# Triaging down to BLS



## ParamagicFF (Jul 17, 2018)

I'd like to start a discussion regarding systems where both ALS and BLS transport are available, particularly ones where ALS can triage calls down to BLS for transport. 

For those of you who work in systems like this, do you have a clear and specific protocol for what requires ALS intervention and/or transport? Is it solely based on provider decision? Maybe it's somewhere inbetween with lots of grey area? Are there any patients that are mandated as ALS transports with no specific ALS intervention required?

How comfortable are you in these systems? Do you feel like the standards for ALS/BLS transports are applied fairly evenly across your system? Are there any patient conditions that you feel on the fence about?

Having only been in a system like this for 2 years, I'm interested to hear about others' experiences!


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## NPO (Jul 17, 2018)

I previously worked in a system where both ALS and BLS was available but hand down was not allowed. They have since transitioned to a hand down system but I'm not familiar with the ins and outs.

My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative. 

A lot of my decision on if I hand off to a BLS partner is their competency level, and my level of familiarity with my partner. If it's my normal partner, I know he's a skilled and capable provider that I can trust. With newer EMTs who may lack experience in assessment, I may be more cautious.


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## ParamagicFF (Jul 17, 2018)

NPO said:


> My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative.



At the risk of starting a tangent, this is how my previous department was. I thought it was a great system for developing EMTs, especially those who were looking to become paramedics. If something goes wrong you can always pull over and swap out if an ALS intervention becomes necessary. That shouldn't be happening often, but it's a good safety net.


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## NPO (Jul 17, 2018)

ParamagicFF said:


> At the risk of starting a tangent, this is how my previous department was. I thought it was a great system for developing EMTs, especially those who were looking to become paramedics. If something goes wrong you can always pull over and swap out if an ALS intervention becomes necessary. That shouldn't be happening often, but it's a good safety net.


I've had to do that only once. It was on a transfer. The patient became extremely anxious and nauseous. To the point of being a safety concern. I took over and treated the nausea. I almost gave him some Versed, but we were getting close. Had it been further I'd have considered it.


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## EpiEMS (Jul 17, 2018)

ParamagicFF said:


> For those of you who work in systems like this, do you have a clear and specific protocol for what requires ALS intervention and/or transport? Is it solely based on provider decision? Maybe it's somewhere inbetween with lots of grey area? Are there any patients that are mandated as ALS transports with no specific ALS intervention required?



As a BLS provider in a system where we are often B/B with a medic fly car, I often take handovers from ALS: the fly car medic with or before us, evaluates the patient (with or without our collaboration) and hands over the patient to us.

My protocols are pretty explicit:



> When transferring care from one provider to another, the transfer must be to a provider of equal or higher level, unless the patient’s condition and reasonably anticipated complications can be effectively managed by a lower level provider’s scope of practice.



In our old protocols, we had a comprehensive list of conditions, signs, and symptoms where paramedic transport (rather than downgrade to BLS) was warranted. I like this approach, but the most important thing is covered in the block quote above...basically, ALS transport is indicated unless there's no foreseeable reason why the patient needs (or could reasonably need) anything more than BLS care.

I've refused to take patients that were downgraded to me and was glad I did. I'm not transporting somebody when I think I can't manage them.


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## DrParasite (Jul 17, 2018)

NJ is an entirely tiered system.... having ALS triage a patient to BLS was very common, especially if ALS arrived first and the patient was BLS.  

As a general rule, ALS may triage a patient who is stable, and who does not require any ALS interventions.  This patient should not require any ALS interventions until they arrive at the hospital.  Have ALS triaged questionable patients?   yep.  have they been pulled into the QA office when the patient deteriorates?  yep.  does it happen often?  no.


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## soflomedic14 (Jul 17, 2018)

As far as my knowledge is concerned, we only have ALS departments in South Florida unless you work for a private ambulance company. 
I definitely think the option of triaging down to BLS would be very beneficial especially in the area I work because it is SO busy all the time so it would help with transports for sure and getting ALS to the scene of a call where ALS is needed and keep BLS where BLS is needed (I hope that makes sense.)


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## Jim37F (Jul 17, 2018)

NPO said:


> My current service staffs only ALS ambulances, but we can allow the EMT to take the call if we think it's appropriate. There is no written guideline or policy on this. It is provider discretion, and as such some paramedics are loose with this, some are very conservative. I tend to be conservative.


Pretty much how my County's EMS runs. I've seen some medics ride in for everything, others will have their EMT attend as much as they can get away with. I've seen a medic hop in the drivers seat calling out thru the passthru for his EMT to go ahead and start a line and give zofran for an otherwise BLS trip lol


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## Uclabruin103 (Jul 17, 2018)

I used to work in LA County, and there was a specific protocol on what constitutes ALS vs BLS. I now work in a B/P staffed ambulance where no one lets their basic attend. There was a protocol to downgrade to ALS if no medic boxes were available, but it was rarely used in my current county .

I was totally comfortable transporting. Only once did a patient deteriorate, so we just pulled over and got an intercept .I feel it's not an appropriate use of resources to tie up medics, let alone ambulance, on obvious BLS transports.

