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ALS units on BLS calls

Discussion in 'EMS Lounge' started by keith10247, May 4, 2008.

  1. keith10247

    keith10247 New Member

    Good evening, I have been noticing a trend in the county I run in and I wanted to know if it was common everywhere else.

    In our county, we have ALS units that are dedicated to being medic units 24x7. On many occasions, I have been dispatched to many BLS calls that were downgraded from an ALS call and the medic unit did not want to transport.

    For example, my favourite was one evening the chief and I were doing a little grocery shopping and we get a call to assist a medic who was about 10 - 15 miles away in the next city. The pt was an adult female who had a minor seizure. We jump on the interstate and it turns out the medic and the pt's location were less than 2 miles from the hospital. The thing that got me was that the grocery store we were at was in our 2nd due. Our 2nd due did not have a BLS unit staffed. This call put us in our 3rd due which means their BLS unit was on a call or not staffed. Being at the edge of the county, that left the west end without a free BLS unit.

    Is this normal? It seems that we should all have the same mission which would be to get people who need to go to the hospital there to the hospital in a timely fashion. The 10 - 15 mile drive put us on a busy street that has stop lights every 100 yards or so.
  2. MAC4NH

    MAC4NH New Member

    Location:
    Northern NJ
    I don't know the arrangement of ALS vs BLS units in your area. In our area, the BLS far outnumbers the ALS. My guess is that they don't want to tie up an ALS unit on BLS patient and leave a potential ALS call uncovered.

    In my agency we have a couple of transport-capable ALS units (a rarity in this state) and they hate to transport even ALS patients. BLS is dispatched to every call and we can cancel the ALS or they can triage the patient to us. We usually transport ALS patients in the company of the ALS unit. Once in a while, if the stars are aligned properly, they will cancel the BLS and transport the patient themselves.

    The benefit to the patient in having both units transport is that the paramedic in the back has another pair of trained hands in the EMT-B if he/she needs them.
  3. Ops Paramedic

    Ops Paramedic New Member

    Location:
    South Africa
    We do not have that problem to such an extent anyway. Our ALS travel on fly cars, which makes them a bit more accesable, the the tendancy for them to get tied down with a BLS patient, also decreases. I can say with great surety that the BLS & ILS practitioners, far outnumber the ALS, hence it is a scarse recource that need to be well managed, as for any other recource as well. There are a few ALS who work on ambo/rig, but those are solely reserved for ALS/ICU transports, and are managed as such.
  4. Short Bus

    Short Bus New Member

    Location:
    Hickory, NC
    EMS Training:
    EMT-Paramedic
    What is a BLS truck LOL? JK, we run all ALS here. Even our Convo trucks are ALS. It would be nice to have BLS trucks, but I really don't think that will ever happen here. We usually have 2 medics on every truck. B)
  5. Ridryder911

    Ridryder911 EMS Guru

    First, what is a "minor seizure"? Never heard of such, especially to be dispatched. This is why all units should be staffed with ALS. BLS has no reason for existence in EMS except non-emergency transport systems such as for transfer and taxi services, in which is really not EMS. ALS is not "too good" for BLS calls, one cannot predict when that patient can turn around and the condition may require ALS care. Such as the patient with seizures, may have recurrence of another seizure or become "status". Again, if ALS was initially dispatched, back-up would not be needed.

    R/r 911
  6. MAC4NH

    MAC4NH New Member

    Location:
    Northern NJ
    I understand from earlier posts that in you work in a wide spread area with long response and transport times. In such an area ALS response to most calls is logical and appropriate.

    I, on the other hand work in a densely populated urban area where there is an average response time of about 6 minutes and you are never more than 5 minutes from the nearest hospital.

    A large percentage of our calls are classified as "sick". These are generally problems for which you would go to your private doctor. The patients making these calls do not have a private doctor so they go to the ER. It is a huge waste of talent and resources to send ALS providers for a patient with the sniffles, a toothache, or a psychiatric crisis.

    Our EMD's triage the calls and will dispatch BLS for all calls and ALS only for calls such as chest pain, difficulty breathing, status seizure, altered mental status, LOC or trauma with significant MOI. BLS usually arrives first and assesses. If there is no immediately life-threatening condition, they will cancel ALS and transport. If ALS is on scene first and they find no immediate life-threat they will release the patient to the BLS.

