What is considered a BLS call in your area

[skyemt]

well,

this issue does really speak towards education... again...

when i got out of EMT class, i thought i knew a fairly good amount...

since then, increasing my education, more A/P, etc...

i have come to the conclusion that the more you learn, the more you realize how much you don't know about medicine and patient care... especially about atypical presentations of common illnesses and the like...

i can only assume that the basics who think BLS can "handle" many of these emergencies are just not there knowledge wise... because if they were, we would NOT be reading many of these posts.

p.s. before you start writing, i am a basic.

 

[skyemt]

also, if there is a definitive time constraint to getting a CVA pt to fibrinolytic therapy (three hours from onset of symptoms), how in the world can they be considered STABLE? or if an ICH, surgery required??

there life may well come down to a race against the clock... can you get more opposite from STABLE than that?

 

[skyemt]

All calls are BLS. All calls are ALS. Hopefully both show up.

I, as a BLS provider, cancel medics all the time. The patient is always stable, never had loc or sob and usually is just needing transport to the hospital. More often than not ALS triages the same types of patients down to me if they are on scene first. I am a medic student. So I want calls to go ALS both for the patient and my personal learning so I am inclined not to cancel medics.

i am a bit confused, i must admit... in one post, you state that ALS should show up at EVERY call, and in the next, you say they can be cancelled by BLS no problem. that doesn't make any sense to me.

also, there are issues in our county with BLS canceling ALS. if you are not 100% sure ALS is not needed, you are opening up exposure to patient care violations and negligence, if it turns out that ALS could have helped.

keep that it mind when considering pain management for "basic trauma", whatever that is. so, a pt has a fx ankle... no big deal, we don't need ALS for that... pt suffers excruciating pain enroute to the hospital, only to find out that an ALS provider could have eased the pain... really, how do you feel about that?

and medical cases? can you be entirely sure ALS is not needed? how?? atypical presentations? differential diagnoses? by BLS instead of ALS?? REALLY??

i'm sure you and others will disagree, because you "cancel ALS all the time"... perhaps as a paramedic student you take more liberties...

i would hope you would acknowledge that your approach, if really as stated, is fraught with issues and exposures that most basics could not defend against.

 

[Outbac1]

Rid

I obviously either missed something or it wasn't there in my training. How do you tell prehospitally if a pt is having a thrombolytic or intracranial bleed? I thought one had to get them to a CT machine to make that determination. Please enlighten.

 

[firecoins]

i am a bit confused, i must admit... in one post, you state that ALS should show up at EVERY call, and in the next, you say they can be cancelled by BLS no problem. that doesn't make any sense to me.

I do believe in general ALS should show up to every call. But I do end up responding to calls of people requiring mearley transport to the hospital. They are sick, have minor trauma or have some reason for needing to get to the hospital but lack transportation. When we are nothing but taxi, I find it hard to justify letting ALS respond.

also, there are issues in our county with BLS canceling ALS. if you are not 100% sure ALS is not needed, you are opening up exposure to patient care violations and negligence, if it turns out that ALS could have helped.

I prefer to have medics. If I am not sure, I am not cancelling. I only cancel when I am 100% positive the problem can be handled by minor interventions and transport.

keep that it mind when considering pain management for "basic trauma", whatever that is. so, a pt has a fx ankle... no big deal, we don't need ALS for that... pt suffers excruciating pain enroute to the hospital, only to find out that an ALS provider could have eased the pain... really, how do you feel about that?

For the 5 to 15 minute transport, pain control is not my biggest concern.

and medical cases? can you be entirely sure ALS is not needed? how?? atypical presentations? differential diagnoses? by BLS instead of ALS?? REALLY??

Chief complaint, relevant past medical hx and vital signs lead me to believe that they will not need ALS. A person with the flu nd no relevant hx doesn't need medics. A person with the flu and a cardic hx may need medics and hence I don't cancel them.

i'm sure you and others will disagree, because you "cancel ALS all the time"... perhaps as a paramedic student you take more liberties...

I cancel the medics on obvious BLS jobs. That is a far cry from "all the time"

i would hope you would acknowledge that your approach, if really as stated, is fraught with issues and exposures that most basics could not defend against.

I don't think you have a good understanding of my approach.

 

[skyemt]

Firecoins,

"for the 5-15 minute transport, pain control is not my biggest concern"

oh, but what about the patient? isn't it about the patient, not what your biggest concern is..it may be their biggest concern? too many EMT's downplay pain management, but it is SUPPOSED to be one of the most important things we do... sorry if the patient inconveniences you too much...