There's always that thought of what might happen, but that's found everywhere . We have to use common sense for some of our policy choices. People die in hospital waiting rooms, so you never can prevent everything.  

Of course there's abuse of the downgrade, especially at night when tired, but that's not the norm.


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## ParamagicFF (Jul 18, 2018)

EpiEMS said:


> In our old protocols, we had a comprehensive list of conditions, signs, and symptoms where paramedic transport (rather than downgrade to BLS) was warranted. I like this approach, but the most important thing is covered in the block quote above...basically, ALS transport is indicated unless there's no foreseeable reason why the patient needs (or could reasonably need) anything more than BLS care.



I'd be interested in seeing what was outlined as requiring ALS. Would you mind sharing some of those details?


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## DrParasite (Jul 18, 2018)

For clarification, are you talking about a B/P system, where the Paramedic "triages" to their EMT partner?  or a case where you have a B/B ambulance, with a paramedic intercept used for ALS criteria calls, and will triage the patient to the EMT crew for transport to the hospital?

The reason I ask is a paramedic can ALS almost anything.  It can be based on the "well, this might happen, so I can't triage it" or it's the "hey EMT, start a line on the patient and give zofran, oh wait, I need to run a 12 lead now, no longer a BLS patient."  Downgrading can be similar, although it's tough (but not impossible) to justify downgrading a 70 year old with chest pain, despite everything else being normal (NSR, no ectopy, no other signs of cardiac issues, etc).  From a clinical standpoint, does your medical director or clinical administration trust your providers judgement as to what should be ALS vs BLS?

Also, in the B/P system, often the paramedic has to write a chart on the patient anyway (based on anyone they assess), so if they triage to their partners, now both need to write a complete chart. Otherwise, how can the paramedic justify his or her rationale for triaging?

As an EMT, I felt very comfortable working in an intercept system.  EMTs were expected to be good at determining whether ALS was needed or not.  Paramedics knew their jobs: to treat sick patients who required ALS interventions.  EMTs treated the rest.  I think it was roughly 80:20 BLS to ALS ratio in terms of BLS treats vs ALS treat.

There are some paramedics who triaged questionable patients.  QA reviewed the calls and took action if needed.  I was on calls where the paramedic triaged a questionable patient.  sometimes nothing happened, and we had an uneventful transport.... during one such calls, where my EMT partner and I were dumbfounded that the ALS triaged the patient, and she went into respiratory arrest on the way to the ER.   But they are the higher level of medical care, so it's their call on who they treat (we ventilated the patient, continued on to the ER, and requested a different unit for an intercept).

for most EMS calls, the patient can be transported by BLS without any negative patient outcome.  There are absolutely those calls that warrant ALS, but if you are working in an all ALS system, and most calls are BLS, than you have those highly trained and educated providers spending most of their day dealing with BLS patients, which leads to skill deterioration and dilution.


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## ParamagicFF (Jul 18, 2018)

DrParasite said:


> For clarification, are you talking about a B/P system, where the Paramedic "triages" to their EMT partner?  or a case where you have a B/B ambulance, with a paramedic intercept used for ALS criteria calls, and will triage the patient to the EMT crew for transport to the hospital?



I'm referring to systems where an ALS first responder or ALS transport unit triages down to a solely BLS transport unit.


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## EpiEMS (Jul 18, 2018)

ParamagicFF said:


> I'd be interested in seeing what was outlined as requiring ALS. Would you mind sharing some of those details?



Sure, here's some examples from a similar set of protocols (albeit not exactly the same):


> The following are some examples of high-risk conditions that will, for the most part, merit Paramedic care and/or monitoring.
> 1. Primary complaint of chest pain, chest discomfort, palpitations, or syncope in patients of any age.
> 2. Complaint of shortness of breath or difficulty breathing.
> 3. Patients with a new neurological deficit or presentation of stroke.
> ...




Now, I don't agree with all of these (i.e. just because the complaint is difficulty breathing doesn't mean they need ALS transport, particularly if they have a DNR or are screaming at the top of their lungs "I can't breathe!"), but they're mostly reasonable if interpreted within the context of reasonable provider judgement.

Here's another (more current) version of a nearby area's guidelines on this:




> The paramedic may release a patient to a lower-level ambulance crew for further care and transport only if all the following criteria have been met:
> 1. The paramedic has performed a complete assessment as outlined in these guidelines and has a high degree of confidence that the patient would not benefit in any way from advanced life support measures on scene or at any time during the transport
> 2. The paramedic and lower-level ambulance crew agree on a plan for subsequent patient care and the ambulance crew agrees to accept responsibility for subsequent patient care
> 3. The paramedic may not release a patient to a lower-level ambulance crew if any of the following exists:
> ...


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## hometownmedic5 (Jul 18, 2018)

My second job is with a municipal service that runs P/B. I tech every call, not because I dont have faith in my basics(I generally don’t, but thats not the point here), but because I hate to drive.

I have however worked in a tiered system. I triaged what I considered to be BLS calls. I defined BLS calls as calls that needed no acute ALS interventions, and were likely to remain in that category. I blew a few calls, like every other medic in the same circumstances, and I definitely took some patients that would have been just fine with a basic. Nobody is going to get this a hundred percent right and no amount of lists of complaints are going to make it a foolproof system. Some people having MI’s have crushing chest pain etc. Some have benign appearing belly pain. You do this job long enough, you’re going to end up in the bosses office trying to dig your way out of a hole.


