# When to call for ALS Backup



## Diddlemt (Nov 20, 2008)

Hey, new here..I have been an EMT -B for about two years and I live in an area where it's well...out there about 40 mins from any hospital. Our company has two stations and sometimes we have just BLS crew.. meaning sometimes its me and a driver which knows and does nothing. I rarely ever call for medic backup.. I usually know when to call, to cover my ***. The state has been QA several emt-b's for taking in things that should have been covered by a medic. I know that I can always tone out another station or meet enroute.
But last night I get a call at 3am for an allergic reaction, red skin, SOB, trimmers, and hes' feeling ill. I am on scene.. get my vitals. Initial BP was 230\138 and pulse was 140. He was tremmoring pretty well and had nausea. Got my history.. heart bypass and Hypertension. He was prescribed Nitro the day before. He thinks it was a reaction to his meds.. could be. I apply 02 and monitor vitals.. the full deal. We get down the road then he states.. my chest hurts.. pressure substernal non radiating. I got a little concerned and ask for a medic evaluation.  Was I wrong? When the medic got one scene he states that the pressure comes and goes.. I just wanted to cya. I could have taken it in, but didn't want to have an oh :censored::censored::censored::censored: by myself. What is the standard for calling ALS in your opinon. Thanks so much


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## mycrofft (Nov 20, 2008)

*Sounds somewhat like ETOH detox too.  Diarreah?*

Pat answer: what are your protocols and agency rules?


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## Diddlemt (Nov 20, 2008)

Well, for true chest pain, als backup. But maybe it wasn't chest pain, maybe it was just discomfort from the reaction. As an EMT-B would you take it in own your own?


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## Gi.Josiah6201 (Nov 20, 2008)

*Tough one.*

I agree that was a tough call. One of two different things or a combination of both could have been occuring.  I think you did the right thing.


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## WuLabsWuTecH (Nov 20, 2008)

If the medic unit gets there and you don't need him, we'll you've got an extra pair (or two depending on his driver) of hands to twiddle their tuumbs with.  But if you need him and didn't call, now you're in some trouble until they can get there.

I'd rather have them and not need them than need them and not have them.  I think you made the right call as well.


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## daedalus (Nov 20, 2008)

I call for ALS:

Cardiac Arrest -rationale- I dont have meds or a monitor, and I will not transport a arrest because CPR sucks in the back. I will continue compressions, airway management and ventilation, and defibrillation until ALS arrives. 

Unconsciousness -rationale- Paramedics can check blood sugar, give D50, and preform EKGs. There is great potential for this to be treated on scene.

Suspected anaplylatic shock -rationale- Lets face it, the patient is never going to have an epi pen when they really need it, patients may also need more than one round of epi.

Trauma with shock -rationale- I dont want the patient to die en route to ER.

and anything else I see fit. Suspected MI, CVA, etc, its better just to rapid transport where I am from. They will get to the ER about as fast as ALS can get there.


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## Jaybro713 (Nov 20, 2008)

For us in my Department there is a list that if the call falls into ALS is automatically dispatched with the BLS truck.  Of course we can always call if needed once we are onscene and we can always call them off if needed.  

The system seems to work well enough to provide the necessary care.


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## bonedog (Nov 20, 2008)

If your not sure ALS is needed I prefer to be called rather than not called and be needed.


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## tydek07 (Nov 20, 2008)

Diddlemt said:


> Hey, new here..I have been an EMT -B for about two years and I live in an area where it's well...out there about 40 mins from any hospital. Our company has two stations and sometimes we have just BLS crew.. meaning sometimes its me and a driver which knows and does nothing. I rarely ever call for medic backup.. I usually know when to call, to cover my ***. The state has been QA several emt-b's for taking in things that should have been covered by a medic. I know that I can always tone out another station or meet enroute.
> But last night I get a call at 3am for an allergic reaction, red skin, SOB, trimmers, and hes' feeling ill. I am on scene.. get my vitals. Initial BP was 230\138 and pulse was 140. He was tremmoring pretty well and had nausea. Got my history.. heart bypass and Hypertension. He was prescribed Nitro the day before. He thinks it was a reaction to his meds.. could be. I apply 02 and monitor vitals.. the full deal. We get down the road then he states.. my chest hurts.. pressure substernal non radiating. I got a little concerned and ask for a medic evaluation.  Was I wrong? When the medic got one scene he states that the pressure comes and goes.. I just wanted to cya. I could have taken it in, but didn't want to have an oh :censored::censored::censored::censored: by myself. What is the standard for calling ALS in your opinon. Thanks so much




Yes, you did the right thing about calling for ALS. Remember its better to be safe then sorry! There are many reasons here why it was a good idea to call for ALS intercept:

1) Of course the Chest Pain
2) Cardiac hx
3) High BP - 230/138

Remember that even tho a persons chest pain may sound as if is not of cardiac origin, you can never be sure without further assessment... aka 12-Lead

So, GOOD JOB on calling for ALS! I know many EMT's around here that are "too good" to call for ALS and its gonna bite them in the arse sooner or later. 

