# ALS Transfers



## Shishkabob (Apr 7, 2010)

So, there is no way to ask this question without making me look like a green medic:


For those that do medic transfers, what is the typical transfer for you like?  What does your company consider an ALS transfer?  Just maintaining fluids or an advanced airway?  I did IFT as a basic, didn't like it that much, but I chalked it up to me not knowing what was going on and not being able to do crap for my patients.



I have an interview at an IFT tomorrow for a paramedic position.  I want to do 911, but honestly in this economy and me being a new Paramedic, I kinda have to take what I get.  I know it's not going to be CCT and I won't have patients crashing on me all the time or even rarely... just seeing what the general call is like and what you do (as if there WAS a usual call in this job...)


I know I'll learn a lot about the disease process and lab values (especially since I finally know some of what's going on!), I just also want to stay interested and not get jaded like I see quite a few IFT medics do.



(Cue someone saying: "It's what you make of it!")


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## medicdan (Apr 8, 2010)

I may not be the perspective you are looking for, but i'll offer one:

I work as a Basic on a PB ALS truck that does mainly transfers. Frankly, the majority of our transfers are 0.3mi, between two buildings of the same hospital. It often takes us longer to do the paperwork then the actual transfer. In Boston, it is considered ALS if there are fluids hung (or the patient's IV cannot be locked for the duration of the transfer), meds being administered, the patient is on a vent, requires deep suctioning,  on a monitor (ER -> Telly floor, ER -> ICU, ICU -> ICU, Post Op -> ICU, etc), or traveling from the ER to Cath Lab (STEMIs). Our ALS transfers outside of that hospital system are often vented patients, or those on complicated drips. Before transfers involving vents, or some medications, we speak to a medical control doctor and get verbal approval, then a signature following the call. Most often, our orders for the meds or vent settings come from the Med Con MD, not the transferring facility MD. Because we are a PB truck, we cannot run full ALS without a second medic or a state deceleration of emergency.

My sense is that you will learn the importance of lab values, etc, but also how to manage fairly unstable patients with the resources at hand... and about some very cool disease processes...
Hope this helps...

DS


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## DrankTheKoolaid (Apr 8, 2010)

*re*

Being in the sticks in Northern California we are both the 911 medics and the CCT medics for transfers from our Podunk facility to the regional level 2.  Transfers can be anything from a gomer to post code resuscitation's and everything in between.   Typical drugs of scope along with the CCT variety as your EMS authority see fit.  But typically you can expect Heparin, Tridil, Blood, K, Automated vents and thoracostomy tube monitoring.

    Dont get me wrong though.  85% of the transfers are seriously BLS and typically include "i don't have enough money to pay for gas to drive down" so the Dr. writes an order for ambulance transfer.  But as long as the written order contains the words (chance of deterioration en route) reimbursement isn't an issue.


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## Outbac1 (Apr 16, 2010)

We do a lot of transports to the cath lab, which is about 100miles/1hr40min away. Cardiac pts w/o drips are considered a PCP transport here. (Our PCPs can do 12L and admin nitro.) We often have assorted drips, heprin, nitro, dopamine, levophed, insulin, pantoloc, blood etc. running on people. We also have a few traumas with chest tubes and vents. Vented pts also get an RT on the transport. On really sick people we will take a RN to have more hands in back. On rare occasions we will take a Dr.. We also handle assorted OBs cases. Moms with expected premature delivery, post delivery complications etc.. All in all some fun times can be had.


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## MrBrown (Apr 16, 2010)

Patient transfer is a very contensious part of the service here but I must digress.

If the patients are in anyway "sick" then they do not meet the critera for a patient transfer officer and must be transported an ambulance crew.

AFAIK there are no "specific" guidelines as to whether you get an Intensive Care Paramedic unless the hospital or sending facility specifically request one its largely around who is free/avaliabe.

Should the patient be really, really high needs and be on a ton of meds and pumps and stuff then the sending facility sends a doctor or nurse as our ICPs are not trained in that stuff.


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## NWParamedic (Apr 16, 2010)

Linuss said:


> So, there is no way to ask this question without making me look like a green medic:
> 
> 
> For those that do medic transfers, what is the typical transfer for you like?  What does your company consider an ALS transfer?  Just maintaining fluids or an advanced airway?  I did IFT as a basic, didn't like it that much, but I chalked it up to me not knowing what was going on and not being able to do crap for my patients.
> ...


