How and Where? The Cornerstone of BLS

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:

  1. 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?
  2. 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?
  3. 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.


  1. Many people still don’t “get” the value of having a couple years of experience as an EMT under your belt before undertaking paramedic level training.

    On EMT Forums there is usually what could be called VICIOUS debate over the subject. Some FNG writes in, “What do you think, should I wait?” and the OP gets followed by post after post of, not examination of pros and cons but more like immovable positions!

    I’m always chiming in on the side of the art first. That literally takes years to master, and, oddly enough, I don’t really remember emphasizing decision-making. Certainly not in the way you did and with the reasoning you expressed; basically, this kinda stuff doesn’t come naturally, you have to develop it.


    I have witnessed more than once experienced EMT’s telling their field-green paramedic partners things like, “Okay, this next!” and them, not having a clue, following blindly and thankfully. The smart EMT’s — who really were doing what they were supposed to be doing — to handle all the logistics so their paramedic partner could handle the interventions — knew how to work with their partners so the paramedics didn’t feel insulted.

    A number of my partners were EMT’s who chose many times NOT to go on to be paramedics. They LIKED the role they were playing and were exceptional at it. Some didn’t want the added responsibility but really had true dedication to being teachers and getting satisfaction out of modeling teamwork.

    Thanks for the thought, hope we don’t have to duck for cover!

    • Nice thoughts, reina. I agree that experience plays a big part here, although I also think that training and education can complement and in many cases replace it. Although you need to be able to fully and properly assess the patient and situation, if you don’t have an adequate understanding of pathophysiology AND the principles of treatment, what are you going to do with your findings? You need to be able to say, THIS clinical sign means the patient needs THAT right away or he’s gonna croak, and making those connections (and hence enabling that decision-making) I think has to come from the books, the studies, the classroom. Because you don’t always see those connections in the field — you could be killing all of your patients with something you’re doing, but never realize it, because it doesn’t happen until a week after you drop them off at the hospital. So I think you need both, which is why I’m sympathetic to both the “experience first” and “ALS first” arguments.

      Now, the very existence of these “super EMTs” is another issue, because everyone’s always going to be asking them why they didn’t become medics, and it’s not clear whether it’s “legitimate” or not to hold onto your BLS spurs. You’re allowed to be a good RN without becoming an MD… but then, those are really different roles, whereas perhaps EMT-B and EMT-P are just points on the same spectrum. I don’t know, I got no answers, I just make the coffee around here.

      • My point more has to do with all the logistical stuff about moving people around to get them where they need to go in a timely matter; essentially the handling of the scene and the setting of priorities which includes when to pull the plug. This stuff isn’t taught in any book I know of; it LIVES in the moment.

        And I really don’t care what anyone does. If they can find a niche where they contribute and are happy with it, who am I to suggest they need to do anything different?

  2. Great post. I had the unique experience of cutting my EMS teeth on an Industrial Fire Brigade as an EMT-B. The game changer was there are members who operate as Paramedics off-site but while on-site have to operate at the EMT-B level. So good BLS is the only care we provide, regardless of the card in your wallet! The medics on site acted as constant preceptors.

    It definitely has colored my approach to patient care. Any Basic who has ridden with me will tell you, “Chris is just here for the narc keys, We run the truck.”

    I find this mentality is better for patients for a few reasons:
    1). Essential assessments, procedures, and treatments are the focus of patient care. Good BLS before ALS.
    2). EMT-Basics–who may go on to be EMT-P’s, RN’s, or PA-C’s–become better providers. They don’t just become an ambulance driver who schleps a few blood pressures.
    3). The atmosphere of patient care becomes one of teaching and learning. It elevates the position of pre-hospital provider above that of just a “Job”.

    Take a STEMI patient:

    – EMT-Basic can acquire the history, baseline vitals
    – EMT-Basic can apply the 3- and 12-Lead ECG
    – EMT-Basic can administer O2, ASA, and NTG
    – EMT-Basic can transmit the 12-Lead if available
    – EMT-Basic can alert the receiving facility
    – EMT-Basic can prep the patient for the cath lab (shirt/shoes/pants off)
    – EMT-Basic can repeat vitals on the patient

    Really, the only thing a Paramedic can do for this patient is interpret a 12-Lead and start an IV. Clearly, I feel ALS is indicated for this patient, but the moral of the story is the EMT-Basic can contribute the majority of care on the majority of calls.

    Every patient needs a Basic, only a rare few need a Paramedic.

    • I’m with you. I work in tiered systems myself and I find the structure 100% acceptable for most calls. BUT, there is also the caveat that a Basic is good enough, if they’re a GOOD Basic. And that’s the rub, because oftentimes it seems like we need to bring in paramedics just so they’ll have half a clue about *BLS* fundamentals like assessment and intelligent clinical decisions. (Of course, getting someone who’s “good” at ALS too is a whole ‘nother menu item!) Boston EMS reportedly has about a quarter of their BLS staff as card-carrying paramedics, as they only hire medics from within their own ranks. I imagine it can be a drag for them sometimes, but it does go to show that an EMT can do the job, if he knows how…

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