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## DrParasite (Jul 18, 2018)

would something from the annals of emergency medicine help?

Can Paramedics Appropriately Downgrade ALS to BLS Transport Based on a Given Set of Protocols?


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## ParamagicFF (Jul 18, 2018)

DrParasite said:


> would something from the annals of emergency medicine help?
> 
> Can Paramedics Appropriately Downgrade ALS to BLS Transport Based on a Given Set of Protocols?



I don't have access to this study. What's the outcome?


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## DrParasite (Jul 18, 2018)

just read the abstract's conclusion, it's in the freely available section.  

the answer is yes.


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## Tigger (Jul 19, 2018)

DrParasite said:


> Also, in the B/P system, often the paramedic has to write a chart on the patient anyway (based on anyone they assess), so if they triage to their partners, now both need to write a complete chart. Otherwise, how can the paramedic justify his or her rationale for triaging?


I cannot say I have ever heard of this. In both states I've worked with split staffing (one medic, one something else), the only person writing a chart was the attending provider. If my EMT takes the call, they can document that I performed an assessment in addition to theirs or put someone on the monitor, and that's about it. Is this common in other areas? That sounds awful.

The BLS ambulances in my area are all but required to transport to either ground ALS or a helicopter. If they do transport to a hospital, it must be the closet facility regardless of patient complaint or status. This sounds bad (and it is) but these are services running at most 300 medical calls a year and they just don't have/won't accept the education to improve to the ability to manage their own patients on what are very long contact times.


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## ParamagicFF (Jul 19, 2018)

I'd be interested to discuss different providers' barometers on different cases. In my agency ALS is definitely a limited resource. You won't be singled out for occasionally transporting a BLS call, but if your charts are reviewed and many BLS transports are found, they will have a discussion with you. Also, there aren't enough ALS resources to simply transport on every call with x complaint.

Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?
I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.
A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?


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## NPO (Jul 19, 2018)

Disclaimer, I tend to err on the side of caution and ALS.



ParamagicFF said:


> I'd be interested to discuss different providers' barometers on different cases. In my agency ALS is definitely a limited resource. You won't be singled out for occasionally transporting a BLS call, but if your charts are reviewed and many BLS transports are found, they will have a discussion with you. Also, there aren't enough ALS resources to simply transport on every call with x complaint.



I don't necessarily have a problem when that. Appropriate resource management is important, especially smaller systems with fewer resources. 

The most important thing is how it's implemented and enforced when they call you in for a talking to.



ParamagicFF said:


> Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?



It depends. Does the EMT know how to assess chest pain and determine the difference between ischemic and nonischemic chest pain? Heck, does the consulting paramedic? Will there be a paramedic doing a full assessment to include EKG, or is this an immediate hand off? 

For nonischemic chest pain with certain presentations it may be appropriate, but if there are adequate resources available it should probably be taken via ALS. 

If an agency has a need to reduce ALS transports due to availability, this is one that needs a specific protocol definitions for hand down if it's going to happen on a routine basis.



ParamagicFF said:


> I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.



Is there evidence or trauma? Other etiologies cleared? Risk of aspiration or airway loss?

If they are conscious, that's better than not.

Again, I feel pretty much the same way, it should probably be ALS, but nonroutine use of BLS when necessary could be acceptable.




ParamagicFF said:


> A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?



If they have a history of hypertension, and are CHRONICALLY noncompliant (as oppose to just missed a dose today), and are truly asymptomatic to the hypertension, then I am fine with that going BLS as long as their BP isnt encroaching over 180 systolic


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## DrParasite (Jul 19, 2018)

ParamagicFF said:


> I'd be interested to discuss different providers' barometers on different cases. In my agency ALS is definitely a limited resource. You won't be singled out for occasionally transporting a BLS call, but if your charts are reviewed and many BLS transports are found, they will have a discussion with you. Also, there aren't enough ALS resources to simply transport on every call with x complaint.


the question you should be asking is "are there enough ALS resources to transport every call that requires ALS resources.  you can't blanketly say every x complaint requires ALS (ok, maybe cardiac arrest..... then again, if they are obviously DOA, do you need a medic?)





ParamagicFF said:


> Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?


my former agency dispatched chest pain under 30 years of age with no diff breathing as a BLS call.  If the patient is under the age of 50, with no other complaints, vitals good, NSR on the monitor, nothing else to make you think it's cardiac related, and you think the patient is stable, would letting BLS give a good ride to the hospital make you uncomfortable? And yes, the older you go, the higher the chances are that a paramedic should probably take a ride, just to eliminate getting flagged by QA and the higher chances of cardiac issues.





ParamagicFF said:


> I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.


again, being drunk is a BLS call.  passing out drunk (and being wakable) is likely a BLS call.  being very drunk is a BLS call.  being completely unresponsive and not responsive to any external stimuli should probably warrant ALS for potential airway issues.  This is, of course, assuming there are no other issues found during a complete assessment, including what else the patient consumed. 





