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Creating a Quality EMS Future
by Michael Gerber

Can less ALS mean better BLS?

Sure, more patients may receive ALS care faster with more medics, but are those patients better off if BLS providers are no longer proficient in actively assessing and treating patients?

By Michael Gerber

Would you prefer a surgeon who did surgery three times a year but started on time, or one who did surgery 50 times a year but got there five minutes late, after the nurses had already prepped you and anesthesia had started putting you to sleep?

This is the question I want to ask communities that insist on putting more ALS providers on the street.

There is scant evidence that more than a few critical interventions make a difference in the first one or two minutes of care; most of these can be performed effectively by well-trained BLS providers.

Critical ALS interventions, on the other hand, while still time-sensitive, can often wait a minute or two. Some research also suggests that health care providers benefit from seeing critical patients more frequently and performing procedures more often.

In other words, fewer paramedics equal more patient contact, and more patient contact leads to better paramedics.

Can too many medics hurt?

One study that I would like to see, but still haven't, is whether having fewer paramedics also leads to better BLS providers. When every four-person fire engine has a paramedic on board, BLS providers often step aside and let the firefighter-paramedic run the show.

As a result, BLS ambulance crews can panic when confronted with a critical patient, because they have never had to treat one on their own.

The consequences of a system having too many paramedics are not quite known, but the side-effects likely outweigh the benefits. Sure, more patients may receive ALS care faster.

But are those patients better off if the paramedic treating them sees only one critical patient each year, or if that system’s BLS providers are no longer proficient in actively assessing patients and providing appropriate treatment?

Other drawbacks are less obvious. At a recent training on mass-casualty incidents, a colleague raised a concern that BLS crews might balk at transporting patients who were triaged as red. BLS providers are so accustomed to yielding to ALS providers that, even in a mass casualty situation, they might not be comfortable treating critical patients.

The September 2013 Navy Yard shooting in Washington, D.C. led to several news stories pointing out how many ALS ambulances and engine companies were “downgraded” that day due to a lack of paramedics. But what those news stories failed to ask was, what difference did that actually make?

Even if the shooter had shot 100 people and they had multiple levels of injuries, would ALS care have saved more lives? Would starting an IV during the 10-minute transport to one of the many local trauma centers have made any difference? Would starting the IV have led to worse outcomes if it delayed transport?

We need more training, not more medics

It is true that certain ALS interventions can be life-saving in such a situation, and ideally there should be enough paramedics on the scene of a mass casualty to perform needed ALS treatment.

There are also places where a lack of ALS resources is truly a problem; where ALS interventions could make a difference and a larger number of paramedics might improve patient outcomes.

But there are many more places where the perceived lack of paramedics, or increased ALS response times, is merely a political problem, or a budget problem, or a contract problem. Doubling or tripling the ALS resources likely won’t save a single life in these places, but providing existing ALS providers more training, more experience, and more support just might.

We don’t like to talk about these issues because, when we do bring them up, people think we are diminishing the importance of paramedics. That’s not what I’m doing.

Paramedics serve a critical role in the health care system, which is why we need to be well-trained, experienced, and valued. Adding more paramedics often has an opposite effect, leading to diminished skills, then more restrictive protocols, and eventually a more restrictive scope of practice.

When an emergency department is busy, or a patient there dies, will you suggest that the hospital hire more doctors, or that medical schools churn out more graduates? Sometimes, but it is just as likely that there weren't enough beds, enough nurses, enough registration clerks, enough technology infrastructure.

Going back to my earlier point on ALS skill dilution, I’d still rather have a smaller number of paramedics on the scene — who have actually seen a critical trauma patient before — than have hundreds of paramedics who rarely have the opportunity to treat truly sick patients.

