# Non transport ALS services



## NomadicMedic (May 19, 2011)

I'm curious as to opinions of the efficacy of non transporting ALS services, i.e: The medic in a chase car or QRV in conjunction with a BLS ambulance. 

In the system I'm looking at, the medic is dispatched simultaneously with a BLS ambulance for calls that meet EMD criteria for an ALS response. If an ALS transport is warranted, the medic climbs onto the BLS rig and transports ALS. If once on scene, the situation does not call for any ALS interventions, following an eval, the medic will send the patient BLS, with an EMT.

If you've worked in, or have experience with this type of deployment, can you tell me pros and cons.


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## ShotMedic (May 19, 2011)

I know this is how North Jersey (bergen county)operates, The medics are out of the hospital or at posts and BLS ambulance(usually Volunteer) is the Transport unit and will upgrade or the medics will downgrade once on scene. La County Fire does the same as well with the Private Bls company. They seem to like it from what i hear from good friends of mine. Frees up alot of off load delay times at the ER. Once the patient is at the ER a turnover is given and they can bounce. The BLS ambulances like it cause there not stuck doing IFTs all day and get good experiences before moving up the in the EMS kingdom.


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## Aidey (May 19, 2011)

I haven't worked in a system like this, but one of our neighboring services uses this model. It is good, up until it isn't. There are two main problems I hear about. 1 is that it can increase on scene times as the medic tries to figure out what is going on. Number 2 is that if the medic's assessment isn't on point and the patient tanks en route the crew is left waiting for an intercept. 

I've also heard some complaints about the fact that if the medic rides in there is no coverage for the area for the next hour or more. That could theoretically be rectified by having an on call medic who backs up the on duty medic, but that only works if your medics live within a reasonable distance to the station.


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## JPINFV (May 19, 2011)

This is how Southern California is largely set up. Assuming there isn't going to be the stupidity that Orange County, CA does with paramedics limited to the fire department (hence placing EMT IFT providers between a rock and a hard place on some non-911 emergency calls), my huge concern is laziness. When the paramedic doesn't have to transport (be it as the driver or as the attendant), the choice sometimes becomes, "Go back to watching the sports game, or give the patient in extreme pain pain meds."


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## jwk (May 19, 2011)

Any concerns that once the medic begins caring for the patient that transferring care to a "lesser" provider would be considered abandonment?


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## Aidey (May 19, 2011)

jwk said:


> Any concerns that once the medic begins caring for the patient that transferring care to a "lesser" provider would be considered abandonment?



King County Medic One seems to think it is perfectly fine, and they are held up as the shining example of what a great paramedic service is.


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## JPINFV (May 19, 2011)

jwk said:


> Any concerns that once the medic begins caring for the patient that transferring care to a "lesser" provider would be considered abandonment?



Assuming paramedic level care or monitoring isn't indicated, no. Is an RN at a SNF abandoning their patient by transferring care to an EMT?


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## ShotMedic (May 19, 2011)

In my local Area we can Officially do BLS downgrades to other providers through the Base hospital MICN. I imagine each system has their own ways/reasons for doing this. Ours is mainly due to resource issues and call volume. Why tie up an ALS rig when a BLS ambulance will suffice? With that said someone has to stay with the patient untill the BLS ambulance arrives. Either the ambulance or the engine will stay committed


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## abckidsmom (May 19, 2011)

jwk said:


> Any concerns that once the medic begins caring for the patient that transferring care to a "lesser" provider would be considered abandonment?



This is my problem with working in a system like this.   I frequently find myself in this situation in my volunteer system, and it's a high-anxiety situation for me as the medic:  unfamiliar crew, unfamiliar monitor (unless I'm willing to bring my own, which is then not able to be plugged in for the hour-long tranport), and that niggling "what if?" in the back of my mind.

I stopped doing it.  Given the limited capabilities of the BLS providers in our system (ie, flat out incomptence) I just wasn't comfortable with it.


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## mycrofft (May 20, 2011)

*Worked fine in 1981 Lincoln NE.*

Bryan Heart Team drove a suburban, met us at scenes. Sometimes they beat us there. They did not leave city limits, we went all over the place. 
The danger was overestimating how much one team can do. Need more than one team.


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## DrParasite (May 20, 2011)

ShotMedic said:


> I know this is how North Jersey (bergen county)operates, The medics are out of the hospital or at posts and BLS ambulance(usually Volunteer) is the Transport unit and will upgrade or the medics will downgrade once on scene. La County Fire does the same as well with the Private Bls company. They seem to like it from what i hear from good friends of mine. Frees up alot of off load delay times at the ER. Once the patient is at the ER a turnover is given and they can bounce. The BLS ambulances like it cause there not stuck doing IFTs all day and get good experiences before moving up the in the EMS kingdom.


all of NJ is like this, with the exception of 4 ALS projects state wide.   if it's a BLS patient, the BLS crew transport.  if it's an ALS patient, the ALS crew treats while the BLS transports.

the only exception to this is when ALS and BLS are the same agency (again, 4 projects state wide), in those cases, ALS can be given an approval to transport (with a waiver from the dept of health).


