# MVA - BLS or Trauma alert?



## LEB343 (Mar 27, 2013)

So I had a call yesterday that I thought was BLS (I'm an EMT) but ended up being a trauma alert according to the ER. What do you guys think?

Got called to a MVA right across the street from the ED. Two cars involved, head on collision, moderate front end damage, no airbag deployment (don't know why, should have been), no windshield damage, and no compartment intrusion. There were 7 passengers in a 4 door sedan, all unrestrained. 1 person spoke english, my patient did not. Also, my patient was the only patient "injured".

Pt was a 26 y/o female 8 months pregnant c/o abdominal pain. She was unrestrained in the back seat. No obvious injuries found except a small abrasion on the top of her forehead. Unknown LOC. Non english speaking but in obvious abdominal pain. Vitals stable: BP 120/82, P 90, R 20. 

Now let me explain what type of system I work in. My partner is a medic and the fire dept has medical control and they have 1-2 medic on an engine. The pt was handed over to me with no spinal immobilization, no IV, not even a SPO2. So this patient was handed over to me with no interventions and no concern from 2-3 medics. Was this an ALS call? 

When I arrived at the ED (in 2 mins) there was a trauma team activated and I almost :censored::censored::censored::censored: in my pants! I was so nervous and I did my hand off speaking a million miles per hour. I felt like an idiot! Do you think my partner is going to get in trouble (I actually hope he does) and maybe the fire dept because they have medical control in the field? Do you think this should have been a trauma alert?

Thanks! I needed to get this call off my chest.


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## CritterNurse (Mar 27, 2013)

8 months pregnant, obvious abdominal pain? I would have been asking a paramedic to come along, calling for an ALS intercept if they refused, and a translator since communication is very important.

Just noticed you said 2 minutes. I guess there wouldn't have been time for an intercept. I'm in a rural area, and used to those time-frames.


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## Veneficus (Mar 27, 2013)

Trauma is not an ALS call. 

There are actually studies showing improved outcomes when rapidly transported by BLS compared to ALS.

There are many reasons a hospital may call a trauma alert, they get paid extra for them which may play a role in liberal criteria for such. 

Additionally, the hospital policy on what constitutes a trauma alert may not in anyway reflect what EMS considers ALS. 

Even if this patient was in cardiac arrest from trauma, there is nothing ALS can offer.

Hemorrhage control is a BLS skill.


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## Medic Tim (Mar 27, 2013)

I hope you didn't put this woman on a board.
The first available transport unit should have taken this pt. like vene said Trauma is BLS . Trauma alerts are different from place to place. I have seen trauma alerts for very minor trauma and even no trauma pts. Did you call in an accurate report? Were you panicked and they might not have heard you or gotten the whole story?

So why do you want you partner to get in trouble? Was he driving and you attending? 
What would you have done differently?


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## LEB343 (Mar 27, 2013)

My "partner" was not my normal partner. He does nothing to help out and I felt like I was on my own with no direction. He's the medic and should have looked at the pt. All he does is sit in the front seat until I'm ready to go. I was so worried I was going to get in trouble after this call. There could have been injuries I over looked.


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## Milla3P (Mar 27, 2013)

I'd bls it, however, as a devils advocate...
8 months pregnant with abdominal pain? 
Unrestrained in a head on MVA? 
Unrestrained with even a head abrasion?

All of these are reasonable justifications for a Trauma alert.


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## CBentz12 (Mar 27, 2013)

As long as you documented and performed every thing in your scope of practice as a EMT then your good. If you neglected to do a proper head to toe and failed to get proper V/S then yeah I would be worried. I live in a area where BLS has transported trauma alerts many times and they have all been handed down from a engine. I have taken 2 trauma alerts myself and as long as you document everything your in the clear.

Reason being for a trauma alert is simple she's 8 months pregnant with severe abd pn secondary to a MVA. Theres no telling what is going on inside w/o proper equipment so I can see the ER calling it to be on the safe side. No need to question yourself or others for that matter if you performed 100% at your certified level. Take the call as a lesson learned. What were her v/s btw


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## Akulahawk (Mar 27, 2013)

Veneficus said:


> Trauma is not an ALS call.
> 
> There are actually studies showing improved outcomes when rapidly transported by BLS compared to ALS.
> 
> ...


I tell people all the time that Trauma is a BLS Sport. EMTs often deal with trauma faster and have better outcomes than Paramedics do. Why? Paramedics tend to stay and play a little bit before rolling. In other words, Paramedics tend to stay on scene a little bit longer than they should. As a Paramedic, I have taken that "lesson" to heart and whenever I had trauma patients, I did only what was absolutely necessary on scene and did EVERYTHING else while rolling toward the hospital. In other words, I "thought" like an EMT. 

As to knowing what constitutes a "trauma alert" for  your EMS system, know your protocols for that. What constitutes a trauma alert for each individual hospital depends upon the hospital's own protocols. Given a choice between having an EMT transport immediately or waiting for a Paramedic to arrive when the ED is literally 2 blocks away, I'd choose the EMT transport every time.

Also, at 8 months pregnant, complaining of abdominal pain, that's a high priority/acuity patient because the fetus could be going south right before you and you wouldn't know it. Put that patient on the backboard and you could very well cause some problems for both mother and fetus because you might forget to roll her over to one side.


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## Veneficus (Mar 28, 2013)

Milla3P said:


> I'd bls it, however, as a devils advocate...
> 8 months pregnant with abdominal pain?
> Unrestrained in a head on MVA?
> Unrestrained with even a head abrasion?
> ...



Nobody is disputing it is a trauma alert for a hospital, we are saying ALS is not going to make a difference.