An "ALS" transfer has everything to do with two things:

What is reimbursable by Medicare as ALS and
What your scope of practice will allow

Everything beyond a running IV and a cardiac monitor becomes ALS in the re-imbursement world.

The second item on the list, your scope of practice, determines the rest. Answer these questions and you will know what it will be like.

Does your scope allow IFT of IV drip medications?
Does your scope allow Paralytics?

Probably these two questions alone, there are others of course, will set how critical your IFT transports will be. Because if you don't have these two abilities in your scope, then you will be regulated to simple cardiac/medical transfers. If you have these in your scope, then you will be taking patients that are considered critical care like you would see in the ICU. Patients that are intubated, on a vent, that require continued sedation and paralyzation, Pressors, anti-biotics, every typical drip medication you see on an ALS patient, nitro, heparin etc. 

IFT's can be very challenging. Just depends on your system and what it allows you to do. What your scope of practice allows you to do.

What is your scope in this regard?


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## irish_handgrenade (Apr 17, 2010)

Linus, you and I are in a similar boat. I just got my state cert this week, and so far have taken everything from stupid transfers that really shouldn't need to got to higher level of care, to critical pts that require my undivided attention as well as some 911 calls here and there. I work on a double medic truck, that being said I'm the rookie I get the majority of the calls just so I can get comfy with the process. My advice is this take whatever job you can get, if its IFT then cool it will help you get comfortable and slowly ease your way into the medic life style. I feel like I get stronger as a medic after every call and transfers help a lot because I have more time to think about what I'm doing and why. Any way hope this helps let me know how it goes for ya.


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## Shishkabob (Apr 17, 2010)

Thanks NWParamedic.  As far as the scope question goes, it really depends on which agency I work for as Texas is a delegated practice state, meaning as a medic I can do theoretically anything that my medical director wants me to do.  They can be as aggressive or as lax as they want.

When I spoke with one of the agencies he said that the medic typically do the IV drip medications, paralytics, and cardiac cath transfers, among other things.  



Irish, how the heck did you get your state card already?  I got my NR before you.  Grr, Texas DSHS irks me.  Who does 911 out in Abilene?   I was trying to find it online but kept getting directed to a hospital that had NO info.


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## irish_handgrenade (Apr 17, 2010)

Actually looking back to your post. If you posted the day you passed then we got ours the same day. As for how I did it so fast, I pestered those women every day for the last two weeks, and I currently have 1 full time job and 3 PRN jobs that also pestered the DSHS ladies. As for who works 911 in Abilene its metrocare www.metrocareems.com good luck I'm not sure if they are looking for any full time, but I haven't worked at metro for a few weeks so I'm not really sure.


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## piranah (Apr 18, 2010)

hey Linuss, as you know I'm also a fairly new medic and I work for 2 services 1 is a interfacility and the 2nd is a 911 gig. With my interfacility we do everything from critical transports from outlaying hospitals to the trauma 1 or cath and BLS psychs(although those are usually the BLS units). My first call was a vented pt who required me to resedate her halfway to boston with versed (which i made sure i had orders for prior to leaving) and up to 20mcg/min of levophed due to her hypotensive status. My second call was a post V-fib arrest vented that almost coded on me again enroute. I have done cath runs,AAA,CVAs... you have to be prepared for anything....you wont have any issues... and the experience is great..i have no doubt you will like it


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## Scubamedic (Apr 19, 2010)

*Transports*

What I found in my time working for a service that did 85% non emerengency transport...is that you never know what you are really getting into. My ambulance service would send us out for a call of " Cardic re-evaluation" ...which I learned was a new way to say "CHEST PAIN". 
Mentally treat every call as " unknown medical" till YOU  decide otherwise.
More than once did I upgrade up to the call and to the hospital due to pt need. But most times you get really normal BLS transports and most of the time the people are really nice... and the mean one you just tell them that you'er going to drive them out into the swap and leave them for the crocs. That will shut them up. (joke)

I have to say that I spent a lot of time driving or working a pt to the hospital...with the knowlage that they would never go home. In this job, I still remember 6 Pt's that I worked and transported... that I got to go back to the same hospital and pick them up and TAKE THEM HOME.... and that feels really good. 