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## firecoins (May 20, 2011)

n7lxi said:


> I'm curious as to opinions of the efficacy of non transporting ALS services, i.e: The medic in a chase car or QRV in conjunction with a BLS ambulance.
> 
> In the system I'm looking at, the medic is dispatched simultaneously with a BLS ambulance for calls that meet EMD criteria for an ALS response. If an ALS transport is warranted, the medic climbs onto the BLS rig and transports ALS. If once on scene, the situation does not call for any ALS interventions, following an eval, the medic will send the patient BLS, with an EMT.
> 
> If you've worked in, or have experience with this type of deployment, can you tell me pros and cons.



Pro - Medic remains available on B.S calls. 

Negative - Requires BLS crew to drive medic back to the SUV after the call keeping both units out of service longer.


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## johnrsemt (May 20, 2011)

to answer firecoins:  on the Con:   the 2nd crewmember on the BLS ambulance drives the chase truck to the hospital,  so that when the medic marks in his vehicle is right there.  
  Only, of course if the driver doesn't go to the wrong hospital which I saw a few times in Indianapolis


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## medicsb (May 20, 2011)

n7lxi said:


> I'm curious as to opinions of the efficacy of non transporting ALS services, i.e: The medic in a chase car or QRV in conjunction with a BLS ambulance.
> 
> In the system I'm looking at, the medic is dispatched simultaneously with a BLS ambulance for calls that meet EMD criteria for an ALS response. If an ALS transport is warranted, the medic climbs onto the BLS rig and transports ALS. If once on scene, the situation does not call for any ALS interventions, following an eval, the medic will send the patient BLS, with an EMT.
> 
> If you've worked in, or have experience with this type of deployment, can you tell me pros and cons.




I worked for five years in New Jersey for a MICU project that was all chase cars.  Hands down, I prefer it over being in an ambulance.  But, my preference for the chase-car is tied to my preference for the tiered system.

I can only speak for where I worked.  Generally, ALS was dispatched on about 50% of all EMS calls; ALS was usually canceled while enroute or shortly after arrival on scene for 40-60% of those dispatches.  There were no protocols for BLS to follow when it came to canceling ALS, so there was a lot of variation between BLS squads and even between EMTs of the same squad.  Some EMTs had no problem cancelling ALS for all but the truly critical and other would keep ALS coming just because ALS was dispatched.  As far as triaging to BLS - again, no solid protocols, but all triages were reviewed by the medical director if it came back that the patient was admitted to tele or a higher level of care.  In my opinion, we didn't triage to BLS enough, which was a product of the QA/QI system as it was almost always considered to be inappropriate if the patient was admitted regardless of whether the patient needed any ALS intervention or could have possibly required it at some point during transport.   So, without a doubt, the a biggest con of the system I was in was the extremely poor oversight and QA/QI of BLS and dispatchers, and unrealistic criteria to determine appropriate triage by paramedics, which when combined created many instances of medics being tied up on calls where they really weren't needed, which is problematic when the county of 450,000 has only 5 medic units (they're now at 6 during peak hours).  So yes, there were times where there would be no medic units available or if there was one, its response time would be prolonged due to distance.  

The biggest pros of the system is concentrated paramedic experience.  Intubation and cardiac arrests were not 2 or 3 times a year events for medics.  I was per-diem, working one day a week for 9 months (due to school) and then 36 hours a week for the balance and I would average around 8-10 tubes a year.  (Most, if not all fulltime medics in SE PA that I knew wouldn't get that many; the ones that did were usually working 60-80 hours a week.)  It wasn't uncommon to have a couple shifts a year where you'd have multiple codes or multiple intubations.  I know some medics that have worked 4 codes in one shift, though that is pretty rare.  Our ETI stats could have been better, but we had an overall ETI success rate of 94% when I left.  I know ASA admin and 12 leads were being tracked for appropriate use and we were in the high 90s (averaged over a year) for both.

As the trucks were staffed with 2 medics, you always had someone to confer with (this was great when I was fresh out of medic training).  When on scene, one medic would get the history while the other did an assessment and initiated treatments, as needed.  If the patient was really sick, both would ride in the back and an EMT would drive our truck.    Though it was not an every shift occurrence for both medics to ride with a patient, I found it to be beneficial when we did, and I think we should have done it more often.  Overall, I think we were generally able to get more done in a shorter amount of time than if it were just one medic and an EMT on the call.

I'm not sure what else to touch on as I need to get going.  But any questions, I'll do my best to answer them.


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## NomadicMedic (May 20, 2011)

Some good stuff here. To answer some of the concerns, this ALS service is dual medic, so if it's a serious call, both medics can treat the patient and a BLS person drives the medic truck to the hospital or other designated spot. If one medic is transporting, the other medic is still available for calls and may be dispatched. (yes, there are multiple sets of ALS gear on the trucks). All of the BLS units are volunteer fire.