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## DesertMedic66 (Mar 28, 2013)

If I gave that call in (with all the info available) I would more then likely get into the ER then a Spanish speaking employee would ask some questions about LOC, head, neck, back pain. If she denied all of that then the ER would most likely have us bypass them and head up to L&D/OB.

And per the protocols in my area nothing about this call would make us call for a trauma alert. We would just transport to the closest hospital that has OB or patients choice.


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## Milla3P (Mar 28, 2013)

Veneficus said:


> Nobody is disputing it is a trauma alert for a hospital, we are saying ALS is not going to make a difference.



Excluding the part where the OP specifically asks if this should of been a trauma alert?


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## medictinysc (Mar 28, 2013)

*No one is perfect.  We all make mistakes*



LEB343 said:


> My "partner" was not my normal partner. He does nothing to help out and I felt like I was on my own with no direction. He's the medic and should have looked at the pt. All he does is sit in the front seat until I'm ready to go. I was so worried I was going to get in trouble after this call. There could have been injuries I over looked.




Yes there could have been injuries you looked over.  It's quite obvious that your partner wasn't very worried (Should he have been?)  Are you a capable BLS crew member?  My first piece of advice is not to be to harsh on yourself.  We all make mistakes.  A 2 min ride to the ED, fantastic.  You definately got there within a reasonable time.  

I have a few questions for you....  Was the B/P stable?  Any obvious life threats?  Did you have time to listen for fetal heart tones or feel for movement from the baby?  If not,  its ok you WERE ONLY 2 minutes away for a hospital with doctors and rn's and a surgical ward.


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## Carlos Danger (Mar 28, 2013)

LEB343 said:


> So I had a call yesterday that I thought was BLS (I'm an EMT) but ended up being a trauma alert according to the ER. What do you guys think?
> 
> Got called to a MVA right across the street from the ED. Two cars involved, head on collision, moderate front end damage, no airbag deployment (don't know why, should have been), no windshield damage, and no compartment intrusion. There were 7 passengers in a 4 door sedan, all unrestrained. 1 person spoke english, my patient did not. Also, my patient was the only patient "injured".
> 
> ...



8 months pregnant, unrestrained passenger in an MVC, complaining of abdominal pain?

And only 2 minutes from the hospital?

I think you can make a case that absolutely nothing should have been done - literally - except BLS airway management, slap some pressure on any bleeding you see, and get her to the ED. 

I wouldn't even bother with vital signs unless I had time to do them during the two minute ambulance ride.


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## emtdansby (Mar 29, 2013)

I agree in this instance "load and go" was the best course of action. However, unlike many medics on here, I would not have given this call to my BLS partner. He has been a Basic for several years and is fantastic at his job, but this patient is an ALS patient all the way. Now, with such a short transport time, I wouldn't have done any ALS interventions, still "loading and going", but the distance of transport should not be a deciding factor on "is this ALS or BLS?" If at any time you don't feel comfortable taking a pt, speak up, your partner should step up and take over.


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## NomadicMedic (Mar 29, 2013)

emtdansby said:


> I agree in this instance "load and go" was the best course of action. However, unlike many medics on here, I would not have given this call to my BLS partner. He has been a Basic for several years and is fantastic at his job, but this patient is an ALS patient all the way. Now, with such a short transport time, I wouldn't have done any ALS interventions, still "loading and going", but the distance of transport should not be a deciding factor on "is this ALS or BLS?" If at any time you don't feel comfortable taking a pt, speak up, your partner should step up and take over.



If you were not going to do any ALS interventions, why is this an "ALS call"? An EMT can sit and watch somebody during a 120 second ride to the hospital just as well as a paramedic can.


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## Action942Jackson (Mar 29, 2013)

In a 120 second transport time.  It would tough to argue anything.  However I share Dans opinion.  For the sake that I am a higher level of care for the patient and should something go wrong, I can correct it immediately without stopping transport.  Unfortunately, liability plays a huge role in my decision process only because my place of employment is too small and can't afford a malpractice lawsuit (even with liability insurance). They put such a heavy emphasis on higher levels of care and the less liability the better.   Personally, the only calls I should be on are Trouble Breathing, Chest Pain, Syncope, Arrests, Diabetics, Unknowns, and calls concerning advanced airway management.


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## emtdansby (Mar 29, 2013)

At my company, the mechanism of injury and the high risk OB makes this an ALS patient irregardless of the transport distance. Also, the OP seemed very uncomfortable taking this pt in the first place, that right there make his paramedic partner very irresponsible and a poor excuse for a medic


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## NomadicMedic (Mar 29, 2013)

Sure. I see your point, and if I were the medic on scene, I would have transported this patient, but my report would have reflected that it was a BLS call. 

If you don't DO any ALS, it's not ALS. It's not JICALS.


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## emtdansby (Mar 29, 2013)

I see your point, at the company I'm at now I would have to document it as ALS per our assessment protocols, but other places it could be documented as BLS


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## Akulahawk (Mar 29, 2013)

As a Paramedic, I would have been the one to be the guy in the back. My verbal report and subsequent documentation would have shown that I assessed at an "ALS" level but did absolutely NOTHING that would have been considered an "ALS" intervention because I didn't have time to do anything during transport. There's no real point in me getting set up to start an IV line or do much of anything else in that 2 minutes. I'm doing the best intervention at that point anyway: transport!


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## Carlos Danger (Mar 29, 2013)

Action942Jackson said:


> For the sake that I am a higher level of care for the patient and *should something go wrong, I can correct it immediately without stopping transport.*  Unfortunately, liability plays a huge role in my decision process only because my place of employment is too small and can't afford a malpractice lawsuit (even with liability insurance). They put such a heavy emphasis on higher levels of care and the less liability the better.   Personally, the only calls I should be on are Trouble Breathing, Chest Pain, Syncope, Arrests, Diabetics, Unknowns, and calls concerning advanced airway management.



