Handsome Boy

 A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster--is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

Where I Stand (Today)

I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student's own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service's medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again.