# ALS or BLS?



## DownSouthMedic (Jan 22, 2012)

Just kind of looking for some opinions on a call I ran this morning...

Ok, I'll just give the basic scenario, I work for a private BLS company, we respond to a call for "sick person", ALS on scene requesting BLS.

PT ripped her trach out, stoma actively bleeding, significant enough to require almost constant suctioning, audible gurgling present, PT coughing up blood.  PT bedridden, ventilator attached to the PT bed, nursing home staff reports is no longer required.  PT appears to be breathing adequately on her own.  PT Hx: Diabetes, COPD, Neuropathy, Stroke (cause of current deficits)  V/S: BP 124/76 PR 64 RR 20, O2 Sat 92%, GCS 11 (Normal Mental Status for the PT).  Anyways that gives you a rough idea of the scene.

Now...one of the medics from the rescue is hanging out in the hallway, the other is attempting to replace the trach when we arrive.  The medic in the room eventually gets the trach replaced, turns to me and my partner if were ok while she goes and grabs the portable suction, then we can get the PT ready for transport.  This is where things go south...THEY JUST LEAVE!  No turn over, all Hx and V/S I have were acquired after this point.  Now obviously they were wrong leaving, but should this have been a BLS call to begin with?  The airway is compromised by active bleeding as far as I'm concerned.  Our protocols are pretty much cut and dry, any airway compromise is ALS.  I ultimately just suctioned enroute, provided O2 and prepared to assist with ventilations.  Just wondering if some of the ALS providers in here would of ran this one in their selves, or turned it over to BLS.  Not trying to rant, was a little bit heated after this one though.


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## ffemt8978 (Jan 22, 2012)

Pt. on a vent with a trach installed, a compromised one no less?!?!?

ALS all the way around here.


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## medichopeful (Jan 22, 2012)

DownSouthMedic said:


> Just kind of looking for some opinions on a call I ran this morning...
> 
> Ok, I'll just give the basic scenario, I work for a private BLS company, we respond to a call for "sick person", ALS on scene requesting BLS.
> 
> ...



As it's portrayed here, this is definitely above the level of an EMT-B.  I'm not ALS, but I definitely say ALS for this call was a necessity.


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## DownSouthMedic (Jan 22, 2012)

I'm finding out more and more I work in a horrible system unfortunately...I get a sketchy call like this almost every shift.


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## EMS123 (Jan 22, 2012)

Would report the ALS crew for Abandonment... Def. ALS call, and at the very minimum at least following you to hospital with one in the rig with you.


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## JPINFV (Jan 22, 2012)

Definitely a paramedic or RT call.


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## DownSouthMedic (Jan 22, 2012)

JPINFV said:


> Definitely a paramedic or RT call.



Yeh the RT hopped right on this one as soon as we got her to the ER.


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## Akulahawk (Jan 22, 2012)

Ok, let me see... You have been handed a patient with a compromised airway, requiring tracheal suctioning because of bleeding. The rest of the patient seems generally baseline, but there is something significant to consider: your patient's airway bleed won't magically stop simply because the trach was replaced.

This was way above the level of an EMT, IMHO.


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## ffemt8978 (Jan 22, 2012)

Even without the trach, basics around here can't transport patients on a vent.


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## Anjel (Jan 23, 2012)

ffemt8978 said:


> Even without the trach, basics around here can't transport patients on a vent.



Pt wasn't on the vent anymore the OP said.

But yea. I would of called ALS right back. And those medics would be in big trouble. 

Def. An ALS call. If something would of went wrong, that's a lawsuit waiting to happeb.


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## ffemt8978 (Jan 23, 2012)

Anjel1030 said:


> Pt wasn't on the vent anymore the OP said.
> 
> But yea. I would of called ALS right back. And those medics would be in big trouble.
> 
> Def. An ALS call. If something would of went wrong, that's a lawsuit waiting to happeb.



Oops...missed that part.


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## Ramathorn90 (Jan 23, 2012)

Abandonment through and through, and a negligent transfer of care to top it off.


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## Handsome Robb (Jan 23, 2012)

So did you tell your supervisors about it? Or just us?

