When an ambulance shows up at your house or an EMS scene, they ought to be able to take care of the most common complaints like pain, nausea, and difficulty breathing, to go along obviously with vfib arrest and anaphylaxis. I want the first ambulance to be able to take care of the problem, not say, â€œOH, shit!, we need to call for the Calvary!â€
Thatâ€™s why I have been a strong proponent of enhancing the BLS level when there is an intervention that can be done safely by BLS that will have a proven benefit to the patient. Starting back with AED, adding epi-pen, and right on through CPAP, Narcan, and as I mentioned in a recent post, Fentanyl (either as an SQ injection or perhaps as a Fentanyl Lollipop). I could throw in oral Zofran and Benadryl, and maybe also include albuterol nebs. Our state recently approved BLS 12-lead for chest pain. The BLS crew doesnâ€™t interpret the 12-lead, but transmits it to the local hospital and if it shows STEMI, they may divert to a PCI center in a farther town. Like Narcan and CPAP, the BLS 12-lead requires the approval and oversight of the serviceâ€™s sponsor hospital, if they think there is a need for that BLS service to provide the skill. Most of these emergencies also call for an eventual paramedic intercept.
A problem with adding all of these modules to the BLS level is what is known as Skill Creep and its effect on the larger EMS system. At what point does BLS become so enhanced that ALS is no longer needed? Assuming that more ALS is a good thing, then BLS skill creep can be a bad thing if it keeps services from either upgrading to the ALS level or from arranging to have ALS readily available either from their own fleet or from other services.
But depending on how much ALS you already have, more ALS is not always a good thing. Too much ALS depletes skills, and may even pose a risk to patients.
When I started as a medic, there werenâ€™t very many paramedics. In Hartford we had one or two medics North and one or two South, depending on the day. We were intercepting with basic units all day long. I used to think that more paramedics would be a good thing, but I am not so certain anymore. Today, there are two ambulance companies working the city instead of one, and at any given time there can be as many as 12 or more medics ambulances on the road. Consequently, medics are not reserved for the â€œbig bad callâ€ or for intercepts, but they do routine calls, from BLS transfers to drunks to EDPs. Now while we did some of these calls in the old days, we do more now. The number of critical calls I do in a day, week or month is much less than it used to be. Where I once got 12-20 intubations a year, I have been averaging 2-5 a year. (I am currently at 5 for the last 12 months). Many medics in my system and across the country are only getting one tube or less a year. That cannot be good for patients. While many intubations may go perfectly fine, too many are likely less than seamless.
Spread skill depletion out across all ALS interventions and your average paramedic today (at least in the system I work) is less experienced and capable than they used to be. Thatâ€™s why if anything, I am for reducing some of the skills paramedics do unless they have access to strong medical direction, quality oversight, and training opportunities. If you are only getting 1 tube a year and you are not required to do quarterly sessions in a Sim Lab, you might not be the safest intubator. If paramedics in your service are only doing two codes a year, you either need less medics or you need to make certain all the ones you have are getting regular training.
I am all for paramedics, but I know for a medic to be good, he has to do the calls. The classroom provides the underpinnings for what you learn on the street. You need experience and practice to do your job to its fullest when the skills required are complex.
Thatâ€™s why I am for simplicity. It shouldnâ€™t be BLS or ALS, it should be about benefit and safety to the patient. Thus, I, a paramedic of 20 plus years, and still working full-time, argue for BLS to give fentanyl, and ALS to stop intubating (unless you are doing 10 or more a year) and/or have regular access to an OR or high tech sim lab. Just how I feel.
Every EMS system is different, but for the ones I know best, more enhanced BLS and less diluted ALS sounds like the right combination.