While I was in Paramedic school, my instructors would say things like “you’re not a real medic until you’ve killed someone” and “soon you will all have your P-cards and a license to kill”
Studies show that ALS interventions give little to no benefit to trauma patients, and in some cases cause harm. We also still have no hard evidence that ACLS drugs are effective during cardiac arrest.
Systems across the country are downsizing their scope of practice, and losing medications and procedures because mistakes are being made in the field. And some medical directors are feeling like ALS is more of a risk then a gain.
The logical conclusion? ALS Kills People. Well, let me be a bit more specific. ALS kills people when it is used inappropriately and or incorrectly.
Don’t get me wrong, I am a firm believer in the benefit and need for ALS care in the field. But it must be done right. Otherwise you run a high risk of killing someone. I know you have heard it before, but its BLS before ALS. And it takes a good EMT to be a good paramedic. And I of course agree, I would also add that a well educated Paramedic with BLS equipment will give better care then an average Paramedic with ALS equipment.
So where am I going with all this? The answer is education, more emphasis on high quality BLS care, followed by appropriate ALS interventions. ALS care,well any level of care for that mater is a two way street of skill and knowledge. With out a thorough education base to start from, is it any wonder why intubation success rates are low and pneumonia patients are receiving Lasix. Not when you consider the fact that some clinical sites don’t allow students to intubate, or that some schools teach airway in a 8hr block and then move on. Another reason ALS is often harmful and seen as a liability, is because many of our new (under educated and under trained) providers go into the field and are so excited to play with their new toys they forget BLS and are unnecessarily aggressive with ALS. Again, this all comes back to more education.
Up until recently, the general consensus has been to remove procedures that are considered “an opportunity for error or that are infrequently used”, rather then provide more training and education to prevent errors and keep less utilized skills current. Why Is it so taboo to want more for our patients and our profession? Should a police department get rid of it’s SWAT team because it’s been 15 years since a hostage situation? Should fire engines respond without lights and sirens because it’s potentially dangerous to other drivers? So why should EMS stop using medications that are harmful when Improperly Used? Or remove procedures that are only used on 5% of the patients.
This is an opportunity to adopt some things from our colleagues in Fire and Law Enforcement. Because as different as our roles are, they are also similar. I am a big supporter of frequent In service trainings and drills. The Fire service often trains and drills for operations that may have been done in the field only a few times in the history of the department, in addition to training on daily operations. Police Officers are frequently at the firing range, even though they may go their entire career without drawing their gun in the field.
EMS is very much the same. we are educated, trained and equipped for the worst. Even though most calls meet BLS criteria, or less. But for that 10% who are legitimately critical ,we still need ALS. So how do prepare for the worst? By completing 48hrs of continuing education every two years…… Really? Kinda embarrassing when you think about. Go look in the back of your ambulance and consider how many things we carry, and how many are actually used on a daily basis. Then consider how many things you remember how to use (Properly)
We as individual providers and as a profession can not just wait for the National Registry or our local agencies to require more from us, because they won’t. We need to be responsible and proactive for our industry and require more from them, and from our selves.
As individuals we can educate our selves and practice skills on our own or in small groups. As a profession we can raise the bar for all of us by increasing the minimum standards for employment. Individual schools can increase the required hours (or years) of education, and begin asking for more prerequisites. The industry standards will not change for us, we must change the industry. And it starts today with you.
If you are interested more on the importance of good BLS care, Steve Whitehead has a great post on the subject. Also Rescue Monkey brings a different perspective, and adds a good dove tail to the issue.
AMAZING post, Jeremiah!
One thing that will stick with me when I debate Wesley again is what you said: “Should a police department get rid of it s SWAT team because it’s been 15 years since a hostage situation?” I have never thought of it that way. We may have never used a surgical cric in our services’ history, but what happens if it’s pulled and we need one? What if *your* mom needs one done? Those things keep me up at night as more and more things are pulled from protocols.
SWAT Teams are used on a regular basis for high risk warrants. If there were no risk warrants then very few communities would have SWAT teams.
If you want to work in a system with a large scope of practice then apply to King County Medic One or Boston EMS where there are few paramedics practicing many skills.
