BLS vs ALS – Cold War or Misunderstanding?

Did you like my last post?

If you didn’t read it, which I suggest you do, here it is: You BLS Guys Have Got This, Right?

Good, glad you’re back if you went and read it. However, if you were too busy to do so I’ll recap. In the post I was decrying the practice of BLS providers of questionable competency disregarding responding paramedics in a ludicrously short amount of time after arriving on scene for a patient that sounded like he/she could have benefited from having ALS assessment. It was an inflammatory post, and it was meant to be.

As regular readers of my blog know, I never reveal where exactly it is that I work. While I will say that I work in Northern Illinois and Southern Wisconsin, I never mention the specific service(s) I schlepp patients for by name anywhere publicly. I do this for many reasons, chief among them is my desire to remain employed, but also because I own my own opinions and don’t need nor wish to speak for any specific organization. I have taken a great many jabs at many things over the years I’ve been doing this and I don’t want to single out any specific person or agency publicly with most things.

However if you read any one of my rants or commentaries and believe that I’m speaking to you, feel free to consider what I’ve said and either debate me or change your ways accordingly.

I’m posting this up because I received a comment on my last post that was exactly what I was looking for. It was from a self-identified BLS/ILS provider who didn’t yell at me for demeaning anyone or for being a “paragod” as I called myself in the post, but instead pointed right at the actual heart of the matter.


Boom. She nailed it (She called herself “Trixie” so I’m saying “She”) Provider attitude is everything.

Here’s Trixie’s comment:

“As a BLS/ ILS provider I run into this constantly with the volunteer FD first responders. To be fair, I also have more than my share of medics who turf syncope, seizure, AMS and 10/10 painful fx off to the BLS crew. When pressured to ride it in said medics typically do NOTHING for the patient except take the history and play on their phones in the captain's chair. So I think this is an issue of attitude, not provider level.*smh*”

Trixie, your comment has it all: Distrust of lower-level providers, seemingly valid contempt for higher-level providers, and disdain for people who are complacent and uncaring. Nicely done.

First off, Trixie, if you see ALS providers, or any provider for that matter, “playing on their phones in the captain’s chair” you need to report them to their administration. That is absolutely, unequivocally unacceptable. If you have the ability to switch the organization that provides your BLS service with ALS intercept response to another service that doesn’t have jackasses working for them, I suggest you do so immediately. It is unacceptable for any healthcare provider to be that rude, callous, and uncaring towards any patient at any time.

Moving on, I can see your frustration with the first responders you mentioned. It draws me back to one of my favorite quotes of all time spoken, quite eloquently, by Donald Rumsfeld who you may love or hate as you please. Here’s the quote:


“There are known knowns; there are things we know that we know. There are known unknowns; that is to say, there are things that we now know we don't know. But there are also unknown unknowns – there are things we do not know we don't know.”

I believe that this statement captures the essence of both your and my frustrations with similar incidents. We know what we know, we know what we don’t know, and we know that there are things we don’t know that we don’t know.

We are also certain that there are things the lower level providers in both of our cases don’t know that they don’t know.

In my case, which may or may not have actually happened recently but which I assure you has actually happened in many places many times, I expressed frustration with BLS providers who are looking at the top political priorities of too many EMS agencies, Revenue preservation, Area preservation, Ego preservation, and Political Capital preservation at the expense of patient care. (I’ve written about this problem too in a doozy of a rant which you can find here) In the call in question, the BLS providers cancelled the ALS providers 3 minutes after arriving on scene of a call where a patient had informed the dispatcher that he most probably was experiencing an acute coronary syndrome related chest pain. I decried that this was laughably too short of a time for the BLS providers to have performed any type of assessment at all, let alone one adequate enough to rule out the need for ALS or to Consider PAPPA for Chest Pain. They simply saw that the patient was not dying fast enough nor scaring them enough for them to consider bruising their egos by allowing people with more education to come in and care for him. There was no consideration of the patient’s actual needs nor of providing quality patient care.

Just like in Trixie’s case, my concern is that the providers don’t know what they don’t know. I have no idea whether or not they have any concept of all of the things I would consider for this patient as an ALS provider. It’s not that I’m diminishing their personal mastery of the BLS assessment nor their worth as human beings, but I am responsible for knowing more things than they are and the patient needs to be assessed and probably treated by someone who knows what I’m responsible to know. By their dismissal of this most-probably-needed service for the patient in what can only be assumed to be a blatant display of egoism, they have harmed him. Of course they have, because they are not responsible for knowing all of the treatments this patient may need that they are not able to provide, nor are they most probably able to assess the underlying pathophysiology this patient may have to determine the need for them.