Just curious what you can correct in 120 seconds that an EMT cannot?

I understand doing things just to follow policy. Sometimes you have to do things just because the people who sign your checks tell you to.




emtdansby said:


> At my company, the mechanism of injury and the high risk OB makes this an ALS patient irregardless of the transport distance. Also, the OP seemed very uncomfortable taking this pt in the first place, that right there make* his paramedic partner very irresponsible and a poor excuse for a medic*



Pretty judgmental stance considering you don't know the rationale for what happened.

Even if this _were_ a poor decision, that doesn't necessarily make anyone "a poor excuse for a medic". That's just emotional drivel.

If anyone needs to some additional retraining, maybe it's the hypothetical EMT who is uncomfortable transporting a BLS patient 2 minutes?


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## emtdansby (Mar 29, 2013)

Halothane said:


> Just curious what you can correct in 120 seconds that an EMT cannot?
> 
> I understand doing things just to follow policy. Sometimes you have to do things just because the people who sign your checks tell you to.
> 
> ...



I stand by what I said, the mechanism of injury and high risk OB factors makes this patient an ALS patient. Any paramedic that would push a patient on their BLS partner who isn't comfortable taking the patient is a bad partner. Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.
As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.


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## Carlos Danger (Mar 29, 2013)

emtdansby said:


> Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.



It is simple logic:

If a patient does not require ALS intervention, it is not an ALS transport.

This patient did not require ALS intervention.

Therefore, this was not an ALS transport.

Even if you were 15 minutes away, it would still be a BLS call, because there would still be no indication for ALS intervention.




emtdansby said:


> As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.



Basic EMT = BLS transport.

This was a BLS transport.


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## emtdansby (Mar 29, 2013)

So you wouldn't put a large bore IV in this patient? 15 min away and you wouldn't even place an IV? 8 months pregnant, severe abd pain, unrestrained head on collision, and you wouldn't even place an IV?!? What happens when that pain she is having is her placenta tearing from the uterine wall and she starts to bleed out? You're up front and your basic starts yelling for help because the pt is unconscious and has no pulse? Great job Mr. Paramedic.  A good paramedic doesn't sit around and what for an need for ALS intervention to be needed, we plan ahead.


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## emtdansby (Mar 29, 2013)

*wait for a need for an ALS intervention. Also, I understand this call was 2 min for the hospital, I am responding to you saying that even 15 mins away, it wouldn't make a difference to you


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## Akulahawk (Mar 29, 2013)

Halothane said:


> It is simple logic:
> 
> If a patient does not require ALS intervention, it is not an ALS transport.
> 
> ...



All I can say is that there's a serious lack of good judgment in that above "simple logic" especially with regard to the specific patient. Your "simple logic" statement above shows me that you're the kind of paramedic that I've met way too often. 

If you follow your "simple logic" long enough, you'll find your paramedic license in jeopardy. Serious jeopardy. I hope you never find out why, the hard way.


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## Action942Jackson (Mar 30, 2013)

Halothane said:


> It is simple logic:
> 
> If a patient does not require ALS intervention, it is not an ALS transport.
> 
> ...



As a paramedic, you are a higher level of care then your EMT partner.  As a rule I set up when I'm on the rig.  My license is my bread and butter.  I will in no shape or form, jeopardize that fact.  My family depends on me.  

I can assure you, if your medical directors were part of this call, they would be rolling over in their scrubs if you even thought about BLSing this call.  You don't treat MOI, I got that.  But, that baby is another 6-8lbs of free floating weight inside a patient.  Not only could you rupture the uterine wall etc, its possible a ruptured diaphragm, cardiac and lung contusions, not to mention an aortic tear can result as the motion of an unrestrained child inside the womb.  It's about anticipating what the clinical course for this patient will be.  You anticipate the need for ALS interventions as that was obviously going to be done in the ED based on OPs report.  

This is just my opinion, but its patient care focused. Not focused on wether or not its ALS or BLS.  It's about thinking ahead to know what the hospital will be doing and starting the process during transport.


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## Handsome Robb (Mar 30, 2013)

Short ride, A&O, pink warm and dry and no obvious life threats or anything requiring immediate ALS intervention I've got no issue letting my Intermediate partner ride this call in. With that said my last few partners are all well above average knowledge and skill-wise when it comes to many intermediates I've worked with.

She can toss the NIBP cuff and SpO2 probe on then drop a line in 2 minutes, I wouldn't do anything different...

Now if I've got a shiny new 2 riding with me I'd probably take this call. 

From what you described she needs an immediate assessment from a physician. It'd be a trauma activation here. "Trauma Pre-alerts" in my system are different, only can be called with a gsw to the torso, profound hypotension after a traumatic injury or unconscious with a unilaterally blown pupil. Everything else the charge nurse decides which team to activate based on their protocols and my report.

Fetal heart tones/rate along with a FAST exam are high on my list of things I can't do but would like to see done on this patient immediately upon our arrival, this fetus is very viable. That's my 12-hours-of-getting-throttled-at-work brain talking though.


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## Handsome Robb (Mar 30, 2013)

Halothane said:


> It is simple logic:
> 
> If a patient does not require ALS intervention, it is not an ALS transport.
> 
> ...



Pain management is an ALS intervention. Sounds like she needed some and I personally would have no issue giving her some fent provided the transport was longer. 

Also unless basics in your area can start IVs your medic should be attending this patient. While we aren't going to use it unless she needs fluids and the aforementioned analgesics it helps the ER out and "kickstarts" the process. 

This is all in the event of a longer transport than 2 minutes. If I didn't ride with an I I'd take this call and drop a line on the way in. Takes 30 seconds to do...


