The Comprehensive Advanced Life Support Course (CALS) Program is alive and well in the state of Montana, thanks in large part to the support of ACEP at both the national and state chapter level. Montana CALS has put on three provider courses and trauma modules. Sixty-five Montana rural emergency care providers are now certified CALS providers, and 20 of those are also CALS instructors. These team members include MDs, DOs, physician assistants, nurse practitioners, registered nurses, certified registered nurse anesthetists, and emergency medical technician–paramedics. The course evaluations from the students have been extremely positive. The veteran instructors from Minnesota, where CALS was born, have given high marks to the Montana instructors. As a result, further courses are in the planning stages.

What Is CALS?

CALS was developed in Minnesota more than 20 years ago to improve rural emergency medical care through improved provider education. The two-day provider course is comprehensive because it teaches a universal approach to the evaluation and treatment of a seriously ill or injured person and because its content incorporates the current guidelines for the care of adult, pediatric, neonatal, and obstetric patients suffering medical illness or traumatic injury.

The CALS provider course differs from the classic, focused emergency care courses— advanced cardiovascular life support (ACLS), advanced trauma life support (ATLS), pediatric advanced life support (PALS), neonatal resuscitation program (NRP)—not only by being comprehensive but also by bringing the course directly to the rural communities to be able to train teams of providers. Because emergency care is clearly a team effort, it only made sense to the CALS founders to have the rural emergency team members train together in managing the many scenarios, which are the highlight of the course.

The three-hour CALS trauma module teaches team leaders critical trauma skills, including surgical airway management, needle and tube thoracostomy placement, and the e-FAST exam. Team members are updated in trauma assessment, helmet removal, and femoral traction as appropriate for their role in the team. The trauma module added to the provider course is necessary for CALS to serve as a substitute for recertification in ATLS for emergency providers in critical-access hospitals according to the state trauma system in Montana as well as in Minnesota and Wisconsin.

What Is the Role of ACEP?

ACEP is committed to improving rural emergency medical care. The College also recognizes that the reality of the workforce landscape is that many rural emergency departments are being staffed by primary care physicians and advanced practice providers. The current Chair of ACEP’s Rural Section is Darrell Carter, MD, FACEP, who is one of the founders of CALS and who is actively practicing in rural Minnesota. The Board Liaison to the Rural Section is John Rogers, MD, FACEP, who practices in rural Georgia and who is deeply devoted to improving rural emergency medical education. I started practice in rural Minnesota four decades ago but moved to Montana before CALS was born. However, many of my former colleagues are CALS instructors and providers, and I became enthusiastic about CALS from hearing their stories.

CALS was already becoming better known throughout the United States and the world. The CALS faculty has conducted the trauma module and provider course in 10 other states and three Canadian provinces, and CALS has become the chosen advanced life support course for medical personnel in U.S. Department of State embassies.

Within this framework, the idea came forth in 2012 that one way for ACEP to help improve rural emergency care was to support the spread of CALS throughout the nation. The CALS Board of Directors in Minnesota is in the process of establishing a national CALS organization to act as an umbrella to oversee a collection of chapters. The ACEP Board of Directors arranged to have the CALS curriculum evaluated by a team of experts, and the results were positive. Then the ACEP Board agreed to help fund demonstration projects to evaluate the feasibility of forming a state chapter. Montana Chapter ACEP jumped at the chance. ACEP provided a $12,500 grant to help offset the additional costs of bringing Minnesota instructors to Montana. This was supplemented by a $3,000 grant from Montana Chapter ACEP. And here we are: three successful courses and more planned.

What Are the Next Steps?

There is much to do in addition to putting on more courses in more areas of the state. We need to engage with the Montana Academy of Family Physicians, Montana Nurses Association, Society of Emergency Medicine Physician Assistants, and MHA–An Association of Montana Health Care Providers. We need to develop grant proposals and work to get funding for our own equipment, transport vehicles, and scholarships to help defray tuition costs. We need CALS to be approved by our hospitals as a viable alternative to recertification in ACLS, ATLS, PALS, and NRP. Montana CALS ultimately will need a real home and administrative staff. But for now, it is enough that the seed has sprouted and taken root. Thanks to the water and fertilizer provided by ACEP, Montana CALS is growing fast and strong.

Dr. Gallea is chair of the department of emergency services at St. Peter’s Hospital in Helena, Montana; Vice-President of the Montana Medical Association; and Immediate Past-President of the Montana Chapter of ACEP.