"I, as a BLS provider, cancel medics ALL THE TIME"...

these are your words... direct quote. then you say that you cancel them sometimes, "a far cry from ALL THE TIME"...

perhaps i don't understand your approach, because either you change you position, or you don't say what you really mean... ALL THE TIME MEANS ALL THE TIME. If you didn't mean it, you can understand why anyone took it that way, because it's exactly what you said.

either way, your posts contradict themselves all over the place, and if i don't follow your approach, that is why.

 

[ResTech]

Firecoins makes several good points. I cant believe Basics on here are so insecure about their ability that they dont know when a patient is ALS or not!

I understand the significance of CVA's and time to tx... we have a relatively short transport time (<15mins) and if the pt. is "stable", the pt is ok to BLS to the hospital non-emergency. What is ALS gonna do that BLS isn't? Seriously. A lock and EKG isn't gonna fix the problem. The pt. needs O2 therapy, transport, and a CT in-hospital. If the pt. is having a subdural bleed, chances are your definitely gonna be able to tell the difference pretty easily.

If this was such a problem, how come the ED physicians are ok with it? How come the ALS providers are ok with it? This is common practice in not one but two EMS systems I've worked in.

I'm all for doing whats best and having ALS on every unit... I always advocate that for Pennsylvania. Hopefully with the new EMS Act and the addition of the Advanced EMT provider level for PA, we can start having ALS on every unit as a start and then have agencies advance to paramedic level. Hopefully that will be a stepping stone.

 

[ResTech]

ALS around here aren't to big on pain management. If you keep them for an isolated ankle fx because you want pain management... you will get some evil stares. I understand Firecoins position. He isn't saying pain management isn't a good idea. But when you have such a short transport time, by the time the medic starts a line, gets med command, pushes the med, were at the hospital where the pt. would be getting pain medication pretty early anyway.

 

[skyemt]

Firecoins makes several good points. I cant believe Basics on here are so insecure about their ability that they dont know when a patient is ALS or not!

I understand the significance of CVA's and time to tx... we have a relatively short transport time (<15mins) and if the pt. is "stable", the pt is ok to BLS to the hospital non-emergency. What is ALS gonna do that BLS isn't? Seriously. A lock and EKG isn't gonna fix the problem. The pt. needs O2 therapy, transport, and a CT in-hospital. If the pt. is having a subdural bleed, chances are your definitely gonna be able to tell the difference pretty easily.

If this was such a problem, how come the ED physicians are ok with it? How come the ALS providers are ok with it? This is common practice in not one but two EMS systems I've worked in.

I'm all for doing whats best and having ALS on every unit... I always advocate that for Pennsylvania. Hopefully with the new EMS Act and the addition of the Advanced EMT provider level for PA, we can start having ALS on every unit as a start and then have agencies advance to paramedic level. Hopefully that will be a stepping stone.

arrogance is a dangerous thing... every provider is just one bad decision away from the end of a career, not to mention what happens to the patient.

 

[ffemt8978]

arrogance is a dangerous thing... every provider is just one bad decision away from the end of a career, not to mention what happens to the patient.

I don't always agree with you sky, but that is my vote for the post of the year!

 

[ResTech]

Arrogance plays no part...

 

[skyemt]

Arrogance plays no part...

i am curious... what is your level of certification?

 

[ResTech]

I am currently an EMT-Basic... I was a Paramedic student in a 2-year degree program that I 3/4 completed before dropping for personal, non-academic reasons. I was 2nd in my class with an "A" average and completed most of the core ALS classes including A&P and clinicals I and II. I performed all the ALS modalities... IV's, meds, intubation (field, OR, and ED) in the field and IO's, surgical airways, and chest decompressions, and more intubation practice on cadavers at the University of MD.

So you see I speak from both perspectives..

 

[reaper]

But, you never worked as a medic? That is where you put what you learned to the test.
Have you never seen a STABLE CVA pt suddenly crash en route?

Pain management is a big deal. The pt with the ankle FX is in pain. You will spend 10-15 minutes to transport them. Then they will sit in ED for 15-60 minutes, before they get any pain meds. It would take a medic less then 5 minutes to get a lock and push a pain med. If your service has to call med control for pain management, then you may need to push your Med director for changes in protocol.

Are all pt's ALS, NO! Can some be evaluated by a EMT and deemed BLS, YES!

CVA's are never BLS calls. Flu's can be very dangerous. Simple N&V can lead to death. You as a basic, need to be truly confident in your evaluation of the pt, or you will get burned in the end. If a pt suffers damage or death because you canceled ALS response, it is all on your head.

