LAUSR

In this issue of the journal, Stiell et al. publish an important paper about the efficacy of out-of-hospital advanced life support (ALS) interventions as contrasted with basic life support (BLS) interventions on patient outcomes, in this case specifically for patients with chest pain (1). This work must be interpreted very carefully as it was performed over 20years ago, with different definitions of basic and advanced life support. Indeed, to this day there are no standardized definitions of what is considered ALS as compared to BLS. Despite the presence of a standardized National EMS Scope of Practice Model in the US, the scopes of practice of the different “levels” of EMS clinicians educated and authorized to perform basic and advanced life support interventions are constantly evolving and often differ from one state to another, and sometimes even among counties within a single state. In other nations, including Canada where the study by Stiell et al. was performed, different definitions and scopes of practice apply. The lines between ALS and BLS became blurred very early in the history of EMS with the introduction of automated external defibrillators (AEDs) into out-of-hospital systems (2,3). Prior to this time, defibrillation, a life-saving skill, could only be performed by advanced practitioners. By 1994, defibrillation by frontline EMTs was permitted in 36US states, and, by 1997, in nearly all states (4). In May 1992, 11 years before the results of the current OPALS study were presented at the Society for Academic Emergency Medicine annual meeting, Dr. Marion Lyver (co-author on the paper) invited several of us who were attending another SAEM meeting in Ontario to a consultation meeting on the future strategy for the Ontario EMS system. The consensus opinion was that the evidence base at the time supported only two out-of-hospital interventions as portending a survival benefit: early defibrillation and advanced airway management. The group’s recommendation was to build a system that included only AEDs and the Combitube as initial out-of-hospital professional skills. Any additional interventions would be studied to prove their benefit prior to implementation as “advanced” skills. While “advanced” life support generally denotes the performance of more “invasive” procedures, such as the establishment of advanced airways or intravenous lines, from a patient-centered, outcomes-based viewpoint, there are relatively few out-of-hospital interventions that are critical and time-sensitive. Treatments that can be immediately life, limb, or brain saving include: Defibrillation Epinephrine for anaphylaxis Naloxone for reversal of opioid overdose Direct pressure/tourniquet for external hemorrhage control Airway obstruction reversal Glucose for hypoglycemia Oxygen for hypoxemia Received March 7, 2022 from Department of Emergency Medicine & Public Health, University of California, Irvine, Orange, California (KLK); John A. Burns School of Medicine, University of Hawai’i at Manoa, Honolulu, Hawai’i (DCC). Accepted for publication March 14, 2022.