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## Handsome Robb (Mar 30, 2013)

Sorry for multiple replys, not trying to do more than one on my phone.



emtdansby said:


> I stand by what I said, the mechanism of injury and high risk OB factors makes this patient an ALS patient. Any paramedic that would push a patient on their BLS partner who isn't comfortable taking the patient is a bad partner. Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.
> As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.



What about an ILS provider attending if your protocols don't allow or the patient refuses narcotic analgesia? 

MOI and OB risk factors doesn't automatically make it ALS in my opinion. If you can show me a reason other than "she got in a decent MVA and is pregnant with abd pain" I'm all ears. You can disagree if you like, I'm open to criticism.

My question is, am I a poor excuse for a medic by allowing my partner who's more than qualified and capable to act within their scope of practice? If they weren't comfortable then absolutely, I'm riding it in, if they're comfortable with it why not? 

Did an emergent IFT for an "active miscarriage" the other day. Orders were for NS titrated to SBP >90 and code 3 transport. No monitor, no ALS medications, vitals all WNL (please don't shoot me for that one) so the line was running TKO. You bet your *** I drove code and let my partner do her thing in the back. Supervisor and QA/I didn't have an issue with it.


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## Action942Jackson (Mar 30, 2013)

For your agency who allows Is in the field to tech.  That might be acceptable. But unfortunately, I come from the land that a paramedic has to take every run.


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## Action942Jackson (Mar 30, 2013)

For your agency who allows Is in the field to tech.  That might be acceptable. But unfortunately, I come from the land that a paramedic has to take every run.


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## Carlos Danger (Mar 30, 2013)

Action942Jackson said:


> As a paramedic, you are a higher level of care then your EMT partner.  As a rule I set up when I'm on the rig.  My license is my bread and butter.  I will in no shape or form, jeopardize that fact.  My family depends on me.
> 
> I can assure you, if your medical directors were part of this call, they would be rolling over in their scrubs if you even thought about BLSing this call.  You don't treat MOI, I got that.





emtdansby said:


> Great job Mr. Paramedic.  A good paramedic doesn't sit around and what for an need for ALS intervention to be needed, we plan ahead.





Akulahawk said:


> Your "simple logic" statement above shows me that you're the kind of paramedic that I've met way too often.
> 
> If you follow your "simple logic" long enough, you'll find your paramedic license in jeopardy. Serious jeopardy. I hope you never find out why, the hard way.



Let's not be quite so dramatics, gents. Reminds of a clique of 14 year old girls when someone tells them their nail polish isn't pretty.

I've been practicing for a long time and my license has never been in jeopardy, nor have my medical directors "rolled over in their scrubs", whatever that means.

Sorry, but you guys are all dead wrong if you think that ALS is clinically indicated for a patient 2 minutes from the hospital. It may be indicated by policy, or tradition, or the expectation of the ED, or what you were taught in school, but it is not indicated clinically. Distance absolutely _does_ make a difference, because transport time is a real factor in the equation that estimates the likelihood of interventions needing to be performed, as well as the time that you might have to perform those interventions. 

"I can get an IV in 30 seconds". Give me a freaking break. It takes longer than that just to spike a bag and flush the line. On an easy patient in good circumstances with everything already set up, yeah, maybe. On a pregnant, emotional, fluid overloaded patient, it will likely take longer than 2 min. Are you really going to delay transport for that? 

And more importantly, even if you DO get an IV during the 2 minute ride, so what? You are backing up to the ED doors now. Have your magic ALS skills now saved the patient? Did you really do anything important that a basic couldn't have done? Have you made any impact at all on the patient's clinical course? 

Now, extend the distance out to 15 minutes, and that changes things a little, I guess, but 15 minutes is still a pretty short transport time. If I were in the back of the ambulance with the patient described, and had a 15 minute ride, would I start an IV? Yeah, probably, primarily for analgesia. You need to be quite cautious about using narcs in a patient like this, though, especially if you can't communicate with her about her history and orientation and pain level. What if she does start to bleed a little a few minutes into the ride?  Gonna flood her with crystalloids? Do you carry blood? What if she starts to contract? You gonna giver her terbutaline? A mag load? Really - in 10 minutes? In all reality, if you are honest, you are probably just going to expedite to the ED. Just like a basic would.

You guys should probably keep in mind the very narrow type and % of patients who have been shown to benefit from ALS intervention, and think realistically about how often your interventions make an actual change in the patient's outcome.


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## medicsb (Mar 30, 2013)

LEB343 said:


> So I had a call yesterday that I thought was BLS (I'm an EMT) but ended up being a trauma alert according to the ER. What do you guys think?
> 
> Got called to a MVA right across the street from the ED. Two cars involved, head on collision, moderate front end damage, no airbag deployment (don't know why, should have been), no windshield damage, and no compartment intrusion. There were 7 passengers in a 4 door sedan, all unrestrained. 1 person spoke english, my patient did not. Also, my patient was the only patient "injured".
> 
> ...



Despite knowing that the hospital called it a trauma "alert", I don't see anything that would warrant ALS... Even if you were 20 minutes from the hospital.  I spent 3 months at a level II for my surgical rotation and they had a hair-trigger for calling "trauma alerts".  A lot of patients had ALS (i.e. an IV) initiated, but, honestly, it was usually meaningless.  

Also to consider is that if there is an EM or surgery residency at the hospital, they will make a lot of stuff "trauma" as it is practice for the residents.  Hospital that don't have to train docs on how to run traumas are likely to call alerts much less (in my experience).


