BLS v ALS – my rant prompted by the EMS Garage

Written a while ago and saved for later publication:

A recent  past episode of the EMS Garage (“BLS Care Is Not Dead”) they talked about a question debated since the creation: BLS v ALS.

In short, I agree. Particularly with all the points they made about education.

Here’s what uspets me. When I did my initial EMT-Basic certification I was taught “what” and “when.” The biggest difference in my Intermediate education was starting to think about “why.”

I don’t see why I had to wait so long. Why didn’t someone teach me to think this way when I was a basic? Because I did “just BLS?” Suddenly I have to be able to think because I can start an IV? An intervention can be just as inappropriate (BLS or ALS) if you aren’t thinking about why your patient needs that therapy.

It’s of much greater benefit to understand the anatomy and physiology of what’s going on. When I hear “difficulty breathing” I don’t immediately think “15L/min O2 on an NRB and high-priority transport” as the National Registry would have me do. I start thinking about the presentation. What could it be? Asthma? Pulmonary embolism? CHF? Pneumonia? I might not be able to do anything differently within my scope of practise, but if I know _what_ is happening to my patient, I’ll know _why_ I’m doing _what_ I’m doing or what I’m not doing. Perhaps most importantly, I can begin to predict what the heck is going to happen. I can tell them what is likely to happen when they get to the hospital. I can be honest, knowledgeable, and professional

We need to diagnose. We need to understand what is happening to our patient and why. It’s _not_ about procedures. It’s about _thinking_ and implementing _appropriate_ interventions based on those findings.

And where does the chip on your shoulder come from, ALS providers? So what if your patch is different form mine? Get over yourself – the things you do that _really_ make a difference, I can do too – even operating as a (gasp) BASIC! Heck, the stuff that makes the biggest difference (chest compression) can (and should) be done by a bystander before either of us even gets there. Paramedics don’t save cardiac arrest patients – bystanders who know CPR and AED do.

We need a unified identity as EMS providers. No matter your rank or speciality in the fire service, you identify with being a “firefighter.” No matter your rank or speciality in local law enforcement, you identify with being a “police officer.” No matter what your sub-specialty is, you all Doctors and Nurses identify with “I am a Doctor/Nurse.” People do not know the differences between EMT, Paramedic, and EMS. It’s a great education opportunity to sit down and explain it someone, but shouldn’t they understand it to begin with? Shouldn’t my time be better spent talking about how to do hands-only CPR or why the flu is not an emergency? We need a unified identity. Maybe the best approach to this is to see what these words mean to the public already. Ideas define words, not the other way around. Language is ultimately arbitrary. What matters is that the ideas are agreed upon. Go ahead, call everyone a Paramedic. I know people who are “just Basics” that put more thought into their assessment than some Paramedics. Not all paramedics are trained/think/act/perform equally, so why be so exclusive with the title? Stop identifying yourself by what you can do, and start identifying with what you know.

In my major we spend a lot of time talking about language. Language changes thinking and thinking changes language. Let me give you a brief example. Before recorded music there was not live music, there was just music. Live music didn’t exist because that was differentiation within. I think our EMS identity crisis is at least somewhat similar. While there are differences, the language to express them is confusing and essentially foreign to people outside of our field. If we can’t to communicate with them, it’s unreasonable to expect them to learn out language. We need to adapt our language to their understanding. If the language is plain enough and chosen carefully, we change how they perceive us.

There has been a lot of discussion lately about EMS education – comparing us to MDs and RNs. I whole heartedly agree with those rants comments. I’d like to study the history of nursing to see how it is that they eventually got to be taken seriously, and figure out what we’re doing wrong as an industry. Maybe our whole education system needs to be rethought. I wouldn’t mind doing a paramedic residency – heck that would be awesome.

I know that when I eventually get my Paramedic patch and card that my education is not complete, but just starting. I know there will probably be deficits in my education, but you better believe that I’m going to do everything I can to fill in those gaps.

Oh…and watching “War Games” recently…I want to close by saying never just trust the machine. NIBP cuff, pulseox…any of it. Evil. Vital signs should be a confirmation of what you already know from a good physical assessment.

Mat Goebel
Research Fellow

My research interests include EMS, EKG, STEMI, cybersecurity, data viz, ML, and NLP.