Review of: Myersa LA, Russi CS, Schultz Jl. Paramedic intercepts with basic life support ambulance services in rural Minnesota. Prehosp Disaster Med. 2010; 25:159–163
This is a retrospective, descriptive analysis of a rural multi-system EMS agencies, between Minnesota and Wisconsin, that evaluates ALS intercepts with BLS services. This "rendezvous" is proposed to provide a transfer to a higher level of care. The goal of this study was to look at the frequency of ALS intercepts, the care provided and the urgency of transport (lights and sirens versus none). More than 1,600 intercepts were evaluated in this study. Paramedics rendered care no higher than the BLS level in 11.6% of the patients (n=194/1,633), and 1,481 patients received ALS care while 64.4% (n=955/1,481) received nothing more than an IV and cardiac monitoring. The authors conclude there's a discrepency between responding lights and sirens for a BLS to ALS intercept and actual ALS care rendered. Furthermore, the authors call for further study on the cost and safety of reducing emergent responses.
Medic Marshall: I have mixed feelings on this study, mostly with regard to how the authors define "ALS care." It's apparent after reading the study that ALS care equates solely to ALS interventions; I disagree. Personally, the phrase ALS care is a broader term that encompasses the interventions we're capable of providing. ALS providers, although armed with a vast array of drugs and equipment, need to know when and how to use that equipment. Furthermore, without analyzing the ALS providers' patient care reports more closely, we're only provided a piece of the puzzle as to why and how those ALS interventions were performed.
The one statistic I didn't see in this study was patient outcomes or how ALS care affected overall patient care. In my humble opinion, it's difficult to gauge the appropriateness of BLS providers requesting an ALS intercept without knowing what happened to these patients after or during an ALS crew's transportation.
Finally, I do commend the authors for studying an extremely important issue of safety within EMS and trying to do something about it. Ambulance crashes can be horrific, and no one wants to get that call either. So it's our responsibility to ourselves, friends, coworkers and colleagues across the country to do our part to continually improve the system.
Doc Wesley: Although this type of publication doesn't represent empirical research, it does highlight the value of descriptive analysis, which is simply the reporting of monitored events and the attempt to enlighten readers with the possible implications of the findings.
In this study, it was determined that only a select number of patients for whom an ALS intercept is called actually require any care beyond that already provided by the BLS crew on scene. The select group included cardiac arrest, respiratory distress, cardiac dysrhythmia, altered mental status and diabetic emergencies.
The most important point the authors make is that ALS responded to the intercept "lights and sirens" 97.5% of the time but only transported in that mode 24.2% of the time. Further examination of the intercepts shows the average distance traveled to the intercept site was around 15 miles with only two services averaging greater than 20 miles.
So what do you make of this? The authors contend that perhaps using a modified version of medical priority dispatch would result in fewer lights and sirens responses. However, my experience has been that services view the request—no matter how trivial—to validate the need for an emergent response, believing that if they don't do so, BLS services will cease to request them. We have to acknowledge that there's more at play in the provision of ALS interecepts than what's merely the best for the patient. Local and regional health-care politics are a primary driver of ALS intercepts.
Although it's clear ALS procedures were utilized in a significant percentage of patients, the authors didn't examine the medical records to determine whether they made a clinical difference. What was the impact on patient survival from cardiac arrest? I suspect there was none.
Cardiac chest pain represented a large percentage of the ALS intercepts, of which the vast majority only received an ECG and IV. Acquisition of a 12-lead ECG is part of the Wisconsin and Minnesota EMT-B scope of practice. Perhaps fewer intercepts would be needed if the EMT-Bs were allowed to perform 12-leads and transmit them to the receiving hospital.
I’m encouraged by the fact that the authors were willing to publish their ALS intercept experience. However, instead of some form of screening of the ALS intercept requests by dispatch, I believe that working with the BLS medical directors to develop better training, education and protocols on what constitutes the need for the interecept and adoption of BLS skills, such as 12-lead, would have had a far greater impact not only on the frequency of these intercepts but italso would improve patient care overall.