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## ccmedoc (Mar 30, 2013)

OB trauma is an ALS pt. Should have had a Paramedic in the back for transport, if there was one on scene. Fancy skills and ability to perform procedures aside, the increased "assessment knowledge" that the paramedic is supposed to posses, as well as the ability to recognize decompensation better than the basic EMT warrants this. A lot can happen in two minutes, and some of the subtle changes in condition that may escape a basic assessment should be noticed by a competent Paramedic and communicated to the ED staff. Hemorrhage for this pt is likely NOT to be external, and subtle advanced assessment would provide her with the best care. If time warranted, IV would be appreciated..anybody ever seen a DIC pt decomp and try to establish peripheral access?? You'd be surprised how fast this all happens in the pregnant pt, as they are already coagulopathic..

Am I wrong?? Being in this position, I would NEVER pass this to a basic..Just not a good professional decision..


On a side note, I have been a member here for many years with hundreds of posts before the forum change...before anyone sends the newb flame...LOL Just been "inactive" for a while here..


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## medicsb (Mar 30, 2013)

ccmedoc said:


> OB trauma is an ALS pt.



Too absolute.  If the patient has "normal" vital signs and a largely benign exam, why do they HAVE to go ALS?  We can "what if" anything, but what is the approximate chance of "deterioration" in this patient for which recognition would not be expected of most EMTs? I think <5% (wouldn't be surprised if it were actually <1%).


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## ccmedoc (Mar 30, 2013)

would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, the best chance of recognizing them is by the higher level provider. Although I do recognize there are outliers in every group.


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## Carlos Danger (Mar 30, 2013)

ccmedoc said:


> would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, *the best chance of recognizing them is by the higher level provider.* Although I do recognize there are outliers in every group.



And the fact that a paramedic _may_ recognize a problem quicker than a basic is going to change the outcome?

On a 2 minute transport?


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## Rialaigh (Mar 30, 2013)

ccmedoc said:


> OB trauma is an ALS pt. Should have had a Paramedic in the back for transport, if there was one on scene. Fancy skills and ability to perform procedures aside, the increased "assessment knowledge" that the paramedic is supposed to posses, as well as the ability to recognize decompensation better than the basic EMT warrants this. A lot can happen in two minutes, and some of the subtle changes in condition that may escape a basic assessment should be noticed by a competent Paramedic and communicated to the ED staff. Hemorrhage for this pt is likely NOT to be external, and subtle advanced assessment would provide her with the best care. If time warranted, IV would be appreciated..anybody ever seen a DIC pt decomp and try to establish peripheral access?? You'd be surprised how fast this all happens in the pregnant pt, as they are already coagulopathic..
> 
> Am I wrong?? Being in this position, I would NEVER pass this to a basic..Just not a good professional decision..
> 
> ...




Honestly. I can't think of a single, not one single, situation in which there could be a patient loaded in an ambulance with 0 interventions done, a 2 minute transport time to ER doors, and ALS would make a difference. Not even extremely severe anaphylactic shock. I can have someone with an ER doc in 2 minutes, it would take half that long or as long to draw up the epi, as long to cric. And the body can compensate for not breathing over 2 minutes in anaphylatic shock. 

I would just as well have a taxi driver or a firefighter or any layperson that could apply a tourniquet in that ambulance. No MEDICAL reason for ALS ever on a 2 minute transport with 0 interventions done when the clock starts...

Now to cover your butt, follow protocol, and reassure the patient, then yes, highest care provider goes with the patient in a head on MVA with unrestrained persons...



On topic for me - I understand the trauma alert. Even if you take the pregnancy and abd pain out of it you have a unrestrained patient in a head on collision with a head injury and unknown LOC. In most systems this would be "enough" to activate a trauma alert of some form. Now if the patient can clearly communicate they did not hit their head that hard and they had no LOC then sure, but with a patient that does not speak english...trauma alert most places. Not saying its right or good, but its true...


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## medicsb (Mar 30, 2013)

ccmedoc said:


> would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, the best chance of recognizing them is by the higher level provider. Although I do recognize there are outliers in every group.



Well, no one wants to be that 1/X patient in any situation.   The mention of "c/o abdominal pain" is a vague complaint without physicial exam findings.  For the prehospital interval, it is highly questionable as an indication for ALS.  Sure, bladder injury is a possibility, but it is unlikely to bleed enough to require ALS. (Yes, I have seen a bladder injury - managed with a foley catheter alone.)  Uterine rupture is a very remote possibility (not much ALS is going to do).  Abruption is not something that ALS is going to make much of a difference on either.  An EMT says "abdominal pain" and they'll be looking for the above - they don't need a paramedic to increase their suspicion (they probably don't know the difference, anyways).

Abd. pain + h/o trauma will likely get this patient watched by Ob/gyn 
(and worked up by trauma) no matter what, but that it is not a reason to make the patient ALS in and of itself.


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## Handsome Robb (Mar 31, 2013)

Halothane said:


> "I can get an IV in 30 seconds". Give me a freaking break. It takes longer than that just to spike a bag and flush the line. On an easy patient in good circumstances with everything already set up, yeah, maybe. On a pregnant, emotional, fluid overloaded patient, it will likely take longer than 2 min. Are you really going to delay transport for that?
> 
> And more importantly, even if you DO get an IV during the 2 minute ride, so what? You are backing up to the ED doors now. Have your magic ALS skills now saved the patient? Did you really do anything important that a basic couldn't have done? Have you made any impact at all on the patient's clinical course?
> 
> Now, extend the distance out to 15 minutes, and that changes things a little, I guess, but 15 minutes is still a pretty short transport time. If I were in the back of the ambulance with the patient described, and had a 15 minute ride, would I start an IV? Yeah, probably, primarily for analgesia. You need to be quite cautious about using narcs in a patient like this, though, especially if you can't communicate with her about her history and orientation and pain level. What if she does start to bleed a little a few minutes into the ride?  Gonna flood her with crystalloids? Do you carry blood? What if she starts to contract? You gonna giver her terbutaline? A mag load? Really - in 10 minutes? In all reality, if you are honest, you are probably just going to expedite to the ED. Just like a basic would.