I hear what your saying. One time we had a medic pull a combitube from a burn patient so he could put in an ET tube. The combitube was doing an adequate job but when he pulled it, he almost lost the airway.
These guys don’t get to practice these skills often enough, so they get overzealous in the field.
The other problem that ALS presents is dependence. It’s not so much of a problem in urban areas where the PM’s are 5 minutes away and the hospital is 10 but where I’m at, we have a 45 minute transport time and the Paramedics are 30 minutes away. We can’t afford to sit around on scene and screw around waiting for them to show up (and some people do just that). It seems like because paramedics are available, BLS providers are afraid to make a decision when a call requires ALS. Even if your just gonna scoop and run and meet ALS in route, for god’s sake just make a decision.
Now don’t get me wrong, I’m not saying that ALS doesn’t have a place in the field. That’s just foolish. What I’m saying is that the paramedics in the field need to use their skills in an appropriate manner and the BLS providers need to be decisive in their patient care when a call does require an ALS response which isn’t as often (at least where I’m at) as dispatch reports would have you believe.
“paramedics in the field need to use their skills in an appropriate manner and the BLS providers need to be decisive in their patient care”
Yes sir.
“We also still have no hard evidence that ACLS drugs are effective during cardiac arrest.” One randomized trial of epinephrine showed no improvement in survival-to-hospital discharge, see Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial. There’s also the infamous before-and-after OPALS cardiac arrest study showing the same thing.
There are two observational studies from the Seattle area suggesting for every minute ALS is delayed survival decreases by 4% and survival increases 2% for each year of experience of the paramedic performing intubation, see Prompt Advanced Life Support Improves Survival From Ventricular Fibrillation and The Effect of Paramedic Experience on Survival from Cardiac Arrest.
Thank you Tim for the ACLS Studies. You may have been a bit confused when I said “ALS Kills People” What I said was ” ALS Kills People when it is used inappropriately and or incorrectly”. I am not dissing ALS You need ALS at a cardiac arrest as well as many other emergencies. And Yes, experience is always a plus. I As for the SWAT Team example, I am a very aware that SWAT is used for many other operations beyond the worst of the worst. I was simply using it as an example.
Also props to King co, they are amazing. And as for Boston having few medics on the street, I think there is more to that story.
I’ve never been able to find out much about Boston EMS. The only data I could find was a 98% cumulative intubation success rate. Here in South King County where I live there are only 75 paramedics for a population of 700,000. I don’t know what the intubation success rates down here are.
Seattle has 78 paramedics for a population of 600,000 and their cumulative intubation success rates per attempt are 75%, 89%, 95%, and 98%. Their numbers might be low because of 20 medic students ten months of the year.
I haven’t been able to find what a set of “acceptable” first and second cumulative success rates would be.
True, Swat teams are used for felony warrants just as paramedics are used to run dialysis transfers during their downtime. I think his point was that the other branches of public safety are keeping up on the skills that they rarely use in preparation for the time that they actually do have to use them.
And to say that a study suggests that “for every minute ALS is delayed survival rate decreases by 4%” is such a generalized and weak statement. Checking a blood sugar is considered an ALS intervention. Show me a study that says “for every minute that intubation is not performed” then I’ll care. I’m sure if you paid someone enough money, they could make some statistic out of the amount of those people that died as a result of eating Taco Bell for lunch.
Anyway, great post. You make some valid points. I have been stressing the importance of frequent practice and education for a while. I feel that EMS should be moving forward not backward. Keep up the great writing!
“True, Swat teams are used for felony warrants just as paramedics are used to run dialysis transfers during their downtime. I think his point was that the other branches of public safety are keeping up on the skills that they rarely use in preparation for the time that they actually do have to use them.” They’re practicing the skills needed during all those “high-risk” warrant cases.
You’re certainly right to question both of those papers. Observational studies are only useful/interesting if they don’t demonstrate some correlation. “Uncontrolled studies have a specificity of only 11%, versus 88% for randomized controlled trials” (Quantifying the Scanty Science of Prehospital Emergency Care)
Well then I guess EMT’s are exercising their “critical driving skills” when running their dialysis transfers
I’m not sure about your area, but the Swat team around here serves warrants the first Sunday of every month. They only do it because the beat cops are short staffed due to budget cuts. They serve all the felony warrants. Not exactly sure how many of those could be classified as “high risk”. Once again, training and retaining those skills for when they are “really needed”.