If you think that I’m being disrespectful towards BLS providers you have missed the point.

In Trixie’s case, she is a BLS provider who decries the exact same practice I’m decrying for the exact same reasons when performed by a lower level of care than her own. However in her case, she is also decrying ALS providers who seem lazy and uncaring as well.

Had a paramedic been on scene and cancelled us I would have felt much better about the (possibly fictional) call.

Had a physician been on scene I would have felt a little better about the call, though I would question whether the physician had any idea of the capabilities of the responding ambulances or believed that all ambulances were the same level of care.

Had the BLS providers taken more time before they cancelled the responding unit I would have felt a little better as it would have been suggestive that they had actually performed some type of assessment rather than looking and saying “Not dying now. Cancel the paragods.”

Trixie’s case is no different. However, she then goes on to observe that paramedics “typically do nothing” for the patients she sees them caring for. This is a complaint that I can understand and answer for because I sometimes may be accused of the same thing. The purpose of the ALS intercept is not always to “do” anything that may be visibly out of the scope of practice of lower level providers. This can cause strife. In our area for example, BLS providers are able to obtain 12-lead EKGs but not to interpret them. When we paramedics obtain a 12-lead, read it, and see that it does not indicate for immediate ALS interventions, BLS providers may see this as not doing anything more than they could do if we weren’t in their way. However, we as ALS providers are responsible for knowing what the 12-lead says and for matching what the monitor tells us with physical assessment findings and the patients both long and short term history in a level beyond what BLS providers are responsible to know. You could be an EMT that lives each day to read and devours Dr. Smith’s ECG blog but as an EMT you may have that knowledge but aren’t responsible for knowing nor acting upon it so you cannot be counted on to have it and must defer to people who are held responsible for knowing it, whether they do or not. The paramedic may be trusted to have weighed the pros and cons of providing the ALS level interventions. The BLS provider cannot be. The patient deserves to have the higher level knowledge making the decisions for them just as they also deserve to have a physician ultimately evaluate and provide care for them once they reach the hospital. This is not ego, it is a well-established heirarchy.

Another problem that Trixie pointed out is that ALS providers sometimes do not do what the BLS provider thinks they should, and in the case of a disinterested ALS provider checking facebook from the captain’s chair, this may be the case. If you’re a BLS provider and you observe an ALS provider not providing adequate treatment for their patient, such as appropriate pain control or other interventions, feel free to speak up. Ask them first, and you may be surprised at their answer such as not being able to give narcotic pain control to a patient with hypotension, or withholding nitroglycerine in an inferior MI. However you also may get a flippant answer, which if you do requires you to inform the appropriate parties for proper investigation and action.

Patient care comes first, y’all.

I personally know Trixie’s frustration with this. A while ago I had a patient who did not have outward physiological signs of a STEMI but had a 12-lead EKG that our machine interpretation flagged as *** ACUTE MI SUSPECTED ***. I read that EKG myself as I always do, and could see what Dr. Lifepack happened to be getting at although it was subtle. Even though I had a low index of suspicion, the patient had underlying chronic conditions that confounded their assessment and I could not rule out a STEMI. I had to activate the cath-lab and bypass the closest ED with the patient for definitive care with suspicion that the patient didn’t really need it.

When I got to the hospital I was met by an angry nurse who chastised me for calling the STEMI alert. She was dismissive of me, my patient, and my assessment skills. She ignored the 12-lead and hadn’t done her part to activate the hospital’s STEMI response as I had requested. In fact, she made the statement “You shouldn’t have bypassed <community ED> with the patient. If He/she was having something real that’s what <name of flight service> is for.”

I was incensed and imagine that this could be the feeling that keeps BLS providers from calling for ALS intercepts when needed. I do not wish to be this kind of provider and if I am or have been in the past, I throw my apology out there to the ether.

The fact is, we all operate under a hierarchy. We all have people who we answer to and who may answer to us. Life is like that and it’s not always pretty. However, when faced by the sheer importance of patient care and our unwavering responsibility to our patients and to those we serve, our respective egos must be removed from the fight.