Take Care,


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## Ridryder911 (Nov 20, 2008)

Here is a simple answer. If you think you should or should had called them, you probably have/had ought to. 

There's a reason you thought so. There are very few (if any) ALS examination is not needed.


R/r911


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## Jon (Nov 20, 2008)

Since you have such a distance to transport... I don't see any reason NOT to call for medics given what you present. Since you have long transport times, start transporting and meet enroute. Chest pain=ALS until proven otherwise.


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## mikie (Nov 20, 2008)

It never hurts to call medical control either!  Especially with a call like that.


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## BEorP (Nov 20, 2008)

tydek07 said:


> Remember that even tho a persons chest pain may sound as if is not of cardiac origin, you can never be sure without further assessment... aka 12-Lead



And you can rule out a non-ST elevation MI?


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## BossyCow (Nov 20, 2008)

According to our protocols, the difficulty breathing with an allergic reaction would have been enough for me to call ALS without the chest pain.

I've called ALS and not called ALS on a chest pain call. Depending on the pt. A hyperventilating pt with a hx of anxiety and a history a mile long of calling us for various 'life threatening emergencies' who is talking in complete sentences, with skin pink, warm and dry, good cap refill, vitals wnl is probably not going to get ALS. Its a judgement call. I have though called ALS for evaluation on a pt just because the call felt hinky to me. 

I tell my volunteers to be sure that they are calling ALS for the pt, not for themselves.


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## Outbac1 (Nov 20, 2008)

To me it shouldn't be a tough call. If you can meet ALS enroute you should. There are several possible problems and outcomes for this pt that a EMT-B can't deal with. If it is an allergic reaction that is or could compromise the airway can you give Epi, Benadryl, Zantac? A b/p of 230/138 with a HR 140 needs to be addressed. Can you do anything for this? You say you have long transports. ALS may not always be available prior to your arrival at hosp. Even though the pt may arrive at the hosp. with their condition unchanged from when you picked them up doesn't mean they should have been untreated. 

 Its not about protocols. It is about judgement and what is best for the patient.

  In my mind you did the right thing.


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## MAC4NH (Nov 21, 2008)

Just based on your vital signs and patient history you should probably call ALS.  Add to that the chest pain and distance to hospital and it absolutely becomes an ALS call.  Without a 12-lead, you have no idea what's going on with this patient. I would transport this patient BLS only if I was close to the hospital (5min or less) and the ALS was more than 5 minutes away from me.


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## Ridryder911 (Nov 21, 2008)

Outbac1 said:


> If it is an allergic reaction that is or could compromise the airway can you give Epi, Benadryl, Zantac? A b/p of 230/138 with a HR 140 needs to be addressed. Can you do anything for this? You say you have long transports. t.
> 
> In my mind you did the right thing.



Anything over Epi pen is considered Paramedic level here. Benadryl, Epi per IV or nebulized, and Zantac is considered ALS/Paramedic level. Actually, although I fail to understand most services do not carry Zantac or many other H2 blocker. 

R/r 911


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## 41 Duck (Nov 21, 2008)

It more concerns me that you have to question as to whether you acted appropriately or not, if there's some type of pressure/prestige in your organization to cancel ALS and do it your ownself.  Your job on the street isn't to prove to your partner or organization how brilliant you are when it comes to applying BLS skills and knowledge; it's taking care of the guy that called you guys out there.  Sad, that many places turn PT care into an ego war.  The prevailing question should be: "What's the best thing for this PT?"  Often, it's not asked... or thought of TO ask. 

You did the right thing.  For reasons people more experienced than I have already stated.  Remember that feeling you had when you were going to cancel, but decided against it.  Remember it well.  You're gonna see it again, and next time, you're gonna know you did the right thing.

Well done.



Later!

--Coop


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## Foxbat (Nov 21, 2008)

Whatever was causing these symptoms, it was an ALS situation - at least in my state. My only concern would be the delay waiting for ALS could cause. PA protocols state it is generally inappropriate to delay transport waiting for ALS (unless long transport time and short ALS ETA).


