We say it so often, it’s become a cliché in our profession. But phrases don’t get repeated often enough to become clichés without containing a kernel of truth. Actually, considering the current resuscitation literature, perhaps it is time for a new cliché—EMTs save lives, paramedics just take the credit.
In the Ontario Prehospital Advanced Life Support (OPALS) study, the most extensive study conducted of the efficacy of prehospital ALS to date, researchers demonstrated that the addition of ALS interventions does not improve survival to hospital discharge when compared to the care provided by an AED-equipped EMT.1
While the OPALS data did demonstrate reduction in morbidity in some of the patients treated with ALS—namely diabetics, respiratory emergencies and acute coronary syndromes—of all the interventions performed in cardiac arrest resuscitation, the only two proven to improve outcomes—early defibrillation and uninterrupted chest compressions—are BLS interventions.
Indeed, some studies seem to indicate endotracheal intubation, an intervention many paramedics identify as a defining part of their skill set, may even worsen outcomes,2,3 particularly if we place a higher priority on it than uninterrupted chest compressions.4
However, a more recent study of 10,455 adult out-of-hospital cardiac arrest patients compared outcomes between those who received successful supraglottic airway insertion or successful endotracheal intubation and found that endotracheal intubation was associated with improved outcomes over supraglottic airway insertion. However, the authors also noted higher survival among patients not receiving any successful advanced airway placement.5 It’s clear that uninterrupted chest compressions are of greater significance than intubation.
In recent years, CPAP has proven itself as one of the more effective tools in the prehospital arsenal. Most states consider it a BLS intervention, and perversely, its success at stabilizing CHF and pulmonary edema patients has resulted in even fewer opportunities for paramedics to perform endotracheal intubation.
Still, absence of evidence does not mean evidence of absence. There may yet be studies that demonstrate the value of the skills we perform as paramedics.6 Until that time comes, we must rely on the proven value of our BLS skills and, by extension, our EMT partners and colleagues. One experienced paramedic working in a tiered response system in New England describes himself as a “stand-back, big-picture, non-interventional paramedic” on EMS scenes, not because he is lazy, but because he recognizes most EMS calls need only the BLS interventions provided by the EMTs in his system, and of the few ALS interventions necessary, most can be performed en route to the emergency department.
While paramedic school may provide you with the skills and knowledge to be a competent ALS provider, many programs fail at teaching effective leadership. While it would be nice if every newly minted paramedic were mentored by a seasoned paramedic partner, the reality is many are assigned an EMT partner and thrown to the wolves, barely competent to make their own decisions, much less direct the actions of another EMT.
The remainder of this article will explore strategies to allow the new paramedic to make effective use of an EMT partner, including knowing how to recognize those times when the EMT might just save the paramedic.
Communication Is Key
The hardest thing to work out with a new partner, and the one most crucial to a smoothly run call, is scene choreography. The only way to make sure both members of the crew perform the right dance steps is through open communication, and the first step is to develop the habit of thinking out loud.
Lay out your treatment plan on the way to the call. Brainstorm likely scenarios, and define what each of your roles will be. Plan what assessments and interventions you will do on the scene, and which you will do en route to the ED. Obviously, no plan survives first patient contact wholly intact, but at least you’ll have a starting point for care.