About the author

Paramedic Michael Gerber, MPH, started in EMS in 2001, when he joined the volunteer fire service while working as a journalist on Capitol Hill. He later served more than eight years in the career fire service as a paramedic and quality management supervisor. Currently, Michael works as a consultant with the RedFlash Group and M10 Solutions, and he also continues to treat patients as an active paramedic with the Bethesda-Chevy Chase Rescue Squad.
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Don Lyng Don Lyng Wednesday, June 25, 2014 5:35:42 AM In my area MONEY is probably the biggest motivator in becoming a Paramedic. BLS providers make $9 or $10 an hour here, RARELY (if ever) get promoted to an Officer/Supervisor position. So many go to the local college, go to the Paramedic Program and instantly get a $3 or $5 an hour pay increase upon graduation, some get promoted with yet more of a pay increase (which is a problem in and of itself due to patient care on a scene, but that is a different rant) and even then, once they get that PARAMEDIC patch.....many LEAVE THE AREA for MORE MONEY somewhere else. And then comes the ATTITUDE of the Paramedic. When I worked Transport (we provided both BLS and ALS), they HATED having to do BLS care (which was the bulk of our work), some would NOT leave the office and make the dedicated BLS crew run and run and run while they sat and did NOTHING for the whole shift because an ALS transport didn't come in......the whole time making $18 to $20 an hour however. When the company changed our SOP's and MADE them work BLS runs.....many quit and the ones who stayed did nothing but complain. Now on the 911 side of things in my area it is a bit different. 95% of Departments here are BLS only. Our Paramedics are dispatched along side depending on the call, or we call them when we arrive on scene after our assessments are done and we find we need an ALS intercept. Our medics work primarily out of the local hospitals, some have trucks stationed at departments that can afford to pay the hospital their cut for providing that coverage. My point is, that everything here revolves around MONEY.....getting paid to do a job and make a living doing it. THAT is the motivator to become a Paramedic. If their skills are diluted, it is because THEY CHOOSE to dilute them by not running BLS calls, downgrading calls to BLS, or just sitting around WAITING for calls that are 'super cool' where they can show the world how great they are as a Paramedic.......from what I have seen and dealt with in my area anyway.
Skip Kirkwood Skip Kirkwood Wednesday, June 25, 2014 10:00:14 AM I'm not sure that it is as much of an individual decision, as Don suggests, as it is a system design and configuration issue. There is pretty good data out there that "too many medics spoil the patients," starting with Bob Davis' USA TODAY series looking at cardiac arrest survival versus numbers of medics per capita. The number of patients requiring ALS interventions is limited, and if you have too many medics they don't have the opportunity to practice those skills. And unless you have a very rigorous and realistic in-service education and practice program, those skills and the critical thinking that go with them are lost. Would you want someone doing heart surgery on you who does one case every year? No - I want somebody who does these every day, who is currently "in practice" with critical skills. At some level, everybody does what they do "for money" so I don't hold that against them. But a well-designed system will not reward "too many" paramedics with "more money." Boston EMS is a great example - they have X number of paramedics in the system, and no more. You may have a paramedic license, but you will work as a BLS tech and not use your ALS until the system needs you.
David Newton David Newton Wednesday, June 25, 2014 10:42:58 AM Do not decrease the medics, increase bls continuing education. It's not about starting an IV but, about the level of education of the person doing the assessment of every patent. If things are going fine with the bls providers then maybe the medics can stand back a little and let the emt run the call. Thats if the medic feels it's going well. Many times I have let the emt's run everything with myself overseeing to ensure patent care goes on the right path.
Robert Martin Robert Martin Wednesday, June 25, 2014 12:31:37 PM I think that the value of paramedics is not in lifesaving. It's in pain control and the mitigation of a call that could deteriorate. A cardiac arrest? Simple, do CPR + AED. There is very little evidence to show ALS interventions make a difference in most cases. A stroke? Rapid transport to the stroke center. A STEMI? Aspirin, nitro, cath lab. Not a huge step up from BLS. Once again, ALS doesn't particularly matter in outcome. A fracture? A fall? Asthma? That's where the difference between BLS and ALS starts to show up.