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## Foxbat (Nov 21, 2008)

Ridryder911 said:


> Anything over Epi pen is considered Paramedic level here. Benadryl, Epi per IV or nebulized, and Zantac is considered ALS/Paramedic level. Actually, although I fail to understand most services do not carry Zantac or many other H2 blocker.
> 
> R/r 911


Would Epi be good for this particular pt., given the hypertension?


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## Ridryder911 (Nov 22, 2008)

Foxbat said:


> Would Epi be good for this particular pt., given the hypertension?


No, not so much due to the hypertension (which in anaphylaxis is usually low) but that it is probably more a drug reaction than anaphylaxis. Although, if it was NTG the pressure maybe low as well. Benadryl, steroids has better outcome and I personally use epinephrine on *true * case of anaphylaxis. 

R/r 911


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## Airwaygoddess (Nov 22, 2008)

*Better to have than have not.......*

I call to get the big guns there, better to have them cancel on scene then having the patient crump on you then call for ALS........ That's my story and I'm sticking to it!


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## YouthCorps1 (Nov 22, 2008)

well first of all...a BP like that isnt normal even if you DO have hypertension. anything relating to medication should have an ALS intercept, as well as c/p due to a potential problem being cardiac-related. i think you did the right thing...just remember...

NEVER DO ANYTHING YOU WOULDN'T WANNA EXPLAIN TO THE PARAMEDICS!!!B)


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## poppawilly (Nov 23, 2008)

i for one am not above calling for als backup if i think the patients condition warrants it.  i work for a fire/ems service in rural oklahoma.  on my crew, we have three basics and one intermediate.  it just so happens our intermediate is our shift commander and getting him to run on a call after midnight takes a act of congress.

for example, we get a 0400hrs call on a diabetic patient who is unresponsive.  the shift commander takes the call but yet elects to send out the bls crew.  once we arrive on scene, the patient is laying in bed and is out.  will not even respond to verbal stimuli but grunts to painful stimuli.  we check the blood sugar with glucometer and get a rediculous high reading.  so we call back to the station and have our als guy come out to push some D50.  when he arrived, he did his job but it was obvious he was not happy about being there.

i believe my als guy has been in the business for a while and doesn't like to take calls.  someitmes, i question if he will even show up when the big one comes in.  in the event he doesn't, i do know other intermediates and paramedics numbers from other crews i will not hesitate to call if needed.  i am a fresh new basic and if i feel i am in a pinch, i'm calling someone and could care less what time it is.  this may change in time with experience but for now, i'm not taking chances.  patient care is my highest priority and i will go above and beyond to better their chances of survival.


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## reaper (Nov 23, 2008)

poppawilly said:


> i for one am not above calling for als backup if i think the patients condition warrants it.  i work for a fire/ems service in rural oklahoma.  on my crew, we have three basics and one intermediate.  it just so happens our intermediate is our shift commander and getting him to run on a call after midnight takes a act of congress.
> 
> for example, we get a 0400hrs call on a diabetic patient who is unresponsive.  the shift commander takes the call but yet elects to send out the bls crew.  once we arrive on scene, the patient is laying in bed and is out.  will not even respond to verbal stimuli but grunts to painful stimuli.  *we check the blood sugar with glucometer and get a rediculous high reading.  so we call back to the station and have our als guy come out to push some D50*.  when he arrived, he did his job but it was obvious he was not happy about being there.
> 
> i believe my als guy has been in the business for a while and doesn't like to take calls.  someitmes, i question if he will even show up when the big one comes in.  in the event he doesn't, i do know other intermediates and paramedics numbers from other crews i will not hesitate to call if needed.  i am a fresh new basic and if i feel i am in a pinch, i'm calling someone and could care less what time it is.  this may change in time with experience but for now, i'm not taking chances.  patient care is my highest priority and i will go above and beyond to better their chances of survival.




Why are you wanting D50 for a high BGL reading?

I think you meant to say that his BGL was low?


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## Brooks416 (Nov 24, 2008)

*State by State*

This is where state protocols come in. In Maine basics can check blood sugar and administer glucose


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## BossyCow (Nov 25, 2008)

Brooks416 said:


> This is where state protocols come in. In Maine basics can check blood sugar and administer glucose



I believe the question is regarding giving more sugar to a hyperglycemic pt. While that's generally protocol if you are unable to determine if the sugar is high or low to give oral glucose, if you know the BGL is high, you would not give D5W.


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