What Should the Basic EMS Package Include?


When you pick a cell phone, cable, or internet plan, packages range from basic to premium, extreme, or turbo. When you call 911, that choice is made by local system design and a dispatch triage program.

On EMS Office Hours, Jim, Josh, and I discussed whether certain medications should be included in the BLS scope of practice.  It was prompted by a proposal to have BLS providers in one system administer Narcan.

To me, this goes deeper than the tired ALS/BLS debate.  We need to ask what treatment is needed by patients in our community, how safely that treatment is delivered by all provider levels,  and how reliably is it made available by their service.

EMS has traditionally been more about what treatment we choose to learn about and deliver than what our patients actually need.  Systems fail patients who do not receive treatment that should be available.

Here are a few interventions that are widely available by EMS, are proven to be effective, and can be delivered safely by competent providers.  I believe the basic EMS package should make them available to every patient before transport is initiated.

1. 12-lead ECG’s, aspirin, and a STEMI alert program.  For every 15 STEMI patients who receive this treatment bundle, one death, second heart attack, or stroke is prevented (1).  STEMI patients do not alway complain of chest pain or alway tell a dispatcher they have it.  If a patient calls 911 with a STEMI, EMS needs to get patients into a system of care that is able to manage it.  There is no excuse for one to go undetected by EMS.

2. CPAP and nebulized bronchodilators.  For every six patients in pulmonary edema who receive CPAP and nitroglycerine, one death or intubation is prevented (1).  Supplemental oxygen and ventilation with a bag valve mask are taught at the first responder level, and CPAP falls in between.  Patients who are short of breath from bronchospasm need medications that open their airways way more often than they need extra oxygen.  No patient should have to keep breathing through a straw during transport.

3. Seizure medication.  Seizures are one problem we have a magic bullet to fix.  One in 4 patients in status epilepticus who receive medication from EMS will have their seizure terminated (1).  Priority Medical Dispatch does not reliable differentiate between seizures that require medication and which ones don’t (2).  It is unacceptable for EMS to scoop-and-run to the hospital with a patient who is seizing.

4. Pain medication.  Most patients who call EMS are in some type of pain.  People who do not receive pain medication from EMS often wait hours to get it in the hospital (3).  This is after they are moved to the ambulance, possibly strapped to a hard board, and are transported in a bumpy ambulance.  Helping patients feel better is important, even if their symptoms do not meet our definition of an emergency.  If pain medication is available in the hospital, I believe we should be have it available for patients before they are moved.

When we talk about specializing in EMS and being professionals, we need to look at how well we do today and figure out how to do better tomorrow.

References:

  1. Myers JB, Slovis CM, Eckstein M, et al: Evidence based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehospital Emergency Care 2008; 12:141-151.
  2. Sporer KA, Youngblood GM, Rodriguez RM: The ability of emergency medical dispatch codes of medical complaints to predict ALS prehospital interventions. Prehospital Emergency Care 2007; 11(2):192-198.
  3. Abbuhl FB, Reed DB: Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehospital Emergency Care; 2003; 7(4):445-447

Comments

  1. Skip Kirkwood says:

    How about prompt, compassionate, clinically excellent care delivered to anyone who requests it, by people who are positive about what they are doing?

    • emspatientperspective says:

      Absolutely! I was shooting for a few things that are easy to measure that a lot of people don’t get now.

    • Nancy Magee says:

      I agree with everything in this article happening After it has been determined that Skip’s prerequisites are met, which kind of fall into the “KISS” principle.

      • emspatientperspective says:

        My objectives are directly related to Skip’s prerequisites. A lot of people out there today, who we allow to wear the same patch as us, could care less about how much pain they are in, how difficult it is to breathe, or if their heart attack is detected outside of a hospital. In my experience, a prevailing attitude is to just get every call done as quickly as possible and get back to sleep or be available for the big one. By adding procedures to our basic package that are standard in other countries, requiring a thorough understanding of those procedures, and monitoring how well they are carried out, we would lose many of the incompetent, uncaring, and unmotivated people we are stuck with now.

  2. Great list. If I had my BLS wishlist, it would include: nebulized bronchodilators (we have ’em here) and CPAP; glucometry (we have it); nitro for CHF; IM/IN analgesia, perhaps Fentanyl; perhaps an IM/IN antiemetic or anxiolytic; a decent blind airway; and a magic, low-cost, low barrier-to-entry way to record 12-leads and call STEMIs. The palliative side of things is often ignored, but probably has higher cost/benefit than the rest combined, as long as you consider suffering important in the same way (even if not necessarily to the same degree) as morbidity/mortality.

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