Prehospital Tradecraft: BLS Before ALS

A Boston EMS ambulance stands ready to roll.
Photo/Chris Bowles

Mike Hudson makes the case why well-trained EMTs, augmented by paramedics, can help urban and suburban EMS services.

On a cold dark January morning, my friend experienced the best of our profession during one of the worst days of his life. We have all seen the novelty EMS t-shirt at the conferences, “Paramedics save lives. EMTs save paramedics.” The iconic saying could not have been more true last winter in Boston, Massachusetts, when two well-trained EMTs saved the life of a fellow paramedic, Chris Bowles.

Chris is a colleague of mine with over 25 years as a “P” and one of the most meticulous and levelheaded paramedics I have ever had the pleasure of knowing. Chris is the kind of paramedic educator that every “new guy” hopes to be partnered with during their field training phase. Chris is a consummate professional with a wealth of knowledge that borders on genius status. He has a lightning-fast sense of the obvious and zero ego to get in the way of a good time on shift. Like myself, Chris is critical of the trend in EMS that favors global paramedic saturation of the entire earth, a trend that has been sold to the public as a “lifesaving” model for public safety. However, those of us on the street know that paramedics can increase mortality and morbidity by extended scene time spent on cookbook ALS workups and performing unnecessary procedures for every patient that dials 911.1,2,3 Today, indiscriminate 12 -leads, POC lactate tests, and glucose testing for every patient contact are the latest band-aids for allegedly over-tasked emergency rooms who expect us to hunt for zebras all the time, so they don’t have to. I digress.

This story begins while Chris was in Boston on business. He was staying at a nice uptown hotel when awakened at 3 a.m. with severe 15/10 abdominal pain. He described it as crippling pain. As most paramedics feel when it comes to their own health, he did not want to call an ambulance as this puts us in the unfamiliar subservient role as a real-life patient. Chris finally called the ambulance as the pain continued to intensify. This is how two EMTs saved a paramedic’s life in textbook fashion.

Duty to Act

Chris was an ex-night guy, and this added to his angst about calling for an ambulance. For EMS crews, nothing good ever happens between 3 a.m. and 7 a.m., but our duty to act remains constant. Just about the time when shift fatigue sets in, patient acuity starts to favor mild chronic health issues and residual inebriation. Stereotypically, there is a marked difference in day units and night units and the personnel who staff them, so when he answered the door, crumpled over, Chris expected to encounter the typical cynically abrupt big-city paramedic crew who would no doubt be dismissive of the severity of his symptoms. He could not have been more wrong.

Assessment and Initial Dispositioning

Chris told me the EMS crew came into his room politely and dressed professionally in Boston’s hallmark brown uniforms, shirts tucked in and boots laced up. He had assumed they were paramedics by their initial presentation and swagger but saw no patches on their reflective jackets. It is important to note that Chris never told them he was a paramedic at any point in the call. The crew got right to work, starting with a typical line of questioning for the usual suspects that cause male abdominal pain. A quick check of the radial pulse during a palpated blood pressure, and after a few more questions, the attending provider abruptly told Chris that he was sick and to gather his wallet and jacket; it seems it was time to go to the hospital.

More from Mike Hudson

A transport decision was already made without any of those elements that can often lead to a breach of duty at 3:30 a.m. There was no snap diagnosis of gastroenteritis and no talk of AMA refusals, nor options given for alternative transport to the hospital, like a bus, taxi or Uber. Chris was even discouraged from walking to the ambulance. Instead, he was secured on the stretcher, given a blanket to fend off the cool crisp morning air, and wheeled out to the ambulance in textbook fashion.

Focused Assessment and Transport Decision

Based on years of prehospital street work, Chris knew he wasn’t pregnant (he’s a genius, remember). He also knew adult males with abdominal pain are typically low-acuity cases and do not benefit from the paramedic skill set, so when there was no priority blood glucose taken or courtesy saline lock in the AC, Chris knew he was in an EMT unit. Almost as soon as the stretcher clicked into its cradle, the ambulance began to move. The driver and attending EMT said nothing to each other as they already knew what facility they were going to. It was just a two-mile trip to Massachusetts General Hospital.

