Quality Corner: How Much ALS is Enough?

There’s a big difference between a technician and clinician as it relates to EMS. A technician performs mechanical skills, such as obtaining vital signs and basic interventions in a very restricted fashion. As a last ditch effort to preserve lives threatened by time sensitive emergencies, a technician may defibrillate ventricular fibrillation or give a fluid bolus to someone who is hypotensive. Conversely, a clinician is a true practitioner of medicine who understands the pathophysiology behind the disease. A clinician understands the importance of early acquisition of 12-lead ECGs in hopes of identifying STEMIs, then rapidly transporting the patient to a facility capable of revascularization in hopes of preventing ventricular fibrillation. Through a thoughtful history, a clinician will likewise recognize the seriousness of the tachycardic patient with nausea, vomiting and diarrhea, and treat them with aggressive fluid management to prevent hypotension and shock.

The first generation of paramedics all started out as technicians, following very limited protocols and calling medical command before doing most advanced interventions. But, over the last 30–40 years, EMS has evolved. That evolution has been gradual, piecemeal and with increased expectations, despite the fact that these expectations have not always been clearly articulated to all EMS providers. In the absence of a comprehensive quality improvement program and active medical direction, you may have several medics who are still practicing paramedicine from the 1970s or 80s. And in the absence of strong leadership and management the default is every provider decides for him or herself what the standard of care should be, which by definition is really no “standard” at all.

Left to their own devices, some EMS providers may still cling to the antiquated mentality of “load-and-go” in all cases—where a quick ride to the hospital and dumping another untreated patient in the already overburdened ER is the answer to any and all medical emergencies. Those who argue in favor of load-and-go must assume the burden of explaining why we should be doing no more patient care today than we did 30 years ago, despite the addition of thousands of dollars worth of advanced technology purchased with the obvious expectation that it would be put to some use. The reality is load-and-go EMS is no better patient care than what the patient could get with a taxi for a lot less money.

One of the most common arguments for load-and-go I’ve heard is, “Well, it’s a short transport time—just five or 10 minutes—so why delay care when they’ll just get an IV as soon as we get to the hospital anyway?”

This doesn’t sound too bad on the face of it, but it conveniently ignores a lot of logic and facts. While the transport time may well be five or 10 minutes, patient contact time is typically two to three times that—if not more—assuming an assessment is performed along with packaging and moving the patient out of their house, apartment or nursing home. Next there’s the reality of hospital treatment. Most providers who make this argument would stop the clock as soon as they arrive at the hospital. But I’ve never seen an IV line drop out of the ceiling the minute I wheel the patient through the door, while a nurse drops everything and runs across the ER with IV catheter in hand, eager to start an IV on the patient I’ve now been with for the last 20–30 minutes.

Hospital staff are very regimented about assessing a patient for themselves before initiating any interventions, even if the patient was already assessed by EMS. And depending on how many—and the severity—other patients the ER has, it could be anywhere from 10 minutes to as long as half an hour before they get around to starting an IV on some patients. So the argument for not treating patients because of short transport time does not hold water. And the whole concept of EMS—if done properly—isn’t delaying care, it’s advancing care.

Most ALS units now carry the first line treatments and diagnostics for a majority of medical emergencies. Why haul all of this high-priced equipment around if we’re only going to rush our patients to the hospital? We can perform the same initial treatments the hospital will, but we can do it more quickly and effectively since we only have one patient to focus on.

The only reason for rushing patients to the hospital in this day and age are those exceptional cases where we do not have the necessary life-saving intervention for the patient, such as surgical repair of internal trauma or revascularization of the cerebral artery after a stroke. In these cases rapid transport is absolutely the appropriate action.

In addition to honing our skills and growing our profession in the decades since the inception of prehospital ALS, EMS has largely earned the trust and confidence of the rest of the emergency medical community, as well as the public. So much so that, in addition to being asked to treat immediate life-threatening emergencies, we’re increasingly asked to perform more frequent non-critical patient care. Over the last couple decades, most EMS systems have added nausea and vomiting, and pain management, to their protocols. We’ve been asked to do these things not because anyone is likely to die from pain or vomiting, but to join the rest of the medical community in its effort to relieve pain and suffering, and promote patient comfort.

Despite these changes in our mission, there are many EMS providers who do not believe pain management or vomit control should be a part of their job. But I can assure you that any EMS provider who has ever fractured their ankle or had renal stones would beg to differ. Why should our patients be made to suffer needlessly for another hour—or even half hour—if we have the means to provide them with some relief?

The public has seen EMS on TV and in the movies. There is now a popular expectation that once EMS arrives, the emergency is over and real treatment will begin. To this end, we need to constantly remind our providers that the “S” in EMS stands for service—service to our patient.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years of experience in EMS. Contact Joe at jhayes763@yahoo.com.