    This system works for us in part because our BLS is very busy and the EMT's are experienced. In suburban areas with less experienced volunteer EMT's and longer transport and response times, the system relies more heavily on the ALS.
  7. BossyCow

    BossyCow New Member

    Location:
    Rural (no... really, really rural) Washington Stat
    EMS Training:
    EMT-Basic
    I'm confused. It sounded to me like ALS was dispatched, assessed the pt and determined that BLS was all that was needed. Isn't this ALS doing what ALS is designed to do? Doesn't a medic have the skills to determine that? Are you suggesting that all postictal pts should be transported ALS because they 'might' seize again?
  8. KEVD18

    KEVD18 New Member

    Location:
    mass
    i understood it as he thinks that every single 911 call, without exception, no questions asked should be handled by a medic unit and that the only thing bls techs are good for is taxi service.

    my baby stubbed her toe and i want her taken to the H because this is my first child and im easily frightened. als response

    i want narcotics because im an addict who is recognized by every H employee down to the janitor and i know i can get them at the er so i'll call 911. als response

    i havent been sleeping well for around three years. im bored and lonely so i guess i'll call 911 and go to the er. als response.

    yip. in R/r's book, apparently all are als calls. definitely no reason to give those types of calls to a bls truck and keep the medics in service for, and i mean this quite literally, a REAL call....
  9. firecoins

    firecoins IFT Puppet

    Location:
    Nyack, NY
    Rid is responding to whats being called a "minor" seizure. That is call that ALS should be transfering. It could be ery serious and if something happens during the BLS transfer, there is nothing BLS could do outside of monitoring.

    BLS is a taxi ride for the most part. Most of my calls are nothing more than picking up someone from home, putting them on my stretcher and transfering them to the ED. Any legit call where I may have something to do usually requires ALS anyway. Either the medics are there or on the way.
  10. Ridryder911

    Ridryder911 EMS Guru

    Is an EMT trained well enough to make a differential diagnosis? NO. Are you certain that patient will not seize again? (patient's with hx. of seizure activity, are prone to more seizures, remember what is the #1 cause of re-current sz?) Are you sure that headache is not a subarachnoid bleed? As well, if they are calling you for a stubbed toe, why is EMS responding and transporting? Again, it goes back to administration and setting up the EMS.

    Five minutes or fifty minutes is mute, don't breathe for five minutes, or can one assure no aspiration or v-fib is not going to occur in that five minute ride. Some of my most dramatic calls, have occurred within five minutes of the local hospital. We do NOT transport level I trauma to the local ER, we transport 30 miles or the patient is flown. No matter, if the occurrence happened in the local ER drive.

    Ironically, I find it is the same ones that gripes about it; always refer to Paramedics should remember where they come from.

    There is nothing wrong with ALS transporting BLS calls, the "in case" factor should be considered. How many posts do we read were the patent deteriorated in front of the EMT? An EMT/ Paramedic partner teamed up so the EMT can ride on BLS calls; in case the patient condition deteriorates and to allow the EMT to obtain experience.

    Sorry, patients that pay for EMS deserves to get the best and have services offered to them if needed, not await if they are available. There really is not that much difference in expenditure on providing the difference, definitely one can offset the costs by appropriate charges and good administrative practices.

    I believe "chase cars" "ALS" roving vehicles are excuses for Paramedics not having to be there. As well, an excuse for a service to charge additional expenses without providing that service. Yes, one still can charge for an ALS exam and tx. without the Paramedic transporting, it is the initial call that determines the rate that will be charged and treatment administered. ALS charges is based upon the procedure, and number of med.'s given, not who rode in with them.

    Is there B.S. calls, you bet. Should there be no-transport guidelines, yes. BLS or ALS, it would not matter, tying up an EMS unit is tying it up.

    R/r 911
    Last edited by a moderator: May 5, 2008
  11. KEVD18

    KEVD18 New Member

    Location:
    mass
    because they called! i dont know about where you work, but dispatchers in ma cant diagnose a call as bs over the phone. if you call, you get a truck. if, when that truck arrives, you want to go to the H, we take you. we cant refuse to transport because we think a call is bs.

    all three of those calls are calls i have done. in your dream system, they all would have been handled by an als truck with two paramedics. does that seem like a good use of resources?
  12. Ridryder911

    Ridryder911 EMS Guru

    No, but that why systems should be reviewed and medical control should be that medical control. How much participation does your medics do and have in making policy changes ? Is your medics involved in local and state legislative actions to change systems requirements? There are systems that has established fines for abuse of EMS. Is it controversial and have risks, you bet, but alike anything else it goes back to education and planning.