ParamagicFF said:


> A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?


asymptomatic HTN is a BLS call.  non-compliance with meds is a BLS call.  What is a medic going to do?  do the stare of life?  maybe an IV lock?  

Now if there was an acute spike (worst headache, numbness, vision issues, etc), that's a different story.  and yes, HTN can lead to CVA and other bad things.  But it's asymptomatic.  they might have had high BP for the past week and didn't even know it.  what is going to change in the next 2 hours (assuming you have a long transport) that hasn't happened in the past week?


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## ParamagicFF (Jul 19, 2018)

NPO said:


> It depends. Does the EMT know how to assess chest pain and determine the difference between ischemic and nonischemic chest pain? Heck, does the consulting paramedic? Will there be a paramedic doing a full assessment to include EKG, or is this an immediate hand off?
> 
> For nonischemic chest pain with certain presentations it may be appropriate, but if there are adequate resources available it should probably be taken via ALS.
> 
> If an agency has a need to reduce ALS transports due to availability, this is one that needs a specific protocol definitions for hand down if it's going to happen on a routine basis.



For the purposes of my agency, about 99% of the patients who are downgraded are done so by ALS. If ALS is dispatched, it is incredibly unlikely for them to be cancelled en route under any circumstances. In fact, EMTs will also request ALS to come perform an assessment even if they weren't dispatched. It is common to be requested for the "5 year old with chest pain and no medical history" or the "patient who is status post stroke with deficit and now has wrist pain" EMTs provide minimal assessment and honestly have little to do with the decision. We have the "EMT comfort" clause in the policy, but EMTs in my system would rather not transport anything with any medical complaint at all. Not being condescending, as we have some who do a great job, but it is largely a culture problem within my agency.

We do not have anything specific about these patients other than to say "chest pain of males of 40 and females over 30 requires ALS assessment, or any chest pain with a comorbidity".




NPO said:


> Is there evidence or trauma? Other etiologies cleared? Risk of aspiration or airway loss?
> 
> If they are conscious, that's better than not.
> 
> Again, I feel pretty much the same way, it should probably be ALS, but nonroutine use of BLS when necessary could be acceptable.



For this discussion I'm assuming all of these patients have had proper assessments and have no other present complications. Yes the K2 or drunk patient might begin to vomit, and the BLS ambulances have suction. We're not going to be intubating a patient solely from intoxication and vomiting anyway I don't believe.




NPO said:


> If they have a history of hypertension, and are CHRONICALLY noncompliant (as oppose to just missed a dose today), and are truly asymptomatic to the hypertension, then I am fine with that going BLS as long as their BP isnt encroaching over 180 systolic



I would say 50% of the patients we respond to have a blood pressure over 180 systolic among all complaints. 

I hope this doesn't come off as dismissive. I really appreciate your feedback.


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## ParamagicFF (Jul 19, 2018)

DrParasite said:


> the question you should be asking is "are there enough ALS resources to transport every call that requires ALS resources.  you can't blanketly say every x complaint requires ALS (ok, maybe cardiac arrest..... then again, if they are obviously DOA, do you need a medic?)my former agency dispatched chest pain under 30 years of age with no diff breathing as a BLS call.  If the patient is under the age of 50, with no other complaints, vitals good, NSR on the monitor, nothing else to make you think it's cardiac related, and you think the patient is stable, would letting BLS give a good ride to the hospital make you uncomfortable? And yes, the older you go, the higher the chances are that a paramedic should probably take a ride, just to eliminate getting flagged by QA and the higher chances of cardiac issues.


Personally I am not made uncomfortable by those patients. I've only been in this system for a few years. I came from a place without triage, where ALS rode almost everything. I'm getting into training new medics in this department and hope from this discussion to enhance my ability to articulate my triage decisions to providers just learning this skill. 



DrParasite said:


> again, being drunk is a BLS call.  passing out drunk (and being wakable) is likely a BLS call.  being very drunk is a BLS call.  being completely unresponsive and not responsive to any external stimuli should probably warrant ALS for potential airway issues.
> This is, of course, assuming there are no other issues found during a complete assessment, including what else the patient consumed.


I completely agree with you. We have such a high amount of intoxication/AMS calls that they explicitly wrote "AMS secondary to intoxication alone shall not warrant als transport". However, MANY providers in my system are very uncomfortable triaging patients that are not alert and oriented. It seems they would rather triage the crushing chest pain with comorbidities "but no ST elevation" than the PCP patient who has become non-verbal but is awake but has no obvious signs of distress. I suppose they give them the stare of life. I've had a BLS crew refuse a patient like this "at shift change" and that's all I did.



DrParasite said:


> asymptomatic HTN is a BLS call.  non-compliance with meds is a BLS call.  What is a medic going to do?  do the stare of life?  maybe an IV lock?
> 
> Now if there was an acute spike (worst headache, numbness, vision issues, etc), that's a different story.  and yes, HTN can lead to CVA and other bad things.  But it's asymptomatic.  they might have had high BP for the past week and didn't even know it.  what is going to change in the next 2 hours (assuming you have a long transport) that hasn't happened in the past week?



