ALS/BLS Defined

[explenture]

Our service is having difficulties with whether our EMT B's are taking enough calls and if when they take the calls it is appropriate for them to attend. We also struggle with transfers when hospitals seemingly randomly check the ALS/BLS box.

I think in both cases part of the problem is nobody actually knows what ALS or BLS means. To some its billing, to others level of care, some see it as ACLS/BLS which covers cardiac but not trauma and finally some see it as just a unit designation.

So, I am asking you to help a brother out and provide your definition of ALS and BLS.

[uglyEMT]

In simple terms

BLS is basic life support. Doing everything up to but NOT including internal interventions and medications.

ALS is advavanced life support. Doing everything the basics cant. Advanced airways, meds, IVs, ect.

If your lookign for the kind of calls each respond to it get harder. I feel ALS should be dispatched along with BLS to any call where IV or ECG will be necessary. Everything from broken bones (als for pain managment) to difficulty breathing (advanced airways if necessary) to MVAs (IV, meds) especially chest pain calls (ECG, meds, manual difib)

BLS can go solo on your average transports for minor aches and pain, general malaise, ect. No advanced care would be likely needed in these cases but ALS should always be available to a BLS crew if required.

As for billing I dunno that one, I dont handle billing so beats me. I know in my service ALS always gets paid and my BLS rig doesnt charge so I am at a loss there.

If your looking for more indepth definitions please feel free to ask for them.

[crotchitymedic1986]

It depends on whether you are profit or non-profit. If money is no object just send ALS on everything, and do not run BLS units (rationale being, why have a limited resource, versus an ambulance that can respond to every call imaginable).

If you are profit driven (which I doubt, since no one in your organization understands billing, that tells me that it isnt important), then you need to use the proper resource, as payment is determined by Medicare Policies (almost all private insurance and Medicaid base their payment schedule on Medicare's). Therefore you can send 3 medics on ever call, but if it is a BLS call, you will only get reimbursed at the BLS rate; conversely if you send a BLS crew on an ALS "rated" call, you will not get the higher reimbursement rate. The following document explains it fairly clearly, skip down to page 25 for explanations of categories (BLS/ALS1/ALS2/SCT).

https://www.cms.gov/manuals/Downloads/bp102c10.pdf

[Rescue0ne]

The private service I work part-time for has an issue that's somewhat relevant to this thread.

Our local Level 3 hospital often requests an ALS ambulance for a patient transfer that is going out with no more than an INT in place. No cardiac monitoring, no meds, fluids, etc. Nothing at all. This means you're taking an ALS truck out of service (basically) to do a BLS transfer, when your EMT's at the station could easliy handle it in their sleep.

It would be one thing if there were mitigating circumstances, but there almost never is. Just an INT.

They are currently trying to educate the nurses on this matter, but one must tread carefully in the world of Convalescent EMS. That's right, it's the nurses that are ordering the ALS, not the Docs.

[PCP]

Sounds like ALS is dispatched for alot of calls down in the US. I know for the most part the ALS crews usually only get dispatched out for SOB, cardiac and seizure calls here in Canada. Of course not all communities have ALS so it is left up to the PCP or I guess you can call us the BLS crew to deal with what ever the call may be. A PCP in Canada can start IVs and admin. pain medication (Entonox only) and admin. D10W IV as well as 0.4mg of Narcan through the IV port. In my opinion a BLS crew should be able to be dispatched out to any call and be able to call for a ALS crew if needed and if available.

Is there a reason as to why the BLS crews are not able to learn how to start a line or give Entonox? I guess to me it just makes sense as alot of times the pt. needs a line or some pain medication.

Brian

[chbare]

Sounds like ALS is dispatched for alot of calls down in the US. I know for the most part the ALS crews usually only get dispatched out for SOB, cardiac and seizure calls here in Canada. Of course not all communities have ALS so it is left up to the PCP or I guess you can call us the BLS crew to deal with what ever the call may be. A PCP in Canada can start IVs and admin. pain medication (Entonox only) and admin. D10W IV as well as 0.4mg of Narcan through the IV port. In my opinion a BLS crew should be able to be dispatched out to any call and be able to call for a ALS crew if needed and if available.

Is there a reason as to why the BLS crews are not able to learn how to start a line or give Entonox? I guess to me it just makes sense as alot of times the pt. needs a line or some pain medication.

Brian

Basic level providers typically have basic level education. While the actual "skill" of placing an IV is rather easy and really nothing more than a monkey skill, appreciating the physiological implications of administering IV therapy is not. Unfortunately, even developing a basic understanding of chemistry and physiology of an isotonic solution of sodium chloride takes time. Marry this fact with the argument that IV therapy may not impact pre-hospital care significantly in some areas, and you have a situation where not every entry level provider in the United States will be providing invasive modalities.