Other's have pointed it out you're only looking at ALS from an intervention standpoint. ccmedoc pointed out the more in-depth knowledge of a _competent_ paramedic which is a plus but even then, I will agree it's tough to do a real thorough assessment in two minutes without a language barrier. Someone was talking about a study about survivability of traumatic injuries when transported POV (homeboy life support), BLS or ALS. I'll see if I can find it. I know Philly cops used to and may still transport GSWs in squad cars. 

Ok, I'll agree 30 seconds was a little ridiculous but yes, I will say I'm confident I could get a line started during transport without delaying it. Is it going to change her outcome at all? No, probably not but it's one less thing for the trauma team to do. In trauma our job is to get the patient to definitive care and help "kickstart" the process. Who care's if I don't use the IV, they generally will. I try not to go around starting IV's in patients that don't need them. With that said, who cares who starts the IV as long as it gets started? If I'm doing it enroute and not delaying transport why is it a big deal. If you want to base this on interventions than yea, it should be an ALS call because she's going to get a full abdominal workup. 

As far as analgesia in this patient I agree you have to be careful, but there's no reason you can't start in small doses to "test the waters". Again, I'm not saying blindly give narcotics to this patient but without any absolute contraindications I see no reason smart, conservative dosing would be out of line. Fentanyl is a category C medication. The OP stated the patient was in "obvious abdominal pain". People always cite "their pulse and BP weren't elevated so they weren't really in pain". That's not true at all, I've seen plenty of people with "normal" vital signs with obvious, painful injuries. If you can get a decent translator to do a better assessment you're golden, if not then I agree with withholding narcotic analgesia. I'm referring to calls with a longer transport time. 

I don;t really see the connection between fentanyl and bleeding. If she's going to start bleeding she's going to start bleeding, the fentanyl isn't going to make a difference either way...no I'm not going to flood her with crystalloids and no we don't carry blood but titrating NS for permissive hypotension is the only option we really have...

We don't carry terbutaline and I'd have to call for orders for mag, unless I have a decently long transport time there's no point, as you pointed out.


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## Handsome Robb (Mar 31, 2013)

Rialaigh said:


> Honestly. I can't think of a single, not one single, situation in which there could be a patient loaded in an ambulance with 0 interventions done, a 2 minute transport time to ER doors, and ALS would make a difference.



For the sake of me feeling argumentative, a complete FBAO relieved with direct laryngoscopy and magills.  

Sorry, my buddy had a cardiac arrest secondary to a choking yesterday so this popped out at me. Plus I'm in a shiesty mood after the day I had today at work so my apologies.


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## NomadicMedic (Mar 31, 2013)

Cardioversion is another...


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## Rialaigh (Mar 31, 2013)

There are obviously no absolutes but in the vast majority of calls (99.999%) a taxi driver can take someone 2 minutes as effectively as a doctor can from the standpoint of discharge outcome....you can always find a situation to fit the one exception...


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## emtdansby (Mar 31, 2013)

All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view. 
There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. With just those facts, would you ALS this patient or not?


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## NomadicMedic (Mar 31, 2013)

I think you're missing the point of the argument. The length of the transport defiantly makes a difference. A two minute transport with no immediate life threat is not an ALS transport. Let's remember that ALS means advanced life support and if you don't support the patients life in an advanced manner, you're not performing ALS. 

So it may be a paramedic riding in, but its still a BLS call. 

I may ride across the street to the hospital with the patient, but I am not going to delay the transport or access to the doc so I can play "super medic".


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## emtdansby (Mar 31, 2013)

I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient. 
Also, there is now way you could tell the patient had no immediate life threats. That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.


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## Handsome Robb (Mar 31, 2013)

emtdansby said:


> I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient.
> Also, there is now way you could tell the patient had no immediate life threats. That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.



Anything that's truly "immediately" life threatening will generally be revealed. Im talking something that is going to kill them in the next few seconds to minutes. Airway issues, uncontrolled external hemorrhage, tension pneumothorax, things of that nature. So yes, we can absolutely tell if there are any immediate life threats, from the EMS point of view.


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## Rialaigh (Apr 1, 2013)

emtdansby said:


> All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view.
> There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. With just those facts, would you ALS this patient or not?



I would absolutely ALS the patient....for reasons that are nothing medical. If I'm the medic I'm running this patient 2 minutes in even if I don't say a word to the patient and do nothing, just so I don't get my butt reamed when I get back to the station or get off shift....sad but true...


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## Carlos Danger (Apr 1, 2013)

emtdansby said:


> All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view.
> There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. *With just those facts, would you ALS this patient or not?*



If there was a paramedic on scene (i.e., you don't have to wait for one) and there was a significant transport time, say 30 minutes or more, yes. 

If I'm 10 or 15 minutes from the hospital, no. The chances of something going bad that the paramedic can do anything about in that amount of time are very, very slim. The paramedic should stay in service in case a call comes out where he really can make a difference.

I am a proponent of EMS systems that are composed primarily of BLS ambulances which are staffed by well-trained EMT-B's who aren't afraid of sick patients and are augmented by paramedic (or physician) fly cars which are only dispatched for certain criteria. 




emtdansby said:


> I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient.
> *Also, there is now way you could tell the patient had no immediate life threats.* That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.



You could tell she had no immediate life threats because she was walking around and talking.