Do you have a threshold where you change your mind on this? What if I told you BP was 210/110? 
I totally agree with your logic, and this category accounts for the highest over use of ALS resources in my area I believe. I have gotten the most "I won't transport that" from BLS providers for this than any other type of patient, usually with the line "they could have a stroke". Even with BP well below the quite high one I listed above. I then proceed to transport and perform the stare of life. ALS providers at my agency seem very mixed on this. Some agree with me, and some simply say "you can't BLS that" with no articulate reason why.

I don't want this to be read as I am looking for support to BLS all patients. If I'm in a tiered system, I wan't to perform in the best way possible. I especially want to ensure I'm articulating my thought process with the new medics coming online so they can be comfortable and confident in their own decision making. 
I believe if the person doesn't require an ALS intervention or immediate transport due to time sensitive condition, or isn't likely to require one during transport, then it can be triaged down to BLS.


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## EpiEMS (Jul 19, 2018)

Tigger said:


> Is this common in other areas? That sounds awful.



In my area, it depends on who arrives first. If I'm B/B on the ambulance and a medic fly car (our usual set-up) arrives on scene first, they'll take charge. If they think it's BLS, they'll transfer care to us we show up. In this case, they'll do a report, too, just stating what they found. If we arrive before them, think it's BLS and cancel them, they just need to report that they were cancelled en route by the BLS unit. It's not so bad, but it is kind of excessive as far as paperwork goes.



ParamagicFF said:


> Do any of your systems triage down chest pain patients? For those that do, does it make you uncomfortable?



I've yet to have an actual chest pain patient down-triaged to me (though I have had calls for chest pain that turned out to be another complaint which were triaged to me). If cardiac or respiratory causes can be ruled out (within reason), I'm comfortable taking the patient, particularly because my transport times are pretty short. I can have a patient from the farthest area of my primary response area to the hospital in less than 20 minutes and I could probably have a medic to me in less than half that time.



ParamagicFF said:


> I'm also interested in how altered mental status secondary to intoxication is treated. I don't mean a little impaired, I mean conscious patients that are entirely incoherent and unable to produce any meaningful verbal response to questioning.
> A point of contention among providers I've spoken with seems to be asymptomatic high BP readings with a history of HTN and non-compliance with medications. Are you all transporting them ALS "just in case"?



I'll take that AMS patient, as long as the ABCs are good/don't look likely to deteriorate. If they deteriorate, I can manage with a BVM and suction pretty well. Aysmptomatic high BP? Not really a problem, as long as the cause is identifiable.


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## DrParasite (Jul 19, 2018)

ParamagicFF said:


> It seems they would rather triage the crushing chest pain with comorbidities "but no ST elevation" than the PCP patient who has become non-verbal but is awake but has no obvious signs of distress. I suppose they give them the stare of life.


so much wrong with that statement (and i'm not saying it's your fault, just so many issues) ...... has your medical director provided you with any guidelines for what is an appropriate triage vs not?  I would imagine inappropriate triaging would result in a sit down with either the MD or QA/QM people.





ParamagicFF said:


> Do you have a threshold where you change your mind on this? What if I told you BP was 210/110?


ehhhh.  still 100% asymptomatic?  I'd be comfortable saying BLS can handle it.  But I wouldn't fault a medic for wanting to ride that in.





ParamagicFF said:


> I have gotten the most "I won't transport that" from BLS providers for this than any other type of patient, usually with the line "they could have a stroke".


or they could get struck by lightning.  or get hit by a bus.  or have a tree fall on their head.  could these things happen?  absolutely.  is the chances slim to none?  sure, but there is still a chance.  

If I was you, and the BLS provider said "I won't transport that, he might have a stroke" my response would be "and??? what am I going to do for a stroke that you can't do?  and do you really think I am going to triage a patient to you if I thought they would have a stroke in the next hour?"

But I have never been in a system where BLS could refuse to transport a patient.  seems like they could justify almost anything being ALS, so they don't have to do any work at all (not saying that all BLS providers in your system are lazy, just making the blanket statement that a lazy provider could do that).  Especially at shift change.


ParamagicFF said:


> I don't want this to be read as I am looking for support to BLS all patients. If I'm in a tiered system, I wan't to perform in the best way possible. I especially want to ensure I'm articulating my thought process with the new medics coming online so they can be comfortable and confident in their own decision making.
> *I believe if the person doesn't require an ALS intervention or immediate transport due to time sensitive condition, or isn't likely to require one during transport, then it can be triaged down to BLS.*


That's pretty much how I operate, and how most tiered systems I have seen operate.  ALS for ALS patients, if the patient doesn't require ALS, then BLS can take them to the ER.

Part of the issue is how the EMTs were originally taught.  If they were taught that any chest pain needs a 12 lead, and that's a hard and fast rule, guess what?  that 5 year old needs a 12 lead and monitor.  If they need a medic to hold there hand to tell them how to assess a patient, then guess what?   they are always going to call and wait for ALS.

