ALS and BLS: In Search of Symbiosis

When in doubt, call ALS. This was engraved in the heads of my classmates and me during our training as BLS providers.

As EMT-Basics we’re trained to provide basic first aid and resuscitation to patients and then summon an ALS unit to further intervene medically if necessary. Of course paramedics have their advanced training for a reason, but EMTs are supposed to be trained to sniff problems out immediately, as for the most part we arrive first on scenes.

It is said to those transitioning from BLS to ALS that you can’t be a good medic if you haven’t perfected your BLS skills. But how can you perfect those skills if your first medical instincts go out the door and, panic ensuing, you grab the radio and spout “ALS!” faster than you can say, “BSI, scene safety!”?

During my training a common theme was get on scene, assess, call ALS, and then check the patient’s vital signs; then begin treatment and either wait or load and go depending on the patient’s condition. Rendezvous with ALS on the way to the hospital if you must to save transport time. If a patient says “chest pain,” as EMTs we’re told to call ALS immediately. But not all chest pain is cardiac, and not all cardiac conditions cause chest pain.

What Do BLS-Level Skills Include?

I’ve been spoiled. My sole EMT job is my volunteer position at an agency that’s properly equipped and staffed with a dozen intelligent and highly skilled paramedics, many of whom follow right behind or in front of my rig to almost every call because dispatch tones them out anyway, even if the patient is BLS.

Many of these paramedics have told me, though, that at times, even if a patient is BLS, EMTs have refused to take the patient or claimed it unsafe or even called for an ALS unit before the patient’s pulse was checked or name received. Maybe the new method of teaching EMTs is to automatically call for a medic, and that’s crushing their confidence and skills as emergency medical providers. Maybe liability is too high these days, with patients and their families suing left and right.

I have doubted my own skills in situations where I had everything under control and the patient was stable and able to go BLS. There have been times that because I was unsure, I’d call a medic personally to chat about what was going on, to see if maybe the patient needed higher-level care. But the fact is, BLS providers can conduct fewer lifesaving treatments than ALS providers can.

BLS-level skills include:

• Scene safety
• Patient assessment
• Chest copressions
• Breathing and airway adjuncts
• CPR and AED use

We can give IM epinephrine, albuterol treatments, oral glucose, aspirin, and oxygen all under our scope of practice. These are standing orders, and although they vary state to state, as BLS providers here in New York, for instance, you do not need to call ALS to give epi to an anaphylactic patient. As an EMT you can do it yourself. Of course the patient will require ALS monitoring, but if any medic arrives on scene with a patient suffering an allergic reaction and you haven’t done your job, it will result in a screaming match and, of course, compromise the patient’s condition. At minimum EMTs can check pulse, blood pressure, oxygen saturation, and lung and heart sounds, all before a medic arrives.

The beauty of ALS and BLS providers is that both are necessary, both are important, and both must work together harmoniously. The relationship between ALS and BLS is like a hot dog and a bun: You really can’t have one without the other. The job of a BLS provider is life-or-death, though, just as much as it is for ALS providers.

Using Your BLS Skills to the Maximum

When as EMTs you’re first on scene, it is your job to rapidly but accurately assess a patient and determine if a medic is necessary. And for the obvious reasons—shock, profuse bleeding, cardiac arrest, etc.—they most likely are. It is also your job to initiate the BLS treatments you were trained to do so the medic can do his or her job. More likely than not, they don’t want to be doing both BLS and ALS work, as there isn’t time, and again, little time is all a patient has between life and death.

On the BLS level, it does EMTs a disservice to rely entirely on medics. The relationship should be symbiotic, not parasitic. Both providers must do their work within their scope of practice, not one leeching off or dominating the other. To perfect BLS skills, you must perform them. And to maintain that harmonious relationship between BLS and ALS, you must be a team player and, most important, do the job you were trained to do.

Caterina DeGaetano-Morris is a newly certified New York EMT-B. She volunteers with New Windsor Ambulance in Orange County, N.Y. She is a mother of one, wife, and writer and aspires to become a physician assistant.