Recently I’ve been reading discussions and research into patient outcomes as it relates to BLS care versus ALS care. The results of this research are pretty sobering. First, some background. Many people know what an ambulance is and think they know what an EMT is; however, I’ve spoken to ER physicians who didn’t realize there was a difference between an EMT and a paramedic. It’s important to differentiate. Since I’m most familiar with the US differences, this post will focus on that, however I know in Canada and the UK there are some differences and I’m happy if my colleagues from those countries could shed some light.
In the States there are 4 nationally recognized levels of pre-hospital medicine providers: 1) Emergency Medical Responder (EMR), 2) Emergency Medical Technician (EMT), 3) Advanced Emergency Medical Technician (AEMT) and 4) Paramedic. In general, the first 2 levels cannot do anything invasive (start IV’s, infuse drugs, so on) and the last 2 levels can. Another way of looking at it, EMR’s and EMT’s are considered Basic Life Support (BLS) providers and AEMT’s and paramedics are considered Advanced Life Support (ALS) providers. Typically, anyone who wants to be a paramedic attends EMT school first. A student can skip the EMR and AEMT levels but rarely can someone become a paramedic (go straight from “zero to hero”) without first stopping and obtaining their EMT certification. The reason has to do with the core content of every EMT course. EMT’s used to be called “Basics”. It wasn’t derogatory or because the skills learned were simple or easy, but because the skills learned in the EMT course were the fundamentals used on every call (scene safety, patient assessment, obtaining vital signs), aka, the basics. Without mastering these skills, a person couldn’t progress effectively to become a paramedic. Hence the prescient saying, “the best Medics are the best Basics.”
Why do we care about these differences? Well in short, research is coming out showing cardiac arrest patients who receive BLS care do better than patients who receive ALS care. This may seem counter-intuitive since the training of an EMT is around 160 hours and the training for a Medic is around 1200 hours. Obviously patients who receive care from a higher trained person should fare better…right? Maybe not. This also isn’t new news. When I was in paramedic school in 2006, studies were revealing that intubation during cardiac arrest by paramedics was delaying other lifesaving treatments (i.e. chest compressions) and either providing no benefit or actually harming the patient (esophageal intubation for instance).
Many reasons have been given as to why ALS providers fail to provide better care. Part of it might be psychological. Since ALS providers have access to all these cool toys and we want to feel like we’re actually doing something, we take time to perform procedures that really aren’t helping the patient but make ourselves feel important or productive, (as a colleague of mine put it once when I successfully converted a patient in SVT by administering adenosine, “isn’t it nice to actually feel like a paramedic once in a while?”)
The answer is yes, of course it is! I got into this field to help people, not to be a taxi driver (and to borrow a line from Seinfeld, not that there’s anything wrong with that). But is too much care, too much care? In my National Registry exam to become a paramedic, one of my practical stations involved a scenario where the right answer was to do nothing. I walked out thinking I got it wrong, I was asking myself how the right answer can be to do nothing. But clearly, sometimes less is more. Now I don’t want to write myself out of a job, but the EMS community as a whole needs to ask itself some tough questions; one in particular, are we providing the best possible care to our patients that we can? I obviously believe there’s a time and place for paramedic level care, but we as a community may need to rethink the best way to utilize such resources.
