# ALS units on BLS calls



## keith10247 (May 4, 2008)

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.


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## MAC4NH (May 5, 2008)

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.


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## Ops Paramedic (May 5, 2008)

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.


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## Short Bus (May 5, 2008)

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)


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## Ridryder911 (May 5, 2008)

keith10247 said:


> 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.



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


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## MAC4NH (May 5, 2008)

> 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.



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.


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## BossyCow (May 5, 2008)

Ridryder911 said:


> 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



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?


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## KEVD18 (May 5, 2008)

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....


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## firecoins (May 5, 2008)

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.


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## Ridryder911 (May 5, 2008)

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


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## KEVD18 (May 5, 2008)

Ridryder911 said:


> As well, if they are calling you for a stubbed toe, why is EMS responding and transporting?
> 
> R/r 911



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?


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## Ridryder911 (May 5, 2008)

KEVD18 said:


> 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?



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


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## BossyCow (May 5, 2008)

Ridryder911 said:


> > 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?
> 
> 
> 
> ...


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## daedalus (May 5, 2008)

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.


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## JPINFV (May 5, 2008)

daedalus said:


> 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.



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)?


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## Ridryder911 (May 6, 2008)

daedalus said:


> 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.
> 
> ...



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


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## daedalus (May 6, 2008)

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.


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## daedalus (May 6, 2008)

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.


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## Ridryder911 (May 6, 2008)

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


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## skyemt (May 6, 2008)

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...


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## medic417 (May 6, 2008)

This would not be a problem if the publics best interests were considered, rather than cheapest route as so many communitys choose.  It would be best for all patients if every ambulance was a paramedic level ambulance.  This would ensure that someone with the education and skills could properly evaluate and treat them.  In fact if all ambulances were paramedic staffed perhaps more services would start allowing denial of transport to stubbed toes.  Thus we would eliminate many transports thus lessening the load of all emergency services.

There is absolutly no justification to send a basic staffed ambulance on any 911 call.  I have had to many calls to check a persons BP only to find an Acute MI.  Or they just want checked out because not feeling well and code as we arrive.  If basic only responded critical care would be delayed waiting on Paramedics to arrive or no care would be given while driving like idiots to the hospital if not waiting.


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## Jon (May 6, 2008)

Keith,

Given the situation.. I can't see why ALS would release to you. It doesn't make sense to have the ALS crew wait onscene for an extended response of a BLS crew when the hospital is closer... although I've seen the same thing in the county where I work... there are some areas that are covered by BLS ambulances, with the primary or secondary ALS being a transport-capable ALS ambulance... unless the patient is critical, the ALS seems to wait for BLS to get out (or fail to respond), sometimes through multiple stations, until the "ALS" unit becomes due as the BLS unit as well.


Overall... I see an application for BLS ambulances with ALS chase cars... that is what we have where I volunteer. I like it, it works. We can recall medics on BLS calls, and call for the medics when a BLS call becomes ALS. Some systems are set up that way, and they work. Additionally... my county has a decent CAD and BLS vs. ALS coding system... this means that we get overtriage much, much more than undertriage... we recall ALS more than we need to request ALS.
Medic417... I agree that it would be nice to have a paramedic on every call... but there are calls were medics aren't needed. Additionally... there is almost never anything absolute in EMS .


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## daedalus (May 6, 2008)

But see, its not basic vs. medic. We are a team. We need to work together. You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.

We are a team. There should be no doubt in anyone's mind that a paramedic is a higher education than EMT.


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## JPINFV (May 6, 2008)

daedalus said:


> But see, its not basic vs. medic. We are a team. We need to work together. You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.
> 
> We are a team. There should be no doubt in anyone's mind that a paramedic is a higher education than EMT.


Turf battles? In medicine? It's more likely than you think.



> Anne Boisclair-Fahey is used to patients doing a double take when she introduces herself.
> 
> She begins by carefully explaining she's a nurse practitioner, then adds "You can call me Dr. Anne."
> 
> Get ready to meet a new kind of hybrid at your local clinic: the doctor nurse. They sport name tags with the letters DNP for doctorate of nursing practice.






> Some doctors object
> 
> For years, physicians have resisted the notion of a doctor nurse.
> 
> The American Academy of Family Physicians, for example, wants it made clear to patients that nurses with an advanced degree are not the same as doctors who have been to medical school.



http://www.startribune.com/business/18292444.html


As to the topic, I do believe that patients deserve, at the very least, a paramedic assessment. The simple fact is that while a lot of patients don't necessarily need a paramedic, a lot of those patients don't really need an EMT-B either. Claiming that Basics are good enough would be like walking into an ER and saying a RN is good enough. Sure, RNs can treat a good deal of medical conditions, but I still expect a physician, hopefully one board certified in emergency medicine, to be there too.


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## firecoins (May 6, 2008)

daedalus said:


> You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.



actually, you do see NPs, PAs and MD fighting turf battles all the time.  Even different specialties of MDs fight.  Seen it happen in the hospital during medic rotations.


