Regular readers of this column know that I'm a strong advocate for BLS services. There are several times more BLS providers than ALS personnel in the United States, and they serve a greater percentage of the population (especially in rural areas). Some people have viewed my advocacy for the idea that someday BLS and ALS capabilities may merge as hostile to ALS education and expertise. But I think I've found an area for BLS expansion that even the strongest advocates for ALS providers would endorse.
Here's my idea: I believe that BLS providers should be able to do the same things that an average layperson might do for his or her own health. This includes administering aerosolized beta agonists, using finger-stick blood glucose testing, administering sublingual nitroglycerin tablets, and administering aspirin.
Let's examine each of these procedures in detail.
Laypeople perform finger-stick blood glucose testing millions of times each day. It is a quick and relatively painless procedure, easily learned, and made simple by the use of standardized test strips and monitoring devices. Most important for the EMT, it represents a means to rapidly diagnose one of the few true "quick fixes" in EMS. As we know, hypoglycemia is a common, and eminently correctable, cause of altered levels of consciousness, seizures, and coma. Screening for hypoglycemia should be a fundamental part of all EMS protocols.
Of course, it's fruitless to speak of diagnosis without providing a means for care. If an EMT is able to diagnose hypoglycemia based on a finger stick test, it does the patient no good if there is a wait for ALS treatment. So the use of a noninvasive agent, such as oral glucose, must be an integral part of BLS care. In many states, EMTs may already administer oral glucose gels.
It seems a contradiction, however, for EMTs to carry this agent without a means to determine when it's needed for use. In addition, we've also learned that in some cases (specifically those related to ischemic stroke), the random administration of glucose prior to confirmation of hypoglycemia can be potentially harmful. In essence, the "status quo" asks the EMT to use a tool with deleterious possibilities while providing no way to discover when it may be lifesaving. Allowing EMTs to perform finger-stick blood glucose testing not only resolves this inherent contradiction, but also paradoxically "raises" the BLS capabilities to the level of the layperson.
(I can foresee an argument that EMTs might misuse the oral glucose preparations in patients with a depressed gag reflex, provoking aspiration of the gel into the pulmonary tree. Clearly, training for the use of these agents must include an assessment of airway integrity and the degree of patient cooperation. If the airway is at risk, the EMT has other things to worry about besides the use of oral glucose preparations, so the point becomes moot).
Patients with respiratory diseases such as asthma and COPD may make frequent use of nebulized beta agonists such as albuterol and levalbuterol. It's not uncommon for an EMS crew to arrive at the scene to find a patient in acute respiratory distress with a plastic mouthpiece firmly in place behind a foggy mist of saline and drug. If patients can use these agents safely, it seems reasonable to consider that EMTs may be able to do so as well. As in the case of hypoglycemia, EMT training currently encompasses the assessment and recognition of respiratory distress. It seems a small step to ask BLS providers to understand the technique of nebulized beta agonist administration, and the possible side effects of aerosolized agents. Allowing EMTs to perform this procedure permits them to provide care at the level of the untrained patient.
The use of aspirin by the EMT is, in my mind, an absolute no-brainer.
The value of aspirin (acetyl salicylic acid, or ASA) in the patient with angina, cardiac ischemia, and myocardial infarction is well known to both health care providers and the general public. Many physicians advise their patients to take an aspirin tablet daily, and ALS protocols often mandate the use of aspirin in potential cardiac cases. Aspirin inhibits platelet aggregation and clot formation. This effect helps to prevent the coronary arteries from being occluded when blood flow get sluggish over the fatty plaques within the vessels. Administration of aspirin has been proven to limit myocardial damage, improving morbidity and mortality.
EMTs are already trained in the recognition of potential cardiac symptoms, and there seems to be no reason why they cannot also be trained to look for contraindications to aspirin therapy (such as signs of stroke, obvious bleeding or bruising, and a history of allergy to ASA). Its use does not prevent the subsequent administration of other anticoagulants, such as thrombolytic drugs, nor does it impair the performance of invasive procedures such as cardiac catheterization or emergency bypass surgery. Once again, permitting EMTs to use this modality not only helps to save lives, but also "raises" the standard of BLS care to that of the untrained laity.
