I’ve been reading some comments on my blog today. The commenter is also an EMS blogger. He happens to be an EMT who’s currently back in school to become a physician’s assistant. He and I have been engaging in a bit of a debate about the role of BLS versus ALS in prehospital care. From my reading (and we all know how perception and tone sometimes get lost on the Internet), he’s one of the people who believes that good BLS care is the critical component of any EMS system. I respectfully say there’s more to being a good provider than good BLS care. I also assert that there’s more to an EMS system than good BLS care or good cardiac arrest survival stats.
I’m not one of those types who likes the shopworn EMS t-shirt slogans like “BLS before ALS,” “Paramedics save lives and EMTs save paramedics,” or the all-time classic, “Do you want to talk to the paramedic in charge or the EMT who knows what’s going on?” First of all, the BLS versus ALS dichotomy, seems to me, to be another example of the inherent bias against education and professional advancement in EMS. That, somehow, the core principles that an instructor tries to convey via “Death By PowerPoint” in a 120-160 hour training class are the only things that matter in emergency medicine and that it’s admirable, nay, even noble to focus solely on this limited set of medical knowledge. The “low information voter” of these types claims that’s all they need to know. The sophomoric (Greek for “wise fool”) EMT advocate claims that the science and studies show that advanced life support care doesn’t make a difference. The science and studies may provide proof of this conjecture for cardiac arrest care, but that’s the low-hanging fruit of studies for out-of-hospital medicine. Dead or not dead. But that’s defining EMS success based on a very small subset of our calls — salvageable patients in cardiac arrest. (And for success there, we’re better off just putting AEDs in public places and mandating CPR training for the public.)
For better or worse, like much of medicine, what we do isn’t easily quantified into a study. How can you measure the pain you took away from an elderly patient with a hip fracture that you administered Fentanyl to prior to moving them? How do you measure the symptom relief you provided to a congestive heart failure patient with CPAP and nitroglycerin? These anecdotal differences are why medicine remains a learned profession that cannot be distilled into a mere science. Science gives us the information and knowledge to provide care to another.
Being a paramedic is a mindset. It’s possessing the full armament of prehospital knowledge. It’s knowing when to use, and more importantly, not use an intervention. It’s using the resources you have on scene. It’s knowing when you need additional resources. It’s managing your partner, regardless of their certification level. It may even be calling a doctor for a consult or orders. Most notably, it’s a set of skills, knowledge, and competencies that can’t be learned in a 120-160 hour course. Heck, in my personal, non-researched opinion, graduating from paramedic school makes you only competent enough to spend the next year or so in a high volume, high acuity EMS system honing your abilities and skills under the tutelage of a mentor. Nope. Not a FTO. Field training is merely orienting the provider to a particular EMS system. You need the mentorship to learn the craft of being the highest level of care outside of a clinical setting. Paramedic education teaches the fundamental knowledge and skills. Tutelage under a mentor makes you a master at the job. It’s the difference between knowing how to perform a rapid sequence intubation and looking at a patient and realizing that they’re in danger of losing their airway.
Paramedicine, or prehospital care, is like all of medicine, more than mere science. It’s the application of scientific knowledge to real people. And the world of paramedicine adds in the confounding factor of applying this knowledge to people in the nonclinical setting. The choreography of EMS is the challenge. Until you’ve picked up the baton as the lead paramedic to conduct the prehospital symphony of your partner, first responders, firefighters, cops, the patient, and hysterical bystanders/family, you’ll never understand the challenge — nor can you understand the sheer joy of it. If you’re an EMT, pick up the challenge and advance professionally. Otherwise, I will politely and respectfully ask you to defer to my prerogatives as the lead. That doesn’t mean that we can’t discuss patient care. It doesn’t even mean that I don’t want to hear your ideas on scene. What it does mean is that we’re not in a democracy and that with my increased knowledge and responsibility comes the decision making authority.
Thanks for reading, y’all.
Very well put sir. I agree with you. Please keep in mind that as the lead, or highest medical authority on scene we also need to remember or obligation to educate those we work with, if they be basic or advanced clinicians. To bring them to a higher level of understanding of the needs of the community and the immediate patient. Keep up the blogging.
Why do you feel that they are mutually exclusive? Can you not have excellent BLS as part of ALS?
I would agree with most of what you suggest, but disagree that one precludes the other. I personally need my other folks to do good BLS so that I can focus on ALS when things are “real”. If I have to do both, I do each not as well. Strong BLS is a good thing and not something to be feared or dismiss. I also think that others doing good BLS and ALS providers making sure that BLS is being done well (agree that BLS isn’t always first) is a part of the equation.
ALS providers need to step back and take note from our ED physicians and recognize that we should be transitioning into a more “leader” role and focus less on being the doer in a way that does not alienate our BLS teammates!
We are all part of a team and need to just refine our part.
I think this is what the ambulance chaser is alluding to. We are conductors of a symphony called prehospital medicine. We are not chefs (no cookbooks here). Our job, as paramedics, is to squeeze the most care from whatever group of people we are surrounded by. This means pushing our partners to excel at their jobs as well as helping them understand ours. It’s utilizing our first responders as more than just “stretcher fetchers” (they are medical providers as well). It’s utilizing family members to assist in advancing the care through the call (history, medications, family hx, etc…).
Yes, ABC’s come first, but sometimes the means to that end are early ALS skills. We are often taught to revert back to our BLS heritage when things get tough and we are stumped. I’m a firm believer in this being a way to temporarily disconnect the mind and reset it. A “cerebral adenosine”, if you will.