I really loved taking any call where you get to take someone home from the hospital, since I am so used to working 100% 911 with trauma and people that won't be going home. 

Enjoy it as a different side of medicine, as great learning experience and an exersize in patient's...lol


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## irish_handgrenade (Apr 19, 2010)

Scubamedic said:


> and the mean one you just tell them that you'er going to drive them out into the swap and leave them for the crocs. That will shut them up. (joke)



ROFL I didn't quite get this until I realized the punchline HEHE. There aren't any crocs in florida those are gators then I laughed pretty hard... 











HEHE jk... I'm bored:wacko:


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## Scubamedic (Apr 20, 2010)

*crocs! Snakes and sharks...Oh My!*

Actually we have a thriving population of saltwater and brachish water crodillia in south Fl, the largest recorded live in the wild was 17.5 feet. Because of hurricane Andrew.  Zoo's , Exotic pet store and animal shelters being destryoed or flooded, we also have growing populations of many new fun things to worry about while fishing. 

Spectacled caiman (Caiman crocodilius) 
	

	
	
		
		

		
			





Spectacled caimans are native to Central and Southern America. Although they look similar to native alligators, caimans can be distinguished by a bony ridge in front of their eyes. Coloration between the two species is also different - young alligators are black with yellow bands while caimans are greenish- to brownish-gray with dark brown bands. Adults attain a length of 6-8 feet. Caimans are established in Dade County, Florida, and have been reported in other areas of the country. They have also been observed in Everglades National Park. Discarded pets are the most likely source of introductions. 








INVASIVE SPECIES: Burmese pythons, an invasive species in south Florida, could spread to one third of United States
The invasion of gigantic Burmese pythons in South Florida appears to be rapidly expanding, according to a new report from a University of Florida researcher who’s been chasing the snakes since 2005.

http://www.youtube.com/watch?v=IckkZVwShd4


And lets not foreget the natives....


The bull shark is well known for its unpredictable, often aggressive behavior. Since bull sharks often dwell in shallow waters, they may be more dangerous to humans than any other species of shark, and, along with tiger sharks and great white sharks, are among the three shark species most likely to attack humans.

Unlike most sharks, bull sharks tolerate fresh water and can travel far up rivers. As a result, they are probably responsible for the majority of near-shore shark attacks


As if we didn't have enough things in this state that can kill you. I like to take a small jon boat into the mangroves and fish from a small sand bar in the Halifax river, which opens up to the ocean about a mile away. The water at high tide on the bar is just over the knee deep. great place for mangrove snapper and trout and redfish ( salt water bass).  One afternoon I was on a two day fishing bender ( we were on the fish!) and I was standing in the water as usual, my friend was just south of me with the large Abu to try and catch a small trapon. 

I was just about to cast we something hit me in the water so hard it knocked me down. I thought it was a dolphin since I have seen them out there before, till it swam by and started to turn. That was the first time I really pissed myself, it was a bull shark about 5 feet long and to it... we were the bait. 

I screamed to my friend , who turned and saw it coming back toward me, but he was to far away, I told him to swim to shore, while I walked on water to get in the boat. Lucky for me, I had angels on my sholders that day and made it, with the bull right on my heals. 

Once in the boat I looked for my friend, he was a life guard for daytona beach and could swim faster than anyone I ever met, but he was comming toward the boat, the fishing pole reversed ready to bash the shark with it...lol

I quickly reached into my bag and as the shark turned toward him, it was in the shallows and I put 13 rounds of .40 cal into it. Before I could think I had a fresh clip in my glock and my gaf in the other hand and I jumped back in the water and hooked the :censored::censored::censored::censored:er in the side, ready to unload again. It was unnecessary, it was dead as Julius Caesar.   

I called Fish and wild life and told them what happend. I was cleared and they hauled away the shark...wish they had not...would have loved to mount this on the wall. 

This is the best pic I can find of a simular shark, My phoone didn't have a camera, So all I have are the wonderfull memories and a scar where the sand paper on his hide scraped of some skin on my left leg. 






I still fish the same spot, except I keep the glock and my K-bar on my " fishing belt" ...LOL


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## Scubamedic (Apr 21, 2010)

irish_handgrenade said:


> ROFL I didn't quite get this until I realized the punchline HEHE. There aren't any crocs in florida those are gators then I laughed pretty hard...
> 
> 
> 
> ...