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## keith10247 (May 6, 2008)

Wow,  I must apologize for striking a bad nerve!  Our dedicated medic units are 24x7 units paid for by the county.  The BLS units are very rarely county paid personnel.  Every unit is free of charge.  If there is a call in my first due, for anything EMS related, a BLS unit is dispatched.  Same way that if there is an EMS call in my first due and there is not a BLS unit in my first due, our engine will be dispatched along with a BLS unit from our 2nd due.  If it is something that could be ALS, an ALS unit from our 2nd due is dispatched as well.  Once the ALS unit arrives, the medics check out the patient and then there is a debate of "who wants to take them?"  The medic points to us and wants us to transport...We have taken many of their transports.  

If it is something like a broken arm or something, an ALS unit will not be dispatched; it is a waste of resources in our county.  We were at the hospital one day and a lady down the street rolled her ankle.  There were no BLS units available at that time so they dispatched an ALS unit.  The ALS responded to dispatch saying "What is the ambulance at the hospital currently doing?"  (They saw we were finishing up our paper work and would be clearing soon).  They went in service, we took the call.  In that case, it was a valid decision.  

I have seen too many times that our medics do not like to transport.  I ran a call for difficulty breathing on a 6mo.  The mother said the baby had started to turn blue and she had to do cpr on him.  She also stated that the baby had the flu.  The medic told her to give the baby a couple baby tylenol and to go to the dr the next day if he was still having issues.  His justification was that babies tend to do that when they have the flu.  

I was also on a call with a woman who was feeling ill and apparently had some kind of an allergy.  She said she was taking benedryl already and the medic told her to double up her benedryl and contact the dr the next day if she continued to have a problem.  

We had another call where a pt was in a MVA and we had him collared, he was complaining that he had pain in his neck.  The medic uncollared him and told him it was just muscle pain and got a refusal.  

Another call I remember was for chest pains.  The guy gets ran a lot; he was a 75yo with history of heart attack.  The medics came in, the second they stepped in, they said "Did you run out of medications again?!"  The wife was so upset that she refused to let the medic transport and drove him to the hospital herself.  It was against protocol for a BLS unit to transport a chest pain pt so we could not help.    

I guess the point of my long post is that it sometimes appears to be a "need vs. want" decision.


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## JPINFV (May 6, 2008)

keith10247 said:


> I have seen too many times that our medics do not like to transport.  I ran a call for difficulty breathing on a 6mo.  The mother said the baby had started to turn blue and she had to do cpr on him.  She also stated that the baby had the flu.  The medic told her to give the baby a couple baby tylenol and to go to the dr the next day if he was still having issues.  His justification was that babies tend to do that when they have the flu.



ALTE ("Apparent Life Threatening Event")=ALS, especially with an extended transport time.

Do not pass go. Do not collect $200

http://www.aafp.org/afp/20050615/2301.html


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## medic417 (May 6, 2008)

Jon said:


> Medic417... I agree that it would be nice to have a paramedic on every call... but there are calls were medics aren't needed. Additionally... there is almost never anything absolute in EMS .



And that is where the right to deny transport would come in.  With properly staffed paramedic ambulances you could triage patient and send them by pov to appropriate care rather than tying up an ambulance and the ER.  It makes no sense to send a basic to any call as we all know how inaccurate callers are with descriptions.  If they call and claim to be dieing odds are they do not even need an ambulance.  But again the call comes in can you just come check my BP almost always turns out to be the call that really needs Paramedics.  Your right there is no absolutes so we should always over respond with a paramedic rather than relying on a paramedic to respond if basic requests.


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## KEVD18 (May 6, 2008)

keith10247,

that medic(or medics) need to be taken out back an shot.


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## jrm818 (May 6, 2008)

All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine.  I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.  

Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.

The only exception to this  that I can think of is the use of CPAP...but I think that is probably moving towards being a BLS skill.  Many studies seem in indicate that "Swoop and Scoop" is probably the best treatment option for many or most patients.

So here's the challenge: find studies that prove me wrong, and post them up.  This thread has been debated to death, so lets try something new - inject something more than personal posturing.


----------



## medic417 (May 6, 2008)

jrm818 said:


> All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine.  I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.
> 
> Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.
> 
> ...



Actually there are numerous studys that show better results of higher care over the scoop and run crap that has killed so many of our members.  If you truly believe we need to just be taxi drivers get a new job as you are hurting our profession.  The study you refer to as evidence has been shown to be very flawed while there have been numerous much more extensive studies showing positive outcomes from more aggressive advanced field care.  Am I going to cite them?  No. The only way you learn is to do some research rather than relying on the smoke blown up your rear by others.  This is research that any quality education would have required you to do.  I will give you a hint though many of those studys have been referenced in many EMS forums.  