Perhaps one could make a good argument that paramedics should have intubation skills once a month and practice on live patients in the OR? All of these arguments are just proving Jeremiah’s points about continuing education.
How about not sending paramedics to BLS calls. I wish I knew how many of the 255 paramedics in Seattle & King County meet the 12 tubes per year requirement.
Great discussion guys. Sean, I am all about medics practicing intubations in skills labs and OR’s often. We should also practice skills during slow times at station, and be quizzing each other like when we were in school.
Tim, BLS calls are just as important as ALS. In fact most 911 calls are BLS, and if medics only ran ALS they would actually get less clinical practice. Also many services have the ability to defer transport to a BLS provider after ALS arrives and assesses the patient. It’s great that King co has a yearly tube requirement. When it comes to being proficient in a skill, Intubation is it. I would suspect they don’t have trouble getting the 12.
“BLS calls are just as important as ALS” no that’s not true. A kid hit by a car with serious leg injury could be delivered to the hospital without professional intervention. A cardiac arrest patient needs high quality compressions, defillibration, possibility ventilations, and be cooled if unconscious.
“most 911 calls are BLS, and if medics only ran ALS they would actually get less clinical practice”
In 2008, paramedics in King County were dispatched 29% of the time with an en-route cancellation rate of 18%. Only 43% of ALS patient contacts involved ALS transport. A while back I found a person claiming a mean of four calls per medic unit a day in South King County. How much “clinical experience” does a paramedic need to hit a 80% and 95% cumulative intubation success. Are there any other good measures of individual paramedic performance besides intubation?
“I would suspect they don’t have trouble getting the 12.” I suspect the number one problem here in King County is patients having MIs who don’t get a paramedic evaluation. Eisenberg told me the county will start tracking missed MIs something this year.
For example to get an ALS dispatch for an MI by the 9-1-1 dispatcher the patient must be having chest pain, be male over the age of 39, be female over the age of 44, having shortness of breath and be over the age of 25, two signs of shock, or have rapid heart rate. I’ve never seen a study of the false positive/negative rates for the 133 indicators for ALS. I have seen a study showing about half of 9-1-1 calls where CPR instructions are given the patient isn’t in cardiac arrest.
Well yes, a pediatric auto vs ped could be transported by private auto. But then again, so could anything. As for South King’s ALS vs BLS dispatch model, It sound like an “”Interesting”" system. Here as well as I’m sure many other places run All ALS, You either get an ALS ambulance or no ambulance.
I’m with Jer on this one… anything *can* be transported by private vehicle… not that you’d want to or anything. And WTF is up with that dispatch system?! It’s more than interesting- it’s plain flawed, son! There are so many things I can say about it but it’s way too early here to get into it. Over here, you get an ALS ambo or none at all, too, Jer.
Natalie of course it’s flawed like any other triage system. All tests have failure rates. The whole idea behind the system here is to have paramedics who are as good as appropriately trained physicians. You can’t reach that level of proficiency and still have a paramedic on every call.
I think the comments section has been derailed. Jeramedic is saying we need to train more on the things we do less often. As a firefighter, we train for all sorts of special rescue situations that we might see once in a career. Why should EMS be different?
What ALS low-frequency high-risk procedures can be drilled on?
surgical and needle cric, needle decompression, more cardioversion/pacing labs, etc etc… we should drill those… and we can if we had cadaver labs opened to us more… just saying.
RescueMunk < My point exactly Sir
Even simple BLS things like delivering babies or applying a traction splint. It may sound stupid, but I have been a paramedic in a busy 911 system for a while and I have probably done each of those skills maybe 2 or 3 times in my whole career.
Granted, neither one of them are very difficult tasks. But it can still be nerve racking if you haven’t done it in a while.
To be fair, the entire BLS v ALS debate is silly and contributes to much of the problems. It breaks up interventions and assessment tools into little boxes with the only root for what’s in one box vs what’s in another box being who originally did what. Is defibrillation a “BLS” intervention or “ALS”? At one time it was “ALS” and now it’s “BLS.” Here’s a question… why aren’t physicians trained in a similar fashion? There aren’t BLS physicians or ALS physicians. If you’re in severe pain due to a broken leg, would you like the physician to just let you lay in pain to see if the “BLS” intervention of ice and elevation lowers the pain level until he has the time to set the bone or would you like him to jump straight to pain medication if, in his judgment, it’s the correct intervention?