If the facts aren't skewed, and I'm not saying they are, what those medics did was negligent and abandonment. If it had gone south even a brand new, bottom of the barrel lawyer could prove it.

Trached patient doesn't automatically equal ALS, however with the complications you stated it needs to be an ALS run.

Basic scope of practice is supraglottic suctioning if im not mistaken. Tracheal suctioning is not supraglottic...

You got the patient to the hospital and made it happen with the bummer of a hand of cards and the tools available to you, you did a good job. Personally I think now it's time those medics are held accountable for their actions. This doesn't seem like something that should just be brushed under the rug in order to not create waves between agencies or departments.


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## LuvGlock (Jan 23, 2012)

> You got the patient to the hospital and made it happen with the bummer of a hand of cards and the tools available to you, you did a good job. Personally I think now it's time those medics are held accountable for their actions. This doesn't seem like something that should just be brushed under the rug in order to not create waves between agencies or departments.



This


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## Veneficus (Jan 23, 2012)

For certain this was an ALS call. It should have been handled by competent ALS providers. If this is an accurate rendition of events, it was definately unprofessional behavior on the part of the medics. Fleeing the scene is generally not professional behavior. 

But in the absense of a competent ALS provider, with the ability of tracheal suctioning, a basic skill in some places like my home state, what exactly makes this way above an EMT?

Bleeding? It needs to be controlled, it is likely doable with some basic dressing.

Suction? Like I said, if it is a basic skill where you are, does a paramedic suction any better?

Restraint? Chemical restraint is much prefered over physical, but in a pinch, tie the pt. up.

A trach patient with a chronically depressed mental status. Not easily made better by starting an IV, tube is in place, doesn't need electrical therapy, could use some versed, but no "life saving medications."

Sounds to me like the medics were out of their element. They were not able to handle such a patient from their described lack of familiarity, and they punted to the first available provider. Aka the OP, who appears equally uncomfortable. 

But really, aside from some versed, what exactly was the ALS provider to do that couldn't be done by said basic?

The tube is probably there to prevent adhesions and likely will later be removed, leaving a stoma. In the few minutes to an hour or so, adhesions will not form, so what is the issue? It would probably help if bleeding was addressed, but that is a wound edge issue. Excess secretions would be no different than bleeding, suction.

The trachea is in the mediastinal fascial plane, not the lung pleura so a pneuno or tension pneumo is not really a plausable scenario.

Once the blood gets in the deep airways, what is the ALS treatment for that?
Nothing.

What is this call really? An altered LOC patient who yanked a tube.

"Oh no! OMG!" 

Restrain, control bleed, suction airway, transport.

Yes ALS has better tools and should have handled it. No,  they didn't act professionally, but what would you have done if there was no ALS available?

I keep hearing stuff like "EMTs save medics, BLS before ALS," and "EMTs are more than a taxi with basic first aid training," 

Put up or shut up.


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## bw2529 (Jan 23, 2012)

Considering ALS was available (and already on scene no less) I would have expected them to ride.


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## Anjel (Jan 23, 2012)

Basics can suction trachs here.

And.to vene..

How the pt right at that moment wasn't way above BLS. But if something would of went wrong, like airway swelling, or swelling of the stoma from the trauma. There wouldn't of been a way to suction or bag.


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## Veneficus (Jan 23, 2012)

Anjel1030 said:


> But if something would of went wrong, like airway swelling, or swelling of the stoma from the trauma. There wouldn't of been a way to suction or bag.



You are a paramedic student, what would you have done?


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## Anjel (Jan 23, 2012)

Umm...ive been a student for three weeks. All ive learned is how to handle death and dying and what the mitochondria is.

But there would have to be something a medic could do. A cricotomy? if what they had was swollen shut? I'm not sure.


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## Veneficus (Jan 23, 2012)

Anjel1030 said:


> Umm...ive been a student for three weeks. All ive learned is how to handle death and dying and what the mitochondria is.
> 
> But there would have to be something a medic could do. A cricotomy? if what they had was swollen shut? I'm not sure.



A trach is a superior procedure to a cric, which is temporary and converted to a trach. 

