In Defense of ALS

In our state (Connecticut), BLS (with sponsor hospital approval) can do the following life-saving interventions:

Defibrillate with AED

Give Epinephrine in Anaphylaxis

Apply CPAP to Severe Respiratory Distress

Give Narcan to Hypoventilating Opiate Overdoses

Give ASA to Chest Pain.

Transmit 12-lead ECG

Speed Trauma and Stroke Patients to the Hospital

Here’s what They Can’t Do:

Cardiovert Conscious Patient in VT

Give Epi IV for Refractory Anaphylaxis

Give Benzos to Seizing Patients

Give Benzos (and sometimes Haldol) to Crazy Violent Patients

Give NTG to Patients in Pulmonary Edema

Give Breathing Treatments to Wheezing Patients.

Perform a Surgical Airway in a Patient Without an Airway.

Give Fentanyl or Morphine to Patients with Broken Bones or Severe Abdominal Pain

Do a Needle Decompression for a Hypotensive Trauma Patient with No Lungs Sounds on One Side

Give D10 to Hypoglycemic Diabetics

Interpret 12-lead ECG and Call STEMI Alerts

Protect Airway with ET Tube or Alternative Advanced Airway

Use McGills to Clear Airway

Give Zofran to a Nauseous Patient.

Use Enhanced Education and Assessment Skills to Treat and Triage their Patients

What Does This Mean?

Here’s how many needle decompressions, and surgical cricothyrotomies I have done in the last 10 years. Zero.

Here’s how many needle decompressions I have done in the last twenty years. One. Surgical cricothyrotomies. Zero.

Here’s how many conscious people in VT I have cardioverted in the last four? One. How many in twenty years? Six.

While many years ago I used to intubate 12-20 times a year, I am lucky if I get 5 a year now. (I precept a lot so my preceptees and EMT students get first crack).

How many working cardiac arrests? Maybe eight a year nowadays. How many walk out of the hospital with full neurological function have I had in the last four years? Two. How many in my career (that I know about)? Not counting ones who coded in front of me and came around with a shock. Seven.

What saved most of these patients? With the exception of one they were all vfib codes who got bystander CPR and came around with defibrillation while still on scene. The one who wasn’t shocked was an asystolic heroin overdose who came around with epi.

How about choking patients have I had to use my McGills on to clear their airway? One.

How many anaphylactic patients have I given IV epi to? 0.

How many seizing patients have I given benzos to? A ton. I would guess 100 or more.

How many times have I had to take down violent patients with benzos? Again a ton. Over 50.

How many CHFers I have pounded NTG into? Once more a ton. At least a 100, maybe 200.

STEMI patients? Well, when I first started since we didn’t do 12-leads, it is hard to count, but I would say I do five to six a year. I have had many I d identify that the machine could not. (We did a study on this that shows the machine is right only half the time when it calls a STEMI and does not call about 30% that are STEMIs).

How many patients have I given pain and comfort meds too? How many days have I worked this job? I use my narcotics nearly every day, sometimes two or three times a day. And Zofran? There is no drug I use more, not even oxygen.

How many patients have I used my advanced education and assessment skills on? Every patient I see. It doesn’t mean I need to use it, it means I can spot someone who is really sick that the nonparamedic eye might not have seen.

Bottom Line:

So despite the recent study —Outcomes of Basic Versus Advanced Life Support for Out-of-Hospital Medical Emergencies — I wrote about that looked at cardiac arrest, trauma, stroke and MI, and concluded ALS did not make a difference and may have been harmful, I have to state that I think ALS has value far beyond these calls.

Considering all the calls (as a full time paramedic since January 1995) I have done, I have saved relatively few lives. But as a paramedic, I have made a huge difference in people’s pain and comfort.