Ideally, if we wanted to stop the fascination with “ALS toys” we’d make paramedic the entry level provider and require the education necessary to properly do the job. If you don’t have college level (and, no, NCTI’s 2 week A/P for paramedics does not count) anatomy, physiology, chemistry, writing, and psych, then no. You’re not properly educated. Requiring paramedics to know the “whys” and “why nots” is just as important as making sure that paramedics know the “when” and “how.”
The next thing that making the paramedic an entry level does is it takes away the “look at what I can do now that I couldn’t do before” because it’s all new. There isn’t any boxes. It’s a continuum. Now, starting an unresponsive patient on oxygen is just as vital as getting a BGL level not because oxygen is a “BLS” skill, but because supplemental oxygen is the correct treatment for a patient who is unresponsive. Similarly, getting a BGL and starting an IV aren’t “ALS toys” to play with because the new paramedic is a paramedic. They’re simply tools that have been integrated from the start into the rest of the treatment and assessment repertoire.
Yes Joe, very true. I think you got my point of more education very well. It’s not a mater of BLS vs ALS, it’s a mater of good medicine.
You’re advocating that inexperienced paramedics be responsible for the care of the critically ill and injured. The critically ill and injured should have priority over all other patients.
Are you implying that paramedics with no experience as a basic is inexperienced? If so, then are physicians without experience as PAs equally inexperienced when they leave medical school? How about RNs who weren’t CNAs?
It is possible to have enough clinical time to provide a decent foundation for paramedics without requiring experience as a basic. However you won’t find it at a 8-9 month patch mill. Similarly, services need to understand that if they are hiring new grads, then they need to take an active stake in the development of their new grads. Hospitals have new grad programs for nurses fresh out of school. Physicians have residency after graduating from medical school. Why does EMS feel that they are so different from the established health care fields to not need new grad programs and require prior experience to put a band aid on their program’s inadequacies?
I’m referring to ALS providers who rarely handle truly critical calls.
“ALS Kills People.” Wow, that’s some lead! Guess this isn’t about Lou Gehrig after all.
Joe P covered my intended remarks pretty well. Just to build on that, I think the ALS/BLS boundary (which, thankfully, is becoming more blurry) complicates EMS resource and risk management. I’m not sure if the ideal prehospital provider is more EMT or medic, but I hope we’ll find ways to purge artificial constraints on what should be a continuum of care.
I don’t see ETI becoming a BLS skill anytime soon.
The ideal provider for the critically ill and injured is a team of good primary care personnel with one or two highly skilled and experienced advanced care paramedics.
Yes, very good points everyone. Tim, I am advocating that Out of Hospital Providers regardless of their experience act in the patients behalf. And to do this by providing a higher quality of care, which is possible (and this is not the only way) through more education. As for responsibility, it’s already there. From the moment we make patient contact until they are in the care of someone equally or higher qualified then us, we are responsible. That does not change depending on the amount of distress the patient is in.
Mike, You are Right. The line between BLS and ALS is blurring, and that is a good thing. I believe that the ideal prehospital provider is a(fill in the blank)______________. Someone who is a highly skilled and educated medical professional that is practicing in the out of hospital environment. And by that time we should also no longer have Basic and Advanced Life Support, just Life Support.
And Joe P, I couldn’t have said it better myself.
Great post, Jeremiah. I cannot count the times I have told EMT students of all levels “The EMT comes BEFORE the P!” Good solid ALS skills are supported by good, solid BLS skills. I just wish the majority of Basics I work with would get out of the habit of assuming that only Paramedics can handle emergencies. They are the backbone of EMS…equally, I just wish many of the Paramedics I work with would remember the BLS before the ALS.
Jer, you really stirred the pot with this post and I LOVE IT!