As already mentioned most calls do not need ALS heck they do not even need a doctor if you want to be honest.  If all ambulances were staffed paramedic then a movement could go to denying transport of people that do not need us and honestly are not going to pay us either.  We need EMS to get back to being for emergencys not taxi rides, but that will require enough education to do an accurate evaluation.  Sorry Basics do not have enough education that medical directors will ever feel safe allowing them to deny transport.  I do not mean to offend I just speak from many years experience, yes I started as a first responder then a basic, then etc.


----------



## MAC4NH (May 6, 2008)

> 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...



Last I heard, there are 0 ALS units in the country equipped with a CT scanner or a procedure room for an LP and *all* BLS units are equipped with an engine, 4 wheels and oxygen.


----------



## Flight-LP (May 6, 2008)

jrm818 said:


> All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine.  I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.
> 
> Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.
> 
> ...



Here you go....................

http://content.nejm.org/cgi/content/full/356/21/2156

http://pediatrics.aappublications.org/cgi/content/full/112/4/976?etoc

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1342973

Just to graze the surface. Now put your money where your mouth is and show us your many studies that prove "swoop and scoop" is the best method of dealing with our patients.

While your at it, why don't you enlighten us to the "numerous pathological events which studies have suggested shows no significant (meaning statical significance) change" with an ALS response. 

Eagerly awaiting your response.........................


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## Flight-LP (May 6, 2008)

MAC4NH said:


> Last I heard, there are 0 ALS units in the country equipped with a CT scanner or a procedure room for an LP and *all* BLS units are equipped with an engine, 4 wheels and oxygen.



Actually some have 6 wheels, depends on the chassis................

A curious question for you, why do you mention oxygen? Would you give it to your "worst headache I've ever had" patient?


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## JPINFV (May 6, 2008)

> Does the Level of Prehospital Care Influence the Outcome of Patients with Altered Levels of Consciousness?
> 
> Abstract
> 
> ...



Now let's consider something about this study. The 3 major final diagnosises were stroke, hypoglycemia, and seziure. Strokes are essentially untreatable in the field past insuring ABCs (which, even here, will vary from location to location. One area's medics might be able to provide surgical/needle airways, another gets to pray if the patient can't be intubated) and making sure it isn't some other pathology (i.e. hypoglycemia).

Seizures was the second category. Well, all seizures stop, eventually. Personally, I'd rather have someone who can stop a seizure treating a seizure patient than one who is limited to making sure the patient doesn't hit their head. On the other hand, a small subset of patients (status epilepticus) would see a paramedic as being worth their weight in gold. Otherwise, there probably isn't much difference between the outcomes if a patient was treated by an EMT-B or a boy scout with an hour of first aid training covering seizures. 

Finally, there is hypoglycemia. A pathology that is successfully treated by paramedics and decreases time in ER by a little over an hour.

Finally, a word about study design. Unfortunately I don't have access to the entire article. It would be nice to see what the actual results were past a simple thumbs up/thumbs down that is statistical significance.


----------



## jrm818 (May 7, 2008)

> If you truly believe we need to just be taxi drivers get a new job as you are hurting our profession



Thanks for the career advice.  If you can't accept that it may be scientifically proven that you need to make a major adjustment to act in the best interest of the patient you do far more harm than do I by suggesting the heresy that ALS may not be worth the expense.


> The study you refer to as evidence has been shown to be very flawed while there have been numerous much more extensive studies showing positive outcomes from more aggressive advanced field care



I meant studies PLURAL.  There are a whole bunch of them.  Most are for trauma or sudden cardiac arrest, I don't recall ever reading a more generalized study - but there are MULTIPLE studies that support my argument.  What one study are you referencing?  My guess is the OPALS study? (which looked decent to me)

Also: Who "showed" the study to be flawed?  It's pretty rare in the scientific community for there to be such unquestionable consensus about a study.



> Am I going to cite them? No. The only way you learn is to do some research rather than relying on the smoke blown up your rear by others.



This isn't smoke blown by others, this is a result of my own research motivated by my own curiosity.  I've read numerous articles and many many more abstracts, and they all seem to be saying sort of the same thing.

Sorry....the literature that my research turned up tends to disagree with you. And yes, I have experience doing this sort of research, and while I have not done an exhaustive literature search, I would be very surprised to find that my skills were so deficient that I completely missed a scientific consensus that ALS works.

If that is the case - I seriously want to be enlightened, and am apparently incapable of locating the literature you are referencing.  Surely it would not be so onerous to give me a starting point.


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## JPINFV (May 7, 2008)

To be fair, there's studies that show that "Home Boy Ambulance Inc" (POV) provides better prehospital care than any ambulance provider. Should we scrap EMS completely in favor of POVs?


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## jrm818 (May 7, 2008)

Flight-LP said:


> Here you go....................
> 
> http://content.nejm.org/cgi/content/full/356/21/2156
> 
> ...



Down, Sarcasm.

This is more brief than I intended because I need to sleep.

Your studies:
1. I've been looking for this actually.  I've been embarrassed that I couldn't find this portion of OPALS.  No clue how it slipped past me.  I'll read it in the morning, at any rate. For now note that OPALS found no benefit to ALS in trauma or cardiac arrest...there's two of your "pathological conditions."