The real joke is that I would never say that to a patient....at least to their face.


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## VentMedic (Apr 21, 2010)

irish_handgrenade said:


> ROFL I didn't quite get this until I realized the punchline HEHE. There aren't any crocs in florida those are gators then I laughed pretty hard...


 
While alligators are still the majority, South Florida is home to over 2000 crocodiles.


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## Shishkabob (Apr 21, 2010)

Well I took it with AMR, and 'orientation' starts Monday.  I put orientation in quotes because I worked at the same branch as an EMT and have to retake it due to being gone for 6 months, so it's basically a formality, and I get paid full paramedic wages sitting in a room for 40 hours next week.



They do a decent amount of standby events too, so that will be fun.  But I don't plan on doing IFT a year from now.


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## VentMedic (Apr 21, 2010)

Scubamedic said:


> I have to say that I spent a lot of time driving or working a pt to the hospital...with the knowlage that they would never go home. In this job, I still remember 6 Pt's that I worked and transported... that I got to go back to the same hospital and pick them up and TAKE THEM HOME.... and that feels really good.
> 
> I really loved taking any call where you get to take someone home from the hospital, since I am so used to working 100% 911 with trauma and people that won't be going home.
> 
> Enjoy it as a different side of medicine, as great learning experience and an exersize in patient's...lol


 
I have always reminded EMT(P)s that the "BS" nursing home call or boring routine transport to a rehab (PT) center might just be another EMT(P)'s "save".  It is amazing how by EMS standards the same human being can go from being a cool trauma or code to a bullsh#$ call by just managing to pull through and live.


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## irish_handgrenade (Apr 21, 2010)

hey how much are they payin you for this service? just curious cuz I  don't know where I'll be at in a year ya know.


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## Scubamedic (Apr 22, 2010)

VentMedic said:


> I have always reminded EMT(P)s that the "BS" nursing home call or boring routine transport to a rehab (PT) center might just be another EMT(P)'s "save".  It is amazing how by EMS standards the same human being can go from being a cool trauma or code to a bullsh#$ call by just managing to pull through and live.



Qreat point Vent, many of us get to be Adrenaline junkies, myself included. I want to be the medic that catches the 4 car mva with roll-over and entrapment, save everyone from the brink of death and be the big shot.

 I think we all have, at one time or another, grumbled and moaned at the "BS" nursing home call or boring routine transport to a rehab (PT) center, Hopeing to jump at "good call " while enroute. 

It wasn't until I worked for a 3rd tier ambulance service, where intra-facility transfers and ALS monitered Dialysis transport were the commpanys bread and butter, that I discovered the other side and I honestly felt more than a little ashamed. 

 I remember the taking a 88 yr F C/C - 7/10 CP and nausa, from her home, treat enroute Fl CP protocol, and tranfer care to the hospital. Her Cp dropped enroute to 2/10 and she was aox3, gcs=15, slighly hypertenive, but in very good shape all things considered.

Like most other patients, After I left the hospital I never expected to see her again. Two days later, I was called to the same hospital for Pt transport home. I was thinking for what a waste of my time and bla bla, untill I walked into her room, her family there and I was very suprised. She waved me over and gave me a great big hug and thanks me and we talked all the transport home. I got to place her in her favorite chair...the same one I picked her up out of before. There are few times in my entire life that I was that happy on the job and it admit , it got me all misty eyed 

I learned a valuable lesson that day and it's one I will never for get. We are all here because we want to help others. I feel there is no higher calling and I now know that it is not always the big things, but the little things too...that make a difference. 

Thanks to you vent for reminding me of this. Happy memeories are few and far between. ^_^


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## Scubamedic (Apr 22, 2010)

*Kutos*



Linuss said:


> Well I took it with AMR, and 'orientation' starts Monday.  I put orientation in quotes because I worked at the same branch as an EMT and have to retake it due to being gone for 6 months, so it's basically a formality, and I get paid full paramedic wages sitting in a room for 40 hours next week.
> 
> 
> 
> They do a decent amount of standby events too, so that will be fun.  But I don't plan on doing IFT a year from now.



Congrats on the new job linuss, best of luck and hope all goes well.