Deaths from trauma generally follow a try-modal distribution in terms of when they occur (_actually, the research on this stuff is evolving, but even if not 100% technically correct, I think it's a useful conceptual model)_:


*Immediate deaths* occur immediately or before anyone even arrives on scene. These are your classic "non-survivable injuries"; massive CNS injury, massive myocardial trauma, immediate exsanguination from large vessel transection, etc. The only "treatment" for these is prevention; nothing whatsoever can be done once they've happened. So these are of no concern for EMS.


*Early deaths* occur secondary to severe injuries which will cause death within a few hours of the accident if not treated. This group is the focus of the "golden hour" concept.


*Late deaths* occur several days or more after the trauma. They are a result of secondary complications which manifest in organ failure. This is your SIRS, sepsis, DIC, MODS, ARDS, etc. These are not really a concern for EMS.

The focus of EMS care is obviously on the 2nd group, the "early deaths".

The problem is, "early" does not mean "immediate". If someone looks fine right now, they are not going to be in extremis in 5 or 10 minutes. We've been waay oversold on the idea that someone can look fine now, but still need to be in surgery within an hour.

I'll give you that OB is a little bit of a wild card, because it is another opportunity for trauma and complications. But still, life-threatening conditions take time to develop, and even once they do, there is little effective treatment that can be rendered in the back of an ambulance, even by a paramedic.

Generally, if someone is really sick, they look it. 

And the other thing is that we overestimate the difference that ALS makes in outcomes, anyway. There are very few times that having a paramedic vs. an EMT-B really affects how the patient turns out.


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## LEB343 (Apr 3, 2013)

After reading all the comments and talking about this situation with other medics, I completely understand why the hospital called a trauma alert. I guess with my limited "basic" knowledge, I didn't realize that at first. I also see why this was a BLS call, mainly because of the short transport time.

The system I work in is an overly cautious one. That's why I was so shocked when I arrived at the hospital and a trauma alert was called. Normally I wouldn't have attended on this call and I haven't had any experience attending on trauma alerts. Because there were 2 medics on scene, I am surprised that neither did an assessment. This call was hard on me afterwards because I should have done a better job. All I can do is learn from this call and do better next time. I appreciate everybody's advice!


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## Wheel (Apr 3, 2013)

Veneficus said:


> Nobody is disputing it is a trauma alert for a hospital, we are saying ALS is not going to make a difference.



Exactly. ALS will make no difference, except having access ready for the hospital (which they can do themselves if they need it.) Definitely a trauma alert on their end.


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## Bullets (Apr 4, 2013)

emtdansby said:


> So you wouldn't put a large bore IV in this patient? 15 min away and you wouldn't even place an IV? 8 months pregnant, severe abd pain, unrestrained head on collision, and you wouldn't even place an IV?!? What happens when that pain she is having is her placenta tearing from the uterine wall and she starts to bleed out? You're up front and your basic starts yelling for help because the pt is unconscious and has no pulse? Great job Mr. Paramedic.  A good paramedic doesn't sit around and what for an need for ALS intervention to be needed, we plan ahead.



What would cannulating a vein do for this patient? No LOC, no immediate life threats, stable vitals, why does this patient need another hole in her? If the patient becomes unresponsive and pulseless then your Basic partner has all the tools and training needed to save the patient, his hands and an AED. And what if her abdominal pan is muscular?


Robb said:


> Also unless basics in your area can start IVs your medic should be attending this patient. While we aren't going to use it unless she needs fluids and the aforementioned analgesics it helps the ER out and "kickstarts" the process.


Sou you would start an IV just because you can? when the patient doesnt need IV fluids? Because you have the training is not a reason to stick her



Rialaigh said:


> I would absolutely ALS the patient....for reasons that are nothing medical. If I'm the medic I'm running this patient 2 minutes in even if I don't say a word to the patient and do nothing, just so I don't get my butt reamed when I get back to the station or get off shift....sad but true...


If you dont do anything besides get a base vital, then its a BLS treat and transport, regardless of your actual certification


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## usalsfyre (Apr 4, 2013)

Bullets said:


> What would cannulating a vein do for this patient? No LOC, no immediate life threats, stable vitals, why does this patient need another hole in her?


There's something to be said for having access prior to circulatory collapse. 



Bullets said:


> If the patient becomes unresponsive and pulseless then your Basic partner has all the tools and training needed to save the patient, his hands and an AED.


:rofl::rofl::rofl:

How is an AED going to treat arrest from blood loss? How is CPR?  



Bullets said:


> And what if her abdominal pan is muscular?


Medics have drugs for that. Basics...not really.



Bullets said:


> Sou you would start an IV just because you can? when the patient doesnt need IV fluids? Because you have the training is not a reason to stick her


No, but my index of suspicion here is definitely high enough I would have a line in case it is warranted later. Think down the road aways.   



Bullets said:


> If you dont do anything besides get a base vital, then its a BLS treat and transport, regardless of your actual certification


The problem is the majority of basics I know are WOEFULLY inadequate at recognizing early stage shock. Which is the key here.


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## usalsfyre (Apr 4, 2013)

Halothane said:


> I am a proponent of EMS systems that are composed primarily of BLS ambulances which are staffed by well-trained EMT-B's who aren't afraid of sick patients



I want to focus on this line from Halothane's post. In an ideal world this is absolutely the way EMS should probably work. However, how many EMTs do you know that fit the criteria of well trained (think of the mean, not outliers on either end). It's very, very few. Further there's far too little Basics can do to help make patients comfortable. 

Maybe the AEMT level is the answer, maybe not. Right now though there are far too few basics that are able to recognize and be comfortable with sick patients to make me think medics aren't needed on a wide scale.


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## Bullets (Apr 4, 2013)

usalsfyre said:


> There's something to be said for having access prior to circulatory collapse.
> 
> 
> :rofl::rofl::rofl:
> ...



Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally

I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it. 

Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep


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## usalsfyre (Apr 4, 2013)

Bullets said:


> Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally


You prove the point of my last post rather beautifully here. 



Bullets said:


> I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it.
> 
> Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep


2 min with no medic available, absolutely. 2 min with a medic? Interventions or not, it's pretty weak to have your lower level partner ride this call. 15 minutes? Abso-freaking-loutely this is a medic level call.


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## Carlos Danger (Apr 4, 2013)

Bullets said:


> Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally





usalsfyre said:


> You prove the point of my last post rather beautifully here.




What was your point?


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## usalsfyre (Apr 4, 2013)

Halothane said:


> What was your point?


Basics (heck, most medics) are woefully inadequate at recognizing issues early. A complete shot in the dark, but I would bet fewer than 20% of basics nationwide have the assessment acumen to figure out who might go bad without it slapping them in the face.


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## Akulahawk (Apr 4, 2013)

Bullets said:


> Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally
> 
> *I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it. *
> 
> Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep


Has everyone forgotten that this patient had (at least 2) medics on scene while waiting for the ambulance to arrive. There's much that _those _medics could have done prior to ambulance arrival. That's "free time" as far as transport time is concerned... Also, has everyone forgotten that the partner that didn't do anything was also a medic who, in all likelihood, didn't asses the patient himself either. So, yes, there _was _an MICU on scene.


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## emtdansby (Apr 5, 2013)

Wow, this really has become a great debate. Glad I finally have some back up on my end. Hal, you are certainly entitled to your opinion and how you treat patients is  your way, but I can easily say I wouldn't want you treating my pregnant wife. The statement I have the biggest issue with is "The OP didn't say she was bleeding." just because there isn't any external signs of bleeding, doesn't mean she isn't bleeding internally. Her ABD pain along with her risk factors (8 months pregnant and unrestrained MVA) raise a considerable amount of suspicion towards internal hemorrhage. Also, the OP does mention that there was a fire medic and his partner( also a medic) on scene. So there would have been no delay waiting for ALS. His partner should've treated the patient, even with a short transport.


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## Clare (Apr 5, 2013)

ACH would not active a trauma call for this patient and I would not ask for one (not that I am likely to get it if I did!) and I would classify her as stable with unlikely threat to life (status three).  

She was in a low speed road crash, has no significantly abnormal physiology, is alert and orientated, and has no life threatening problems.  

I absolutely agree that her being pregnant is a cause for concern and that she should be immediately referred to a hospital emergency department but her problem is not one that is time critical. 

Although it is quite difficult for many people to accept (myself included) we must think of a patient's status as being defined by how time critical their problem is, regardless of the history of mechanism.  For example, a patient who has been in a road crash but has no significantly abnormal physiology and no time critical problems is not time critical just because they were in a road crash, somebody who is in decompensated septic shock but got bitten by a mosquito 3 days ago (as their avenue of infection) is time critical despite the fact that the road crash has significantly more potential to create a time critical problem than being bitten by a mosquito. 

In the past mechanism of injury was quite an objective factor in determining how a patient was classified (particularly, but not exclusively, road crash) and this must stop because regardless of the mechanism it is the state of the patient that determines how time critical they are.


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## LEB343 (Apr 5, 2013)

This has turned into a great debate! I guess this call could have been BLS or ALS. Just wanted to clear up a few things.

 There was a language barrier with pt. Her orientation was unknown along with unknown LOC. Also, in our protocols, we as ems cannot call a trauma alert. There are no criteria to call an alert.

The most frustrating thing about this call is how it got passed onto the ambulance crew (my partner and I). I've been told by ED physicians that when we bring in a pt and give a hand off, they pick up were we left off and go from there (obviously). We as EMS set the tone. The fire engine that arrived on scene first set the tone. There were about 6-7 people involved in the accident and we were told right away that there were no patients. We stood around for 5-10 mins before we were handed our patient. The fire medic did not seem concerned and therefore my medic partner did not seem concerned. I was then not concerned and figured this was a basic call until I got to the ED.

I guess the lesson to learn was don't be lazy! lol  Whether you are a EMT or paramedic, do a full assessment of the pt even if you were handed a pt from another medic.


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## Akulahawk (Apr 5, 2013)

LEB343 said:


> This has turned into a great debate! I guess this call could have been BLS or ALS. Just wanted to clear up a few things.
> 
> There was a language barrier with pt. Her orientation was unknown along with unknown LOC. Also, in our protocols, we as ems cannot call a trauma alert. There are no criteria to call an alert.
> 
> ...


That's a HUGE lesson right there. Always do your own assessment of the patient, even if you got the patient from a provider with higher medical authority than you. You could end up finding something that makes the patient require care that is outside/above your scope of practice. I can't count the number of times I was "given" a patient that had something that I wasn't authorized to monitor... and some of my former colleagues would have taken the patient on faith that the other provider said it was OK and/or deemed it to be appropriate for them to transport. 

Remember, if you feel (and can especially verbalize) that a patient requires care above what you can provide when taking over care from another provider, you (usually) have the right to refuse to take the patient and punt back to the other provider... if that provider is a higher level than you.


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## Handsome Robb (Apr 6, 2013)

Clare said:


> ACH would not active a trauma call for this patient and I would not ask for one (not that I am likely to get it if I did!) and I would classify her as stable with unlikely threat to life (status three).



I respectfully disagree. 

I'll agree with the no abnormal, obvious, physiological changes, with that said she needs an abdominal assessment from a physician, like I stated before in my replies. 

Not sure if I posted it in my earlier replies but per our Trauma Center's trauma criteria this patient would be the lowest level trauma activation, a "Trauma Green". Significant mechanism of injury with gestation >20 weeks and an abdominal complaint is a trauma here.


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