If the airway starts swelling closed, all you can do is put a tube in it. Since there is already a tube in there, what can be done has been.


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## exodus (Jan 23, 2012)

In most places deep suctioning is an ALS skill considered invasive. BLS can't do it. ALS also has ETCO2 + Capnography and SPO2 to better monitor the airway and the ability to intubate the trach if gets jacked up.


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## Veneficus (Jan 23, 2012)

exodus said:


> ALS also has ETCO2 + Capnography and SPO2 to better monitor the airway and the ability to intubate the trach if gets jacked up.



Honestly, in a trach patient, if you need a devise to tell you the airway is compromised, you probably missed someting obvious.

The ability to intubate is not always possible. In procedures like laryngectomy, the trachea is attached directly to the fistula wall. There is no longer a passage between the upper and lower airway.

Other problems like neoplasm or already advanced upper airway swelling from various procedures may have required the trach to begin with.

I am not suggesting ALS shouldn't have handled this call, only that is could adequetely be done by properly utilized and experienced BLS. 

If your area doesn't allow BLS to suction trachs, I would point out that laypersons are taught to do that for both adult and peds on homecare, so your medical direction may want to join the modern world.


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## DownSouthMedic (Jan 23, 2012)

NVRob said:


> So did you tell your supervisors about it? Or just us?
> 
> If the facts aren't skewed, and I'm not saying they are, what those medics did was negligent and abandonment. If it had gone south even a brand new, bottom of the barrel lawyer could prove it.



I know it sound's like I'm just trying to trash this ALS crew, but I have not exaggerated at all.  Ultimately we transported the PT with no further complications, but looking back I should have just called the ALS crew back.  I will be notifying my supervisor about this next shift.


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## Anjel (Jan 23, 2012)

DownSouthMedic said:


> I know it sound's like I'm just trying to trash this ALS crew, but I have not exaggerated at all.  Ultimately we transported the PT with no further complications, but looking back I should have just called the ALS crew back.  I will be notifying my supervisor about this next shift.



I wouldnt wait. Call now. The longer you wait the more chance of mixing up the facts.


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## triemal04 (Jan 23, 2012)

Veneficus said:


> *For certain this was an ALS call. It should have been handled by competent ALS providers*. If this is an accurate rendition of events, it was definately unprofessional behavior on the part of the medics. Fleeing the scene is generally not professional behavior.
> 
> But in the absense of a competent ALS provider, with the ability of tracheal suctioning, a basic skill in some places like my home state, *what exactly makes this way above an EMT?*


See?  See what having a little common sense will do?  It'll make you say silly things like this and cause the equivalent of crickets to start chirping in a thread...oh so funny...and accurate.

The only thing I'd be to worried about with this patient wouldn't be so much airway swelling (well, actually it would be, from a different cause) but a build-up of subq air; depending on where the bleeding was coming from and how much damage had been done I could see that being a problem, especially if positive pressure ventilations were ever used.  Which didn't seem to be a problem in this case.  That isn't neccasarily the end of the world, but that would take a *competant* paramedic to maintain the airway.  Having a paramedic ride this patient in would probably be a good idea for that reason.

But beyond that...everyone who is immedietly jumping on the "I need a paramedic NOW" bandwagon...why?  Once again, ignore your personal bias and "experience" and come up with a valid medical reason that this patient needed a paramedic RIGHT THEN.  Not in 5 or 10 minutes, not in a worst case scenario, but as presented, and IN THAT CONDITION.


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## Veneficus (Jan 23, 2012)

triemal04 said:


> The only thing I'd be to worried about with this patient wouldn't be so much airway swelling (well, actually it would be, from a different cause) but a build-up of subq air; depending on where the bleeding was coming from and how much damage had been done I could see that being a problem, especially if positive pressure ventilations were ever used.  Which didn't seem to be a problem in this case.  That isn't neccasarily the end of the world, but that would take a *competant* paramedic to maintain the airway.  Having a paramedic ride this patient in would probably be a good idea for that reason..



For the sake of continued discussion, what is your plan if those worst case events were to transpire?