2. The kirby study isn't even about prehospital care.  It's about in-hospital care and suggests that it may be hard to transfer lessons learned in childrens hospitals to normal hospitals, never mind to prehospital providers.  ALS is only mentioned in terms of interfacility transport.

3. Haven't read this study, will later.  Have read at least one similar study (from Spain as I recall), Peds may be one case where ALS is beneficial.


My counter list (chosen because OPALS is huge, and the other 2 are analyses of multiple other studies).  Sorry, too late at night for me to get you links, you have to find them yourselves.

1. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.
CMAJ. 2008 Apr 22;178(9):1141-52.
PMID: 18427089 [PubMed - in process]

2. Liberman M, Mulder D, Sampalis J: Advanced or basic life
support for trauma: meta-analysis and critical review of the literature.
J Trauma 2000, 49:584-599.

3. Isenberg DL, Bissell R.
Does advanced life support provide benefits to patients?: A literature review.
Prehosp Disaster Med. 2005 Jul-Aug;20(4):265-70. Review.
PMID: 16128477 [PubMed - indexed for MEDLINE]


I can post more random links later if you want me to keep proving myself.  

Also that one posted above by JPINFV.

Ok time to sleep, adios for now all.


----------



## Ridryder911 (May 7, 2008)

jrm818 said:


> All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine.  I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system actually improves patient outcome.
> 
> Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.
> 
> ...



Alike most medicine, injury prevention and treatment prophylacticly is the usual goal. It is hard to measure one's worth, if the injury or illness did not occur. The whole reason EMS was developed was because more injuries and deaths occurred from "scoop and swoop" methods, than was occurring in Vietnam conflict at the time. There is your answer on anecdotal incidents. 

Amazing everyone tends to review the OPALS study, but when critiqued it is rarely cited for several reasons. Yes, it did have a numerous amount of participants and yes was lengthy in time. Maybe too much. Again, there study revealed that BLS should be within four minutes for every response... Wow! That would be nice, as well a comprehensive emergency department to receive the patient. And I would like McDonald's to give me free meals.. see which occurs first. OPALS study alike many other studies did not reveal ALS caused harm rather not much change in outcomes. 

The same could be said about Level I Trauma Centers does not have any benefit in patient care over Level II. In fact when investigating American College of Surgeons (ACS) review, Level II has equal to better outcomes. Now, consider CPR with an outcome of <6-10%; would we consider this a success? But we still have both and still perform those measures as well ... Why? Until something better can be developed, we have to provide the best care possibly known at this time. BLS care success past the 4-8 minute response drops remarkably and again has to followed up with ALS care. So why not deliver both simultaneously?  I am definitely all in favor for patient outcome based medicine, but we also have to place "common sense" in the factor. Costs, potential reduction of over burden to providers, are more than anecdotal factors that are not commonly placed in studies. 

Now, consider this... if OPALS was such as success, why are they still pursuing ALS care (even more in-depth than U.S.)? 

In regards to the Paramedic that informed the mother to see a PCP for her baby, I hope that this was turned in. His/her should be formally investigated and actions should be taken for gross incompetence. 

As well in regards to my posts abut headaches, my intent was most headaches are "blown off" when in fact, they could be life threatening. BLS providers are not adeuately trained to determine if it is life threatning or not. Rarely, I ever see a physician that does not perform a whole work up on a "worst  H/A ever" complaint. It only takes once .. and they won't do that again. 

R/r 911


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## daedalus (May 7, 2008)

firecoins said:


> actually, you do see NPs, PAs and MD fighting turf battles all the time.  Even different specialties of MDs fight.  Seen it happen in the hospital during medic rotations.



In my four years in public health and community medicine, I have seen PAs, NPs, and MDs work together like clockwork in simi valley, california. No turf wars except when the Kaiser residents would come in to volunteer, which one would get to remove the toenail.

Thats not the point. Team work is important. BLS first responder giving a seemless and competent report to the arriving paramedic ambulance, working as a team to load up, and things to that end.


----------



## MAC4NH (May 7, 2008)

> As well in regards to my posts abut headaches, my intent was most headaches are "blown off" when in fact, they could be life threatening. BLS providers are not adeuately trained to determine if it is life threatning or not. Rarely, I ever see a physician that does not perform a whole work up on a "worst H/A ever" complaint. It only takes once .. and they won't do that again.



So how can an ALS provider in the field determine if it's life threatening or not it if the physician needs to do a full workup?  Sounds like ABC's and prompt transport are the solution.  In an area where there are long transport times, I agree that ALS would be better in case the patient crashed.  In an urban area, there's not that much more an ALS provider can do for the patient than a BLS provider.  BTW, in my system, a headache not accompanied by AMS is a BLS dispatch.  And no, we don't blow them off, even if we do think it's BS.


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## daedalus (May 7, 2008)

Now this thread has got me going. Can we review medical emergencies where we as prehospital providers can make a proven difference?

