ALS or BLS?

ALS or BLS? Who decides?

By Alan Perry

Your Department’s circumstances

There are many types of EMS delivery systems operating in the United States and around the world. No two systems are exactly alike but many share one of several delivery models, I’m not so much talking about system structure; Fire based, third part, public utility, etc., as I am staffing make up. Some systems are all ALS, some all BLS, most fall somewhere in between with a combination of levels of education, training and certification. One common question that arises in these diversified systems can be the determination of the appropriate level of care required for a particular patient in a specific circumstance. We all know that not all such decisions are clear cut, and frequently those that appear to be, fool us the worst.

ALS shortages

Becoming an ALS or BLS provider has been increasingly more difficult over the last twenty years. ALS providers in particular require a significantly greater commitment, many paramedic programs are now 2-year college degrees and maintaining certification requires over a hundred hours of CE over the course of two years. Understandably the ranks of paramedics have thinned. The EMS systems that employ them are having more difficulty recruiting and retaining them given budget pressures to reduce costs. Many systems are finding themselves in the position of having to shuffle their staffing models to make sure they have ALS providers available for the most serious calls that require them. This has produced some interesting models and a degree of increased pressure on those providers, and systems to make it work.

Competence of all providers

In our Brave New EMS World, all patients would be provided with the best care and best trained provider for the circumstances. Let me be clear that in most cases that may be a competent BLS provider or an ALS provider who is competent providing BLS care. Not every patient requires an ALS provider to give appropriate and effective care. Any provider should aspire to handle any call clearly falling within their scope of practice, if they do not feel competent and confident in doing so; it is incumbent upon the provider to seek out training and experience that will accomplish that. The ALS provider should recognize subtle signs, symptoms and circumstances that are reliable for determining the need for ALS care, as well as the comfort level of other providers. This is a very difficult balance point because either provider will have reached a conclusion about the level of care needed independently. I always encourage discussion of the facts, observations and rationale if a consensus is not evident. If an impasse exist one should always err on the side of caution and the needs of the patient; which is us providing the best care possible as a professional and competent team.

The needs of the organization

Each EMS organization has different needs, budgets & resources, the staffing model chosen will reflect this. We must remember that ultimately we are there for one purpose, and that is to provide the best patient care possible with the resources the organization can provide. Our jobs, and those of our co-workers, depend on our stewardship of these resources.

The needs of the patient

In all our actions and decisions we should keep the welfare of the patient paramount. The patient’s outcome will be directly affected by our words and actions, keeping a professional, caring attitude and working as a team to appropriately manage each patient should be our primary goal when making decisions regarding the appropriate level of care.

Medicare’s role

Of course the State and Federal governments will have a say in the way the EMS service gets compensated for calls, there are guidelines for what qualifies as an Emergency, the need for transport, and the definition of BLS or ALS care. This is for the accountant to worry about; you must focus on what is right and appropriate for the patent. Of course you need to be worried about proper record-keeping, make sure your report is accurate, making false statements to garner payment as an ALS transport may result in substantial monetary, civil & criminal penalties.

Opportunities to educate and grow

When disagreements about level of care arise it should be handled professionally and respectfully with the highest level of care provided for the patient as the default. Once the call is completed, and the patients disposition ascertained, a debrief should occur to determine what the nature of the conflict was and how to best correct it. If patterns emerge where patients are routinely over or under treated it must be addressed immediately to ensure the safe and efficient operation of the system. This should be managed like any other good QI program, providers need to feel free to express themselves and be free from punitive actions, when additional training is indicated it will provide an additional venue for ALS & BLS providers to interact and understand one another.

How will it all turn out?

The EMS profession continues to grow and develop, I view these new challenges and the additional responsibly they place on us as a further maturation of the profession. We need to accept that change will be a large part of our future as we grow, as professionals we need to conduct research and advocate for what is best for our industry and the public we serve. As long as we maintain a positive attitude and commit to moving forward intelligently and cooperatively our lives, the lives of our patients, and our industry will benefit.

Be Safe,