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Creating a Quality EMS Future
by Michael Gerber

Why redefining ALS, BLS is key to EMS survival

In order to defend our existence in an era of cost-cutting measures and evidence-based health care, EMS needs to move past the old definitions

By Michael Gerber

I have worked as a paramedic in both a tiered response system and an all-ALS transport system — both of them fire-based but different from each other in many ways.

Nonetheless, both systems use the terms Advanced Life Support and Basic Life Support to differentiate between providers, types of calls, and levels of service provided.

In the tiered system, ALS providers on ambulances and fire engines often tell BLS ambulance crews that the call is BLS and they can “handle it” without them. In the other, every transport is ALS, but ambulance crews are still expected to advise dispatch after the call whether it was ALS or BLS.

When I started in the all-ALS transport system, I often struggled with how to answer that question.

In the tiered system, I had learned that most injuries were typically BLS; ALS was not even dispatched to a broken leg call. Nonetheless, in the all-ALS system, I often used ALS skills in my assessment or treatment of these so-called minor injuries.

If a patient had abdominal pain but I placed her on the cardiac monitor, was that call ALS or BLS? The patient did not necessarily “need” any ALS interventions, but because I am a paramedic I used the tools I had with me to perform a more thorough assessment.

I quickly learned that it didn’t really matter whether I told dispatch the call was BLS or ALS, which was fortunate since the line between the two is a lot fuzzier than they teach us in school.

After several years on the street, I now realize that, as EMS evolves, the line between ALS and BLS line needs to fade even more. Otherwise, we risk doing a disservice to our patients — and also endangering our own relevance.

Moving past old definitions

More and more, evidence is showing that many of the ALS interventions paramedics were established to perform are not necessary, and might even hurt patients. At the same time, the treatments that evidence shows actually save lives — such as defibrillation, IM epinephrine for anaphylaxis, tourniquets, even CPAP in many places — have become standard BLS care.

That’s not to say ALS is not critical, but in order to defend our existence in an era of cost-cutting measures and evidence-based healthcare, EMS systems need to move past the old definitions of BLS and ALS.

A patient with chronic abdominal pain should no longer be “BLS” if insurers expect paramedics to appropriately triage the patient to an alternative destination, such as an urgent care clinic or primary care office (as several agencies around the country are beginning to do).

A patient with a broken leg should expect adequate pain management prior to transport, even if his life does not depend on it, in systems where ALS is readily available.

These changes can’t happen overnight, and they require a meaningful and drastic shift in how we educate prehospital providers.

EMTs who think that attending paramedic school means avoiding “boring” BLS patients need to learn right away that BLS and ALS are not types of patients, but rather levels of training and treatments.

Indeed, there is no such thing as a BLS patient or an ALS patient — there are just patients, some of whom may receive different levels of care based on their needs and the resources available.

