When to Upgrade to ALS!

[RanchoEMT]

When running BLS when do you guys upgrade to ALS?
(obviously when you're not comfortable running the call, but what other tips, tricks, advice and General Rules do you guys have for upgrading code3?)

 

[Ewok Jerky]

Mostly when your pt has an ALS complaint. For us that is things like chest pain, ALOC, BP<90, in some cases difficulty breathing. Now if I am a block away from the ER and ALS has a 10 minute ETA then I might go BLS code 3

 

[medicdan]

It's also, to a certain extent, about how long you are going to wait at triage in the ED. I had a chest pain about 1/4 mile from the ED yesterday, and ended up grabbing an ALS crew clearing from a call at the same facility--which I wouldn't have done 2 years ago-- simply because we waited nearly 30 minutes for a bed, and it was good to have a 12-lead before arriving at the ED, which was well worth sitting on scene for a few minutes. We tried several times for an IV as well, but nobody could get one, so we held off on the nitro and stuck with Aspirin.
It was unexpected, but the EDs were absolutely packed today, and partially as a result of the DPH ban on diversion, we knew we would be waiting.

Long story short: based on a lot of factors, to include distance from ED, patient complaint, patient condition, crew comfort, ED wait time, etc.

 

[Melclin]

A pt that requires ALS treatment:
- Cardiac Arrest (obviously).
- Head injuries with GCS < 13/ hypoxic brain injuries.
- Hyperthermia >39.5 (103.1F) with poor response to cooling/fluids.
- VT
- Cardiogenic, Septic & obstructive (when T. pneumo) shock.
- Any paed need IV analgesia/fluids.
- Status asthmaticus.
- Any respiratory failure.
- Status epilepticus.
- Full field Acute pulmonary oedema.
- Airway burns.

Might have missed something. The advantage we have is that, at least in theory, BLS and ALS ability to assess & develop a working dx for a pt is the same. So we don't have the "not comfortable with pt", "pulse over 100 type stuff".

Time to ED makes a difference in some of these. Except cardiac arrest. They stay where they drop.

 

[emt_irl]

when my clinical practice guidelines tell me too.

as for spacific cases: anything cardiac, any major trauma, pain management beyond what otc's and entanox can handle.

then we have alot of consider als guidelines which puts the ball in our side of the field and lets us decide weather we want/need als or not.

 

[LuvGlock]

Also when the pt has yakked/crapped/peed on themselves. Automatic upgrade.

 

[NomadicMedic]

Also when the pt has yakked/crapped/peed on themselves. Automatic upgrade.

I hope you're kidding.

If you are, it's not all that funny.

If you're not, please leave my profession immediately.

 

[AnthonyM83]

We have specific protocols that state what falls under ALS criteria.

As a general guidelines, though, I like to say when the ALOC, airway, breathing, or circulation don't seem stable (that covers a lot). In addition, some should be ALS just by nature of complaint: Chest pain, MOI, mult-system trauma, certain poisons.

Welcome to hear if anyone has other general non-list explanations. This is a hard one for new EMT's or students if they don't have specific protocols.

 

[Veneficus]

I hope you're kidding.

If you are, it's not all that funny.

If you're not, please leave my profession immediately.

I thought it was funny. h34r: :unsure:

When I was working as a medic in the ED, my solution to that was usally to address the immediate needs of the pt then call a nurse.

 

[mikie]

No need when dispatch sends everyone!

...when the second unit shows up (ALS, obviously) and says "We'll take it from here"

 

[MrBrown]

Lets see .... when the patient requires more than some oxygen and a ride to the hospital?

Locally speaking Brown considers calling for an Intensive Care Paramedic provided they can locate significantly faster than the patient can be deliered to hospital for ....

- Life threatning asthma or resipratory problem
- Severely shocked patient of any etiology
- Advanced analgesia (ketamine and midaz)
- Severely compromised arrythmia requiring amiodarone, pacing or an adrenaline drip
- Sick paeds
- Patients who potentially or do require rapid sequence intubation
- Any patient who is status one (critical) or two (serious problem) with no obvious cause and severe physiologic abnormality

Now Brown might also get an ICP along for a look if a patient is severely sick and/or Brown is not sure how to proceed however it must be balanced with do we stay here and wait for ALS to turn up and have a nosey vs delivering this patient to the hospital in thier current state?

Is it better to stay on location with an emergently or potentially time or intervention critical patient or take one who is perhaps a bit unstable in thier current form to the hospital?

 

[HotelCo]

Around here, I never do. I'm usually less than 10 minutes from a level 1, and ALS has an ETA of about the same... just to cover my butt, ill request and intercept, but they never end up meeting us in time to take the patient.

.

 

[Sasha]

Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.

Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.

 

[AnthonyM83]

Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.

Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.

My patient has a broken pinky. Paramedics are closer than the hospital. Should I call ALS or transport on a BLS unit?

I know you know that one. Just stating his question was more about asking what qualifies as a patient who needs ALS (whether it's ALS from the ER or from a paramedic unit).

 

[truetiger]

+1 for emt.dan for mentioning wait time. On average it can take a doc 10-30 mins to make it in to see a pt once they have received a room depending on what other pt's they have. If it takes an extra 5-10 mins to get ALS and its not life threatening, consider ALS. The nurses I work with appreciate that as it cuts down on their workload as during busy times.

 

[JPINFV]

Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.

Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.

I think there's a few kinks with this attitude, albeit I do largely agree with it. The really big one are patients who might meet criteria for a specialty center (such as chest pain patients) where the closest hospital is not a specialty hospital for that issue. In that case, what's important is not transport to nearest facility, but transport to the specialty center.

 

[jjesusfreak01]

I thought it was funny. h34r: :unsure:

When I was working as a medic in the ED, my solution to that was usally to address the immediate needs of the pt then call a nurse.

Hah...on a call the other day. Pulled into the ambulance bay at the hospital, opened the doors, and then the medic paused to say,

"Are you feeling any pain or nausea right now, cause this is your last chance to get drugs before you get into the hospital where it's going to take a lot longer?"

 

[Sasha]

I think there's a few kinks with this attitude, albeit I do largely agree with it. The really big one are patients who might meet criteria for a specialty center (such as chest pain patients) where the closest hospital is not a specialty hospital for that issue. In that case, what's important is not transport to nearest facility, but transport to the specialty center.

Ok, when transport time to the closest appropriate facility exceeds the time it would take for ALS to meet you and transfer care. Better, oh technical one?

 

[Sasha]

My patient has a broken pinky. Paramedics are closer than the hospital. Should I call ALS or transport on a BLS unit?

I know you know that one. Just stating his question was more about asking what qualifies as a patient who needs ALS (whether it's ALS from the ER or from a paramedic unit).

I think transport time is one of the qualifications and something to take into account. You cheeky bunny!

 

[LuvGlock]

I hope you're kidding.

If you are, it's not all that funny.

If you're not, please leave my profession immediately.

Of course I'm joking. Obviously I failed @ comedy, which is why I save lives for a living now.