Pushing Down the Skills – Bringing New Tricks to BLS

A post by Peter Canning, one of my favorite EMS authors who writes the blog “Street Watch: Notes of a Paramedic” has got me thinking. The post deals with what skills we should push down a level or two from the Paramedic scope of practice and allow EMT-Basics to perform in the field. In his very well written article “Where I Stand (Today)” He brings up many of the facets to this complex issue.

You should read the article, but this is my favorite part:

“I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.”

“Allowed only if there is a demonstrated need.” I like that statement, even if I can come up with arguments against it in both an academic and practical sense. As I stated some years back in a previous post: “A Late Night Rant about Petty Politics in EMS” there is a hierarchy of things that guide too many EMS decisions, and they’re not positive things, they are:

  1. Revenue Preservation
  2. Area Preservation
  3. Ego Preservation
  4. Political Capital Preservation

Make no mistake. Those four things are at play in this whole debate on what skills should be in the scope of practice for every EMS level. I’d bet that if I were to take an informal poll, most BLS providers would support their being allowed to perform many new skills now considered to be in the realm of the “advanced” provider. I’d also say that most ALS providers would not support giving a lot of those skills to BLS. There would be some disagreement, as some BLS providers would see the additional education required as being burdensome, and some ALS providers would see giving ALS skills to BLS providers as lessening their workload by reducing the number of calls where they are needed. However, I look at it as a very contentious issue.

Mr. Canning is correct when he says that this should not be an arbitrary decision based upon anything other than a demonstrated need and good information, however I can argue against that statement as well. I believe that patient physiology doesn’t change when one crosses a political boundary which is why I’m generally in favor of setting a national minimum standard for our profession. However, I also believe that there are places that have a better mix of available resources than other areas and/or a specific health complaint that is represented in their area and not in others. An example would be in my area of Illinois which is not known for jellyfish stings nor altitude sickness.

I’ve sat in meetings sponsored by EMS educational institutions and listened to groups of EMS and fire chiefs decry the academic standards that dictate the pass/fail standards for EMS students. Not a one of those chiefs ever wanted the standards increased. They simply wanted their personnel to pass the classes. I’ve also had a few EMS system directors make the comments that their protocols have to be written for the “lowest common denominator” of providers… because skills that were too complicated wouldn’t be appropriate for everyone. I say that EMS has an unfortunate downward-pressure on our educational standards as it is yet I agree with the EMS coordinators when they say that there are some EMS people out there who are simply too… dumb? Unmotivated? Non-academic? Oh what’s an appropriate word for it… “unable” to provide the skills that others could reliably and safely perform.

I’ve been on a lot of sides of this issue and I know that my opinion is not any more valid than some others on this topic, as the answer is probably data-driven and I’m not that smart. However I believe that there are skills that should be pushed down to BLS providers that they are currently not allowed to perform. I believe that these skills would most probably improve patient care and have other positive impacts upon the EMS systems in the areas where these skills were moved down. On the same coin, I believe that there are skills that a provider should only attain with the requisite educational background. For instance, the motor skills required to perform a surgical cricothyrotomy aren’t really that hard. If you can carve a turkey or change an oxygen cylinder, you can probably perform one. However, the background knowledge required in order to safely know when to and when not to perform one in favor of any of the alternatives is pretty vast and requires both a lot of experience and education.

Here’s the deal. If you are a BLS provider or someone in charge of BLS providers you should be looking for skills you can add to the BLS scope of practice. You should look first for what benefit will be added for your patients by providing the skill your considering and then look for the risks. All patient care interventions, from bandages to brain surgery have both risks and benefits that must be weighed carefully by someone well-educated before being performed on or withheld from a patient. My opinion is that if a provider’s educational level cannot be reasonably expected to carry the requisite knowledge required for safely performing a skill, than that provider should not be able to provide said skill. Things like BLS IV initiation, BLS narcotic pain medication administration, and BLS endotracheal intubation fall into that category. Sure, there are numerous patients who might benefit from having those skills performed by a provider of lower educational background, but there are many more that in my opinion would be harmed rather than helped by a BLS provider choosing to employ those skills improperly over the alternatives already available to them. Another one of my EMS mantras is that a provider should have “A reason for everything they do, and a reason for everything they do not do” for every patient. These skills are too risky, in my opinion, for BLS providers to perform due to the risk of harming more patients than they help.

On the flip side of the coin, this happens with ALS providers as well. A partner of mine (who, by the way runs a very popular EMS related business and Facebook page) related his own story about bringing a new device to the very progressive medical control system that is in charge of our service. He introduced to them a point-of-care testing device that would obtain lab values such as a troponin and other valuable tests using an easily performed prehospital blood draw. He thought that it would have been useful in cardiac care and help us dial in on both STEMIs with questionable ST elevation patterns and non-STEMIs alike. He was very disillusioned when the medical directors not only denied his request to incorporate the tool, but suggested that instead of using that device “if he really wanted to help” he should place EMS patients into patient gowns before arriving at the ED to make it easier on the ED staff. Would the devices have been helpful in our area? There are a handful of services in the state that use them, but in our area it was deemed to be not useful as we have a number of PCI capable facilities within a half-hours drive of most 911 calls and we would be taking any patient with a suspected cardiac issue to one of them anyway. In other, more remote areas, this is not the case and those services are using these devices in the field to varied success. The point is, when denied with what was considered to be such a flippant denial, our paramedics felt exactly the way I assume EMT-Bs feel when they have to call a paramedic to start an IV.

I’ve said before that there are providers of all levels that in all honesty cannot intelligently debate this issue. This is because “they do not know what they do not know.” Just as it would be unwise to call your neighbor if you were having chest pain and accept their diagnosis that you “probably just pulled something” as your neighbor would have no possible way of knowing, you can’t intelligently debate these topics if you’re not willing to dig as far down into the issue as it takes to fully understand it. That requires education, not necessarily formal education, but education none the less. As an ALS provider I have heard BLS ambulances transport patients who I considered to be in need of ALS interventions without calling for an intercept too many times. I’ve also heard their justifications for doing this and a vast majority of those justifications sounded like one of the four reasons above given to me by people who wouldn’t consider that they didn’t know what they didn’t know about the care the patient really needed. To be completely fair, those providers probably left the conversation considering me to be just another arrogant “paragod” and maybe I am, but I believe in my heart of hearts that I’ve got patients’ best interests in mind.

Also, always remember… there’s a name for BLS providers that have the ability to provide more advanced skills. They were called EMT-Intermediates (now called AEMTs) and they have more skills because they’ve had more education and have been held to higher standards. Come to think of it, that’s why paramedics have more skills than AEMTs do and why Doctors have more skills than paramedics.

This debate is going to continue on for a very long time and many potential paths can be taken. Every single skill that EMS providers at any level are able to perform requires knowledge, practice, and judgment. Each skill should have a thorough risk/benefit analysis that shows clear and real benefit to a wide enough subset of patients without producing undue risk. These skills should be easy to master, carry a low risk of harm, and be either better than the existing treatments or not have effective alternatives. If you’re going to make the suggestion, make sure you do your homework because our patients deserve that we know what we’re doing.

In a later post, I’ll detail what skills I believe EMT-Bs should all be doing. I believe we should expand their scope of practice and I’ll explain how then.


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