Several great points are made up there, but I’d definitely like to say that Harwetopa said it best: “The EMT comes before the P” I don’t know how often I’ve rolled up on scenes where basic things were not done that should have been ie: bleeding control over meds etc etc. And I wanted to comment on Tim’s question about “inexperienced ALS providers,” Well, Tim, we all start out at the bottom of the food chain. But we learn as we go. We have what we’re taught and we build from there. It’s not like they stick a Bus Boy on the ambulance one day and say- SAVE LIVES TODAY, KID. We learn as we go, we use our resources to the fullest extent. I’m only one and a half years into being a medic… do I know everything? HELL NO. So what do I do when I’m on a call and I get stumped? I call my medical director, I call my boss, I call my colleagues who have been medics longer than I’ve been breathing. One day, I’ll be the medic the new kid calls, because with time comes experience. Yeah, we don’t get to do hard core ALS stuff super often, like crics and cardioverting, and decompression- it’s why you’re required CE hours. But as Jeremiah said above, 48 hours isn’t enough. We have to push ourselves as medics who want to *grow* versus stay stagnant in our healthcare to seek additional resources. We need to go to labs and attend hospital seminars, some systems like mine set up QI labs. Our medical director sees what skills we haven’t performed in a while and opens up time in the hospital under his direction to perform those. If there is one person or a few people struggling with intubations, IV sticks, EKG interpretation, protocol evaluation, we are pulled off to the side and given hospital clinicals again. Employers who pay attention to these things should be given gold stars. Now, Tim, I understand you live in a place with a cool system… but there are other ways of successfully functioning out here. I’m not bashing you or anything… I’m just simply showing you the other side.
Bazinga, as Justin Schorr would say.
This is a subject that kind of gets me a little hot under the collar, protocols, medictions, procedures being dropped becuse of incompetence or poor skill levels.
We all make mistakes but jus pure incompetence is not excusable. I have been in EMS for 25 years and I’ve seen the scope of practice expand and now begin to contract and all based on our inability to do our jobs. I agree with you that good bls has often been overlooked because of preoccupation with als. example anyone who says they have never missed an intubation is lying, the crime isn’t missing the tube it’s failing to recognize that the tube isn’t placed properly and responding with good bls savvy and removing the tube and bagging the patient ( BLS!!) we all are in some way responsible for this either by our own incompetence or because we look the other way to avoud conflict. forums like this are a start toward fixing this. thanks for you hard work here jeramedic and I’m glad to see so many others care about this. we can fix this but it wont be easy.
Interesting discussion, so let me change that!
First, there is no good analogy between physician education and EMS education. Second, most calls are BLS and should be handled by BLS providers. Which means that ALS providers should be far fewer in EMS systems. Look at the systems that have low intubation success rates and high esophageal intubation rates. They are all ALS systems where the medics have far fewer tubes per year than tiered systems. Every call does not require a paramedic, in fact most don’t.
As Jeramedic’s post states, the problem is with EMS education, particularly BLS education. Refreshers, whether BLS or ALS, are pretty boring as a rule. The additional education required can vary widely, as we all know.
Sirenman has a point, but it’s truly a matter of being able to document how well we do our jobs in addition to being able to do our jobs well. Until we can demonstrate on a consistent basis that we are able to perform the skills the current scope of practice well, we’ll not only not see more skills, we’re likely to see fewer skills in general.
Great post and I agree with you. The system I work in is great, we do 5-6 hour paramedic OTEP every month with skills labs. Also there is normally only 1 medic on a call and we get cancled if the BLS agency on scene can handle it. I was way over my needed tubes for my first and second recerts and we just got some new meds added to help with RSIs and STEMIs. I am a firm believer in training on the skills/meds we don’t use as often and BLS before ALS. Someone once told me that the difference between a paramedic and an EMT is that a paramedic has a broader knowledge base, therefor needs to be a diagostician. Meaning that instead of cookbook medicine(if I see this I do this, if I see that I do that), I am too assess the patient and formulate what I believe is wrong with the patient and base my treatment modalities on that. I believe it is far more important to do a complete assessment and have an idea of whats going on then it is to perform ALS interventions that may not be needed. I like what sirenman said about tubes too. Thanks for a great topic.
Haha I am really the only reply to this great post?!
I agree with more education and practicals. As far as killing anyone, aren’t they already dead if you’re applying acls measures. You can’t kill a dead man but you can resuscitate one. This was a good post and insightful.