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The Question
by EMS1 Community

Is prehospital advanced life support really necessary?

Check it out and add your own thoughts in the comments

By EMS1 Staff

A question posted recently on Quora asked, “Is prehospital advanced life support really necessary?”

 

The question pointed to two studies that have raised doubts about ALS in EMS. The first, Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers, concludes: “This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians.

 

The second, Emergency medical systems in low- and middle-income countries: recommendations for action, states: "Some evidence has shown that training paramedics in basic life-saving skills improves patients’ outcomes. There is no evidence to support training paramedics in advanced life-saving skills."

 

Paramedic Anderson Moorer gave his opinion on the topic. Check it out, and add your own thoughts in the comments.

 

Is prehospital ALS really necessary? No, not really; field paramedics and advanced life support (ALS) care is actually very new after all, largely not having existed even 50 years ago. Before then those countries were fine, they just had more people needlessly die.

By all means, shove critically injured patients into the back of a truck and drive like hell to a doctor if you wish. If they aren't breathing, well you see there’s this study saying doctors intubate patients better than paramedics ... and from this you may conclude that it is better to not try at all, I guess?

You say some studies cast doubt on the efficacy of field ALS level care? Then by all means, if your mother is down gasping for air and about to code from pulmonary edema please feel free to tell the nice medics not to treat her with anything other than first aid, because some studies say it won't help her. Besides it will cost some money. She's old, anyway.

(By the way regarding the second study you cite, most paramedics would point out that a critical-care physician will tend to be more skilled at intubation. And most other medical skills. As long as they don't have to use those skills while hanging from a harness upside down inside wreckage while gasoline drips down the back of their neck ... or they haven't spent the last 20 years as a podiatrist.)

Paramedics are not meant to replace medical doctors. They are meant to be the alternative between an impossible "everything" and an intolerable "nothing." 

We can't afford to put a trauma surgeon on every street corner, but neither can we afford to let mommy die simply because we didn't want to spend enough to invest in actual treatment and instead equip "medics" with little more than a bit of trumped up CPR training and a joke of a first aid kit.

But is it necessary to think like this? No. Place what value you wish on human life.

