Administration and Leadership, Columns

Analyzing the Threshold for ALS Response in EMS Protocol

Issue 3 and Volume 42.

As part of this series of columns from the National EMS Management Association, we posted a survey in December 2016 on to elicit responses from EMS providers around the country about the level of care their agencies would provide for certain types of patients.

This survey was meant to help determine how EMS has evolved over the last 50 years and where we had divergent approaches to prehospital care across America. We were interested in the impact of dwindling reimbursement and the rising cost of EMS, and thought there might be an impact on patient care.

This was not a scientific study, just an informal survey. Although the data can’t be firmly relied upon as comprehensively representative of the status of our EMS systems, nor the cause of different practice patterns, they’re helpful in identifying broad similarities and differences among our operations, and may help to inform more research on this subject.

The results were a bit surprising, showing no universal consensus on where the line is between BLS and ALS intervention. Certainly, some of this disparity lies in the scope of practice definitions we use for ALS and BLS in various states, as well as a region’s EMS system design-such as “all-ALS” or “tiered response” with dispatch protocols, as an example.

More than 2,000 readers registered their responses for each of four specific response scenarios designed to focus on where agencies divide BLS care from ALS. Let’s review the results of the survey, complement them with comments from readers, and analyze what the larger trends may be.

Scenario One

A 78-year-old female patient who experienced a loss of consciousness that lasted, according to bystanders, about three to four minutes. Upon arrival, she’s found conscious, oriented and aware, with no memory of passing out.

The assessment reveals she has no apparent injuries other than a hematoma the size of a quarter on her forehead, and her vital signs are within normal limits. She doesn’t think this has ever happened before, but she lives alone.

In our survey, 67% of respondents indicated this to be an ALS case, while 33% said it’s BLS. Comments fell into two basic categories: ALS for precautionary purposes, or clearly BLS based on the lack of need for ALS intervention. Many made mention of their system’s protocols and what they required. This is very interesting because some comments indicated that age was a determinant factor in this scenario.

Does age matter? In some systems, if a patient older than a certain age (say 75 years) experiences any altered mental status, they require ALS intervention and transport to a hospital. The theory behind such requirements is that the possibility of a serious medical problem, such as a stroke, carries a much higher probability with elderly patients and, therefore, it warrants ALS presence and care.

Scenario Two

A single-car motor vehicle accident occurred at 2:00 p.m. on the interstate highway. Upon arrival, a 28-year-old male single-occupant driver is found leaning against his car, located in the median grass strip. There’s significant front end damage, with the bumper ripped off and lying next to the car. There’s no damage to the windshield, but the airbags have deployed.

The patient reports he feels fine other than pain in his wrist, and never lost consciousness. He admits he was texting while driving and drifted off the roadway, lost control of his car and ended up in the middle of the highway. He has significant pain upon palpation and attempted movement of his wrist. He reports no significant medical problems other than hypertension, for which he takes medication.

This time, only 17% of respondents said ALS was the right level of care, with 77% indicating BLS was more appropriate. This could be considered a classic BLS incident, with no apparent need for any ALS intervention. And yet, almost one in five respondents still selected ALS. Some commented this was due to their system design as all ALS. But, what ALS care would be provided in a case like this?

Interestingly, no one expressed concern about “mechanism of injury,” an old phrase used to justify ALS in traumatic injury cases where the patient’s signs and symptoms didn’t point to serious injury. Is this no longer a useful analysis for EMS personnel to consider in determining the potential condition of the patient?

Again, age may be a significant factor in determining the appropriateness for ALS. If this patient had been 75 or 80 years old, it’s likely many EMS systems would require ALS monitoring at the very least. Older patients carry a higher risk of injury in such cases and underlying medical conditions may either be at play or exacerbated in a case like this.

Scenario Three

EMS personnel find a 9-year-old girl who is conscious, although a little disoriented and quiet, following a reported seizure. Her mother states she has had seizures before and this one was typical in nature. The father says that when she has a seizure, she normally only has one, but they want her “checked out” at the hospital just to be safe.

The child isn’t feverish, appears to have no injuries other than a slightly swollen lower lip-probably from biting it during the seizure-and is gradually becoming more oriented and aware. Her vital signs are normal for her age.

In this case, we saw a nearly even split among respondents, with 57% classifying this situation as needing ALS, and 43% determining it requires only BLS services.

It’s interesting that our profession could be so significantly divided on a simple EMS case experienced countless times every year across the country. Could it be age again? If this were a 25-year-old, the numbers might be different and BLS favored heavily. No ALS intervention, not even an IV, is necessarily warranted by most systems’ protocols in a case similar to this, for neither the 9-year-old nor a 25-year-old. Yet, we seem to still worry about the kids. For many EMS providers, pediatric patients pose one of their worst fears and expose a point of insecurity.

Final Scenario

Dispatch sends a unit to a “diabetic emergency” call. It’s a 58-year-old male patient unconscious in the home he shares with his wife. She reports he passed out after suddenly acting abnormally.

She says he’s on an insulin pump and has noticed no unusual dietary changes during the day. He hasn’t had a diabetic crisis in many, many months. While his vital signs are taken, including a finger stick that reveals a low blood glucose level, an IV line is immediately started and 50% dextrose (D50) administered, according to standing orders protocol. The patient quickly regains consciousness. He’s assessed again and found to be appropriately oriented and his vital signs are within normal limits.

The overwhelming majority (84%) of our 2,000-plus respondents found that this case justified ALS care, while 16% believed it to be BLS.

In some jurisdictions, IVs and the administration of D50 are no longer considered an ALS intervention reserved for paramedics only. Instead, AEMTs are permitted to provide this care. In fact, the National EMS Scope of Practice Model classifies it as such. Based on the comments submitted with the survey, it was likely respondents indicated this as an ALS case because an ALS intervention took place, not because their system’s ALS units should have been dispatched. In fact, in those EMS systems where AEMTs operate, this appears to be the type of case they would have handled instead of an ALS unit.

It does appear that some EMS systems around the country utilize BLS units staffed with AEMTs to perform some advanced skills previously reserved for ALS units and paramedics. In these instances, lower-cost EMS units are providing care that was traditionally reserved for more expensive ALS units. With the upcoming review and revision of the National Scope of Practice Model by the National Highway Traffic Safety Administration (NHTSA) over the next two years, we may be seeing even more skills and interventions formerly provided only by paramedics transferred to AEMTs. This would continue to lower the delivery cost of ALS, and therefore EMS in general, bending the EMS healthcare cost curve downward.