Don Leuchtag Don Leuchtag Wednesday, June 25, 2014 1:05:20 PM Look at King County Medic 1 and you can see how a system should be set up. You have a limited number of paramedics who only respond to ALS calls. The basic calls are handled by basic emt's from the fire departments. The medics in this program also receive one of the most in depth educations out there. Get rid of the ALS Engines and put an AED and basic airway and bleeding control on them.
Jason Krout Jason Krout Wednesday, June 25, 2014 2:21:09 PM I work in a system that is split heavily between BLS fire and ALS ambulances. Only 4 fire departments have ALS resources. Our EMS authority, of three counties, also uses Intermediates (I am one of them). We are often non-transport units, but we arrive on scene, stabilize, start IVs, give ASA or Nitro, then hand off to the transporting medic unit.
Kevin Sweeney Kevin Sweeney Wednesday, June 25, 2014 4:00:35 PM In many urban areas paramedic skill Fulton is a real thing. When I worked in a total area with less than 10 paramedics I used my advanced skills fairly often while running fewer calls than I currently do. In my current service area there are almost 300 paramedics and while I run 5 times the call volume, I can't remember the last time I've intubated or even pushed more than basic meds.
Steve Plympton Jr. Steve Plympton Jr. Wednesday, June 25, 2014 4:16:55 PM I agree with this 100%
Bob Sullivan Bob Sullivan Wednesday, June 25, 2014 7:10:06 PM Paramedic skill dilution is a real problem when there are too many in a system. However, remember that even in the new education standards, most EMT courses are less than 150 hours, no field internship is required, and students are not assessed for competence on any skills on live patients. While many EMT's learn more after certification, the baseline is much lower than other countries. Check out the Recruits: Paramedics series from Australia on YouTube for an example. Having worked in a variety of designs, and based on today's education standards, I believe the best model is paramedic/EMT ambulances, backed up by a small number of advanced or critical care paramedics for high acuity calls, and supported by BLS first responders. An paramedic-level assessment would detect more life threats in patients with non-specific symptoms, such as 12-leads on dizzy diabetics. Paramedics are also able to medicate symptoms before transport, which a big limitation of BLS ambulances. To limit skill dilution, paramedic ambulances should only go on 911 calls - no non-emergent transfers or fire. The best paramedics could then be promoted to advanced or critical care paramedics for the high risk/low frequency patients, which would get them more exposure to the sickest patients.
Michael Schadone Michael Schadone Wednesday, June 25, 2014 10:21:28 PM Hey, so how about getting rid of the dividing line between providers?! How about we focus on initial education and competence, then we can talk about making a difference. This topic surfaces so often because most people get that something is wrong but cannot see the required paradigm shift for the trees. Let's get everyone on the same page and working together. Then, maybe, we can start to make a difference.
Marie Diglio Marie Diglio Thursday, June 26, 2014 4:47:44 AM Skill dilution is a real problem, but better educated providers are needed.
William Smith William Smith Thursday, June 26, 2014 6:50:52 AM Are you serious? Too many medics is a negative? And the surgery comparison, you assume that both "are" surgeons. Not the case. Only one has the skills for surgery, the "other surgeon", or basic, is the prep person for the surgeon, they can only do so much. If a basic is not paying attention during a paramedics treatment of a patient and not helping in any way, sure, their skill set will suffer. But that would be an individual work ethic and certainly not warrant a generalization. The reason "more" medics do not receive appropriate compensation is due, in my perception, more to a lack of recognition for what they can and do provide for a patient. It is more the mix of licenses; paramedic, specialist, basic, medical first responder, and first aid provider; that convolutes the value of a paramedic. The term "paramedic" is used universally throughout the lay person's world, and so their perception may be skewed of the value of a paramedic. But that is simply ignorance on their part. More public education is required for everyone in the EMS field, not just paramedics, to gain the recognition they deserve. It is absolutely staggering at the extent of ignorance the general populace has regarding EMS. For me, I