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EMS From a Distance: ALS? BLS? Let skills fall where they may

Basic versus advanced EMS training and care continue to evolve

Let’s encourage multitasking and relegate “BLS before ALS” to the recycle bin of medical clichés.

BLS before ALS!”

I doubt there’s anyone with more than a few months in EMS who hasn’t heard that cliché. It used to make sense to me. As an EMT, I liked the way it prioritized my low-tech contributions over the meds and monitors of my paramedic partners; and as a new medic, it reminded me not to overlook basic care, no matter how cool my tools were. So why does “BLS before ALS” sound so silly to me now?

ALS, BLS: The limits of labels

Prehospital care rarely follows a BLS-to-ALS hierarchy. More often, we combine basic and advanced interventions as cases warrant: the alert cardiac patient with crushing chest pain, for example, who gets aspirin and a 12-lead as her vitals are checked; or the obtunded diabetic with an unremarkable pulse, whose finger stick is more significant than his blood pressure. Now that we’re introducing EMTs to naloxone, CPAP and other measures once reserved for ALS providers, I don’t think categorizing skills as BLS or ALS is as helpful as asking whether EMS needs such a distinction at all.

Labeling care as basic or advanced is rare outside EMS. Broad-spectrum medical reference volumes like Taber’s and Borland’s don’t even include definitions of ALS or BLS. My paramedic textbook from 1994 offers limited guidance in this glossary entry for advanced life support: “Provision of advanced-level care by paramedics or allied healthcare providers.” No kidding.

When I joined EMS in 1992, “advanced-level care” implied invasive procedures, medication administration and/or cardiac monitoring. The closest I could legitimately get to any of that as an EMT was to insert airway adjuncts or dispense oral glucose. I wasn’t even allowed to use an AED in New York without targeted training (EMT-D certification). Such restrictions begged the question: Should some advanced skills be simplified and taught to BLS providers?

Empowering EMTs

Before I became a medic in 1995, I’m pretty sure I could have done a better job assessing and treating unstable cardiac, respiratory and AMS patients if I’d had, say, another 50 hours of advanced instruction in low-risk, high-yield techniques. The folks running Suffolk County EMS, where I worked and volunteered, must have felt the same about the rest of their EMTs; SCEMS implemented two novel pilot programs to evaluate ALS extensions to BLS protocols:

  1. Endotracheal intubation: At SCEMS in the early ’90s, the I in EMT-I meant intubation, not intermediate, after a few dozen EMTs were trained to perform advanced airway management. That program was discontinued when its cost wasn’t justified by clear improvement in patient outcomes – results consistent with research 10 years later that would highlight prehospital intubation’s limited effectiveness.
  2. 12-lead EKGs: As 12-leads were becoming a national standard for paramedics, SCEMS loaned clunky Lifepak 11s – state of the art in 1995 – to selected agencies whose ALS and BLS providers would send 12-lead tracings to medical control for interpretation. Despite transmission and reception problems, procedures were introduced that would one day lead to STEMI alerts.

Although neither initiative lasted more than a year, each showed that some elements of advanced care could be extended – prudently and methodically – to basic EMTs. Today, New York’s BLS protocols include the following interventions that were once classified as ALS only:

  • Intramuscular epinephrine for anaphylaxis.
  • Intranasal naloxone for opiate overdoses.
  • Nebulized albuterol for bronchospasm.
  • Aspirin and sublingual nitroglycerine for ischemic chest pain.
  • CPAP for respiratory distress.
  • Blood-glucose measurement.

With IM glucagon and 12-lead EKGs soon to be added to EMT curricula in some systems, is EMS close to abandoning the increasingly contrived separation between BLS and ALS? No, but maybe not for the reasons you’d think.

ALS: Privilege or responsibility?

Have you noticed how often we refer to ALS “privileges” in EMS? To me, “privilege” sounds like something of value awarded after years of service. My dictionary supports that notion by defining privilege as “a right, advantage, favor or immunity.”

Is that what ALS is? Perhaps for those who just want to add a patch. That might explain some of the exaggerated concerns on social media about BLS providers administering IN naloxone – a drug that used to be carried by advanced practitioners only.

I hope we’re not seeing resentment directed at EMTs for not paying their dues. Limiting lifesaving therapeutics because of some internal EMS turf war would be an appalling example of immaturity. It would be a shame to give the medical community another reason to view our industry as provincial.

As prehospital practice evolves, softening the distinction between basic and advanced care, let’s encourage multitasking and relegate “BLS before ALS” to the recycle bin of medical clichés.

Mike Rubin is a paramedic in Nashville, Tennessee. A former faculty member at Stony Brook University, Mike has logged 28 years in EMS after 18 in the corporate world as an engineer, manager and consultant. He created the EMS version of Trivial Pursuit and produced Down Time, a collection of rescue-oriented rock and pop tunes. Contact him at