BLS Skill Creep

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, “OH, shit!, we need to call for the Calvary!”

That’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 doesn’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 service’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 weren’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 “big bad call” 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. That’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.

That’s why I am for simplicity. It shouldn’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.


  • Sandra Moritz RN says:

    As a school nurse who needs EMS from time to time, I wonder why there is not one course for all responders? Would this be a solution?

    • Bob Jamison says:

      I can summarize this with some initials that you’ll recognize; CNA, LPN, RN, NP. Why isn’t there one course for all nurses?

    • medicscribe says:

      As Bob says above, there are clearly two different skill levels and supporting education/training for each. I am not advocating doing away with paramedics, who I consider essential. I am merely if there is an intervention BLS with their limited trainimg and and in some cases experience, can do safely then, they should be allowed to to it if it benefits the patient. You still need paramedics.

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    My experiences as a paramedic led me to the realization of 2 things……1. how close I had actually come to having my leg traumatically amputated and 2. how it would have been handled, or rather, mishandled, on an ambulance or to someone in the military, or a bombing, or a natural disaster.

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    • EMS Artifact says:

      I have to agree about the Fentanyl patch/lollipop thing. Controlled substance control is hard enough when it’s limited to ALS crews.
      Aside from that, ETCO2 is almost at the standard of care level for administration of analgesic/sedative agents and I don’t see that happening soon.

      As far as the paramedic to EMT ratio, Boston EMS has operated under a philosophy of having fewer paramedics in the system for almost 40 years. While there are a number of reasons for that, one of the big ones is to prevent “rust out” from medics not seeing enough acute patients.

      There are far too many paramedics in the field. To the point where a lot of them can barely handle a fairly straight forward emergency and totally fail if the patient is acutely ill and requires complex care.

  • Christopher says:

    You want to give an opioid to EMTs without any other advanced skills in place? As soon as you said that you invalidated your entire article. I couldn’t read a single sentence more…

  • Iain says:

    Unfortunately I must agree with Chris about pain meds. After the huge issue of opiate misuse and overuse, and the fact that you just wrote a post about opiates, and submitted a recommendation to CEMSMAC for changing the pain management protocol, I am amazed you would write that.

    But lets talk about this. First and foremost, there is an educational issue here. The state decided that 150 hours was sufficient to train an EMT, but all they get out of that is “call for a medic”. How often do we hear about a BLS crew call for a medic when they could get to the hospital faster, and there isn’t a thing that you or I are going to do to help? What should be done about this? EMT should be a volunteer certification only. You want to get paid to do this full time? AEMT. Both for the increased pathophys and assessment ability, and to have an idea of what you NEED a medic for. There are regions in the country that (appropriately) ALS less than 50% of all 911 calls, I’m afraid of what CTs statistic is.

    Second, I feel we have given a lot of these skills to EMTs not because they have the clinical knowledge to use it, but because it “can’t really hurt” if they do it wrong. But all of these things can go wrong, mostly because they sat on scene doing one of these “really cool, totally awesome, fun” interventions and didn’t drive to the hospital. Lets go down the list:

    * AED – YES
    * Epi-pen – YES – but given your argument, why not do IM from the ampule?
    * CPAP – MAYBE – Research shows it’s beneficial in all respiratory distress, but is there an underlying reason that should be treated instead?
    * Narcan – NO – for respiratory depression: BVM. You’ll have EMTs giving it and causing NPPE or aspiration PNA because they didn’t appropriately manage the airway.
    * Fentanyl – absolutely NOT – Given all the misinformation from the drug industry about opiates for the last 20 years (this is the only time I agree that the drug industry is 100% at fault), we can’t be handing opiates out for BS complaints, and not from EMTs.
    * ODT Zofran – MAYBE – Low risk, sure. But there have been several recent events of people receiving zofran and immediately having dysrhythmias (I know of two at Midstate). While I think a monitor isn’t appropriate for everything, you’d want to have it handy then.
    * Benadryl – MAYBE – Ok, epi is the important part, and benadryl soon after.
    * Albuterol – MAYBE – with the appropriate complaint and appropriate assessment, sure. But published researh shows even medics aren’t great at distinguishing when it’s appropriate and not (COPD/Asthma from PNA from CHF). What on earth will the BLS crew do when they flash someone?
    * 12-lead – MAYBE – Sure you’ll see the STEMI sooner, but now that BLS crew needs a medic, and if they don’t have one they go closest facility anyways. Similar to the argument against everyone gets a 12 lead – yes people have abnormal presentations or silent MIs, but if you’re going to a PCI center already, you’ll still meet D2B if they do it in the room.

  • medicscribe says:

    Thanks for the comments.

    Key to BLS giving opiates is a minimum 4 hour education program and on-line medical control authorization to administer. This was safely tested in the study I mentioned in the post “BLS Fentanyl.”

    Giving Fentanyl SQ was shown to have almost no side effects.

    Also, the service would have to have authorization from their sponsor hospital, who would have to agree that it will fill a gap in the local EMS system.

  • Ian says:

    It isn’t about the ability to safely administer. It’s about allowing even more people to provide opiates to more patients, when much of what we think we know is predicated on lies from the pharmaceutical industry. (I am not anti pharma, I even worked in the industry, but in this there an issue. re

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