Ones off the top of my head:

1. Cardiac Arrest. If patient is taken to hospital by POV, pt is a gonner. Pt needs EMS intervention to live. And fast.

2. FBAO. Without bystander clearance maneuvers, BCLS by EMT, or body removal with ALS technique, pt will die.

3. Near Drowning and Respiratory arrest. Pt needs resuscitation and medical transportation to hosp ED.

4. Trauma with entrapment. Medically supervised extrication and immediate transport, DX and TX shock PRN.

5. Syncope and Seizure. EMS needed as much for calming the public and providing transport as needed. This is a presence factor.

All others, including SOB, COPD exasperation, chest pain, broken arms, etc etc, can probably be transported to ER by POV, BLS and ALS care in the field will probably just delay definitive treatment.

This is a theory, can you prove it otherwise?


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## JPINFV (May 7, 2008)

jrm818 said:


> Also that one posted above by JPINFV.



Of course for 2 of the 3 pathologies of that study, there would most likely be zero difference between if the patient was transported by POV vs being transported by an ambulance.


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## firecoins (May 7, 2008)

daedalus said:


> In my four years in public health and community medicine, I have seen PAs, NPs, and MDs work together like clockwork in simi valley, california. No turf wars except when the Kaiser residents would come in to volunteer, which one would get to remove the toenail.
> 
> Thats not the point. Team work is important. BLS first responder giving a seemless and competent report to the arriving paramedic ambulance, working as a team to load up, and things to that end.



what makes you think EMT and Medics don't work as a team?  Because they argue on an internet forum?  

Yes PAs, NP and MDs will work together and have turf battles.  They aren't mutually exclusive.  Not everything occurs in front of a patient.


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## Flight-LP (May 7, 2008)

MAC4NH said:


> In an urban area, there's not that much more an ALS provider can do for the patient than a BLS provider.



AMI

BLS - O2, rapid transport to ER, possibly ASA and NTG administration

ALS - O2, ASA, NTG, Morphine, 12 Lead EKG for confirmation, Lopressor, Heparin, direct transport to Cath Lab

Seems like a pretty big difference to me......................


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## daedalus (May 7, 2008)

Paramedic with heparin?  Not in my county. They can't even transport someone with a drip of hep going. Lopressor...forget about it.

A CCT unit is needed for both those meds. 

Even RNs make mistakes with these extremely dangerous drugs. At Cedars-Sinai.


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## JPINFV (May 7, 2008)

Daedalus, just wondering, where are you currently working?

As to Flight-LP, where I worked you could cross off lopresor, heparin, and ASA from that list.


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## MAC4NH (May 7, 2008)

> AMI
> 
> BLS - O2, rapid transport to ER, possibly ASA and NTG administration
> 
> ...




I didn't say anything about AMI.  I was referring to a headache.


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## daedalus (May 8, 2008)

Just started with AMR in LA County. 911 transport provider for LACOFD.
I live in Ventura county.

I used to work for another private service, which shall remain nameless. I did CCT and ALS transport as the EMT/Driver. Interfacility only type of stuff.


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## Ridryder911 (May 8, 2008)

Okay, here we go again. Lower level and those without the medical expertise that assume they know what medications are dangerous, what is best for the patient. Not to be sarcastic, but that would be similar if I took a basic firefighting class and attempted to tell a Fire Chief on how to fight structure or handle a haz mat incident. Really, where and why do so many assume they have the insight to make assumptions. 

Please cite where Heparin is such a "dangerous drug"? Yes, the incident in regards to neonate (as all medications) can be considered such. Heparin is a routine medication that is given thousands of times an hour in the U.S. without any major problems. Can it be dangerous... you bet, alike ASA, Tylenol, etc.. 

As well, what expertise do most have to determine what is needed metro, rural, suburban, and to describe ABC's are enough? Really, how many thousand calls and years of education, did you make that determination? How many respiratory arrest have you actually managed by yourself? How many aspirations did you care for? As well, in regards to fracture arms, strains, possible fxr ankles, denying pain management is horrible treatment and poor care! Sorry, break your arm and see if you would like to suffer with it. Where do we get off saying patients should be denied analgesics for fractures & potential fractures? That those are really a BLS call? Again, is there really such a thing? I could debate that statement on most or almost all calls. 

So it goes back again, many that do NOT have the education and knowledge, attempting to "assume" they know what is best. Maybe, furthering ones education, gaining experience, should be considered first before making assumptions. 

R/r 911


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## Flight-LP (May 8, 2008)

MAC4NH said:


> I didn't say anything about AMI.  I was referring to a headache.




I realize that, but the point has been made. Not just to you, but to the rest of the EMT-B's that have this belief that they are the best level of care and that ALS is pointless. Every single time this topic comes up, there a few statistically significant events that occur..............

1. An EMT-B initiates the point that ALS care isn't better than BLS care.

2. One or more additional EMT-B's jump on the bandwagon.

3. All parties then side step rebuttals from statistical research that is presented by ALS providers who know better as evidenced by the care they provide on a daily basis.