Trixie is right that there are some jerks out there wearing paramedic patches that may inappropriately downgrade patients to BLS out of laziness or the nebulous condition known as “burn out.” To those providers, I say that it is easier to seek other employment before you get fired for killing someone than it is to try and find a job afterwards.

To the BLS providers that are afraid of having their egos bruised further and don’t call for ALS when it’s indicated, I say exactly the same thing.

It’s clear that we need better communication throughout the entire spectrum of care and the medical hierarchy. We also need to all be better leaders, be more tactful and compassionate, and to obtain more education because there is always something more to learn. Those unknown-unknowns are things that can kill someone some day and it is one of our highest responsibilities to prevent that from happening.

Remember, it’s not about you, it’s about others. Be nice, be professional, and know your stuff.

Let's stop the war.

Star of Life upside Down


For more on this topic, from both sides, read these: “Who Needs them paragods?” or “Paramedic Honored for Inaction in Local Ceremony.” In addition, for more information on the ALS intercept, read “Paramedic Intercepts and Rural EMS.”

  • BLS_for_17YRS

    While I appreciate the points you make about hierarchy and the fact that those with additional training and certification are responsible for more, what I have most often experienced is more of the dismissive attitude of paramedics of BLS providers with significantly more experience. Why dismiss me and my years of knowledge just because of the patch on your sleeve? I appreciate your comments about stopping the war. That is really the issue and where we need to be. Let’s communicate more and remember we should be operating as a team of providers.

    • Rural_Medic_3

      As a medic in a very rural area…With a fairly new ALS capability…I find that our “older” medics (I define older as those who have more than 10 yrs experience) who have not been on a 911 for at least 5
      years prior to joining us, tend to almost devalue the BLS providers that were here long before they arrived on the scene so to speak… They do not appear to “trust” any of them with the simplest of assessments for the fear of an Zebra in that herd of Horses. And thus insist on a medic attending every single call without fail. I find that this leads to resentment and loss of volunteers to run 911 calls leaving it to the Paramedics (of which we only have 3). I am a firm believer in the best ALS is a solid BLS, but this comes from a Medic who just finished my first year with the gold patch, and I rely fairly heavily on a joint assessment, my BLS partner to speak up, and be part of my team. But then, until recently, I was one of the BLS providers, in my service….and have felt powerless by these same actions….maybe I’m the only one that sees this, and feels this way…but I have a feeling that is not the case.

      • Art Dardeau

        Absolutely BLS BEFORE ALS….I cant just put an ET in without looking to see if pt is breathing, I cant defib without checking for a pulse, (BLS skills) need those folks. Use them for the pts advantage for a better outcome. They can help with every single call, if you ask them…

        • Art Dardeau

          Just as a note, I was a NEW EMT once upon a time, dont be afraid to ask questions…now just medic/emt/driver…….

  • Ambulance Driver

    As a BLS provider, one with 20 years of rural/urban experience, teaching experience, and administrative experience I have one problem with this article. The largest issue I take with ALS providers is not any of the aforementioned issues. One of the biggest issues I have seen with ALS providers is that they fail to first perform BLS skills. Unconscious patients shouldn’t have to wait 2 minutes to get an ET tube when you can start with and OPA. Providers should NEVER delay transport of a critical patient so they can get an IV established. Trauma patients need an assessment and control of life threatening injuries before you worry about pain meds. Major bleeds should be stopped before performing a 12-lead. CPAP is usually the preferred starting point over RSI for cyanotic patients. Far too often I see ALS providers, especially the young and inexperienced providers delay transport, fail to treat obviously life threatening injuries and over think the basics in a manner that puts patients at greater risk. Pre-hospital care is a team approach. If I ever needed an ambulance, I would take a good BLS team over an OK ALS team any day- but I would much rather a team approach with high quality BLS and ALS providers.

    • TheAP

      You can’t speak as too what ALS skills should be done and when when you
      are not allowed to do them. I always start my IVs before transport. It
      is better to delay moving the 10 seconds it takes to start a IV than to
      do it on a bumpy road and miss or poke myself. Trauma patients do need
      control of life threatening injuries first, however they may benefit
      from pain management before moving them. Major bleeds should be
      controlled first, however a 12 lead should be the first thing done in
      situations where the patient has no immediate ABC threats. This threw me
      for a loop when I started medic school. As far as CPAP goes, its
      contraindicated in hypotension and AMS, take that into account.