We get paid more for what we know than what we do. Our BLS partners look to us for leadership. In my humble opinion, the ability to step back and conduct a scene (the whole scene, not just the patient) is where the magic happens. My best calls have had very little hands on by me. My worst, conversely, have been fueled by my ego and refusal of help.
ALS does preclude BLS as long as BLS providers lack the knowledge and training that we, as paramedics, possess. “Paramedics save lives but basics save paramedics” is, on my truck, a way to inspire confidence in my partner just as continued mentoring does. The fact is, paramedic knowledge only saves lives when that knowledge is applied and while leadership exists.
Truly 1+1 can only =3 when we act as a team with a leader.
Stay safe, everyone.
If EMTs are so awesome then how come I’ve only worked with a handful who were actually any good at their jobs with the correct attitudes?
I think that this debate has become almost silly. The distinction between BLS and ALS was once significant: ALS did invasive therapies, BLS did not. Now, it’s just an artificial line in a continuum of care.
The question is whether a 100-hour technical course gives one the right to claim to be an EMS provider, or not. I say…not.
We’re talking about different things, I think!
I absolutely think that “good BLS care is the critical component of any EMS system.” But that doesn’t necessarily mean BLS-level PROVIDERS (meaning EMT-Bs). If they’re good enough it can mean them, but as you’ve pointed out and I don’t dispute, the core national curriculum for EMTs is in no way adequate to ensure this. So there are rockstar EMTs as well as really lousy ones. Paramedics are much more likely to have these skills due to their greater training, although they’re not a guarantee either.
The skillset I’m referring to as “BLS” is the fundamental understanding of disease and medicine that underpins all real care. It’s asking the right questions and grasping what’s going on and knowing what the patient needs. EMTs, medics, and the doc you’re delivering to all ought to be able to do this if they’re going to function as independent providers. This stuff is hard, but it’s the heart of all medicine, and I think we agree that anybody without adequate foundational education to operate on this level should not be running an ambulance.
The additional interventions available at the ALS level are a whole ‘nother topic. I hesitate to weigh in because the skill retention issue is so central and I can’t say much about it. But I like the examples you chose, because if I had to make a list of the interventions I’d like available on as many ambulances as possible (whatever we call the level of care), it’d include all the palliative measures I could fit, like analgesia and anxiolysis and bronchodilators and CPAP and on and on. I love EBM but I hate when it washes over the value of these things in pursuit of mortality and other flashy numbers. We can’t save nearly as many lives as we can make people more comfortable.
That’s not really the point I was trying to make, though; picking the ideal scope of practice is a bigger and different question. My main point is that even on an ALS rig that can move mountains, the drugbox and the LifePak aren’t the most important tools there — it’s the medic’s ability to perform bedside medicine with his eyes, ears, hands, and brain. Because he’ll use those every call, whereas the drugs and monitor will only be used sometimes… and moreover he won’t know when to use them without the other stuff. And while that clinical acumen is often lacking in BLS-level providers, I believe it is nevertheless “BLS” in the sense that it’s available to them; no EMT will ever be breaking the law or violating his scope for knowing too much pathophys. And just like the medic, he won’t be able to do his job without that competency. That’s what I mean by BLS and that’s why I mean it’s not the sole providence of the EMT-B. Everyone should be doing it; and some folks (medics) should be doing other things too.
That’s why I called my site “EMS Basics,” even though I frequently get people asking whether I really think topics like hemorheology are “basic.” Not in the sense that most EMTs learned them in their training program, no. But it’s not outside their scope, and it’s not only for them anyway. “BLS” stuff like asking exactly, precisely the right questions to lead to a diagnosis is “basic,” but I expect I’ll be learning to do that for the rest of my career.
So with all of that said, I think we probably disagree on some things, but I’m pretty sure it’s less than it seemed like at first. Heck, you’re the attorney… you know how tricky everything gets when definitions are unclear…
I just wanted to share my thoughts on this article from an Australian Paramedic perspective, however i should provide some context just so you know where i’m coming from. I work in a service where Emergency Ambulances are staffed by 2 Paramedics at a minimum (Unless it is a training car and it has one specialist Clinical Instructor to work with the Paramedic Intern). To become a Paramedic here, it is a minimum 3 years university of which only people with exceptional grades get into that course. It is then a 12 month paid internship which is highly competetive and only the best get through. So that is some background on the service. My personal background is 6 years study and i have a Registered Nursing background, am now a Paramedic Clinical Instructor. We also have people who work in a transfer services tier who would be the equivalent of EMT qualification so that is the similarity. The article above argues the merits of ALS over BLS and makes some interesting points. I can see both arguements as at the end of the day, ego aside, basics can get the job done in most instances when you are talking about getting someone to difinitive care. However, why give someone the basics when you can offer more whilst getting them to that care. If i was a patient, and i had a choice, i would take option number 2. To be relieved of pain, to have interventions started prior to getting to hospital sound better than just scoop and drive. Now i don’t say this to put down EMT’s as i feel they have an important role in pre hospital care. ALS just makes more sense and is proven (well here at least) to vastly improve patient outcomes in many circumstances. It’s about offering what the patient needs when they need it, within reason and i don’t see how that is a bad thing.
I need to say just one more thing. I don’t get the whole, i want to become a paramedic just so i can become a fire fighter thing. If i had a choice between a complex medical case and making important decisions to assist a patient or putting wet stuff on hot stuff i know what i would choose. Has always perplexed me.