4. EMT-B's get mad and feel personally insulted.

5. Admin eventually steps in and locks thread.

So why do we continuously argure this point? YOU ARE WRONG, PERIOD!

Stop bi^#*ing about it. Want to make a difference, then promote your career and level of care by becoming a Paramedic. Then you won't have this continuous inferiority complex that constantly plagues the forum. 

ALS care is and always will be more efficient for patient care. It allows for a higher knowledge base, a more thorough assessment, and more definitive care through the use of available ALS pharmaceuticals and diagnostic equipment. Regardless of the previous arguments about having ALS everywhere, the consistant belief presented is that ALS is still a higher level of care than BLS and therefore is better if available to that particular community.

Trauma studies to support your mythical belief offers zero validation. Neither BLS or ALS saves a trauma patient. A TRAUMA SURGEON saves the trauma patient. Time, distance, and extent of injuries determine the outcome.

Sorry to jump on you MAC4NH, but these topics get old after years of argument, its nothing personal, just something to think about. Just a strong belief from one who has witnessed it first hand for almost 2 decade's......................

Keep it safe friends!


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## Flight-LP (May 8, 2008)

Ridryder911 said:


> Okay, here we go again. Lower level and those without the medical expertise that assume they know what medications are dangerous, what is best for the patient. Not to be sarcastic, but that would be similar if I took a basic firefighting class and attempted to tell a Fire Chief on how to fight structure or handle a haz mat incident. Really, where and why do so many assume they have the insight to make assumptions.
> 
> Please cite where Heparin is such a "dangerous drug"? Yes, the incident in regards to neonate (as all medications) can be considered such. Heparin is a routine medication that is given thousands of times an hour in the U.S. without any major problems. Can it be dangerous... you bet, alike ASA, Tylenol, etc..
> 
> ...



New rule, Rid, you can no longer type when I am! 

Too much logic and truth at once can hurt................


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## Arkymedic (May 8, 2008)

KEVD18 said:


> 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?


 
This is why ABNs exist.


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## Arkymedic (May 8, 2008)

daedalus said:


> 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.
> ...


 
I think we need to make it so EMT is at least a 2 yr associates program with A and P I and II, english, life span development, etc and Paramedic needs to become a four year bachelors degree. I think this would add to both sides education. Canada had this one right...


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## mdkemt (May 8, 2008)

Our protocols state to call ALS no matter what.  This may have been a load-and-go situation which they should have done but you still have to call ASL.  You can never be to safe or careful.  Sometimes situations can turn real bad real quick.


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## skyemt (May 8, 2008)

Flight-LP said:


> I realize that, but the point has been made. Not just to you, but to the rest of the EMT-B's that have this belief that they are the best level of care and that ALS is pointless. Every single time this topic comes up, there a few statistically significant events that occur..............
> 
> 1. An EMT-B initiates the point that ALS care isn't better than BLS care.
> 
> ...



try not to generalize, please... i am a basic, and have continually argued the same as you... just because there are basics that are misguided out here, there are also a great number that are not...

but you are correct, the same thing happens every time... lol

and frankly, the arguments against ALS care is just silly.


----------



## Flight-LP (May 8, 2008)

skyemt said:


> try not to generalize, please... i am a basic, and have continually argued the same as you... just because there are basics that are misguided out here, there are also a great number that are not...
> 
> but you are correct, the same thing happens every time... lol
> 
> and frankly, the arguments against ALS care is just silly.



I actually thought about you when I posted, I figured a response was coming. Sorry for the generalization, but sometimes people just don't get it. I do appreciate your postings and your effort. It nice hearing the same thing coming from someone other a "Paragod" with a huge ego (as I have been called numerous times!).....................


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## JPINFV (May 8, 2008)

skyemt said:


> try not to generalize, please... i am a basic, and have continually argued the same as you... just because there are basics that are misguided out here, there are also a great number that are not...
> 
> but you are correct, the same thing happens every time... lol
> 
> and frankly, the arguments against ALS care is just silly.



It helps to realize that sometimes you are the exception, not the rule.


----------



## MAC4NH (May 8, 2008)

> Originally posted by *Flight-LP*:
> 
> 1. An EMT-B initiates the point that ALS care isn't better than BLS care.



I think you're misunderstanding my point.  I don't believe that ALS and BLS are at the same level.  I do believe in the importance and necessity of ALS and I may even become a paramedic myself someday (if I can inflate my ego enough )

However please understand that conditions and situations are different in different areas.  What is good for rural Utah may not work as well in the middle of Boston or in DC.

In my system, medics are getting burned out from running around chasing calls that do not require ALS (this comes from the ALS providers, not from me).  There are many people here who abuse the system and call 911 for everything from a hangnail to head lice.  I hear all the arguments that we need to change the system and triage these calls or refuse to respond to some calls.  I agree.  Everyone involved in the medical field here agrees.  However there are tens of thousands of lawyers in the northeast who are trying to prevent this with every fiber of their being.  Oh, BTW, most of the politicians in my state are, guess what?  Lawyers.  Yes, change would be good.  But until then, this is our reality.  We have to answer every call that comes in and treat it like a real emergency.  If we don't, we could get sued or, even worse, our employer could get bad press (No! Anything but that!).

