Expanded BLS: Better Than Nothing, But Not Good Enough

Following up on Rural Patients Deserve the Same EMS Care as Urban Ones is the issue of expanding the BLS skill set.     The line between an ALS and BLS procedures used to be one that required a needle, drug, tube, or electricity. Improvements in technology and risk/benefit analyses have blurred this line.  Expanded BLS procedures  include Epi-Pens, transmitted 12-leads, IN Narcan, Versed autoinjectors, and albuterol. The thinking is that patients will be better receiving these interventions from EMT’s when paramedics are not available. While most of the time this may be true, I believe it is a Band-Aid approach that takes American EMS in the wrong direction.  My position is that one paramedic should be the minimum staffing requirement for an ambulance responding to 911 calls.

I agree that the benefits of most of these interventions outweigh the risk of them being delivered inappropriately.   The harm from inappropriate delivery will probably not be long-term.  But from a professional standpoint, shouldn’t people be expected to know more about the interventions they are credentialed to perform than a short presentation and sterile skill station?  Remember that the expanded EMT course is less than 200 hours, and it requires no clinical skill practice on live patients or field internship before certification. In rural volunteer systems, more responsibility will be given to EMTs who see the fewest patients and get the least amount of experience after certification.

This reminds me of a 2007 JEMS.com column Bryan Bledsoe wrote titled “I Can Do That.” Here is an excerpt:

First, I m one of the biggest advocates for EMS that you ll encounter. I’ve devoted more than 30 years of my life to EMS and its people.But it still concerns me that people believe that this profession can advance without education. When somebody mentions improving educational standards, people start to squeal,Ive been a paramedic

Or in this case, EMT

for 10 years. I know what I need to do. I don t need any more education.

He goes on to write:

Our society has determined that certain educational levels are necessary for a skill or trade. Some levels, because of the unique fund of knowledge, are called professions. Medicine is a profession and has high standards because mistakes can result in injuries or death….

On my shelf here in my study are 15 books from Pearson Education (the main company that owns Brady my textbook publisher). The books include Pearson s package for the two-year associate degree nursing programs, plus books on anatomy and physiology, medical surgical nursing, human development, pharmacology, medical math, psychiatric nursing, pathophysiology, ICU nursing, public health, nutrition, obstetrical nursing and more all to become the lowest level RN!

There’s no such thing as a “graduate” or “intern” EMT.  Depending on the service’s field-training practices, they may be the highest medical authority on the day they get their card.  Most nurses also work as part of a team and see a lot of patients.    EMT’s with a fraction of the education are expected to function alone in uncontrolled environments.  Ones in rural areas may see only a dozen patients a year. Given the short educational requirements, I believe it is unrealistic to expect  EMT’s with Epi-pens to differentiate anaphylaxis from a panic attack, or ones with Versed injectors to differentiate seizures from shivering.

Now compare our minimum education requirements with those of EMS Educast co-host Rob Theriault’s program in Ontario,  Canada:


Mandatory Courses

PARA1000 Anatomy and Physiology 1
PARA1001 Communication for Emergency Health Workers
PARA1002 Paramedic Fitness Training
PARA1003 Patient Care Theory 1
PARA1004 Patient Care Procedures 1 – Laboratory
PARA1005 Medico-Legal Aspects
PARA1006 Anatomy and Physiology – Advanced
PARA1007 Crisis Intervention
PARA1008 Patient Care Theory 2
PARA1009 Patient Care Procedures 2 – Laboratory
PARA1010 Ambulance Operations
PARA1011 Hospital Clinical 1
PARA2000 Patient Care Theory 3
PARA2001 Patient Care Procedures 3 -Lab
PARA2002 Advanced Skills for Primary Care Paramedics Theory
PARA2003 Advanced Skills for Primary Care Paramedics – Lab
PARA2005 Hospital Clinical 2
PARA2007 Professional Issues, Research and Leadership
PARA2008 Paramedic Comprehensive Review
PARA2010 Pharmacology

And that’s just the core requirements, there are other general education classes required as well.  Two years of full-time college coursework is the MINIMUM requirement to do BLS in Canada.  An additional one-year, post graduate certificate program is required to become an advanced care paramedic, which has a skill set comparable to American ALS providers.

Less than 200 hours for BLS and one year for ALS in America, two years for BLS and one more for ALS in Canada.  Why do we think are effective with so much less education?  Which country would you rather call an ambulance in?

Bryan Bledsoe concludes his column with this:

So, in answer to the often-asked question as to how EMS can get a seat in the house of medicine, I say education. This is inevitable. Fortunately, a few EMS educational programs throughout the country will continue to push the envelope and enhance the education of EMS providers. Then, the resultant dichotomy among paramedics will force employers to seek those with the better education. In the end, Darwin will be right again evolve or die.

Short education programs make it easy to get into EMS, nearly impossible for the field to adapt to changes, and easy to be replaced.  We already have the lowest education requirements of any first world country.  Other healthcare disciplines in this country have embraced requiring more formal education, which eventually brought higher salaries and diverse career paths.  We need to embrace more education at all EMS certification levels, not push additional responsibilities onto people will less.


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