      • Ambulance Driver

        Last week I reviewed a run report of a 36 yo m who had sudden onset of difficulty breathing and a history of asthma. Medics started a dual neb. Pt condition did not show signs of improving after 2 minutes. Brand new medic, right out of school found it appropriate to RSI this patient. Unfortunately for this medic, the patient was a difficult intubation (which even a brand new medic should have been able to identify on this person) and he was twice unsuccessful with his intubation. A medic from another city was requested for the RSI and he arrived 4 minutes after the first unsuccessful attempt and surgically inserted an airway.

        As far as starting an IV, if you can get it in 10 seconds, then I think this comment was not meant for you. I am referring to the medics who are incapable of getting an IV on the first try, or just plain take waaaaay toooooo long. A person with a stroke needs definitive medical care, and they need it fast. Last Friday, I reviewed a run report in which two medics who are notorious for having prolonged scene times spent 28 minutes on scene of a patient who was exhibiting textbook signs of a stroke. After talking with this crew they told me they had a difficult time getting an IV established and they were getting a lot of artificat on the 12-lead and that was the reason for the prolonged scene time.

        A couple of years ago, a neighboring service brought a trauma patient into a local ER, dual 14’s, RSI enroute, 4-lead in place, an arm splint on and clear fluid spurting out of where the patients foot was suppose to be. The crew failed to even consider stopping the major bleed before performing superfluous ALS skills.

        The point of my comment is that far too often, ALS providers who are inexperienced, fail to realize that we are not doctors, we are not going to save the world and we don’t know everything about a patients condition by hooking them up to the limited amount of equipment we have in our ambulances. Our job is to provide transportation to definitive care and treat/control life threatening injuries while transporting to a hospital.

        • Tattoos

          I’m sorry. As a paramedic, with 10 years urban BLS before becoming a paramedic, I find great issue with a lot of the things you’re saying here. I don’t understand, and I’ve seen this far to often, how you as a BLS provider can comment on anything that ALS providers do. It doesn’t matter how long you’ve been an EMT, you don’t have the level of training paramedics do. Just because you’ve been doing BLS a long time, it doesn’t make you a paramedic. Plain and simple. I also don’t see why you’re reviewing and questioning paramedics on their call reports and interventions. I imagine you’re some type of supervisor, but again, that doesn’t make you a paramedic or give you the same knowledge as a paramedic. All I really got out of your comments is that you think paramedics should listen to you because you’ve been doing this for 20 years. Sorry, where I’m from, that’s not how this works.

  • MN EMT

    I work on a BLS/ALS rig meaning its just me and a Medic on all calls.

    My question is, do you believe that all calls are BLS until they have to be ALS? or everything starts ALS until it can go BLS?

    I have been lucky enough (and unlucky) to see both sides of your story first hand.

    • Ben D.

      I work with a similar situation (I’m the medic on the truck)…to answer your question, we typically both do everything to begin with; we’ll both start gathering vital signs, she may ask the SAMPLE while I pop in with additional non-standard questions. We’ll both decide who’s better suited to take the call. And I do sometimes let her tech calls that should “maybe” be ALS (as opposed to obvious ones). I’m sure that Trixie is probably talking about a system where the BLS transporting unit doesn’t have any ALS capability on it (as opposed to my situation, where I drive), but something to consider is that sometimes, medics will pass on teching a call to help their partner or colleague grow professionally. It sucks to get your EMT-B and then do nothing but take vital signs, spike a bag, and drive for the rest of your career. Again, if it’s done on obviously unstable patients that’s a system problem. But an MVC patient with a mild TBI, a syncope with low-risk of sudden arrhythmia, or *gasp* a simple opiate OD with good cardiovascular function who just needs an NPA and a little bagging every now and then? I have no problem driving those in (if SHTF I’m right there), and my partner gets to grow professionally and feel sometimes like she’s being pushed to her limit in a way that’s still safe to the patient. And I don’t think that’s wrong.

      • MN EMT

        That’s Awesome to hear!! and just the way I believe it should be! I too get to take all the obvious BLS calls, but she will let me work for my money on other calls. Its nice to be taken out of my comfort zone once in a while. I

  • PoliceMedic

    Exactly! BLS needs to learn that sometimes, instead of a “load and go” to the closest ED, its far more important for ALS intercept. Why let a 10 minute emergent trip to the ED by BLS happen when you can play on the side of the road for an extra 10 to give an I.V. and take an EKG. Gotta knock that stuff so you can bill for ALS.