About the author

"The Question" section brings together user-generated articles from our Facebook page based on questions we pose to our followers, as well as some of the best content we find on Quora, a question-and-answer website created, edited and organized by its community of users who are often experts in their field. The site aggregates questions and answers for a range of topics, including public safety. The questions and answers featured here on EMS1 are posted directly from Quora, and the views and opinions expressed do not necessarily reflect those of EMS1.
Comments
The comments below are member-generated and do not necessarily reflect the opinions of EMS1.com or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Judi Costa Judi Costa Thursday, January 16, 2014 5:06:53 PM My thoughts exactly!!! I speak this from 5 yrs as a volunteer EMT followed by 21 years as a paramedic so I think I know what I'm talking about. If it's me that needs ALS skills and medications, you damn well sure better have when I dial 911!!!
Ken Adams Ken Adams Thursday, January 16, 2014 5:43:05 PM Although certain patient populations may benefit from alternative airway devices some simply will not survive without endotracheal intubation. In addition, if you remove this skill from the Paramedic standard of care, you will create Medics who also will not be able to successfully clear a foreign body airway obstruction with a laryngoscope and magill forceps.
Dana Arbeit Dana Arbeit Thursday, January 16, 2014 11:14:18 PM My experience ended 10 years ago when I retired but what I experienced was that ER personnel and Pre-hospital care administrators had not made the adjustments necessary to allow ALS personnel to deliver the appropriate level of care to the patient. I started at the level of EMT(actually before it was required) where only basic care was available before and during transport. I moved up to ALS ability after having observed providers taking excessive time in the field before transporting because the base station demanded extensive ALS before transport. Over my career most of my fellow medics and I realized that ALS wasn't "everything" and should be used only when appropriate. However, the ER staff and MICNs would order extensive ALS as a matter of common practice or question the PMs judgement if they didn't call it in. Eventually we were transporting everyone and getting flak for not using our ALS because the ERs had become accustomed to being notified of every patient. ALS is a tool and valuable one when used appropriately. Now "studies" are being used to say it isn't appropriate. Maybe it isn't appropriate because the 'system' hasn't caught up with problem. The "system" dictates the level of care instead of relying on the trained, experienced and motivated personnel that are in the field to use their judgement about the level of care needed in a particular patient situation. In short, it isn't the Pre-hospital ALS that is the problem but the hospital and administrator that is the problem. I could go on forever but I will end with saying that the emergency care team is not a team(meaning not just the ambulance but the whole 'tranport, ER, hospital' environment) but too many seperate fiefdoms bumping heads all the time. Until it becomes a team, patients will suffer either too much treatment or too little.
Jamie Bingham Jamie Bingham Friday, January 17, 2014 11:52:06 AM Time and time again, in prehospital care, the treatment found to have the greatest benefit, particularly in trauma is time (and in STEMI and stroke). Yet one example I see all the time is that we still see medics sitting on scene to "get the line" and I would ask, does that closed head injury, for example, REALLY need the line NOW? Some say it's too hard to get it in route and as a medic for nearly 30 years now I'd say BS to that. What matters most, convenience for you or the life of the patient? And with some I noted they don't want the embarrassment of getting to the ER and not having a line - so the patient suffers so the medic don't. Do what's best for patients, not you. Something like that may matter one day when we have a true blood substitute in the line that brings oxygen and saves the trauma patient for awhile, but for now, saline doesn't do anything, and what meds do we honestly anticipate in trauma? The other aspect is that especially as paramedics we always talk about "critical thinking" and then I rarely see any critical thinking and it's always "we have to have the line" we "need to intubate" and so on.....when in truth we don't always "need" to. But if there is an emphasis on using the "toys" then a medic IS going to use them. That to me is a fatal flaw. Evidence shows again and again - not to perfection - that peds intubation ISN'T related to good outcomes, but watch the debate when there's even a little talk about not doing it - there's really no debate actually it's just don't take away that toy (it's not a toy, but for effect I use that term). When are paramedics especially going to start thinking like true medical professionals that we claim we are, and stop being robots, we usually claim we're not and get offended by, and when are we going to use our knowledge, and stop only seeing ourselves on we get to "do" and instead and what we are?
