Is the line between BLS and ALS getting fuzzy?
Doing the best for the patient may mean changing the EMT's role
By Mike Ward
In 1990 my fire department was looking to place defibrillators on engine companies. Firefighters were EMT certified and the pumpers carried oxygen and an ambulance-sized jump kit. Only paramedics or EMT-Cardiac providers could operate a defibrillator in the Commonwealth, following the Emergency Medical Technician – Ambulance curriculum.
Staffing increased to four in 1994 when five engines upgraded to paramedic. The fourth position was for an ALS credentialed firefighter. That was the same year major revisions were made to the National Standard Curriculum (NCS).1
Under the 1994 NSC revision:
- EMT-Ambulance providers became EMT-Basic with a less intense curriculum
- EMT-Basics could operate defibrillators.
- Physician medical direction expanded from ALS providers to EMT and First Responders.
Under administrative regulations, the bright line between ALS and BLS was the ability to start an IV, administer drugs, decompress a chest, run a three-lead EKG and intubate.
Bright Line gets fuzzy
This spring I have had the opportunity to conduct EMT refreshers at a handful of agencies that are teaching to their local medical protocols. It has been exciting to see the expansion of care that EMTs are expected to provide.
In one system, EMTs are providing continuous positive airway pressure (CPAP) without direct paramedic direction.2 Looking at the 2013 review of CPAP peer-reviewed literature shows the first mention of EMT-provided CPAP in 2007.3
EMT-level medical assessment includes obtaining a blood glucose level (BGL) and documenting a pulse oximetry reading. (I feel compelled to call the 900 year old EMT instructor that scolded me for stating BGL was not an EMT level assessment tool a few semesters ago. "EMTs never perform an invasive therapy!")
Shared Tasks in a 1-and-1 transport unit
There appears to be no difference in tasks delivered in a simulated cardiac arrest with a one paramedic and one EMT crew.4 Using the "pit crew" approach to cardiac arrest means that EMTs are applying 12-lead patient cables, spiking IV bags and participating in the medication administration cross check (MACC).6
Shared tasks also mean shared patient responsibilities along with an expanded use of specialized equipment and procedures by EMTs. They are expected to immediately master new patient care tools and procedures.
Outcome-based EMS care requires close monitoring and implies intensive continuing training, as providers focus on tasks and procedures that improve patient disposition.
Finding a sweet spot using a mix of techniques
At the 2013 EMS State of the Science conference, Dr. Paul Pepe shared the results of paying attention to cardiac compressions as part of the Resuscitation Outcomes Coalition research in the Dallas-Fort Worth region. Using monitoring equipment that showed detailed feedback on chest compressions, training was provided in 2006 and 2009 to improve provider delivery of fast-and-deep chest compressions.
The sweet spot is 120 compressions per minute. Using a metronome that provided both a light and sound significantly improved the consistency of the compressions. Comparing the "Survival to Hospital Discharge" results from 2006 to 2011 showed dramatic improvement:6
Research is showing the importance of uninterrupted chest compressions to maintain adequate cardiac flow. Trials are underway to determine the safety and efficacy of external defibrillation WITHOUT stopping cardiac compressions.8
In addition, there is an indication that using an Impedance Threshold Device (IPD) with an Active Compression-Decompression (ACD) during CPR improves long term survival with favorable neurologic outcome.9
Looking at a military example
Soldiers who take the 40 hour Combat Lifesaver (CLS) Course are taught to handle massive hemorrhage, lung collapse and airway blockage that cover 90% of the battleground fatalities.10 CLS trained warriors use oral airways, decompress chests, start IVs, splint fractures and administer a pill-pack.
They are not combat medics but are trained beyond the level of self-aid or buddy aid. The CLS is not intended to take the place of medical personnel, but to slow deterioration of a wounded soldier's condition until medical personnel arrive or the wounded can be transported to a medical facility.
EMS first responders function in a similar role, providing rapid response to deliver immediate life-preserving skills until arrival of a paramedic or transport vehicle.
EMTs are in the middle of the breadth and depth spectrum of the 2009 EMS Educational Standards.11 Paramedics are expected to integrate pathophysiology, physiology, anatomy and patient assessment into a patient care plan. Emergency Medical Responders are expected to use tools and procedures, remembering "sticky side down." It is time to reconsider the expectations of EMTs as the National EMS Advisory Council looks at the next version of the Educational Standards.
1. United States Department of Transportation (1994) EMT-Basic: National Standard Curriculum. Washington DC. National Highway Traffic Safety Administration.
2. Grayson, S. (11/01/2012). Saved by the Basic EMT. EMS world. , 41 (11), p. 32
3. Williams, B. When Pressure is Positive: A Literature Review of the Prehospital Use of Continuous Positive Airway Pressure. 2013 Prehospital and disaster medicine. , 28 (1), p. 52.
4. Bayley, R; et. Al. Impact of Ambulance Crew Configuration on Simulated Cardiac Arrest Resuscutatioin. Prehospital Emergency Care. 2008 Jan; 12 (1) 62-68
5. Lammers, R; Byrwa, M. and Fales, W. Root Causes of Errors in a Simulated Prehospital Pediatric Emergency. 2012 Academic Emergency Medicine 19, 37-47
6. Braithwaite, S., (2013, February 23). Back to the MACC: Medication Administration Cross Check. EMS State of the Science: A Gathering of Eagles XV.
7. Pepe, PE, (2013, February 23). Go With The Flow: The Sweet Spot, "Snappy" Concepts and Stutter CPR. EMS State of the Science: A Gathering of Eagles XV.
8. Youngquist, ST, (2013, February 23). Keeping It Close to the Vest: Hands-On Defibrillation at the Great Lake State. EMS State of the Science: A Gathering of Eagles XV.
9. Aufderheide, TP et al. Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. (2011) Lancet 377(9762): 301-311.
10. Campbell, A, (2007, September 6) "Combat Lifesaver Course Trains Soldiers to Save Lives on Battlefield." American Forces Press Service. Accessed 3/1/2013 at http://www.defense.gov/News/NewsArticle.aspx?ID=47327
11. U. S. Department of Transportation. (2009 January) National EMS Education Standards. National Highway Traffic Safety Administration.