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## VentMedic (Apr 23, 2010)

Scubamedic said:


> It wasn't until I worked for a 3rd tier ambulance service, where intra-facility transfers and ALS monitered Dialysis transport were the commpanys bread and butter, that I discovered the other side and I honestly felt more than a little ashamed.


 
Even for the dialysis patient, few look past the diagnosis of "renal failure" to see what actually caused the patient to need dialysis.  Some don't realize the patient may not have had any kidney disease but rather they may have had some catastrophic event such as a cardiac arrest or a trauma which initiated the events that severely damaged their kidneys.  

Not all "saves" turn out perfectly even if they are able to walk out of the hospital. But again, some EMT(P)s fail to acknowledge them as worthy patients or even as people on some ambulances if they are no long having a situation that stimulates the adrenaline.


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## Scubamedic (Apr 28, 2010)

VentMedic said:


> Not all "saves" turn out perfectly even if they are able to walk out of the hospital. But again, some EMT(P)s fail to acknowledge them as worthy patients or even as people on some ambulances if they are no long having a situation that stimulates the adrenaline.



Agreed.


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## Shishkabob (May 7, 2010)

40 hours in, and 1 ALS transfer, which was of a STEMI pt who had cardiac arrest a week prior.  Essentially just had to maintain an infusion of .45% NS, and keep them on an EKG.


Wondering why it was .45% NS and not .9%, but the nurse I spoke to had no clue and Google has turned up nothing.


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## 46Young (May 7, 2010)

Linuss said:


> 40 hours in, and 1 ALS transfer, which was of a STEMI pt who had cardiac arrest a week prior.  Essentially just had to maintain an infusion of .45% NS, and keep them on an EKG.
> 
> 
> Wondering why it was .45% NS and not .9%, but the nurse I spoke to had no clue and Google has turned up nothing.



Sounds like a really high speed shift. Was the rest BLS discharges and such, or did you just have one call in 40 hours?

Was the pt hypernatremic? If so, maybe the 1/2 NS was being used as a corrective measure? 

Also, what pumps are you using? Just curious. We used the Abbott Plum pumps. We had to deal with frequent cassette test failures. Reston Hospital in Fairfax County uses them and they told me they have the same issue. At my IFT gig here we use the Baxter 3 channel. It doesn't give me much of a problem. If you change over the pumps, and get a proximal air occlusion, you're supposed to back prime. If it's too much air for the pump to do that, you can use a syringe at a nearby port to aspirate the air without having to run all of the med through the tubing. Some drips can't be interrupted for long, and this will resolve the occlusion quickly.

Another piece of advice, it would be wise to know the typical loading dose and infusion ranges of common drips, such as heparin and tridil, for example. You may catch a med error. If you txp a pt with a dose range that's way off, you may be on the hook for not knowing any better, not just the sending RN.


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## Shishkabob (May 7, 2010)

My shifts are currently 16/16/8 Mon/Tues/Wed during my FTO time.  The ALS transfer was Monday.  We had a decent amount of BLS calls the rest of the time.   My FTO said I'm doing well and as soon as we start getting more ALS calls I should be cleared.  



Looking back I guess the .45%NS was because of the hypernatremia... should have critiqued the pts files more.


The pumps we use are the Alaris MedSystem III








I'm going to probably end up buying an ALS / CCT fieldguide for the odd drips.  I have my Drug Guide for Paramedics pocket book, but those rely more on EMS use of drugs and not the hospital uses.


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## 46Young (May 7, 2010)

Good idea with the CCT guide. I haven't seen those pumps yet. Are they user friendly?


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## DrParasite (May 7, 2010)

forgive my ignorance, but what is an ALS (paramedic) transfer?  I am about 98% sure that we don't have them in NJ.

Most of our IFTs are of the BLS kind.  hospital to hospital of stable patients, hospital to rehab centers, home to doctors offices, etc.

any time the patient has running drips, needs to be on a cardiac monitor, or anything of the sort, an RN is required, which makes it a critical care transport.  this includes transfer pre-surgery, STEMI/Trauma transfers, and other potentially life threatening and pre-scheduled stuff.  a medic is NOT required, and many/most are done by private companies with an EMT/RN and an EMT or 2 EMTs and an RN.

if a vented patient is transferred, it sometimes involves a BLS crew (2 EMTs) with a resp therapist from the sending facility, depending on the patient's condition (but can go with nurse and monitor if the situation warrants.