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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Ray Bange Ray Bange Thursday, June 05, 2014 9:35:35 PM Establishing baseline definitions for paramedics and related practitioners is absolutely vital if the profession/industry is to evolve. If you don't know who or what you are - and why - then it is no wonder that legislators and bureaucrats can't place a value on the services and practitioners beyond the (well-deserved) accolades.
Daniel Gerard Daniel Gerard Friday, June 06, 2014 3:28:28 PM We don't need to change the definitions, I think you are missing what is going on. We aren’t trying to justify our existence, I think that was a poor choice of words. We all need to read Atul Gawande and Brent James, take a page from the Cleveland Clinic, and move forward…not back. It isn’t about defending our existence when you look at the numbers coming out of CMS (Medicare and Medicaid) only 3.4% of your patients are ALS…the true sickest of the sick. We knew this when the Institute of Medicine first published it’s paper on EMS in 1966, almost 40 years ago when the Robert Wood Johnson Foundation published their Special Reports 1 and 2 regarding EMS, and we knew this from when Robert Davis was a Kasier Health Fellow and published ‘6 Minutes to Live’.The thing is, those numbers, basic life support versus advanced life support versus chronically ill, those numbers never ever really changed. The system, our system, our clinical care have been in melius for the last 50 is just that some changes have been coming at glacial speeds, but some have happened so long ago, I guess for some people, they are just coming to the realization that the worm has turned. What are the numbers? What are we giving up, turning over from ALS to BLS that threatens our existence? When you talk about cardiac arrest and defibrillation (which represents roughly one percent of our call volume) or IM epinephrine for anaphylaxis (which occurs between 0.2% to 0.4% of all of our EMS calls), those were always BLS skills, the problem was in the case of defibrillation, it took a few years for COST and technology to catch up to reality, and in the case of IM epinephrine, there were rural EMS systems using it on a Basic EMT level since 1970. We have had AED's on BLS ambulance since the late 80's, but there were EMS systems that have been using manual defibrillators since the late 70's. NYC EMS has been giving nebulized by basic life support EMT's since the 1990's, almost 25 years, without a problem. They have literally treated millions of people with asthma, yet someone is going to come with some distorted rational why it is wrong, in spite of the numbers and the proof it can be done. You say that you respond on scene and do an ALS assessment. How many times does that result in a treatment? Are those numbers particular to your city, service, or system, or are they reproducible across the continuum of EMS? Or are you just using your skills because you can? isn't that the biggest danger? using skills to drop an IV or do something someone doesn't need because we can, not because they need it? We have too many paramedics, and we need to redesign the system. Michael, you have three types of patients: emergent (ALS); urgent (BLS); and chronic (community out-of-hospital care). You had those same three classes of patients 100 years ago. We need fewer paramedics in the system otherwise we run afoul of Rohmers Law. You have to answer the three questions: is it efficacious? Is it efficient? Can we guarantee availability? Before you can approach the question of economic efficiency, you have to be able to tell me that you are technically efficient, and that isn’t happening in the all ALS systems. Our duty isn’t to justification of jobs, our duty is toward patients and ultimately reducing death and disability in our communities. We can’t do that with more paramedics, just as you can’t reduce trauma deaths by increasing the number of trauma centers, or cardiac and stroke deaths by increasing the number of stroke and STEMI centers. It boils down to cost, quality of care, and provider competence. The value of anything lies in the equation cost multiplied by quality. If you keep the same number of providers in there, and they aren’t improving cardiac arrest survival, trauma survival, asthma, CHF, cardiac/MI survival, is the expectation now that you really want them to do other ‘things’ (like screen out your abdominal pain patients), further diluting their skill set. The paramedics won’t be any better, we will just continue to redefine mediocrity. If we need fewer paramedics, and the evidence points that we do, we need to take it on the chin, and say yes we devised the system poorly…and re-engineer the system for the better, right-fit the system for those patients who need us. If you are saying that oh, we can keep the same number of paramedics, we can justify it because insurance carriers will expect us to triage patients to alternative care facilities, etc., that may not fly, or at least it shouldn't. We can accomplish the same thing through the use of carefully designed triage protocols, alternative call screeners (PA/NP), better training and education of the EMT basic, and use of alternative response configurations, in a system designed where you have 1 paramedic unit for every 80,000 – 120,000 people and 1 basic life support ambulance for every 20,000 – 30,000 people. RWJ figured this out 45 years ago, and that is why that in cities that have followed this paradigm, they have the best cardiac arrest survival rates (Seattle, Boston, etc.). Michal if your goal is to maintain the status quo, or to justify our existence, sorry cannot buy it. If you are looking to re-engineer the system, reducing the number of ALS units, etc. let’s talk. The definitions don't need to change, just the system.
Grant J Wood Grant J Wood Saturday, June 07, 2014 12:19:38 PM I couldn't agree more. Well said
Skip Kirkwood Skip Kirkwood Saturday, June 07, 2014 12:49:47 PM The distinction is a made-up, arbitrary line, that varies from state to state, at the whim of lawmakers or committees. "ALS v BLS" is not the same as "EMT v Paramedic" etc. None of that means a hill of beans as long as we have the lowest educational standards for EMS personnel of any civilized country on the face of the earth.
Drew Thorne Drew Thorne Saturday, June 07, 2014 1:27:23 PM Appropriate use of appropriate resources.... Skilled clinicians to perform competent triage.
Scott Ireland Scott Ireland Saturday, June 07, 2014 1:47:22 PM Yes ALS intervention is vital if used for the right reasons not for the and these are spelled out in detail in protocol manuals provided by the local ems that regulates your jurisdiction BLS works as line as would triage in a MCI we use our training and if needed we seek a higher authority ALS/ medivac/ some would say this is all in the name of cost cutting and savings the math does not add up could go on longer but I will stop now respectfully posted from32year veteran fire/Ems service
Dan Schuler Dan Schuler Saturday, June 07, 2014 2:19:22 PM I take great issue with the statement that ALS interventions are hurting our patients. ALS interventions improperly applied maybe, but not the intervention itself. Maybe we should spend more time and energy on proper training and making sure medics can actually perform at a high level of care rather than discussing arbitrary definitions. After all, a properly trained EMT will be able to give the best care possible regardless of their designation.
Bob Morrison Bob Morrison Saturday, June 07, 2014 2:20:00 PM biggest problem are insures are having influence in how and where a patient goes for treatment.
Gwen Hardy Prevatt Gwen Hardy Prevatt Saturday, June 07, 2014 6:23:28 PM Drew Thorne has it right. There are to many "ALS providers" and to many patients going to an ER when it is not an emergency. We ALS for money not need, the majority of the time. In some instances, agencies trying to justify jobs and budgets, do ALS unnessarily.
Bob Sullivan Bob Sullivan Saturday, June 07, 2014 6:52:45 PM Amen. I wrote an article about this last year for EMS World. The ALS/BLS distinction is an artificial one that we made up. While the frequency of time-sensitive ALS interventions may not justify sending a paramedic on every call, I believe that the value of an ALS assessment and symptom relief does. Dizzy diabetics deserve to be assessed by people who are capable of interpreting 12-lead ECG's. People who are in pain deserve caregivers who can administer pain medication before they are moved to an ambulance and transported down bumpy roads. Eventually someone will direct the least-sick patients somewhere other than an emergency department. I hope it is us, but that will require even more education about unsexy topics than American paramedics have today.
Anne Castioni Anne Castioni Saturday, June 07, 2014 6:59:11 PM DG: As far as emergent (ALS); urgent (BLS); and chronic (community out-of-hospital care), I would disagree with urgent as BLS across the board. The urgent may be a patient with a fracture who requires pain management. It is not so cut and dry when you start to examine each case individually. A paramedic assessment may uncover problems not found by an EMT. Also, given EMS systems are operating with limited health care dollars all costs will need to be justified.
Skip Kirkwood Skip Kirkwood Sunday, June 08, 2014 5:46:30 AM The distinction is a made-up, arbitrary line, that varies from state to state, at the whim of lawmakers or committees. "ALS v BLS" is not the same as "EMT v Paramedic" etc. None of that means a hill of beans as long as we have the lowest educational standards for EMS personnel of any civilized country on the face of the earth.
Ahmet Haki Türkdemir Ahmet Haki Türkdemir Thursday, July 31, 2014 2:42:22 PM In the pre-hospital paradox: more trained and qualified staff or staff with a greater number of less-educated high technology does more than human life is saved? Is this an issue for discussion or unnecessary?

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