I was taught a few hard and fast rules in EMS: 1) never wait for ALS; if the patient needs ALS, load and go, and meet ALS enroute to the hospital (this has changed since I started, especially for cardiac arrests) 2) ALS are dispatched on call that might need ALS; if they aren't dispatched and you find you need them, call for them (preferably while enroute to the ER, for a line of sight intercept), and if you arrive and find the patient doesn't need ALS, than just cancel them.  3) EMTs are going to make mistakes, paramedics are going to make mistakes; however when all else fails, take the person to the hospital

the one rule I tell all of my EMT students early on in class: If you learn nothing else in this class, learn how to do a good assessment, so you can tell the difference between sick and not sick, and sick and dying.  Not sick people need a ride to the hospital.  sick people need to have a through assessment, and def need to go to the hospital.  dying people need an intervention, and an early intervention, and likely an ALS intervention before they deteriorate further.   Make sure you understand the differences between sick and not sick and sick and dying.


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## ParamagicFF (Jul 19, 2018)

DrParasite said:


> so much wrong with that statement (and i'm not saying it's your fault, just so many issues) ...... has your medical director provided you with any guidelines for what is an appropriate triage vs not?  I would imagine inappropriate triaging would result in a sit down with either the MD or QA/QM people.



My agency has had several OMDs within the past decade. We operate under a mixture of protocols and orders. The protocols haven't been updated in SEVERAL years. We are a large agency and dont have much direct contact with our OMD. He seems more interested in a public health type role than EMS, and works on lots of those initiatives. I truly don't think he even has a clear picture of our actual operations, or how our units respond to calls. Our assistant OMD seems more interested, but again there isn't much contact between her and front line paramedics. I don't think either of them could even fully articulate the different operational staffing models we have with ALS/BLS.

I think if you triage inappropriately and there is a bad outcome, they will take you off the streets for sure. Unfortunately, everyone's idea of inappropriate is so different. 

Thanks for all the discussion so far, I hope to get even more input on different case suggestions that may give others pause.


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## Aprz (Jul 19, 2018)

Like someone else said, I work on an a p/b truck where I can give the call to my EMT and there is no black and white criteria for it (except we do not give any "specialty"/alerts to them like STEMI, stroke, or trauma (even if code 2)). It depends on both crew members. The EMT never had to accept a call that they are uncomfortable with. We usually talk it out throughout the call and are usually on the same page. Generally if there is no added benefit of a paramedic (like you wouldn't benefit from Zofran ODT or an IV), the complaint is minor, the patient had 1 in a million chance to deteriorate or less, I'll give the call to her.


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## StCEMT (Jul 19, 2018)

I hate that I can't pass calls to my partner, otherwise I'd do a 1:1 or 2:2 rotation on who takes calls. Unless its a true ALS call that needs a lot of things immediately, I try to let my partners work to the fullest of their ability and run things a bit. There are some very capable BLS providers I work with and I would absolutely have them tech the calls if I could.


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## DrParasite (Jul 20, 2018)

ParamagicFF said:


> I think if you triage inappropriately and there is a bad outcome, they will take you off the streets for sure. Unfortunately, everyone's idea of inappropriate is so different.


Well, your medical director or whomever sets the clinical standards should be making that decision.  And that standard should be enforced by whomever does your QA.  Someone needs to set the standard, otherwise you have every medic doing there own thing, and then it's russian roulette as to whether you get a good medic or a bad one, which no recourse for the medic who is bad

And also, and just throwing this out there, just because there is a bad outcome, or the patient gets admitted, doesn't mean the triage was inappropriate.


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## EpiEMS (Jul 20, 2018)

DrParasite said:


> And also, and just throwing this out there, just because there is a bad outcome, or the patient gets admitted, doesn't mean the triage was inappropriate.



Agreed. Triage is a probabilistic judgement.


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## ParamagicFF (Jul 20, 2018)

DrParasite said:


> Well, your medical director or whomever sets the clinical standards should be making that decision.  And that standard should be enforced by whomever does your QA.  Someone needs to set the standard, otherwise you have every medic doing there own thing, and then it's russian roulette as to whether you get a good medic or a bad one, which no recourse for the medic who is bad
> 
> And also, and just throwing this out there, just because there is a bad outcome, or the patient gets admitted, doesn't mean the triage was inappropriate.



You just summarized our system, the standards are unclear. Though this is arguably the most important aspect of our operations, it doesn't seem to be a focus of the OMD for protocol or training. When I was hired and oriented, what I was taught depended on who was "training" me that day. It is very much a russian roulette on what quality of medic you will get.

I tend to be more decisive regarding treatment and triaging than many of my coworkers, so I wanted to open this discussion with others who have been in a similar role to solidify my ability to articulate my triaging process.

Here's another patient that gets mixed responses. The asthmatic that does not have his own albuterol who presents as follows: Speaks in full sentences, no accessory muscle use or tripod position, expiratory wheezing upon auscultation, SpO2 95-98%, EtCO2 within normal limits but capnogram shows an obstructed waveform. No other complications with history, no other remarkable assessment findings. BLS can administer/transport albuterol/atrovent. Is this a patient you triage or ALS transport?


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## EpiEMS (Jul 20, 2018)

ParamagicFF said:


> The asthmatic that does not have his own albuterol who presents as follows: Speaks in full sentences, no accessory muscle use or tripod position, expiratory wheezing upon auscultation, SpO2 95-98%, EtCO2 within normal limits but capnogram shows an obstructed waveform. No other complications with history, no other remarkable assessment findings. BLS can administer/transport albuterol/atrovent. Is this a patient you triage or ALS transport?



