In a Perfect World, Is All EMS ALS?


 
 

Howard Rodenberg, MD, MPH, Dip(FM) | | Wednesday, December 19, 2007


I took a management course last year as part of a master's degree program in public health. One assignment was to watch a video of a man who (tanned, healthy and obviously richer than stink) stood on the deck of a sailboat in San Francisco Bay and proclaimed, "Hi. I'm a futurist." While my first thought was, "How do I get a job like that?" his message, like that of most management "gurus," is that the rules have to be broken to make progress.

I was reminded of this while reading a recent discussion on an EMS listserv regarding the question: "Are there too many paramedics in this world?" The overwhelming response to the poor guy with the temerity to post the question was "No."

We've grown up in a climate where more paramedics are good, more ALS is good, and more everything is good. And even if you reject that culture, job preservation is a pretty good reason to say no.

But this person was right to ask the question, and to try to answer it we need to take a few hints from the futurist and break some of our rules. We need to scientifically address the very difficult and emotional issues from which lesser souls shy away. Do ALS services make a difference? Does everyone in EMS need to be an ALS provider? Are there any dangers in an all-ALS world? For someone born too late for the '60s, taking on these issues is the most anti-establishment thing left for me to do.

The place to start is a look at the inherent efficacy of prehospital care. It makes no sense to discuss the format of a system if we don't even know what the system can do, though we seem to have an intuitive sense that ALS care is better than BLS care (and certainly better than no care at all). But if the devil is in the details, the details here are the definitions. Is better defined as more lives saved, by decreased morbidity (the severity of the illness or injury)? Is it characterized by levels of skill or training or by the "toys" available for ALS care? Is it defined by the patient's perception of the amount of care and comfort that can be provided? All of these definitions have different implications for determining the efficacy of an EMS agency.

The core of the contention that we need EMS agencies within our communities is that EMS systems save lives. That may be true maybe. A close examination of the literature indicates prehospital efforts can be proven to save lives in only two situations: the provision of electrical therapy to patients with pulseless cardiac arrhythmias (ventricular fibrillation, pulseless ventricular tachycardia) and the provision of airway management. (One might make a case for EMS systems preventing trauma deaths, but it seems that prehospital care only prevents death from injury as part of a system with designated trauma-receiving facilities. The advantage to individual patients lies in airway management, as previously noted. In air-transport services, the main advantage is simply the speed to transport to the receiving hospital).

Despite this limited database, we can certainly make a case for the provision of EMS care. But note that neither electrical therapy nor airway management is exclusively the province of ALS services in this new millennium, and certainly the success of electrical therapy is more dependent on response times than anything else.

I bring up the issue of the millennium because just as the years change, so must our thought patterns about EMS. Ten years ago, the idea that this lifesaving care electrical therapy and airway management was the exclusive bailiwick of ALS was probably correct. But changes in technology have made that argument obsolete. BLS providers can now provide defibrillation with semi-automatic or automated external defibrillators, and the advent of the laryngeal mask airway (LMA) challenges endotracheal intubation as the "gold standard" for airway management. In addition, evidence is increasing that missed intubation rates are higher than realized and that intubation attempts may do more damage than maintaining airway patency and ensuring oxygenation using nasal or oral airways and good bag-valve-mask technique.

What about those lifesaving episodes that have not been studied? Again, there is probably no doubt that prehospital skills are useful in preventing death and disability due to prolonged seizures, respiratory distress or prolonged cardiac ischemia. But if we look specifically at the differences between BLS and ALS capabilities, my sense is we once again see no clear advantage for ALS providers. Anaphylaxis can kill quickly in the prehospital setting; but if ALS providers can use subcutaneous (SQ) epinephrine and airway management techniques, we find BLS providers are able to use pre-loaded SQ epinephrine and similar airway techniques.

In the case of seizures, airway protection is the highest priority, and short of drug-assisted intubation, both ALS and BLS providers can use nasal airways. IV diazepam does fall within the province of the ALS provider, but rectal diazepam would lie within the tool kit of the EMT. It's also worth recalling that most seizures stop spontaneously.

What about asthma, emphysema and other causes of respiratory distress? An EMT can use noninvasive aerosolized bronchodilators, mechanical ventilation (using continuous positive airway pressure devices or CPAP) and if all else fails the LMA and the old reliable Epi-Pen. For chest pain and angina patients, you can make a case for using noninvasive sublingual (SL) nitroglycerin. We already allow EMTs to use SL dextrose gels. As long as we're not asking for an interpretation, there's no reason to think an EMT can't acquire and transmit a 12-lead ECG.

I could make a strong argument that victims of drug overdoses should not be "awakened" in the field (a topic for another time) and that the supportive care provided by a BLS crew is sufficient during transport. Inhalation analgesia, such as nitrous oxide, and traditional measures of splinting, ice and appropriate spinal padding and packaging can even achieve pain control.

Another point to consider as we evaluate the efficacy of ALS care is that many of the ALS interventions we've relied on for years have been shown to be of no help, if they don't actually cause harm. The discontinuation of high-flow IV fluids in the prehospital care of trauma patients is a classic example. And we've already mentioned data that casts doubt on the efficacy of endotracheal intubation (in fairness, I must also note that some of our old reliable BLS interventions [MAST suits, for instance] have also fallen by the wayside).

If you're a bit confused because my definitions of ALS and yours differ, it's because I'm talking in terms of absolute extremes. To some extent, this is a result of my "EMS raisin'" in Florida, where only the BLS EMT and the ALS paramedic exist. In other states, there are a basketful of prehospital certifications, including EMT-B (Emergency Medical Technician-Basic), EMT-I (Emergency Medical Technician-Intermediate), EMT-A (EMT-Advanced or EMT-Ambulance) and MICT (Mobile Intensive Care Technician). This fractionation of prehospital personnel adds credence to the argument that ALS and BLS levels of care are increasingly blurred and that the differences between a BLS EMT and an ALS paramedic are really academic.

The key term in my definition of a BLS provider is noninvasive. This phrase holds two meanings for me. The traditional meaning of an invasive procedure is a process characterized by the use of tubes and needles to access body spaces for the administration of drugs and fluids (this conventional meaning is obscured in practice; in Florida, an EMT may start an unmedicated IV in the presence of a certified paramedic). I would continue to subscribe to this idea. But I also consider as noninvasive those procedures performed by EMTs that patients can perform themselves at home and of which any resultant side effects are not likely to require ALS care. These include such procedures as administering SL nitroglycerin, using a nebulized bronchodilator and inserting rectal diazepam (yes, patients do have family members do this for them at home). To the extent that this definition calls for a new class of provider, I plead guilty as charged. However, I believe that if the various state laws governing EMT practice were unified into one national standard, this level of provider would already exist.

Now can I have my sailboat?




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