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?
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.