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

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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