want paramedics. That should be a standard of care. If a community cannot afford this, which many cannot, than basic is what they receive. If, however, they supplement their basic response with a private or other paramedic transporting unit, than that is still a good, not a bad. The first arriving basic unit still has to prioritize the patient and, if ALS is not required, THEY are in charge of that patient. Unless, of course, they only respond and do not transport. In that case, they may, indeed, become lax in regards to their patient. Again, though, that is a trained in or personal ethic issue. The main frustration I have is that a paramedic unit "should" be staffed with no less than 3 paramedics (one will have to drive, of course). The American Heart Association and Red Cross both agree that two is insufficient to provide ALS treatment. But the law requires that only 2 are required (and as far as I can decipher, that law was enacted in 1972, a mere 6 years after the White Papers!) But the US government's standard, which they use to teach other countries wanting EMS improvements and assume most of our country uses, is a tiered approach. This would be the optimal manner to function, but it is usually not feasible for anything but large metropolitan areas. So, the rest of us have to live with the 2 staffing law even when we do not have a BLS unit to aid us. My daughter was taught to dial 9-1-1 in preschool and that education continued throughout elementary and even into the middle school years. The problem with the teaching of the 9-1-1 system is that there is no further education. No one explains what will be coming your way or how long it will take. There are assumptions on the public end and most of these assumptions are that paramedics will be coming fast. This, too, needs to be addressed. As you may see, my approach is universally public education. A more educated public will help the EMS world more than anything else we can do. So, there's my two cents worth.
Skip Kirkwood Skip Kirkwood Thursday, June 26, 2014 3:58:38 PM Oh yes. There are quite a few studies that show it very well - too many paramedics yields worse patient outcomes. Here is the link to Bob Davis' seminal series in USA TODAY. More medics per capita, worse patient outcomes in cardiac arrest. Here are some more articles: Sayre MR et al. Cardiac Arrest Survival Rates Depend on Paramedic Experience. Academic Emergency Medicine May 2006;13(5) Suppl 1: S55-56 Persse, DE: Resuscitatio 59 (2003) 97-104 Then look at the San Diego and Seattle airway studies - San Diego 1-2 advanced airways per year, they added paralytics and increased BAD outcomes by 9%. Seattle, 12 airways per year, added paralytics and increased GOOD outcomes by 70%. One of the reasons why places like Seattle and Boston have good patient outcomes is a small number of medics working the high acuity calls, with BLS handling the rest. It's not to do with "work ethic." It has to do with the number of times a given population needs advanced procedures. I'd rather have a cardiac surgeon who does 250 cases per year than one that does 25 - the data shows better outcomes.
Courtney Elizabeth Courtney Elizabeth Saturday, June 28, 2014 8:12:31 AM I agree, as a BLS provider starting to go into the ALS education, there are a few things that we can do that isn't like starting an IV--like BGL for instance. In my state BLS providers are able to use narcan... I personally think it's good we are getting more education, but I think it's worthless in some areas in my state, whereas checking someones blood glucose would be more practical everywhere and useful for the patient, providers and the ER.
Anne Castioni Anne Castioni Saturday, June 28, 2014 8:26:36 AM Skip Kirkwood Thanks for the USA TODAY link. The article is very accurate in its description of the EMS system problems. Boston and Seattle lead the nation in well run EMS systems for many reasons but smaller number of medics allows for better skill retention and better patient care.
Anne Castioni Anne Castioni Saturday, June 28, 2014 8:38:03 AM Skill dilution is an issue in ALS and BLS. In one local community that uses solo paramedics responding in a tiered response with EMTs, many EMTs report hanging back too often particularly when paramedics have been on the scene treating the patient well before they arrive. Here EMTs want to use their skills but don't have an opportunity.
