lollypops every day in Afghanistan. Titrate to effect, which is basically they suck on it until it’s gone, their pain is relieved, or they pass out. If either of the latter two happen, you pull the lollypop, dose over.

    Hell, it’s safer than a civilian paramedic giving Fentanyl IV.

  • Jim A. says:

    Okay, I am an old Medic and i can agree with enhanced BLS but i thought that came with the different levels such as EMT – I or EMT- IV. I am registered in Florida where there are only 2 options EMT or Paramedic, and by state law all advanced skills are reserved for the Medic. However in this discussion it should certainly be possible to allow EMT’s with training to administer 12 leads in the field, or to apply CPAP, or to administer certain medications. These same treatments are being done in Doctor’s offices by medical assistants everyday so why shouldnt an EMT be allowed to do them also?

  • Joe says:

    In NJ, the paramedics are all hospital based so they are basically regional, one ALS truck is assigned to each Hospital, or they operate out of a near by EMS or Fire station and provide ALS service to a handful of towns. Even if the locals wanted to have an ALS service, they couldnt. DOH would not approve the certificate of need since there is already ALS coverage in the area. The town would have to show that the ALS project isnt responding a significant majority of the time, and the ALS agencies make sure that doesnt happen

    Unfortuatley for Paramedics, the vast majority of EMS requests are not “ALS” calls as viewed by the system. Pains, flu-like symptoms, general weakness, atraumatic falls and lift assists are all “BLS” calls. Add to that the evidence that stacks against the Paramedic: more medics=bad medics, ACLS kills patients, ALS doesn’t improve survivability in traumas, ALS doesnt treat CVA, ALS increases scene times.

    There is a lot against the Paramedic and until that changes, there wont be a huge push to change the system.

  • Sergio says:

    I thought we were getting rid of the “Basic” terminology. Emergency Medical Technicians are not people with first aid badges and ambulance drivers. They are quite capable of starting IVs and administering medications. With appropriate standards of education, continuing education/training, appropriate medical direction and most importantly systems in place that make the common, mostly benign skills simple–expand their scope of practice. Great BLS enhances ALS when it’s needed. I’m with Joe. We don’t need 3 paramedics on every scene and we certainly don’t need them on every fire apparatus.

  • Mary emt says:

    Sometimes when there are no advanced emts or paras available due to the volunteer and rural nature of some services, a load & go method is much much better than nothing….

  • Ben Vaillancourt says:

    Hi, I’m a medic in Montreal, Québec, Canada. Up here the levels of certification are quite different. As a “Primary Care Paramedic” I can give NTG, AAS, Glucagon IM, Epi IM (not epipen), and Ventolin in nebulisation. I can use Combitubes, a rigged-CPAP, 12 lead EKG (applying and interpretation). We can activate cath labs, neuro and trauma center. Soon we’ll be able to give Versed IM, Narcan IN, Fentanyl IM. That’s the basic level.

    “Advanced Care Paramedic” is a much more smaller group (9 ACP still practice in Montreal, compared to 4000 PCP province-wide). They provide a level similar to critical care down in the states. They go to “Echos” in the Clawson system. And do high acuity transfert.

    Is it a “cheap system”? I don’t think so. It’s giving every patient the best medic we can offer as a society. We don’t have a lower certification were they can only give you encouragement while zooming through the city to the hospital.. So EMT ++ can be a good system 😉

  • Ben Hoffman says:

    In New Zealand a “BLS” Ambulance Officer is called an “Emergency Medical Technician” and they complete the National Diploma in Ambulance Practice; this is a 9 month qualification aimed mainly at volunteer Officers and is 300 hours of learning plus a Portfolio of Evidence of clinical mentoring which takes around another 100 hours; although somewhat quantitative there is a strong qualitative component.

    The scope of practice for this level is as follow (to 9/13)

    OPA, NPA, laryngeal mask airway, PEEP, tourniquet, automated defibrillation, automated cardioversion, 12 lead ECG acquisition, basic rhythm interpretation, entonox, methoxyflurane, paracetamol elixer, aspirin, GTN spray, oral glucose, glucagon IM, nebulised salbutamol, nebulised ipratropium, nebulised adrenaline, oral ondansetron, oral loratadine.

    Intramuscular adrenaline for anaphylaxis is coming later in 2013.

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