If they are normally on albuterol, haven't been intubated for an asthma attack before, and we administer albuterol and they experience symptom relief, I'd probably take them BLS.


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## Bullets (Jul 20, 2018)

Yes, in a tiered system we can and often do triage patients to BLS transport. Of the 50ish patient contacts i do a month i usually end up triaging about 10ish. Our department does have a policy on this, and it is largely a no brainer. Its mostly falls under the rule that after your assessment you determine the patient needs ALS treatment then we stay. If the patient doesnt need ALS treatment and didnt receive some treatment before we arrived that changed the treatment (Epipen, Narcan) then we can release.


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## ParamagicFF (Jul 20, 2018)

Bullets said:


> Yes, in a tiered system we can and often do triage patients to BLS transport. Of the 50ish patient contacts i do a month i usually end up triaging about 10ish. Our department does have a policy on this, and it is largely a no brainer. Its mostly falls under the rule that after your assessment you determine the patient needs ALS treatment then we stay. If the patient doesnt need ALS treatment and didnt receive some treatment before we arrived that changed the treatment (Epipen, Narcan) then we can release.



Narcan requires an ALS transport for your agency? What about albuterol by the BLS crew?


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## Tigger (Jul 20, 2018)

EpiEMS said:


> In my area, it depends on who arrives first. If I'm B/B on the ambulance and a medic fly car (our usual set-up) arrives on scene first, they'll take charge. If they think it's BLS, they'll transfer care to us we show up. In this case, they'll do a report, too, just stating what they found. If we arrive before them, think it's BLS and cancel them, they just need to report that they were cancelled en route by the BLS unit. It's not so bad, but it is kind of excessive as far as paperwork goes.


I mean on P/B ambulances. I I had to write a report on every patient I gave to my EMT I would just transport them all myself. We have pretty long transports and I can finish BLS charts before we get to the ED. 

It is a little different in Colorado too. My partner can start a line and give zofran/fluids so that eliminates a lot of ALS comfort rides. They can give albuterol though it's rare I don't take those calls. They can give narcan IV/IM/IN so I'll have them take those in if these patient's are pretty awake post admin. Same with D50, though usually they write the wake-up refusals. I may or may not throw these patients on the monitor before I give them to the EMT and have them document the results under my name which is a regionally accepted practice. The expectation here for the EMTs is to alert the medic if there is any sort of change in patient condition so switch offs are not uncommon. A few of my employers teach a basic level EKG class as well. I don't want the EMTs interpreting EKGs for anything but their knowledge, but we find that it has them leave the monitor on patients for the transport which makes my job much easier if we have to switch out. Switching providers during transport is encouraged and no incident report is needed. I'll document their part up until I take over and then the lead provider signature will of course be in my name.


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## Bullets (Jul 21, 2018)

ParamagicFF said:


> Narcan requires an ALS transport for your agency? What about albuterol by the BLS crew?


So BLS doesnt carry albuterol in NJ, only drugs BLS can carry are narcan, epipens, aspirin and oral glucose

From our protocols:

a. Epinephrine for anaphylaxis: It is the expectation that, due to the potential that the half-life of epineph-rine is shorter than the physiologic reaction that indicated their administration, those patients who received Epinephrine prior to the arrival of an ALS units will be treated by the ALS unit during transport to the hospital. Also additional considerations need be given to those patients who received these medications, with unclear indication, that are prone to potential side effects such as cardiac dysrhythmia and airway compromise. This includes administration to patients with no clear anaphylaxis prior to admin. The potential side effects of the miss administration of Epinephrine warrant an ALS treat/monitoring. Any deviation from this should involve a Medical Control Physician.

b. Narcan: It is the expectation that, due to the potential that the half-life of Narcan is shorter than the half-life of the agents that indicated its administration, those patients who received Narcan prior to the arrival of an ALS unit will be treated by the ALS unit during transport to the hospital. Also additional considerations need be given to those patients who received these medications, with unclear indication, that are prone to potential side effects such as cardiac dysrhythmia and airway compromise. Consider the effects of agents used to cut the narcotics on your patients.

c. Nebulized bronchodilator/MDI: It is the expectation that, due to the potential that the underlying etiol-ogy of dyspnea will outlast the medication, any patient who had a complaint of dyspnea prior to the use of nebulizer and/or MDI will be treated by the ALS unit during transport to the hospital.

d. NTG: If the reason the patient administered nitroglycerin was presumed by the patient to be cardiac, it is the expectation that the patient will be treated by the ALS unit during transport to the hospital.

e. Diastat: Any patient who experienced a seizure and has Diastat administered will be treated by the ALS unit during transport to the hospital


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## EpiEMS (Jul 24, 2018)

Tigger said:


> I mean on P/B ambulances. I I had to write a report on every patient I gave to my EMT I would just transport them all myself. We have pretty long transports and I can finish BLS charts before we get to the ED.



Fair point. If I had an ePCR tablet, I think I'd do the same in your place!