Just something to keep in mind!

 

[firecoins]

when I a medic, you can let me triage ot down to you.

 

[firecoins]

If your not confident in your ability to know or when not to cancel the medics, don't cancel the medics. Very simple. My ability to do so comes from doing this for on a daily basis for a long time. The EMT class in and of itself is not enough training but experience really moves you in the right direction.

 

[BossyCow]

also, if there is a definitive time constraint to getting a CVA pt to fibrinolytic therapy (three hours from onset of symptoms), how in the world can they be considered STABLE? or if an ICH, surgery required??

there life may well come down to a race against the clock... can you get more opposite from STABLE than that?

Yep, and all hospitals should have a neurologist on board too! And who's paying that salary??

We had a CVA pt, who needed fibrinolytic therapy. She was picked up by EMS within 45 minutes of first onset and by a system close to the hospital. Unfortunately, the airlift that was to take her to the closest center for the procedure was grounded due to fog and ground ambulance transport put her arrival outside the 3 hour time limit.

Now, you can say that if our hospital had the ability to perform this procedure (as all should according to Rid) the outcome for this patient may have been quite different. But, at what cost? The cost of the facility, staff and infrastructure needed to perform this one procedure would have had to be at the expense of other services our hospital offers.

We run into the same situation with Peds calls. Our ability to diagnose and treat Peds pts is limited. Most are airlifted to Seattle, but our location makes it a crapshoot as to whether airlift is going to be able to land or even see where we are under the fog.

Yes technological advances are wonderful and increase positive outcomes. But the sad old reality is, that a public district hospital cannot afford the latest and greatest technology in all areas. So, they pick those that get the biggest bang for their buck. Those what will provide the greatest benefit to the greatest number of patients.

So, is it technology that is 'stuck in the 70's' which is the problem, or is it a financial issue? None of this technology comes for free. Who pays for it?

 

[skyemt]

If your not confident in your ability to know or when not to cancel the medics, don't cancel the medics. Very simple. My ability to do so comes from doing this for on a daily basis for a long time. The EMT class in and of itself is not enough training but experience really moves you in the right direction.

ok... now you are coming around...

so, it is dependent on education and experience, both of which you have a lot of to feel like you can "cancel ALS".

i agree.. and after much experience and learning, you start to develop this..

but, you must admit, the key is to know when you can not know...

do you endorse canceling ALS for a CVA patient? it doesn't seem like your approach...

if you would not, then you are disagreeing with the basics who are posting otherwise...

you have to admit, from the posts, canceling ALS seems to be an issue for some... canceling when you should not! a more serious decision than, oh well, what can ALS do anyway...

that is all i am saying... i do not call for ALS every time... but if there is substantial pain, or even the chance they could become unstable, i will absolutely want ALS...

am i unconfident? absolutlely not...
do i fully realize the limitations of the basic level, i certainly do.

 

[skyemt]

Yep, and all hospitals should have a neurologist on board too! And who's paying that salary??

We had a CVA pt, who needed fibrinolytic therapy. She was picked up by EMS within 45 minutes of first onset and by a system close to the hospital. Unfortunately, the airlift that was to take her to the closest center for the procedure was grounded due to fog and ground ambulance transport put her arrival outside the 3 hour time limit.

Now, you can say that if our hospital had the ability to perform this procedure (as all should according to Rid) the outcome for this patient may have been quite different. But, at what cost? The cost of the facility, staff and infrastructure needed to perform this one procedure would have had to be at the expense of other services our hospital offers.

We run into the same situation with Peds calls. Our ability to diagnose and treat Peds pts is limited. Most are airlifted to Seattle, but our location makes it a crapshoot as to whether airlift is going to be able to land or even see where we are under the fog.

Yes technological advances are wonderful and increase positive outcomes. But the sad old reality is, that a public district hospital cannot afford the latest and greatest technology in all areas. So, they pick those that get the biggest bang for their buck. Those what will provide the greatest benefit to the greatest number of patients.

So, is it technology that is 'stuck in the 70's' which is the problem, or is it a financial issue? None of this technology comes for free. Who pays for it?

not sure how that relates to the post of mine which you quoted...
don't know how to respond to that, other than, "ok, your hospital doesn't have it"....

does that mean it should be BLS not ALS?

 

[reaper]

One thing with CVA's. Don't get stuck on the "3 hour" time window.

Most stroke centers have multiple treatments available. They can go up to 16 hours out. You need to find out from your local stroke center, what they have available.