Karen Michele Wells-Lunsford Karen Michele Wells-Lunsford Friday, January 17, 2014 4:49:32 PM I think you are wrong...if you have a Medic that knows what they are doing. There are times an advance airway is the only thing that will save their butt. Speaking with 20+ years in EMS and 24 saves later I do believe I am qualified to make this call. I know the majority of my patient's improved with a secured airway. Not to mention being able to monitor CO2 is priceless!! We need to have those who can do. We can't afford to have someone that cannot perform standard of care. What you are weak at you practice....practice....practice. Practice makes perfect. I have noticed with the new changes of delaying advance airways is not a good idea the majority of time. I know because I can see the difference!!! Visibly speaking and capnography! I am proud to be able to make a difference when I go to work!! As far as not being able to provide care enroute....you need to get a new job or get your partner to drive better. If you do not get them back in the field...they are brain dead!!
Skip Kirkwood Skip Kirkwood Sunday, January 19, 2014 12:29:42 PM The statement, "There is no evidence to support training paramedics in advanced life-saving skills" is simply false. See (amongst many), Myers, Slovis et al: Evidence Based Performance Measures..... Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51. The person writing would never get past a peer review, as he has obviously not performed an adequate review of the literature.
John Lindsey John Lindsey Sunday, January 19, 2014 12:42:51 PM Too many people get "code blue" blinders when judging ALS. Timely intervention in anaphylaxis justifies ALS, and there are so many more reasons.
Bruce A Mills Bruce A Mills Sunday, January 19, 2014 1:13:03 PM Why is this even getting a sniff ? There is no ownership in who wrote the article. EMS1 staff doesn't cut it. This is again a fine example of us tearing down are own and in fighting. You will never see IAFF running a article should we put wet stuff on the hot stuff. We are horrible self advocates
Michael S Miranda Michael S Miranda Sunday, January 19, 2014 1:42:41 PM These articles get my blood boiling. It is arrogant to think one type of medical provider is better than the other. Everyone has there place, doctors, nurses, paramedics...They all exist because there was a need for them. What irritates me is the comparison of hospital care to pre-hospital care. Hospitals are a controlled environment and pre-hospital is not. Since intubation seems to always be a topic, lets set a couple scenes. A doctor intubates in a room, patient on a flat bed, 10 nurses surrounding them, setting up equipment for them, plenty of light, ect....A paramedic intubates in an endless amount of possible scenes, a dirty floor, a corner, a chair, on a dark street, in a moving ambulance. How is it fair to compare the success of intubation between the two? Lets also remember, just because a doctor is a doctor, doesn't make them perfect. They invest in malpractice insurance because they too, make mistakes.
Robert Balsan Robert Balsan Sunday, January 19, 2014 2:09:38 PM If there was no prehospital personnel out there then we would have more deaths due to no help. I will leave it at that.
Jason Bryant Jason Bryant Sunday, January 19, 2014 2:22:47 PM I think that's also dependent upon quality of training, education, and experience. I have seen many patients treated by ALS personnel who would have been better off being hauled away in the back of a pick-up truck.
Jose C Bautista Jose C Bautista Sunday, January 19, 2014 2:22:55 PM In Tijuana Mexico we have found that 67-70% of the calls don’t require an ambulance. Approximately, only ~2% of the patients are in critical condition. This data coming from a health system with serious resource limitations. With this information we are evaluating the need for advanced technicians and making an emphasis on proper training for first responders and medical dispatch. We are in the process of publishing the data. We’d like to compare our data to an “advanced” system, so feel free to contact me in case you are interested on a collaboration.
Skip Kirkwood Skip Kirkwood Sunday, January 19, 2014 3:04:53 PM And my question for EMS1.com - why do you run articles that start out with blatantly false statements? Is this just journalistic trolling? I think you guys can do better than this.....
Bob Soucy Bob Soucy Sunday, January 19, 2014 3:06:37 PM At least they didn't ask for commentary on higher education requirements
Bruce A Mills Bruce A Mills Sunday, January 19, 2014 3:07:21 PM The MSNBC of EMS periodicals . They don't report the news they make up the news
John Farlow John Farlow Sunday, January 19, 2014 4:22:28 PM Could or would someone take credit for writing the article? Will you just simply hide behind EMS1Staff? This could mean that you were sitting at the bar after a tough day of trolling the internet and someone asks the usual question. Are we worth a damn? You are answering your questions with more questions. Sure lots of studies, yep well the study I have says this, Pick one of you and do research before you make out a headline that is bound to get you readers. Or is that all you are really looking for?
Scott Lancaster Scott Lancaster Sunday, January 19, 2014 4:27:27 PM I'm not a fan, but it reads like satire to me.
Clyde D Baisey Clyde D Baisey Monday, January 20, 2014 4:08:22 AM Dana, Like you, I have been retired from EMS for 14 years now, and like you I started working EMS in its' infancy. Starting in 1973, in my state of NC basic EMT classes were being taught for the first time and were quite extensive back then. I lived in a rural small town and we had average transport times to a trauma center of 45-60 minutes without any ALS. We depended on our SKILLS as a basic EMT and sometimes; well most of the time, on personal ingenuity, to assist us on sustaining that patients life during transport. I worked for 10 years as a basic EMT without any type ALS training before enrolling into an Associate degree Emergency Medical Science Program and becoming an EMT-Paramedic. Over the next 14 years, My ability to provide ALS was an accessory to providing BASIC EMT skills. But, proper training, assessments and re-evaluation of ones' own skill sets in ALS/BLS should be second to none. I am proud of my accomplishments over the years and to this day, I still have patients who remembered me and thank me for providing my services for them or a family member.