Tigger said:


> It is a little different in Colorado too. My partner can start a line and give zofran/fluids so that eliminates a lot of ALS comfort rides. They can give albuterol though it's rare I don't take those calls. They can give narcan IV/IM/IN so I'll have them take those in if these patient's are pretty awake post admin. Same with D50, though usually they write the wake-up refusals. I may or may not throw these patients on the monitor before I give them to the EMT and have them document the results under my name which is a regionally accepted practice. The expectation here for the EMTs is to alert the medic if there is any sort of change in patient condition so switch offs are not uncommon. A few of my employers teach a basic level EKG class as well. I don't want the EMTs interpreting EKGs for anything but their knowledge, but we find that it has them leave the monitor on patients for the transport which makes my job much easier if we have to switch out. Switching providers during transport is encouraged and no incident report is needed. I'll document their part up until I take over and then the lead provider signature will of course be in my name.



That's a good setup. The comfort ride is something that not every medic is happy to do. While I'd be happy if a medic could administer some ODT and then send the patient BLS, I don't know if that is allowed in my system. Makes me wish we had a decent AEMT scope.


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## DrParasite (Jul 24, 2018)

I'd be happy if EMTs could give IM zofran......  This way you don't even need to tie up a medic to make the patient feel better.....  based solely on my own personal experience, I still think it's a miracle drug


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## NPO (Jul 24, 2018)

DrParasite said:


> I'd be happy if EMTs could give IM zofran......  This way you don't even need to tie up a medic to make the patient feel better.....  based solely on my own personal experience, I still think it's a miracle drug


But but but...

QT PROLONGATION!


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## DrParasite (Jul 24, 2018)

NPO said:


> But but but...
> 
> QT PROLONGATION!


yeah, that's a potential side effect that every medic I have asked has never seen has not seen happen.....

Even the study on this very topic says "When used in patients with cardiovascular disease (eg, heart failure or acute coronary syndromes) with one or more risk factors for torsades de pointes, ondansetron may significantly increase the QTc interval for up to 120 minutes after administration. From a patient safety perspective, patients who are at high risk for torsades de pointes and receiving ondansetron should be followed via telemetry when admitted to hospital."  So I agree, if they have a heart history, and are complaining about severe nausea, better have a medic who can monitor for the increased QTC interval (then again, if a I have a sick patient with a heart history that nausea can be a cardiac sign, so I should probably have paramedic put the patient on the monitor just in case).

but I digress......


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## NPO (Jul 24, 2018)

Perhaps the sarcasm wasn't well transmitted lol.

I only brought it up because people love to cite it, but there's like evidence. The only time is ever been problematic is in dosrs of 32mg.


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## EpiEMS (Jul 24, 2018)

DrParasite said:


> I'd be happy if EMTs could give IM zofran......  This way you don't even need to tie up a medic to make the patient feel better.....  based solely on my own personal experience, I still think it's a miracle drug



Or ODT, even easier. (If they're not profusely vomiting, anyway.)


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## DrParasite (Jul 24, 2018)

EpiEMS said:


> Or ODT, even easier. (If they're not profusely vomiting, anyway.)


I was given that when I had my kidney stone..... didn't help, although after it dissolved it may have been swallowed, which caused the resulting vomiting.

My opinion is if EMTs can give epi IM, they can give zofran IM


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## Tigger (Jul 24, 2018)

DrParasite said:


> I was given that when I had my kidney stone..... didn't help, although after it dissolved it may have been swallowed, which caused the resulting vomiting.
> 
> My opinion is if EMTs can give epi IM, they can give zofran IM


Yea, we are lucky that Colorado went along with that line of thinking. Our EMTs (with an additional class) can give both Zofran IV or IM (and Narcan for that matter). Great for the medics who now don't have to attend every patient that we can't collectively gain IV access on. Regular, straight out of class Colorado EMTs give ODT.


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## NPO (Jul 24, 2018)

That sounds great. But it doesn't matter because we can't get IV Zofran anyway. Reglan is all we've got right now.


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## Carlos Danger (Jul 24, 2018)

NPO said:


> But but but...
> 
> QT PROLONGATION!



It actually is a thing. I've seen it many times personally, and it has been show to prolong the QT more than droperidol, which it effectively replaced for the same reason.

The problem isn't so much the zofran itself, but that fact that lots of drugs we give effect the QT.  So if someone is on Celexa (for instance), and you give zofran, and that doesn't work so you give benadryl, you could definitely see some effects. It rarely causes problems, but they do happen.


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## NPO (Jul 24, 2018)

Remi said:


> It actually is a thing. I've seen it many times personally, and it has been show to prolong the QT more than droperidol, which it effectively replaced for the same reason.
> 
> The problem isn't so much the zofran itself, but that fact that lots of drugs we give effect the QT.  So if someone is on Celexa (for instance), and you give zofran, and that doesn't work so you give benadryl, you could definitely see some effects. It rarely causes problems, but they do happen.


Yeah. It's something to be aware of, but not freakout over. 

Now, if the patient has multiple causes for concern for prolonged QT, like hypokalemia as well as multiple medications, then perhaps an EKG is warranted.


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## ParamagicFF (Jul 25, 2018)

In my system there is about a 5% chance a patient with no categorically ALS conditions receives zofran for their nausea/vomiting. We have the drug and a protocol for it of course, but those patients always end up triaged to BLS.


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