Who wins when paramedics fight BLS use of an ALS intervention?
Naloxone administration by BLS providers and laypersons is the latest intervention to transition from paramedics to firefighters and bystanders
Alright, let's circle around the campfire and let me tell you a story about EMS history. It starts like this:
Once upon a time …
There was a mythical creature called Paragod. You could recognize the creature in a flash. Paragod wore a utility belt loaded with bandage shears, a window punch and forceps. Paragod carried a 65-pound lightning generator in one hand and in the other an oversized orange and white tackle box filled with magic potions that revived the dead. Paragod used special tools to breathe air into lungs and pour special liquids into veins that gave life.
All of these gifts were fiercely protected by the Paragods. No mere mortals could use them in the field as they would be too dangerous in the wrong hands. Paragods objected to attempts by the Firemenicus or Ee-Em-Tee tribes to acquire and use those gifts.
But times were about to change.
Do you recognize a few parallels in this parable?
The fact is the line between so-called "basic" and "advanced" life support has been blurring for quite some time. Think of esophageal obturators in the 1970s, AEDs in the 1980s, epinephrine intramuscular injections in the 1990s and CPAP in the 2000s.
Today, there are states that authorize their EMTs to perform interventions formerly restricted to the ALS practice. While some of the procedures are dubious in their efficacy, others are clearly time-dependent and can reverse the life-threatening situation quickly.
The use of naloxone by laypersons, law enforcement and first responders is a contemporary example. As with any epidemic, public health procedures must be quickly developed and implemented to stem the threat.
Clearly there are some risks associated with injection, and training is required, along with a comprehensive monitoring and analysis program. As this report about Canadian firefighters being trained on the delivery of naloxone to opioid overdose patients points out, there is an urgency to reverse the effect of respiratory depression quickly.
While some may argue that assisting ventilations with a bag mask may be adequate, that simply is supportive care, not a reversal. On the other hand, the chance of taking the brake off of a polydrug overdose is very real, resulting in an agitated and potentially increases the deleterious effects of the remaining stimulant. However, I do believe that the benefit outweighs the risk in the majority of situations; good history taking, a careful physical exam and judicious administration can minimize the harm in more risky incidents.
There must also be a way to restrict the rising cost of what is a cheap drug — naloxone — to manufacture and package.
By the way, there is another Paragod story for our next campfire. In that story, the Almightynurses feel threatened by the rise of mobile integrated health initiatives.