  • Jonathan Farrow

    I think some of the problems that you described can be fixed with proper communication. When collecting a 12 lead I will usually make a quick interpretation and then hand it to my partner and ask what they see. It provides a learning experience, lets them know why I am or am not treating what they felt I should be doing. I try to explain the medications and interventions so that everyone on scene knows whats going on.
    Our BLS providers in my service have very advanced protocols, they can preform to the level of many ALS providers so it is important to allow them keep their skills up. Before I pass a patient to a BLS provider I will often discuss treatment plans, interventions and diagnosis. We also run three person trucks during peak times, which means that we will have two people in the back, we alternate calls between all three providers. which means that I may be in the back on a BLS call where there is an EMT attending. I feel like my job is to supervise but allow them to make their own decisions, I will often sit in the Captains chair and chart (Rescuenet without dispatch info takes forever to fill out) however I talk to the EMT duing the transport and make sure they are comfortable so again I think it goes back to communication,
    If you are having a problem with a Medic not interacting, are you talking to them? Asking them questions? Try turning the attention on to him and see if he still plays on his phone. If you are having a problem with BLS providers doing whatever you are having a problem with are you debriefing them? I run a combined Fire/EMS service, with paid EMS and volunteer Fire. We cross train everyone and frequently will have the Fire guys jump in on EMS calls, whether to drive for us on a critical call, to translate if neither of the Medics speaks Spanish (which about 60% of our population speaks) or just to assist in the back. It is awesome though because our BLS guys and volunteer Fire Fighters are all competent and understand what is going on. The other day I had a volunteer fire fighter with us on a respiratory failure call who helped bagging the patient following RSI, he sat next to the patient and bagged based on capnography for most of the trip. With good communication and training I am proud to say that my uncertified volly FF understands more about ventilation than many EMTs I have come into contact with.

  • ssk593

    I have been a EMT/Paramedic for 21 years now. And yes I say both because I was an EMT first then a paramedic. And the rule is BLS before ALS. I have worked both sides of this. I have been dismissed and talked down too by paramedics, and I have had BLS crews delay calling us as paramedics for fear of being talked down too.
    It does all come down to attitude. I currently work in a system that is 100% ALS. First responder Fire departments are ALS but do not transport. The ambulance service is ALS and does all the transport. A True public Utility Model. Working for the Ambulance service, we get treated much like the BLS crews do by the fire department. We have even had them refuse to cancel on a simple call that we arrived on first because they think that their assessment skills are far greater than ours. So it does not matter, ALS or BLS. it is A-hole or not A-hole.
    Remember, DO NO HARM. by acting like idiots towards each other, we are doing harm to our patients. When all this crap happens or is weighing on ours minds, then the patient is not getting our full attention. And every patient deserves that at least. Even the frequent flyers we all know and love. And trust me, it is those frequent flyers that will come back a bite you on the ass for not doing the right thing.

  • Barefoot in MN

    I find this entire thing scary– & this part utterly TERRIFYING:
    “…When I got to the hospital I was met by an angry nurse who chastised me
    for calling the STEMI alert. She was dismissive of me, my patient, and
    my assessment skills. She ignored the 12-lead and hadn’t done her part
    to activate the hospital’s STEMI response as I had requested. In fact,
    she made the statement “You shouldn’t have bypassed
    with the patient. If He/she was having something real that’s what
    is for.”… Oh …my…. God…. I felt nauseus with fear just reading this. I hope you were able to advocate not only for yourself against Nurse Witch but also for your patient. WHAT ????????? was the entire hospital busy being evacuated due to an earthquake?!? did the patient have AIDS & TB with extreme vicious psychotic episodes & a history of attacking Nurse Witch???? come on! It sure sounds like she over-reacted. But reading from the standpoint of a patient or relative of a patient, I would never want her “caring” for me – she’d probly eat me & spit me out for daring to ask for a change of bedpan. No wonder so many people think you only go to a hospital to die. Please, oh please, all ye who carry our lives & health in your hands– please make it “patient first”. Please. Trixie is right – it’s all about attitude. & attitude, unfortunately, is so often about control &/or credit.

    I write this as a brand-new (still in diapers, metaphorically) First Responder who is over 50 & thus has a bit of “life experience” on me. hey – I already KNOW I don’t know nuthin’. I can tell you that. Let’s keep the patient first & our egos waaaaaaaaaaaaay back in, like, 7th place maybe? thanks.