Jason Bokow Jason Bokow Saturday, June 28, 2014 9:29:16 AM There are studies out there that do show that too much ALS can affect positive outcomes... not knocking paramedics but where i started (in NJ) BLS was dispatched first unless it was a critical call. Then BLS assessed and determined the need for ALS. I do believe that BLS SHOULD definitely be allowed more skills BUT als is also very much necessary but NOT for every thing above a stubbed toe and or cough. In the last ten years ive seen a decline in the skills of BLS providers due to so many ALS units around that BLS at least by me just calls for ALS and then loads and meets them for the intercept. That way of doing things definitely DOES NOT lead to better care....just higher bills and EMTS looking like they dont know what they are doing. let alone ALS units basically being wasted on calls they arent needed on.
Ian R Frankel Ian R Frankel Saturday, June 28, 2014 1:45:46 PM If you work for a busy service this argument is irrelevant. When you work in a city were you have 150 Paramedics running over 55,000 calls a year, everyone gets in the mix. We get a lot of garbage calls but we also have plenty of ALS to go around. We wish we could get some EMTs to pick up the minor calls.
Bill J. Hufford Bill J. Hufford Saturday, June 28, 2014 2:56:48 PM With an ALS ambulance you have BLS. Everyone acts like a Paramedic cannot perform BLS skill's. When you get a paramedic ambulance you have the best of both worlds. BLS is initiated immediately and if ALS skill's are required that also is initiated immediately with no delay. Therefore the patient receives the best care with no delay and in a timely manner.
Chris Mancuso Chris Mancuso Saturday, June 28, 2014 3:41:27 PM When I am there, I am the only Paramedic. No department in this Area would have several.
William Smith William Smith Saturday, June 28, 2014 10:39:57 PM Skip Kirkwood , The USA article does, indeed, shed light upon a consistent problem within EMS, but nowhere does it infer or even propose that "too many paramedics" was the reason of that woman's death. What it did point out was that there were ethical issues, namely who does a better job, fire based or non fire based EMS. It also pointed out that uneducated governmental officials and public allow such atrocities to continue. I have been in a fire based EMS system for over 20 years. I began as a basic and we, as a union, decided to go paramedic despite 2 hospitals within our 7 square mile, 20,000 population community. We also had a powerful and gung-ho councilman backing this decision. This department entered into EMS in 1972, a mere 6 years following the white papers of 1966. We went paramedic, the first municipal paramedic in our county, in 1994. From my knowledge of the history of EMS and these warring attitudes of us vs. them nonsense, our department is quite progressive. Surrounding us are the complete mix; volunteer basic departments, part-paid basic and/or paramedic departments, full time paramedic departments that respond but do not transfer and, in Detroit, the similar to the article split of fire and EMS under the same roof. I am well aware of all of the varying levels of response and their qualities- good and bad. I have noticed that a department mind set is not only extraordinarily difficult to change, but also taught to continue by those within the department. Such a change will never come easily, nor will it come quickly. We had our "dinosaurs" within our own department who could not fathom anything but the load and go format. They grumbled, but we were making a difference and saving lives- like Seattle. But we still had to simply wait until they retired and a department full of cross-trained fire/medics became the norm. I reiterate that ignorance was at the heart of our personal growth. For a fact, I saved less lives as a basic without an AED. When AEDs arrived, we used them with limited success ( as you are aware, it will only shock 2 rhythms and then you're doing CPR). But as a paramedic, I have witnessed a drastic change in patient outcomes. Whether it was a simple fluid bolus which allowed a patient avoid the need for CPR, a full ACLS code which brought them back, pacing or cardio-version which retained a stable patient, pharmacological treatments sustaining their viability to our current ability to transfer ECG to the hospital and bypass the ED and go straight to the cath lab, we have saved more lives as a result of paramedic skills. It is now recognized that good Basic skills does make for a better Paramedic. The educational and licensing authorities here require a one year minimum of working as a Basic before you are eligible to become a Paramedic. That, too, is education. Personally, I think it should be more than a year, but I will have to educate a greast many people to believe this. Our battle is with ignorance. Our battle is not who is better than who or what type of uniform we wear. Our battle remains, for us within the realm of EMS, in educating not only government officials and the general public, but ourselves as well. The continual obstacle of finance and change will hopefully collapse in the light of sound