It’s common to observe, and not wholly off-base, that the EMT-B has only a limited toolbag at his disposal for the field treatment of his patients. There are literally only a fairly small number of interventions he is trained and permitted to perform, and most of those are for the trauma patient; for the typical medical patient, he can do very little unless they are actively trying to die. Now, it’s true that for those dying patients, he may have everything he really needs; BLS is the backbone of life support, no matter if you’re a doctor or a lay responder. Still, it’s easy to feel powerless as a Basic with the many distressed or ailing patients for whom we can do very little except transport them and set the stage for their eventual definitive care.
The first and largest clinical skill that the EMT needs to master is undoubtedly patient assessment, but if we’re talking about interventions — that is to say, actions you take that directly change the course of the patient’s care — I believe that limited or not, he has at least one very important role to play. The most important BLS intervention is decision-making.
No, we don’t push drugs or relieve pneumothoraces, but we still make decisions. These can be treatment-related, such as the decision to assist respirations or splint an extremity; they can be logistical and somewhat banal, such as how to best maneuver a stretcher into a home or where to park the ambulance. But with every single patient, we’ll repeatedly make one particular group of decisions — decisions which, at the least, will play some role in their care and eventual outcome, and at the most can determine whether they live or die. Foremost among these decisions are three:
- Where does this patient need transport to? What facility or point-of-entry will be most beneficial, given his presentation and suspected diagnosis? Would it be appropriate or acceptable for the patient to refuse transport?
- In what manner should this patient be transported? How quickly does he need to go? Is there no hurry, or does every second count? Do we need lights and sirens? Does the receiving facility staff need to be notified of special circumstances (such as trauma, stroke, or cardiac alerts)? After arriving, what information and what degree of urgency do you convey in your report?
- Would the patient benefit from any additional resources? You may be the only eyes and ears on scene; if fire or police are needed for safety reasons, it is your responsibility to call for them. Furthermore, would the patient benefit from ALS-level care?
It may be true that we generally can’t cure the primary cause of a patient’s complaint, and in many cases can’t even offer meaningful supportive care short of true life support. But these decisions are still central to the care the patient eventually does receive, and most of all how quickly. Of course, some decisions are made for us by our policies and protocols, and other decisions are patently obvious, but that still leaves substantial room for wisdom or foolishness.
Consider a critical trauma patient extricated from a MVC. In one case, we arrive and direct the fire department’s rescue, setting up the scene for safe and easy access. The patient is rapidly removed and assessed, loaded up, and transport is begun emergently to the level I trauma center 10 minutes beyond the closest community hospital. As we depart, we call ahead and notify the trauma team, relaying our status and ETA. En route, we are able to intercept with a paramedic crew, who hops aboard and jump-starts the patient’s care with IV access, pain management, and other measures. We quickly navigate through traffic and arrive in good time, bringing the patient directly into a trauma room, where staff are waiting and immediately assume care. The report is handed over, including several critical findings, and the patient is stabilized and rushed into surgery.
In this case, we “did” very little for the patient, in the sense of treatment. But consider if things had gone differently. We arrive on scene and bungle things, parking in the wrong spot and jamming up the access routes; it takes us many minutes to assess the situation and call for heavy rescue. The extrication is slow and belabored; when finished, we evaluate the patient incompletely, with a medical rather than a trauma approach. He is loaded and transported to the nearby community hospital, driving with the flow of traffic, and no entry notification is given. When we finally arrive, we sit in the triage line, give a minimal report to the nurse, and the patient is placed in a secluded hallway bed. We head out for our next call, never realizing that the patient sat there for many minutes until a doctor finally assessed him more closely and realized his severity, at which point he called immediately for ambulance transfer to the trauma center. The transferring unit took 10 minutes to arrive, 10 more to assume care, the transport itself took another 20, and the patient finally arrived in surgery an hour and a half after we first arrived on scene.