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## 46Young (May 7, 2010)

Also, Linuss, check out the small print on the fluid bags. They tell you the osmolarity of the fluid. It will give you a clue as to their hydration status, hydration goals, and/or treatment goals in general. And while we're on the subject of small print, take a look at your IV catheters. They tell you the flow in ml/min for that size.


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## Shishkabob (May 7, 2010)

46Young said:


> Good idea with the CCT guide. I haven't seen those pumps yet. Are they user friendly?



Pretty straightforward with drip set up... press the corresponding "A/B/C" button to choose the chamber, then you set the drip rate, amount left to infuse etc etc.  It's pretty picky with it's air bubbles though.



ALS transfers here at my branch are ones that cannot be maintained by an EMT, but dont require the service of CCT.  Mainly just infusion of common Paramedic drugs, maintaining IVs, and EKG monitoring.  The drugs that aren't typical to EMS are done through CCT, and CCT around here is usually a CCEMT/P and either an RN or RRT, depending. 


Like the other day, we get dispatched priority one to a local hospital for a transfer of an active head bleed, and CareFlite HEMS couldn't be used because of weather.  We got canceled less then 5min out because it was found out the pt was on Cardizem and so CCT had to transfer them.


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## 46Young (May 7, 2010)

DrParasite said:


> forgive my ignorance, but what is an ALS (paramedic) transfer?  I am about 98% sure that we don't have them in NJ.
> 
> Most of our IFTs are of the BLS kind.  hospital to hospital of stable patients, hospital to rehab centers, home to doctors offices, etc.
> 
> ...



Depending on the area, medics do many xfers that nurses do in NJ. Back at North Shore LIJ, the medics did everything from baloon pump jobs to the vented, sedated neurosurgery xfer. These were double medic in the back jobs, one of which was a CCM, of course. We also did some minor PICU txps. The NICU's and other PICUs would have an RN, RT, MD Fellow or some combination of the three.

IMO, these xfers should be the domain of the RN instead of the medic. They'll have the background and specialization for that particular pt, where the medic is just a "Jack of all trades." This is a major reason why I don't see the medic's education increasing significantly past the EMS AAS for some time. If you want to do real IFT, you're not going to increase your medic clinical education (currently unavailable in the US and it won't result in better salary anyway) when you could just become a nurse and have all the pay, scope, prestige, benefits and such that are deserved with the educational investment. It wouldn't be so with a four year medic degree (not the EMS BA, which is mostly admin stuff, not clinical). 911 prehospital medicine doesn't need much past the two year degree, unless your agency is initiating their own studies and trials.


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## 46Young (May 7, 2010)

Linuss said:


> Pretty straightforward with drip set up... press the corresponding "A/B/C" button to choose the chamber, then you set the drip rate, amount left to infuse etc etc.  It's pretty picky with it's air bubbles though.
> 
> 
> 
> ...



Your scope sounds like what a medic "one" was back at my old hospital in NY. A medic one only did simple non emergent cardiology xfers, a single drip, etc. No emergency calls or vent discharges, though. A medic one is a new, inexperienced medic. The medic 'two" is a medic one off probation, and can handle the active MI cath lab jobs, some PICU xfers alone, emergent calls, two drips, vent discharges, etc. Vented/sedated, baloon pump jobs, more than two drips, other emergent vent jobs, post arrest > 24 hours, are the domain of the CCT. Many of these require two medics, a one or a two to accompany the CCM. We only saw in hospital staff on NICU's and PICU's. CCT's could titrate tridil, propofol, and some other meds on standing order, whereas the medic two could not. It would seem that North Shore's ALS was on the higher end of scope when compared to the industry as a whole from what I can gather.


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## Shishkabob (May 7, 2010)

AMR Dallas isn't too progressive with their medic protocols.  We don't even have IOs for adults... have em for kids under 6 though!  I'm so screwed if I get a code with no veins... one of our trucks had an ROSC code the other day.  But we can do up to 3 simultaneous infusions using the pump. 

I know I read somewhere the defining criteria of ALS vs CCT... I just can't find that form.


We do nursing home emergencies with some frequency, like the usual chest pain or sob, and also get called out to the Dallas county jail on emergencies too.  We only have a handful of Paramedic trucks on shift at any time, with most trucks being dual EMT, so they spread us medics around, but we still do a fair portion of the BLS transfers.


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