MSM 006 Are Paramedics Obsolete?

In all industries, those interested in the development and future of the industry must, from time to time discuss their future. Specifically, the road ahead for the industry must be discussed. If we are to continue to move forward and grow as a profession, we must ask difficult questions and have difficult conversations as to how we can best operate and provide the best care for our patients in addition to be being the most efficient we can be. The topic this week will be whether or not we continue to need the distinction between basic life support and advanced life support.

This topic has been tackled before at conferences and in meeting rooms across the country, and indeed the world. When we really consider the need for ALS over BLS what is it that paramedics can provide that BLS providers cannot? There was a time when interventions such as supraglottic airway placement, intramuscular injections, intranasal medication administration, and other skills were reserved for the medic units. Those days have passed us by. Since the advent of SGAs such as the iGel there has been a significant increase in EMTs and EMT-(I)s providing advanced airway management[1]. CPAP is now a BLS skill in many states, and considering that it is, at its base level a fancy oxygen mask, it’s a shame we waited so long to implement it. As the opioid epidemic in the United States continues to worsen we are seeing EMTs administer the drug with very little negative outcomes[2].

Arguably the most important reason for the existence of EMS is in the setting of out of hospital cardiac arrest. These settings used to be where a paramedic could truly shine. Skills such as IV placement, medication calculations, advanced airway management were, at one time the focal point of resuscitation. It seems now that there is data being published daily that supports the use of early CPR and AED use, both BLS skills as the most useful tool in resuscitation.[3][4]

It may be that the time has come to consider what value a paramedic unit offers. Are there truly that many skills or interventions that a paramedic provides that an EMT simply can’t? What volume or percentage of patient contacts genuinely requires a medic unit? How much of the paramedic paradigm is little more than a function of ego? I submit that if you ask a paramedic their value as it relates to patient care, you’ll find an argument for experience and training, both of which a progressive system with committed EMTs can accomplish.

Perhaps the solution lies to a different end of the spectrum. Perhaps instead of eliminating the role of paramedic we move toward advancing the role of both paramedics and EMTs. Just as we once considered CPAP a skill that was beyond the capability of BLS, are there skills that are presently beyond the scope of a paramedic that should be rethought? Is there anything that is stopping a paramedic from placing an arterial line in a critical patient, or making a house call for a high-volume user? Projects throughout the country are exploring the latter in the form of community paramedicine and have seen encouraging results.[5]

As the face of healthcare in the United States changes, so too must our practice and implementation of care. Expanding both practices would no doubt be better for patients in both the short and long term. Reimbursement rates for BLS interventions are known to be higher[6] which would increase the solvency of many agencies, and an increased skill set may improve retention in a field where burnout is likely compounded by the mental stress of repeating the same activities day in and day out. One thing is clear: A change is desperately needed.

[1] Ryynänen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010, 18:62

[2] Wesley, Keith http://www.jems.com/articles/print/volume-38/issue-11/2013-buyer-s-guide/argument-bls-cpap.html

[3] Berg et al Part 5: Adult Basic Life Support

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care  Circulation November 2010

[4] Sanghavi Et al. Ann Intern Med. 2015 November 3; 163(9): 681–690

[5] Wesley, Keith http://www.jems.com/articles/print/volume-38/issue-11/2013-buyer-s-guide/argument-bls-cpap.html

[6] CMS.Gov