Take care,

chbare.

[PCP]

Basic level providers typically have basic level education. While the actual "skill" of placing an IV is rather easy and really nothing more than a monkey skill, appreciating the physiological implications of administering IV therapy is not. Unfortunately, even developing a basic understanding of chemistry and physiology of an isotonic solution of sodium chloride takes time. Marry this fact with the argument that IV therapy may not impact pre-hospital care significantly in some areas, and you have a situation where not every entry level provider in the United States will be providing invasive modalities.

Take care,

chbare.

Yes, I do agree that appreciating the physiological implications of administering IV therepay is not easy and takes time to understand when you are giving an isotonic solution of sodium chloride or other medications through an IV. I RESPECT all ALS medics for their knowledge and understanding of the chemistry and physiology of these certain solutions that they administer to a patient, as well as their more indepth knowledge of anatomy and physiology of the human body. As I am only a PCP with just the basic understanding of anatomy and physiology and always striving to learn from the ALS medics or by reading text books, so that I can offer better pt. care due to having a better understanding of what that pt may be experiencing that day. I was just wondering about how come a BLS medic down in the United States do not learn how to initiate an IV and administer normal saline to a patient who is in need of fluid replacement due to hypovolemic shock, hyperglycemic pt., or to a pt experiencing some dehydration, just to name a few.

After reading the original post, I was trying to think of ways that a BLS unit could generate more calls, as well as not have the medical director or whom ever may be second guessing their ability to handle the call without having an ALS unit respond just to initiate an IV for a sick pt. who is a little dehydrated, or as mentioned for a pt. with trauma that needs a fluid challange to up their BP and then maintain at TKVO. I agree with you (chbare) starting an IV is a skill that a monkey can do and in most cases does NOT save lives!

Sorry for being so ignorant to the way the EMS system is ran down in the United States and what the BLS and ALS units are allowed to do under their scope of practice I have lots to learn about the EMS.

Brian

[chbare]

Yes, I do agree that appreciating the physiological implications of administering IV therepay is not easy and takes time to understand when you are giving an isotonic solution of sodium chloride or other medications through an IV. I RESPECT all ALS medics for their knowledge and understanding of the chemistry and physiology of these certain solutions that they administer to a patient, as well as their more indepth knowledge of anatomy and physiology of the human body. As I am only a PCP with just the basic understanding of anatomy and physiology and always striving to learn from the ALS medics or by reading text books, so that I can offer better pt. care due to having a better understanding of what that pt may be experiencing that day. I was just wondering about how come a BLS medic down in the United States do not learn how to initiate an IV and administer normal saline to a patient who is in need of fluid replacement due to hypovolemic shock, hyperglycemic pt., or to a pt experiencing some dehydration, just to name a few.

After reading the original post, I was trying to think of ways that a BLS unit could generate more calls, as well as not have the medical director or whom ever may be second guessing their ability to handle the call without having an ALS unit respond just to initiate an IV for a sick pt. who is a little dehydrated, or as mentioned for a pt. with trauma that needs a fluid challange to up their BP and then maintain at TKVO. I agree with you (chbare) starting an IV is a skill that a monkey can do and in most cases does NOT save lives!

Sorry for being so ignorant to the way the EMS system is ran down in the United States and what the BLS and ALS units are allowed to do under their scope of practice I have lots to learn about the EMS.

Brian

Some basic level providers do provide said modalities. EMS in the united states is an amalgamated mess of levels and scopes of practice among all the various "levels" of providers.

Take care,

chbare.

[Lone Star]

It's been my experience that BLS is 'basic life support'. This includes O₂, CPR, bleeding control, splinting and basic shock control. This does not include invasive procedures such as IV, BGL and doesn't include cardiac monitoring.

ALS is Advanced Life Support, which includes the invasive procedures, cardiac monitoring, advanced airway management, and pharmacology.

Just because ALS isn't initially dispatched to the call, doesn't mean that the patient isn't in need of ALS treatment. Therefore ALS can be dispatched after patient assessment.

It's my understanding as an EMT-B, that certain patients couldn't be transported by a BLS crew. This included central line IV, PIC lines, IV's other than NS and INT, ETT, vent patients and patients that required a monitor to name a few. There was even some question about whether or not a BLS crew could transport a PEG tube.

The rationale behind this ruling was that if something went wrong, it was out of the BLS scope of practice to be able to mitigate the situation.

[PCP]

Thanks for the information. It sounds like it is a little tricky when trying to understand the scope of practice for each level of care. I feel lucky that I can do as many procedures as I can working here in Canada as a Primary Care Paramedic. I would love to do a ride along one day somewhere down in the US just to see how things are done and to give me a better understanding of the level of care that can be done by each level.

Have a good day