Although the eventual treatment might be identical, the difference in the timelines for these parallel patients could very well have a profound effect on their outcome. There is some debate currently as to whether time-to-care for many EMS patients could be far less important than we traditionally assume, but even if it is, there is no question that some subset of patients still exists for whom time is critical.
For a realistic illustration, consider the following, a true story of a call I ran:
You are dispatched BLS and non-emergent to a rehab facility for the complaint of “cellulitis.” On arrival, you take a report from a nurse, who explains that the patient has been with them for a week and has been experiencing inflammation of his arm for much of that time. He is severely demented but otherwise has a minimal medical history.
While you talk, your partner comes out of the patient’s room, informing you that she was unable to obtain his blood pressure. Curious, you head in, finding an elderly male accompanied by his wife. He is cheerfully confused, oriented to self only (baseline per his wife), but in no distress. He appears generally well.
His respirations are unremarkable, but his radial pulse cannot be felt, and he has a thready, barely palpable brachial pulse, 90 and regular. With several attempts, you are able to obtain a BP at ~84 systolic. His skin, however, is warm and slightly red — not overtly hot, but certainly not cool. (Your service does not carry thermometers.)
You speak with the nurse, who checks the chart and confirms the patient is typically normotensive, up to and including his last vitals check earlier today. You begin loading the patient onto your stretcher while you obtain a detailed history from the wife. Eventually, you learn that during his recent hospital stay, he had developed a seemingly minor infection of the arm due to an infected IV site.
Although the patient is still presenting well, your assessment is challenged by his poor cognitive baseline, and you are very concerned about the possibility of a developing sepsis. The seeming rapidity with which the patient’s blood pressure has dropped is especially troubling. You load up the patient, giving him some supplemental oxygen for good measure (pulse oximetry is not available), and obtaining further details of his history.
His requested facility is also the closest, a community hospital 5-10 minutes away, and the same hospital at which he was recently an inpatient. If an ALS intercept were available, you would attempt to meet them, as early goal-directed therapy for the treatment of sepsis has been shown to significantly improve outcomes, and some of those milestones are achievable in the field (such as fluid bolus). However, the nearest fly-car is several towns away, and an intercept would take much longer than direct transport. You elect to head straight for the emergency department. You attempt to call in an entry notification, but are unable to raise the receiving staff prior to your arrival.
Upon arriving, you wheel the patient into the busy ED. A harried nurse asks if this is the cellulitis patient (the facility had called previously), which you affirm. She tells you to put him in an overflow hallway bed. Pulling her aside, you mention that you have some concerns about the patient’s hypotension and the possibility of sepsis, painting a brief clinical picture. She has one of the techs clear out the critical care room near the entrance, and you move your patient there instead. After a detailed report to another nurse, you transfer over care, shake hands, and clear out. As you leave, the patient is in the process of having blood drawn.
This was ultimately a simple call, with neither sturm nor drang, and the prevailing emotion was an orderly calm rather than any frank emergency. But consider: supposing this patient were indeed septic (I was unable to obtain any follow-up), there is a clear correlation between time to definitive care and eventual morbidity and mortality. (The best practices of early sepsis care are still evolving, but most would agree that the condition should be treated as a time-critical life threat just like stroke or acute MI.) The fact that the patient seemed to be in minimal distress or extremis does not entail that he was not at a critical juncture. If he had been treated as a simple cellulitis patient going in for evaluation and non-urgent care, he would have — at best — languished in a hallway bed until eventually funneling through the facility’s triage process and being stepped-up to a higher acuity of care.
This, to me, is the central clinical skill of the EMT, on top of basic life support and trauma care, and of course patient assessment. Skilled assessment with the knowledge of pathophysiology and best practices to understand the meaning of your findings is the first half of the puzzle, and making the appropriate decisions to streamline the patient’s continuity of care is the second. This is something that can and should happen with every single patient, and it’s the most basic of BLS tools.