In your view of the system, highly trained ALS providers would spend half their day picking up homeless drunks.  *The same drunks they picked up yesterday and the day before* for the *same reason they picked them up the yesterday and the day before*, ie they were cold and/or hungry.  They will also pick up the 25 year old with the head lice.  They will pick up the 30 year old complaining of non-specific pain who, BTW, somehow always manages to call when his/her percocet runs out.

We have a statewide paramedic shortage as it is.  If we add these calls to their workload, what will that do the burnout rate?

As an EMT who has been doing this for 20 years, I realize that the above patients are abusing the system.  But I also realize that the system is a semi-willing party to this abuse.  Many of these people do need help.  Do they need ALS?  No way!  Do they need BLS?  Probably not.  They need an alternative to the ED.  There are smarter people than me working on alternatives.  Until then, this is what we have to live with here.  

While I did not mean to Medic-bash, I hope you ALS providers realize that you are not doctors either and that whether ALS or BLS we all basically *take patients to the hospital*!  And maybe in your particular system, you don't need or want BLS. In mine the medics would be pretty upset if they had to do my job.


----------



## daedalus (May 8, 2008)

Ridryder911 said:


> Okay, here we go again. Lower level and those without the medical expertise that assume they know what medications are dangerous, what is best for the patient. Not to be sarcastic, but that would be similar if I took a basic firefighting class and attempted to tell a Fire Chief on how to fight structure or handle a haz mat incident. Really, where and why do so many assume they have the insight to make assumptions.
> 
> Please cite where Heparin is such a "dangerous drug"? Yes, the incident in regards to neonate (as all medications) can be considered such. Heparin is a routine medication that is given thousands of times an hour in the U.S. without any major problems. Can it be dangerous... you bet, alike ASA, Tylenol, etc..
> 
> ...


Sir, you have no right nor standing to make such a claim. And yes, Heparin is very dangerous if it is allowed to drip more than it should. Special care is required to ensure it is given safely in controlled circumstances. As a RN, you very well know that. My four years of partnering with the chief of staff (an MD) of a local hospital to learn about hospital and internal medicine give me the right to say that, not my silly "EMT" training. As a rule, definitive diagnosis and treatment are in the domain of doctors, and EMS should provide critical, simple interventions proven to influence positive outcome, and rapidly transport in an ALS ambulance. EMS should leave definitive treatment to the hospital. 

While I know next to nothing about LMWH, I can tell you that a patient on UH needs to be hospitalized and watched closely by an experienced RN. Check the Journal of Family Practice, because that is their recommenced guidelines for using UH.


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## JPINFV (May 8, 2008)

daedalus said:


> As a rule, definitive diagnosis and treatment are in the domain of doctors, and EMS should provide critical, simple interventions proven to influence positive outcome, and rapidly transport in an ALS ambulance. EMS should leave definitive treatment to the hospital.



Ah, but if only it were that simple. The fact is that paramedics are required, if not in written word, but by the reality of their function, to produce a differential diagnosis. Not all patients with shortness of breath need Albuterol while not all chest pains need nitro. The decision on what the patient has, and the development of a proper treatment plan due to that, is in simple terms, a diagnosis. Yes, EMS is not definitive care, but there are plenty of conditions in systems with the right tools, training, and education where EMS is definitive emergency care.


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## daedalus (May 9, 2008)

Agreed. I am speaking about advanced therapies such as tPA and Heparin. Im am not putting down the education and abilities of a paramedic. Most of which are very well capable of differential dx and should be as well.


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## firecoins (May 9, 2008)

Ridryder911 said:


> Okay, here we go again. Lower level and those without the medical expertise that assume they know what medications are dangerous, what is best for the patient.



All drugs are dangerous in the hands of untrained professionals.  They are even dangerous to medical professionals who don't pay attention.  The misuse of heparin has been the subject of many lawsuits. But yes, Heparin is not dangerous to a trained professional who is careful in his opr her use.    

http://www.drugs.com/pro/heparin.html


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## ffemt8978 (May 9, 2008)

Flight-LP said:


> 5. Admin eventually steps in and locks thread.



Sorry, I've been busy the past couple of days with a new job.  In catching up on this thread, that is exactly where it is heading unless everyone takes a deep breath and calms down.


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## JPINFV (May 9, 2008)

JPINFV said:


> Does the Level of Prehospital Care Influence the Outcome of Patients with Altered Levels of Consciousness?
> 
> Abstract
> 
> ...


http://pdm.medicine.wisc.edu/adams.htm


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## BossyCow (May 9, 2008)

Okay, I'm really confused now! How can a thread that starts out with an EMT-P, Paramedic, ALS unit determining that a call is only BLS and turfing it to a BLS unit for transport turn into EMT-B bashing???? 