Gary R. McHugh Gary R. McHugh Monday, January 20, 2014 6:24:30 AM Only about 5% of ambulance calls require ALS treatment, but it takes an ALS Paramedic to properly recognize who is in that 5%. Pain management may not always save lives, but it is the humane thing to do. If you don't allow your Primary cares to deliver, then ALS is needed. BTW, do we really need doctors in every emergency room or can nurses handle most of the patients care?
Jesse Carpurso Jesse Carpurso Monday, January 20, 2014 6:26:26 AM Scott Lancaster Yes, I read a lot of satire and I don't think (by reading the comments) that anyone else is catching on it lol. I honestly think he is saying that ALS is necessary and is making a joke out of the very few Doctors and nurses who don't agree with pre-hospital ALS.
Pascal Hay Pascal Hay Monday, January 20, 2014 6:35:10 AM The debate on intubation is a real big one. From the articles and research I have read it seems like a double standard for success rates are used when it comes to pre-hospital vs. in-hospital. If an EMS practitioner uses the skill sets they are taught and are able to treat a patient successfully without having to use intubation then that is counted against the EMS practitioner as a failed intubation. The same is not true of an in-hospital practitioner who does the same. If a pre-hospital practitioner is able to use an alternative airway to secure and maintain the airway successfully that is held against them as a failed intubation. In the hospital this does not occur. Of course if an EMS practitioner misplaces an ET tube and does not discover it then my God, everyone is howling and this is now the poster child for why field intubation shouldn’t be allowed! In my practice in the hospital I have seen anesthesia group professionals get tunnel vision and really screw the pooch knowing that if this had been done in the field it would never be lived down. When a physician made a statement about a certain group of paramedics that shouldn’t need to be placing ET tubes in children because they were within a close proximity to specialized children’s hospitals everywhere within their district of coverage. The statement was picked up and suddenly changed to reflect that “NO PARAMEDICS” should be placing ET tubes in children. Of course for those of us who need to secure an airway in a child and are 45 minutes to an hour from the closest any type of hospital that really did not make a whole lot of common sense and made it where we would have to fight with an unsecured airway for prolonged periods of time with hopes of a positive outcome and yes this event would be held against us as a failed intubation attempt. I brought an infant to the ED with ET tube in place and the biggest thing the receiving physician did other than pronounce the infant dead was to try and prove that I had misplaced the tube. After about 20 minutes of looking he looks at me and says, “Good job on placing the tube.” As far as the efficacy of advance pre-hospital life support; our records are full of citizens in our community that are true believers as we have saved their family members or themselves from certain death by treating them and correcting life-threatening conditions before throwing them in the back of the truck and racing down the road. We have entrusted in our citizens’ trust through compassion for our citizens, excellent treatment of our citizens, and maintaining our professional composure with our citizens. If, in the future, we could have unbiased and fair research into our treatment modalities and practices then I think we would have a more positive advancement of EMS as a whole. EMS practitioners are still looked upon by many other professions as being a bunch of part time mechanics and tow truck drivers who are barely educated to the high school level. This is not helped when we have people who are not professional interact with the hospital staff. An EMS unit came to our hospital the other night. The ERMD was standing outside in the ambulance driveway as they unloaded. One of the crew grabbed our automatic doors and began to pull them open. The ERMD said please don’t do that the code is #### you are going to break our doors. To which the crew replied, “I have broken many doors before.”, and laughed. Then proceeded to break our doors and go into the ED with the patient.
Jim Robson Jim Robson Monday, January 20, 2014 6:43:09 AM So would it be a better investment to train your primary care medics to give pain management and ALS?
Josh Rodas Josh Rodas Monday, January 20, 2014 6:53:17 AM I don't really understand all of the angry, negative comments about this article. People are bashing it by saying its wrong and then backing up their argument by saying the exact same thing the article is saying, only in less creative words.
William Chang William Chang Monday, January 20, 2014 7:08:39 AM Penthrox AKA the green whistle, very effective and safe (short-term) however, may be nephrotoxic and hepatotoxic
Phil McHugh Phil McHugh Monday, January 20, 2014 8:59:15 AM Ontario now has a protocol for Ketorolac IV/IM for pain management.