    Dream system no; but the patient has to be informed of the costs and consequences of transporting as well as if they had refused. Sure, I make a lot of taxi rides as well as contacting medical control and having a Doc tell them they don't need an ambulance. Also, I will inform them they will be sent to triage, instead of going straight back to a bed, so there is no advantage in fact chances are they will be seen much later.

    That is what supervisors are for as well, to enforce such policies if there is a problem. Sometimes, it is much easier to transport them, but you are already out and about. One as to use common sense.

    Again, I prefer to be transporting a b.s. call than and not to be needed than to see an BLS unit have a patient detonate and not be able to provide adequate care. Remember to err on the patient's behalf.

    R/r 911
    Last edited by a moderator: May 5, 2008
  13. BossyCow

    BossyCow New Member

    Location:
    Rural (no... really, really rural) Washington Stat
    EMS Training:
    EMT-Basic
  14. daedalus

    daedalus New Member

    Location:
    Ventura, CA
    EMT make a diff diagnosis? You bet they can. I have done it many times. Call out for dyspnea at a jail, pt found in slight distress with obvious signs of heart failure or some sort of ventricular pathology. Pitting edema, tired, short of breath, somewhat lower BP than normal for pt....

    Turned out I was right.

    Because my hands are a little tied with the treatments I can provide in no way means I cannot treat a patient who goes south in front of me. I have treated sudden onset of bradycardias, sudden onset SOB, and many more emergencies in my BLS unit.

    The bradycardia turned out to be a 2nd degree heart block. Did I consider a block? You bet.

    Can I push atropine for a symptomatic block? In a few years yea but for now Ill keep the patient trendelenburg with some 02 and the defib ready. Continue my assessment and HX and upgrade the call.

    BLS is more than sufficient for some 911 calls and transfers.

    Educate the EMT a little bit more and soon we will check glucose level, give some glucagon IM, asses the patient's vitals and take a through history, watch them eat a sandwhich, cancel ALS and keep a bed free.

    That way ALS can respond to the TC w/ multiple severe injuries and transport them to a trauma center.
  15. JPINFV

    JPINFV Gadfly

    Location:
    404: No Meme Found
    Define "a little bit more." If by "little bit," you mean, in addition to any skill training and pathophys education, you mean requiring college level anatomy and physiology, then maybe it will be worth it.

    By the way, why would you cancel paramedics from a patient they can help (diabetic) for a patient that, for the most part, they can't (trauma)?
  16. Ridryder911

    Ridryder911 EMS Guru

    This is exactly the reason and need for ALS. Several wrong factors here, although the intent is nice.

    Many assume that the basic EMT gives enough knowledge to actually know much more than the initial treatment of an injury and very little to any medical knowledge or background in medical illnesses. Sorry, there is only so much one can teach, and learn in 150 hours. Fact is fact....

    Let's look at the examples given..

    How would one know second degree block without advanced education, and if one has such they are no longer considered BLS... As well, Atropine is strictly contraindicated in blocks, as well is trendelenburg (albeit it does not work for low bp's) but can cause the heart to work harder ( is this something we want?)

    Glucagon, and a sandwich? Really, ever hear of rebound glucose? I don't suggest any treat and street for diabetics.. too risky, I have seen multiple patients bottom out after Glucagon has been metabolized.

    Now, not picking on the poster.. but, in reality, yes we transport a lot of B.S. Yet, if just one of those patients did go unresponsive and just one patient aspirated... Would that not be worth having ALS? Again, really how much neuro assessment does an EMT really know and can perform? Can you really tell me, why and what occurs when you check PEARLA, even most Paramedics lack the in-depth knowledge to tell the difference in neuro assessments. That is why all "worst headaches" get either a CT scan & or a LP. Sorry, even ER Doc's will not even touch that one... Again, most EMT's do not understand the seriousness of what is considered "presumed routine" illnesses that actually can be severe. It is not the fault, but again one can only be taught so much in 150 hours.

    Even that flu deserves an IV fluid replacement and detailed assessment. Again are you sure it is the flu? Are you sure the symptoms are not caused by another illness or symptoms similar?

    I have seen UTI's that most would consider B.S. when in actuality are very severe and are in septic shock.

    I agree most do not pay, ill or not. So why not transport with ALS. One can generate revenue for ALS and write off just as much as for just transport, reimbursement loss that can be retrieved later. Again, good management and administrative practices needs to be in place.

    If you do educate, why not go all the way or nothing at all? Is there a place for BLS, yes as first responders only. There is way too much that can occur during transport, as well placing the care to a lower level can open the door for abandonment too. One has to be very, very careful. As the industry becomes more busier, and the patients become more ill before they seek tx. we must focus on improving the care delivered.