The attending EMT told Chris that there were other transport choices that may have been more esthetically comfortable for a tourist, but if things went sideways, the plusher facilities were less equipped to “handle business.” Chris could only assume that Mass General was the chosen destination because of its Level 1 trauma designation and all the surgical and critical care fixing’s that go with it. Regardless of the reasoning, this transport decision was one of the factors that saved his life.

Appropriate Destination Decision and Transfer of Care

Chris arrived at Mass General with the same unchecked, unbearable, right sided abdominal pain he started with. The EMS crew gave a short, concise turnover to the staff and assisted with registration to facilitate a quick transfer of care. Then just as quickly and professionally as the Beantown EMTs entered his life, they disappeared through the ambulance bay doors. Soon after, Chris was diagnosed with a partially ruptured appendix that had caused concurrent infections of the small and large intestines with fluid aggregation around the rupture causing distension and swelling throughout the right-side abdomen. Paramedics would not have made one bit of difference with this case. The attending physician told Chris that the damage was done, perhaps days prior, and had he been outside of the country or stayed in that hotel room any longer, sepsis would have killed him.  

BLS Before ALS

Boston EMS has a reputation as one of the best functioning third-service systems in the country, where all newly hired paramedics are required to work several years on the city’s EMT units before promoting to a paramedic unit. Instead of blanketing their system with paramedic units, most of Boston’s units are BLS configured with roughly one ALS truck for every five or six active EMT units. It has been tradition that Boston’s EMTs are trained as EMTs internally using a traditional public safety academy format, regardless of possession of paramedic certification. Historically, EMT-configured ambulances have always been the backbone of Boston’s EMS operations, while paramedics are justifiably reserved for higher acuity patients.

Fewer paramedics do not equate to a lower standard of care as long EMTs can manage a scene and quickly get a patient to an appropriate facility without delay. Boston uses a population-based paramedic staffing strategy of one practicing ALS paramedic per 10,000 residents in the system. This formula has been shown to foster better trained and better prepared paramedics while avoiding dilution of critical procedures eventually leading to skill degradation.4 For big city systems, an accepting facility with applicable resources and proper internal EMS triage receiving procedures often become the primary factors leading to positive outcome for prehospital cases, with or without advanced care in the field.5,6,7,8 For tiered EMS systems, transporting the patient to the right place becomes the predeterminate factor for a good outcome in most cases, not medics. A good example of this conclusion is outlined in a recent  repeat study coming out of  Philadelphia.5

There are four relevant predisposing factors that lead to better outcomes and do not include ALS. Below are the components of what I call the “Golden ½ Hour.” Each factor is within EMT Basic scope of practice and comprehension, and each can be applied to both medical and trauma cases.

  1. Total scene time refers to the patient’s overall time on scene from onset of injury to initiation of transport. For medical calls this could equate to onset of chief complaint or sign of life threat. A patient scene time of greater than 15 to 20 minutes is often associated with increased mortality and morbidity for both high acuity trauma and medical cases.
  2. Distance from scene to the receiving facility. A shorter distance to rapid surgical intervention or critical care services improves outcome. A distance of less than 15 miles seems to be the average distance leading to improved outcomes under certain circumstances involving higher acuity events. Remember that distance also equates to time.
  3. Level of care at the receiving hospital. Just as important as speed of transport is the destination. Trauma Level 1 or Level 2 care has always been associated with better outcomes for both blunt and penetrating trauma. The level of care and comprehensive resources at a receiving facility can also influence the outcome of high acuity cardiac and neurological cases. One can conclude that a common thread leading to improved outcomes timely transport to physician led specialty surgical teams or critical care services.
  4. Do not wait for ALS, instead, consider medic intercept on the move if there is no predicted delay in delivery to specialty care. One can expect improved outcomes in certain scenarios. Look at the data regarding patients who have been on scene for less than 15 minutes at distances of less than 8 to 15 miles from a specialty facility. Of course, those few national and international EMS systems that allow paramedics to administer whole blood and TXA or those critical care EMS calls led by prehospital physicians have shown increased survivability under special circumstances. 