Phil McHugh Phil McHugh Monday, January 20, 2014 9:01:05 AM Jim Robson ALS is more about critical thinking than it is skills, it's knowing when to apply them and when not to, not all primary cares want to/ can do that. We have guys here that put the Combitube in upside down, and don't know how to give nitro or what it does, I wouldn't start letting them Intubate and give narcotics.
Jim Robson Jim Robson Monday, January 20, 2014 9:29:46 AM If that's the case, It's no wonder we are having trouble keeping up with the rest of north america. You can't build a great house on a crumbling foundation...
Michael Vlachos Michael Vlachos Monday, January 20, 2014 10:11:31 AM I'd posit that ALS is about more than just Intubations and Codes. How many ETI were avoided due to the use of Epi for an allergic reaction? How many Asthma patient didn't die due to the use of ALS drugs? How many People with fluttering hearts have been helped? How many hypoglycemic patients have been helped? How many OD deaths have been prevented via Narcan? To assume athe ALS providers are only good for codes and tubing a patient is utter BS.
Frédéric Brazeau Frédéric Brazeau Monday, January 20, 2014 1:55:48 PM At least Primary Care will have soon a Fentanyl protocol for pain management. Obviously it will be a touchy one as Phil said, its a narcotic so that's the reason it is still a pilot project. Still, we should have at least one pain management drug in our kit because the little tap on the shoulder and saying "we arrive soon" doesn't resolve pain at all..
Phil McHugh Phil McHugh Monday, January 20, 2014 2:15:56 PM I'll believe the Fentanyl for primary care when I see it. I doubt it'll ever come to Quebec.
Mike Makay Mike Makay Monday, January 20, 2014 4:38:46 PM Even this crusty old ladder guy has use and value for you para-magicians.
As If As If Monday, January 20, 2014 10:41:44 PM This was very entertaining, thank you. I've experienced some losses, as we all have, but as far as I'm concerned...just one person gaining one more day because of me makes it all worth it. Question away...I'm not quittin'.
Michael Vlachos Michael Vlachos Tuesday, January 21, 2014 2:43:37 PM Ahhh thanks bro.
Steve Weaver Steve Weaver Wednesday, January 22, 2014 12:32:42 AM If anyone can explain to me how BLS only would help a 14 y/o male in Vtach at a rate of 264 presenting with dizziness and chest pains, this along with a minimum 30 minute transport time to the nearest appropriate facility, I will gladly advocate for the removal of ALS throughout the world. Y es, he may be only 1 patient among many, but who wants the job of telling his mother "he is dead but look on the bright side, we saved you a bunch of money"?
Terry Boors Terry Boors Wednesday, January 22, 2014 3:53:13 AM Every action of EMS personnel has the potential to save a life. Having said that it depends on your physical location/geography, the state you practice in and most importantly your access to a hospital that has 'the tools' and resources to operate at a higher level. Where I live we almost always transport our trauma patient's via our two major air ambulance providers to 'trauma centers' located in Pittsburgh. We're 50+ miles away and our two local hospitals (one small and one larger) simply do not have the staff 24-7 to handle an onslaught of trauma patients to their facilities. We all have had situations that require pre hospital advanced care and I've been very fortunate that what I knew and was able to provide made the difference in many people being alive today by the decisions I had to make with their conditions.
Joffry van Grondelle Joffry van Grondelle Wednesday, January 22, 2014 12:00:27 PM Is modern medicine really necessary? Cost are running up hill because of not daring to speak with patients about end of life situations, meaning of life for p[atients and relatives, boundaries of human medicine. Medicine is nowadays more about avoiding juridicial claims and problems besudes making money out of patient care. I think more people will do better with good nursing care and psychological help rather then futuristic very costly medical procedures that only put some small time extra to patients life.
Mike Kacsur Mike Kacsur Sunday, January 26, 2014 8:48:32 AM I'm more impressed when providers at any level are able to accurately diagnose the true problem, then by their ability to perform the "parlor tricks" that we learn in school. And I believe that most ER physicians can appreciate that as well. I take more pride in my ability to assess a patient than being able to intubate upside down in the middle of a snow-storm, etc... If you are an EMT or medic who can properly identify the problem first, then decide the proper course of treatment, then you are really making a huge impact in that patient's outcome. The expectations have changed. When my career started, we could drop patients off at the ER with a minimum amount of fuss and report. Now, in order to keep up with the newer expectations, we need to do better assessments and field diagnostics. True progressives in EMS and Emergency Medicine will not look to remove ALS from the field. But they will continue to reinforce the focus for both ALS and BLS providers to do the best assessments possible, in order to provide the best continuity of care for our patients.
Donovan Warren Donovan Warren Sunday, January 26, 2014 9:00:05 AM "Assessment is the gate to intervention" (don't remember where I originally heard that), and to that I add "A & P (and particularly pathophys) is the key that unlocks the gate." If you can't do a good assessment, you don't get to use your tools, or you will use them improperly, and both outcomes are bad for patients.
Cory T. Spankowski Cory T. Spankowski Thursday, February 06, 2014 3:27:13 PM Very well said!

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