and reasonable evidence based results. EMS is vital. EMS works. EMS is not ever going to disappear, but it may regress. We simply have to continue to work to educate EVERYONE about us. We are professionals but are not recognized as such. It is because we bicker and point fingers, sure. But it is also due to the tremendously vast array of a means to become educated and licensed. It is also a lack of reciprocity between states (primarily due to the varying standards and educational paths from state to state). Our lack of cohesion is our downfall. EMS is a young professional field. We are experiencing growing pains. We are wanting to point fingers, bicker over whose better and perpetuate an unorganized and varying educational process. Until these maladies are addressed, we shall remain in pain. If, however, we look upon such cities as Seattle for guidance and inspiration, we may actually experience the growth as well.
William Smith William Smith Monday, June 30, 2014 6:58:36 AM Are you serious? "There is little evidence to show ALS interventions make a difference in most cases"? Perhaps this would be true for prolonged response times, but unlikely otherwise. Our response time is 5 minutes or less from time of call, unless mutual aid is required. How many people have you saved just doing CPR? And is that all they will do when they get to the hospital? Of course not. They will do ACLS procedures, just 10 - 20 minutes later because of basic pt. access and transport times (and I'm sure that I am being generous regarding the times). My own research has found little to no "true" research regarding pt. outcomes that include EMS work done as well as hospital. Statistics predominantly are associated with hospital efforts alone. Only recently have they statisticians been considering us in their research, and usually with an insufficient number of patients to deem a true study. A stroke, I concur there. Not much can be done before cat-scan. A STEMI, how would a BLS unit even know this? That pt. will go into the ED to be evaluated and then taken to the cath lab. How much time has elapsed? Twenty minutes or more to be sure. And they still haven't even received any medications. Isn't this why we transmit from the scene the ECG to the hospital staff who then concur with our findings and direct us to the cath lab? Plus the aspirin and nitro have been on board prior even to transport. To save time and potential further damage, I would count this as life saving. I also agree with pain management and pharmacological treatments. Do not get me wrong. I am not necessarily bashing Basics. I am, however, promoting the effects of Paramedics. This type of reduction of value or importance of paramedic over a basic, especially coming from individuals within the EMS community, is why there remains a lack of proper respect for both levels of licensure. If you are a Basic, be proud of what you do and continually strive to become the best you can. You are important to the community and essential for their care and survivability. But do not disparage the Paramedics with remarks about effectiveness or necessity. That only reduces the public mindset regarding EMS as a whole.
Glen Killam Glen Killam Tuesday, July 01, 2014 8:59:06 AM In NH, every town has its own fire department and many have their own ambulance service. The mutual aid compact I live in has 23 towns covering 644 square miles and there is potential to have 19 medics on duty to serve about 126K residents. The town I live in has a population of just over 5,000 and the ambulance does about 725+/- jobs a year (about 1/4 to neighboring towns that contract to the FD). There is a medic on every shift. The City of Concord has a population of 43K and 3 ALS units(1 medic each) plus medics on fire apparatus 24/7. How proficient can they be with such a small call volume. Not to mention the expense involved and squandering of resources.
Dominick Walenczak Dominick Walenczak Wednesday, July 02, 2014 7:53:02 AM A lot of recent research has shown that Epi and antiarrhythmics don't make much of a difference in overall cardiac arrest survival rates. In fact, Epi was associated with worse neurological outcomes. There are some problems and flaws with the methodology used in the studies. But it's the best data we have to work with. 90% of cardiac arrest survival is dependent on BLS measures -- good, high quality CPR and defibrillation. As far as STEMI, why not have a Basic EMT acquire and transmit a 12-lead to a PCI center for interpretation? I think that this will be the single most important advancement for BLS providers since BLS level CPAP. As Paramedics, it is not often that we have a significant difference on patient care. But when we do, it is profound.

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