My contention is that our EMS system is fundamentally built around or should be built upon pain and comfort management. If someone is puking their guts out or has a broken leg or severe abdominal pain enough to require an ambulance, it is nice that here in America, we don’t throw people in the back of the donkey cart, or force them to ride the city bus with a vomit bucket. Now I know there are abusers, but I am not a judgmental guy. Fentanyl and Zofran have earned me more genuine thank yous that any number of cardiac arrests I have done.

NTG for CHF, Combivents for Asthma and COPD, Cardizem and Adenosine for SVTs, Versed for Severe Anxiety — these are all great thank you drugs. My old EMT instructor, Judy Moore, used to say, the emergency is over when you get to the scene. These drugs are about customer service. They called because they were in distress and you answered their call.

There are many more examples, but you get the gist. When someone calls for help, we ought to be able to help them. And ALS has a greater ability to answer that call than does BLS. That said, I support moving successful interventions down the line from ALS to BLS if the benefit outweighs the risk. I see no reason why Oral Zofran, Oral Bendryl, and Combivents can’t be BLS skills (I know Combivents are BLS in some areas). In an ideal world we would have even Fentanyl Lollipops at the BLS level, but I’ll save that argument for another day.


For True to Life EMS Fiction about Hartford EMS in the 1990’s (during the Latin gang wars), order Mortal Men Today.

Mortal Men: Paramedics on the Streets of Hartford


  • Dan says:

    I would love to see nitrous oxide for pain control at the BLS level for pain levels below the threshold where calling for ALS is essential. Giving people an icepack for a broken bone or dislocation is ridiculous.

  • Tom says:

    I’m amazed at the above comment. In the UK, volunteer advanced first raiders can give entonox. There’s no good reason why an EMT can’t.

  • medicscribe says:

    nitrous oxide is very rare in US EMS at any level

  • Ivan says:

    I can only imagine the kind of stir that study has caused to my neighbours down south (currently I work as a Primary Care Paramedic in Ontario, Canada). I don’t think for a second that BLS treatment is more beneficial than ALS treatment or vice versa. We must approach each patient and situation differently and treat appropriately. Moreover, perhaps we should shift our ALS training and mindset to a model that encourages working on the move rather than the stay and play model?

    Here in Ontario, Primary Care Paramedic’s use critical thinking and clinical judgment to determine whether or not to use their medical directives. PCP’s can administer ASA, Nitro, Salbutamol, Epi (IM and Nebulized), Glucagon, Oral glucose, Dimenhydrinate, Diphenhydramine, Ketorolac (Toradol), Acetaminophen and Ibuprofen as well as interpret 12 and 15 lead ECGs and call STEMI alerts, perform manual defibrillation, terminate resuscitation on Medical and Traumatic Cardiac Arrests and as well use supraglottic airways (King LTs) and CPAP. This is after a 2 year college course where the primary emphasis, despite all these tools, is determining whether a patient is a “load and go” or “stay and play”. Obviously that emphasis is typically put on “load and go”.

    The drawn out point I’m trying to make is that rather than reducing skill set and knowledge base, perhaps the key is to diversify and expand the way we look at and treat patients in the pre-hospital setting? Just because we have the tools doesn’t mean we always have to use it.

  • Zachary Elias says:

    I would just like to add that there is a difference in mortality and morbidity. There are many types of patients in the prehospital setting that ALS makes a big impact on morbidity. Morbidity is just much harder to measure.

  • Just a Medic says:

    I’ll second the motion for “Fentanyl Lollipops at the BLS level.” That one brought a chuckle. “You broke your forearm? Here, have a lollipop.” Or “you shot yourself in the foot? Here, have a lollipop.”

  • J.P. Martin says:

    Taking this discussion to the next level, EMS systems are evaluated and compared based on their cardiac arrest survival rate, instead of all the harder-to-quantify interventions listed above. As a profession, we need to establish a more accurate measuring stick. Otherwise, less educated politicians and bean counters, the ones who make the funding decisions, will devalue the importance of ALS.