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## thegreypilgrim (May 20, 2011)

As others have said, this is essentially how most of LA County is organized.

In my opinion, it's probably the ideal way to set things up in terms of efficiency and system optimization provided several other features of the system are also in place. By this I mean it doesn't work in LA County because it's LA County. It's a fire-based system in which the majority of the medics were trained at one of two mill-type programs and operate within a firehouse culture that is as hostile towards EMS as one could ever possibly be. The result is the medics essentially look for any and every reason to downgrade every call to BLS so they can clear back to station which doesn't make for the best patient care.

So, I suppose in the right system doing this this way is probably ideal. But it has to be the right system with the right culture otherwise it'll just end up like LA County which is not what anyone should aspire to.


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## the_negro_puppy (May 20, 2011)

We have intensive care paramedics in fly cars. We can request them once on scene, or they are usually dispatched to arrests and major trauma.

They add skills like intubation, thrombolysis, IO, ketamine, chest tubes, RSI

Works reasonably well


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## firecoins (May 20, 2011)

johnrsemt said:


> to answer firecoins:  on the Con:   the 2nd crewmember on the BLS ambulance drives the chase truck to the hospital,  so that when the medic marks in his vehicle is right there.
> Only, of course if the driver doesn't go to the wrong hospital which I saw a few times in Indianapolis



Thats not allowed here.


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## medicsb (May 20, 2011)

n7lxi said:


> Some good stuff here. To answer some of the concerns, this ALS service is dual medic, so if it's a serious call, both medics can treat the patient and a BLS person drives the medic truck to the hospital or other designated spot. If one medic is transporting, the other medic is still available for calls and may be dispatched. (yes, there are multiple sets of ALS gear on the trucks). All of the BLS units are volunteer fire.



In NJ, medics are not allowed to split unless there are two patient on the scene (e.g. an MVA) and another medic unit is not available or close enough.  So if one medic is following behind and a call comes out nearby, you can't go to it.  I think this is silly, especially since we had two sets of gear.  
In Delaware (which is 100% chase car), the following medic can leave to go to a second call, but another medic unit has to be dispatched as all critical patients are to be tended to by 2 medics.  However, if the lone medic gets on scene and the patient is not critical (but still ALS), he or she can cancel the other medic unit and ride the patient in.  This is how I'd prefer it to be done in NJ.


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## medicsb (May 20, 2011)

DrParasite said:


> all of NJ is like this, with the exception of 4 ALS projects state wide.   if it's a BLS patient, the BLS crew transport.  if it's an ALS patient, the ALS crew treats while the BLS transports.
> 
> the only exception to this is when ALS and BLS are the same agency (again, 4 projects state wide), in those cases, ALS can be given an approval to transport (with a waiver from the dept of health).



It's more than 4 now.  JCMC, UMDNJ, Atlanticare, Underwood has one (LS 5), RWJUH New Brunswick, MONOC, and based on MICCOM unit designations, St. Clare's is all transport.


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## NomadicMedic (May 21, 2011)

I'm looking at the Delaware systems. Seems like it works well, and I haven't heard any real negatives.


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## medicsb (May 21, 2011)

n7lxi said:


> I'm looking at the Delaware systems. Seems like it works well, and I haven't heard any real negatives.



I oriented a medic who worked for one of the DE ALS services and he had some gripes about management, but I hear those sorts of complaints from almost every place.  DE has a state wide ALS response time standard (8:00/90), so the lower two counties, which are mostly rural, have more medic units than necessary, in my opinion. (Stupidly, the standard isn't as strict for BLS.) So, the skill concentration thing isn't going to apply as much.     I talked with a medic from one of the lower two counties and he said that they almost never triage to BLS and used an example of BLS requesting medics because they got a SpO2 reading of 80%; the medics discovered that it was malfunctioning, but rode the patient in anyways.  Another downside I've heard of the lower two counties is that because medics can split, it's possible to end up at hospitals that are far apart and having to wait hours to meet back up with your partner.  But, I don't know how common that is (to me it's not a big deal anyways).  

Overall, I think DE has a pretty good system.  Strong QA/QI, good medical oversight, good protocols, research, etc.   New Castle County has a utstein survival rate over 30%..  The statewide ETI success rate is around 92%.  It's all county based and as far as I know, they have all have decent career ladders, benefits, and retirement packages.  Also, if you like to fly, the medics in the lower 2 counties will accompany the patient for the flight if it is the state police helicopter responding.

The state website has a lot of great info.  Since I don't work there, take what I say with a grain of salt as I could be wrong.  

If you go to connect.jems.com, there is a NCC medic by the name of Bob Sullivan that regularly posts, I'm imagine he'd be willing to answer questions you may have.


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## NomadicMedic (May 21, 2011)

I've talked to a couple of guys that have some experience there, I really wanted to see if there was anything I was missing...


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