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Blurring the ALS/BLS distinction

One step closer to mobile healthcare

One of the themes I noticed in the 2013 State of the EMS Science conference was a continued blurring of the distinction between paramedic and emt level skills. This was reinforced by preparing refresher lectures for agencies that have expanded the skill sets of EMTs into areas I never imagined would be provided by a basic life support provider.

You can read the details in my ems1.com column "Is the line between BLS and ALS getting fuzzy? Doing the best for the patient may mean changing the EMT's role."

Others have recently written about this issue:

Emotional Issue

Peter Canning, writing in Street Watch: Notes from a Paramedic, provided his perspective on enhanced EMTs with this item "Where I Stand  (Today)"

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

His post quickly got 11 responses.

Chris Kaiser responded to Canning's post in "Pushing Down The Skills – Bringing New Skills to BLS."  Kaiser referred to an earlier Life Under The Lights article:

“Allowed only if there is a demonstrated need.” I like that statement, even if I can come up with arguments against it in both an academic and practical sense. As I stated some years back in a previous post: “A Late Night Rant about Petty Politics in EMS” there is a hierarchy of things that guide too many EMS decisions, and they’re not positive things, they are:

  1. Revenue Preservation
  2. Area Preservation
  3. Ego Preservation
  4. Political Capital Preservation

Make no mistake. Those four things are at play in this whole debate on what skills should be in the scope of practice for every EMS level. I’d bet that if I were to take an informal poll, most BLS providers would support their being allowed to perform many new skills now considered to be in the realm of the “advanced” provider. I’d also say that most ALS providers would not support giving a lot of those skills to BLS. There would be some disagreement, as some BLS providers would see the additional education required as being burdensome, and some ALS providers would see giving ALS skills to BLS providers as lessening their workload by reducing the number of calls where they are needed. However, I look at it as a very contentious issue.

Moving to mobile and unscheduled healthcare

Agencies that define EMS as medical transportation will have a rough decade. Technology, demographics and economics will result in EMS expanding into the area of mobile and unscheduled healthcare. The practices needed to provide 24/7/365 ambulance service provides EMS with a strategic advantage over existing health care providers who provide regular or as-needed home-based medical services.

Chris has laid out the battlefield.

Mike "FossilMedic" Ward

Comments - Add Yours

  • Guest

    Listening to a tone out last night, I commented to my wife that it was another call to the community ER. We live in a very isolated rural area with limited medical services. So the ability to provide these services are important to our community. Where people used to bundle up their loved one into the car and drive to the hospital, 3-6 hours away depending on the ferry, or the doctor, they now call 911. Yes, we are becoming the mobile medical service.

    • http://www.firegeezer.com/ Mike “FossilMedic” Ward

      Thanks for the post. I think the trend towards mobile healthcare is especially important in rural areas.

  • Bob Sullivan

    There are two sides of this argument. If BLS is responding alone, are patients better off if they are equipped with 12-leads, albuterol, and epi-pens? Probably yes. The next is is a profession, how much should we be expected to know about the interventions we are carrying out? Why is an associate’s degree required in most of Canada (where everyone’s a paramedic) to carry out these interventions, when in the US we require a few hundred hours? I would rather have their education model.

    • http://www.firegeezer.com/ Mike “FossilMedic” Ward

      Bob – thanks for the response. Not disagreeing with the education model, we need to think about what we want our lifesavers to do (and how well.)