Conclusion

I want to thank the EMT crew that saved my friends life that night and to thank Boston EMS for setting the example by continuing to prove that EMTs who are vetted, well trained and treated as medical professionals can make critical lifesaving decisions without being paramedic dependent. One can conclude that if more urban and suburban EMS systems utilize a robust BLS transport model staffed by professional EMTs that are augmented by only a few highly experienced and properly deployed paramedic units, patient outcomes will improve, and less talk of paramedic shortages would occur. I’d bet my friend’s life on it.

References

  1. Ventilation patterns in patients with severe traumatic brain injury following paramedic rapid sequence intubation Daniel P Davis, Robyn Heister, Jennifer C Poste, David B Hoyt, Mel Ochs, PMID: 16159059 DOI: 10.1385/NCC:2:2:165
  2. Critical care paramedics: where is the evidence? a systematic review | Emergency Medicine Journal (bmj.com) Johannes von Vopelius-Feldt, John Wood, Jonathan Benger. Correspondence to Dr. Johannes von Vopelius-Feldt, Academic Department of Emergency Care, Emergency Department, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK; johannes.vonvopelius-feldt@uhbristol.nhs.uk.
  3. Emergent Endotracheal Intubation and Mortality in Traumatic Brain Injury. West J Emerg Med. 2008 Nov; 9(4): 184–189. Kurt R. Denninghoff, MD, Mervin J. Griffin, MD, PMCID: PMC2672276 PMID: 19561742. Emergent Endotracheal Intubation and Mortality in Traumatic Brain Injury (nih.gov).
  4. Six Minutes to Live. Robert Davis, USA Today: Five-part series published 5/20/2005. USATODAY.com.
  5. Association of Police Transport with Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania | Emergency Medicine | JAMA Network Open | JAMA Network AMA Netw Open. 2021;4(1):e2034868. doi:10.1001/jamanetworkopen.2020.34868, Eric Winter, BS.
  6. Paramedic response time: does it affect patient survival? Peter T Pons, Jason S. Haukoos, Whitney Bludworth, Thomas Cribley, Kathryn A Pons, Vincent J Markovchick. Acad Emerg Med. 2005 Jul;12(7):594-600. doi: 10.1197/j.aem.2005.02.013.
  7. Does out-of-hospital EMS time affect trauma survival? Am J Emerg Med.  1995 Mar;13(2):133-5. DOI: 10.1016/0735-6757(95)90078-0.
  8. Association between prehospital time and outcome of trauma patients in 4 Asian countries: A cross-national, multicenter cohort study. Chi-Hsin Chen, Sang Do Shin, Published: October 6, 2020. https://doi.org/10.1371/journal.pmed.1003360.
  9. National Study of Triage and Access to Trauma Centers for Older Adults. Tarsicio Uribe-LeitzAnn Emerg Med  2020 Feb;75(2):125-135. 10.1016/j.annemergmed.2019.06.018. Epub 2019 Nov 13. PMID: 31732372 DOI: 10.1016/j.annemergmed.2019.06.018
  10. Distance to Trauma Centers Among Gunshot Wound Victims: Identifying Trauma ‘Deserts’ and ‘Oases’ in Detroit | National Institute of Justice (ojp.gov), NCJ Number 255756 Date Published 2019 Research (Applied/Empirical), Report (Study/Research), Report (Grant Sponsored), Program/Project Description Grant Number(s) 2013-R2-CX-0010
  11. Effect of transport interval on out-of-hospital cardiac arrest survival in the OPALS study: implications for triaging patients to specialized cardiac arrest centers. Daniel W Spaite, Ian G Stiell, Bentley J Bobrow, Melanie de Boer, Justin Maloney, Kurt Denninghoff, Tyler F Vadeboncoeur, Jonathan Dreyer, George A Wells. PMID: 19167783. DOI: 10.1016/j.annemergmed.2008.11.020

No posts to display