    R/r 911
  17. daedalus

    daedalus New Member

    Location:
    Ventura, CA
    atropine is contraindicated in a block with symptomatic bradycardia? ah I stand corrected. you pace than? anyways...

    After re reading your previous post ridryder, and now this one, I think I missed your intent, and I apologise. Yes, BLS has NO business transporting MOST calls, and BLS should really be first responder only, along with a transport capability for routine transfers. In addition, however, I am an EMT advocate, and think that we as EMTs should be able to have a better education in a longer class and be taught so we know what the F u C k we are doing, and should be able to provide emergency care without a paramedic if necessary, and do it competently.

    I long for Doctor House's abilities, i want to look at a patient and just know.
  18. daedalus

    daedalus New Member

    Location:
    Ventura, CA
    To clarify further,

    since no one can decide on where EMS should be going, how can we decide how much education an EMT should have? Is what we have enough? or do we need more even though most transporting should be done by paramedic ambulance?
    Perhaps we need a bit more. Im not saying EMT should be almost paramedic level in scope and education, but we need a more worldly view of medicine in general before we get to the field. And yes, anyone wanting to be in charge of a 911 call, become a medic, and save the whining on how BLS is just as good as ALS.

    In a nutshell, yes a properly educated EMT should know what they doing.
  19. Ridryder911

    Ridryder911 EMS Guru

    One of EMS major problem unlike other medical professions is that we accept "status quo" and actually promote lower or worse do nothing. Compare us with respiratory therapy, radiology, nursing, and almost all other medical professionals and we sadly have became retarded. Part of this can be blamed upon many of the EMS providers are in fact not really in the health profession rather associated with Fire or other unrelated healthcare business.

    We in EMS must become proactive that we would want the best for our patients. Yes, there are many areas so remote and rural the best care will be BLS, but one needs to consider that should be the abnormal rather than the normal. How sad that when one views the nearly 40 year old television show "Emergency; that patients still do not even receive that much care in the U.S. Who's fault is this.?...... ours. The public places its trust in us to deliver what is best, yet we have failed to do so.

    We as EMT's and Paramedics should rally and demand that what we have is inadequate, and we as a profession should have the mind set that the minimum level or lowest level is not good enough. Unlike the other medical professions I described that has changed their professions, we have not. We can blame it on funding, lack of personnel; what ever, the same obstacles those other medical professions had but overcame. The difference is that they would not settle for lower care to be provided and poor associated effects to their profession, alike we do.

    Almost everyone agrees what would be best, but very little discussion is made upon what they are doing to change things. Rather much more discussion is made of what excuses or why things should remain the same even though knowing that is not the best interest for the public.

    Again, I ask how active are you on changing things or are you satisfied with delivering the lowest care possible? Are you active with legislation, EMS associations in promoting better care, and increasing our profession? Remember, if you are not part of the solution you are part of the problem.

    R/r911
  20. skyemt

    skyemt New Member

    Location:
    NY
    EMS Training:
    EMT-Basic
    my oh my... we find ourselves here again... in the land of basic vs.medic...

    firstly, i am a basic right now, so keep it in mind that i am not basic bashing...

    having said that, if one reads the posts on this thread, you will find Rid consistently talking about the interests of the patients and what is best for them. however, there are many "basic" posters, talking about what they can do, and what is best for the basic...

    to me, this is an issue... because of the constraints of my system and area, i am involved in more calls that medics would not want basics really involved in... i do the best i can, because there is no alternative for our patients... that may be for another thread... however, in my heart of hearts, i am fully aware of the limitations of the basic level, and have seen things change enroute to the hospital many times... would ALS be good for the patient on most calls, yes, but not gonna happen in my system.

    my solution, is to become a medic, which i will start in the fall... i always fall back on this... if it was a love one, who needed care, who would you want showing up... if everyone is honest, there really is NO debate here...

    even if there are skilled basics... even if 99% of the time (for argument's sake), the medic wasn't needed for the "what if" factor... who wants to tell the family of that ONE patient, that the system didn't think it important enough to have the highest level care tending to their loved one...

    brutal yes, and it has happened and will happen again... perhaps, in some places, there really is no alternative sometimes...BUT

    we are in full control of our attitudes, how we want to approach "patient care", what we feel the patient deserves, and what to do about the "what if" factor... it is the failures of these attitudes sometimes, that lead us down this path we travel over and over again out here...
    Last edited by a moderator: May 6, 2008

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