In the original post, the pt was assessed by a Medic, so what does any of this have to do with EMT-B educational standards or levels of training? Higher level made the call and its still a matter of EMT-Bs overstepping their authority? I really don't follow the logic on this one!


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## keith10247 (May 9, 2008)

First of all,  this thread has gone crazy!  

I just want to clarify something.  I did not start this thread in any way to start a debate.  My question was simple; is it common for ALS to downgrade calls and request BLS to come and transport the pt or will they transport a BLS patient to the hospital if there are no BLS units within a 10 mile radius.  

I am in no way implying that ALS is useless.  We get calls every once in a while where a pt will degrade during transport and we will ask a medic to rendevouz(sp) with us so they can provide ALS care to the pt.  If it is a call that we do not feel comfortable taking because it is out of our scope, we call for a medic.  

In my county, BLS units are not allowed to transport ALS pt's unless a medic tells us it is a BLS call and they release the pt to us or if it is quicker for us to get to the hospital before they can get to us (ie, during times we are low on medic units).  

I am not sure how this got in to a debate of "who's is bigger" thread and I apologize for starting the topic.  

I am very greatful for most of our medics!


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## skyemt (May 9, 2008)

BossyCow said:


> Okay, I'm really confused now! How can a thread that starts out with an EMT-P, Paramedic, ALS unit determining that a call is only BLS and turfing it to a BLS unit for transport turn into EMT-B bashing????
> 
> In the original post, the pt was assessed by a Medic, so what does any of this have to do with EMT-B educational standards or levels of training? Higher level made the call and its still a matter of EMT-Bs overstepping their authority? I really don't follow the logic on this one!



if you read the thread, it should be obvious to you... posts, which reveal a 
lack of knowledge.... opinions, based on no experience and innaccurate information, the usual culprits, but not necessarily from the OP.

you've been out here long enough to know what sends these threads this way and why...


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## Jon (May 9, 2008)

OK FOLKS.

MOVING ON.

Here is the original post... so look at it again and see if you can answer the question. Is it normal for ALS to downgrade to BLS? How does it occur?

We've got enough BLS vs. ALS threads - we don't need another.

Rather than knock holes in each other... why don't we all recognize that our systems are NOT perfect worlds... and we've got lots of stupidity in our EMS systems and protocols... nationwide... so stop critizing others, and post what YOU do to answer the OP's question!




keith10247 said:


> 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.
> 
> ...


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## NJWhacker (May 15, 2008)

NJ makes the whole BLS and ALS thing weird. ALS can only be hospital based. There is only one ALS transport company that I know of in the state. I could be incorrect but its the only one Ive seen or heard. So BLS is the many source of transport in the state. I know with our town we have the list of what kind of calls, based on dispatch nature, will have ALS dispatched along with us. Most of the time they get cancel on scene, but Id rather having them rolling in case SHTF then having to call for them.


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## MAC4NH (May 16, 2008)

> NJWHACKER wrote:
> 
> NJ makes the whole BLS and ALS thing weird.



It gets more weird.  A SCTU is staffed with a nurse (MICN) and a paramedic (some units add an EMT-B driver) so they can do the critical care transports as well as answering ALS calls.  Although this is an ambulance, if it gets sent on an  ALS call, the patient still goes in a BLS rig.  If it doesn't have a paramedic (just the Basic and the RN), it can do BLS transports in addition to the SCTUs.  It never does ALS transports except as follows:  In Newark and Jersey City (and probably other cities too) where ALS and BLS both work for the same hospital, ALS ambulances do transport.  In Hudson county, ALS ambulances generally will transport only within Jersey City so they don't step on out of town BLS toes.  In an extreme case they will transport a patient from outside the city but only if the patient is in bad shape and there really isn't any BLS available.  The units answering calls outside the city are usually non-transport capable Tahoes.

While this seems to make little sense, there are two reasons for this mess.  1:  In the volly areas, it's a turf battle.  The volunteers see ALS transporting as an intrusion on their turf that is really just a money-making scam for the hospital.  2:  In paid areas, there is a lot of truth to reason #1.  Medicare rules at this time will only pay the *Transporting* agency for the call.  So if the ALS unit works up a patient, renders treatment and sends a bill, said bill is ignored by Medicare if the ALS unit did not transport.  Now the BLS provider who primarily transported the patient  will get paid the full amount allowed.  In Jersey City or Newark, it doesn't really matter who transports as the bill comes from the same agency.  In the North County, only the transporting agency's bill is paid.  That is why the ALS providers want to transport and the BLS providers are trying to block them.  BTW, whatever Medicare does is generally followed by other insurance providers.  

In NJ, if something doesn't make sense, follow the money and the picture gets much clearer.


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## MAC4NH (May 16, 2008)

I forgot one thing:  If the transporting agency is a volly, the ALS provider gets paid because the transporting agency doesn't bill.  Medicare will pay for a transport but they see paying for both ALS and BLS as paying  twice for the same service.


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