A final area of consideration is the use of nitroglycerin (NTG). Many people give themselves nitroglycerin for chest pain. EMTs in Florida and elsewhere are allowed to assist patients in the use of their own nitroglycerin, but not to administer it in an independent fashion. As best I can understand, the theory behind this is that a patient who has had nitroglycerin prescribed for him by a physician already carries the diagnosis of angina. In a patient with coronary artery disease, the benefits of coronary and systemic vasodilation on myocardial oxygen demand and the workload of the heart outweigh the risks of headache and hypotension. When NTG is given to the patient without documented disease, there is a small (but real) risk of inducing unwarranted hypotension and shock.
I won't argue with this theory, at least in the abstract. If an EMT is not certain that the patient has chest pain suggestive of myocardial ischemia, if the patient is already hypotensive, or if there are no means at hand to combat any side effects of the drug, I'd agree that EMTs should probably not administer NTG. But we already teach EMTs the signs and symptoms of cardiac emergencies, as well as means to assess patient status before and after NTG use. EMTs have some capability to cope with any inadvertent hypotension through the use of positioning techniques. The biggest safety factor in the use of nitroglycerin is the self-limiting nature of the drug. Even if given inappropriately, the effect will be gone within minutes.
The case for EMT administration of nitroglycerin reinforces an important point in the expansion of BLS capabilities. There must be intense medical direction oversight of the performance of these procedures by BLS personnel. Focused training efforts, specific and benchmarked protocols, tight quality assurance, and the liberal involvement of on-line medical control are key. Over time, I suspect that as both prehospital providers and receiving physicians become more proficient and comfortable with the techniques, they would gradually become part of the standard prehospital armamentarium.
My view of the ALS/BLS dichotomy is rooted in my Florida experience. In the Sunshine State, the only two levels of prehospital provider are EMT and paramedic. There are no EMT-A's, EMT-B's, EMT-I's, or any of the other fine divisions of BLS care that characterize the prehospital milieu of other states. In addition, there seems to be a great reluctance on the part of the state to allow the expansion of BLS capabilities.
During my tenure as the local EMS medical director, I learned that the only way I could authorize the EMTs under my direction to perform nitroglycerin administration, use nebulized medications, or do finger stick glucose testing was to obtain a variance from the state. To make a long story short, it involved two revisions, a county attorney, an attorney for the state EMS office, and still nothing got done (not to promote myself, but it's a sad commentary when an educated citizen cannot successfully complete a state-sponsored application).
In fairness to the Sunshine State, Florida requires EMT training to correspond with the 1994 Department of Transportation Core Curriculum, and further authorizes EMS Medical Directors to permit an EMT to operate an automatic or semi-automatic external defibrillator (AED/SAED), to use an epinephrine auto-injector, and to start unmedicated IVs under the supervision of a licensed paramedic. But even these skills fall short of those things that patients are allowed to do for themselves.
If you're thinking that the expansion of BLS procedures plays into my theory of the blurring border between ALS and BLS, you're certainly correct. But I think that even opponents of my idea that BLS and ALS may eventually merge can recognize the logic behind this assumption. I'm not intending to chip away at ALS skills, or to establish an equality between BLS and ALS care. I'm simply acknowledging that if a layperson with a minimum of training can perform a medical procedure, then surely an EMT with at least a semester of formal training and some field familiarity with clinical care ought to be able to do the same thing.Some might argue that allowing BLS providers to perform these procedures somehow violates the integrity of ALS care. To me, those who advocate this position are working off the wrong premise. I think the correct question to ask is not whether BLS performance of these procedures interferes with ALS care, but how it augments our overall clinical capabilities. More providers, trained to perform more procedures, should help to maximize available EMS manpower and extend the reach of prehospital care.