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## Medic Tim (Jan 23, 2012)

Def an ALS call. Any airway compromise or possible airway comprise gets ALS if available


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## triemal04 (Jan 23, 2012)

Veneficus said:


> For the sake of continued discussion, what is your plan if those worst case events were to transpire?


Tell the EMT on scene that it's now his call, run out the door, go back to quarters, curl up in the corner while sucking my thumb and hope my medical director doesn't find me...:rofl:

I'm not sure what the best way would be.  If there is a buildup of subq air it's either because the trach tube is in a false lumen, or there is enough damage below/near the end that any positive pressure is forcing air in.  (Like I said, I think this would be more a problem with positive pressure, not spontaneous breathing, but I'm not positive; probably still be a problem, but maybe not as bad).  

Best idea would be to GENTLY pass an eschmann through the trach to ensure that you had access to the trachea and wouldn't create a new false lumen when you replaced the trach, and GENTLY replace it with an ET tube.  Assuming that it did enter the trachea, it'd have to be inserted deep enough so that the balloon was below the site where air was entering the skin; potentially this could mean only ventilating 1 lung.  The balloon also might need to be overfilled.

And the liberal use of diesel.  

That's the first thing that pops into my head, and really, I don't know what else would/could be done in the field.  Honestly, I'm not sure anything else could be done in the hospital; the cause for the subq air needs to be fixed, but sutures or otherwise, but the lungs still need to be ventilated.


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## triemal04 (Jan 23, 2012)

Oh, and get on the phone with the hospital and tell them to get anesthesia and ENT into the ER immedietly.


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## Veneficus (Jan 23, 2012)

triemal04 said:


> If there is a buildup of subq air it's either because the trach tube is in a false lumen, or there is enough damage below/near the end that any positive pressure is forcing air in.  (Like I said, I think this would be more a problem with positive pressure, not spontaneous breathing, but I'm not positive; probably still be a problem, but maybe not as bad).



I am not sure I understand this?

If the tube was pulled out, I would suspect a false lumen between the skin and trachea. That shouldn't be difficult to identify. As you bag, it would get worse. 

My simple minded solution would be to decompress this lumen, leave the tube in it, and put an ET tube in the proper lumen.

There is also a real possibility if the trachea was surgically connected to the stoma that it was traumatically mobilized. In which case you simply have to find it and put a tube in it.

But here is where I don't quite get what you are saying.

You potentially suspect an actual hole in the anterior or posterior trachea?

Anterior, I would definately doubt. Just because of the actual cartilage ring construction and the real quantity of them.

Posterior could occur if somebody was a little too forceful replacing a beveled trach tube. In which case you now most likely have a hole into the mediastinum which if no other way out you would expect to see gastric distention or less likely signs of a tamponade.

If the esophagus was penetrated by the replacement attempt, it would be a surgical emergency for sure, but I doubt a rapidly decompensating one, more of a sepsis risk.    

Could you clarify what you mean?


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## triemal04 (Jan 23, 2012)

Veneficus said:


> I am not sure I understand this?
> 
> If the tube was pulled out, I would suspect a false lumen between the skin and trachea. That shouldn't be difficult to identify. As you bag, it would get worse.
> 
> ...


I don't know about decompression...I haven't seen subq air from this particular cause, but with others it was over a wide enough area that that wouldn't work.  Even in this case I don't think it would; the air is going to spread out under the skin and I don't see one needle fixing that.  Or did you mean something else?  And if you left the misplaced tube in place, how would you pass an ET tube into the correct pasage; your access to the stoma is blocked.  Standard oral intubation?  Crich?

The trach tube being in a false lumen (I think there's an actual term for when that happens but damned if I can remember) would be a concern, but I doubt it would be the cause; if it was it would be a problem almost immedietly after the trach tube was put in the wrong place, not later on.  And, yes, I would be a bit worried about the cause being someone being to forcefull in replacing the tube and causing more damage and potentially tearing the trachea, or creating a new passage between the skin and trachea.

Even if it went through the back of the trachea I think you'd see some subq air though, not positive but it seems like it'd still come up.

I was thinking more along the lines of this becoming a problem later on, not initially.  In that case I'd be more worried that, in pulling the trach tube out the patient caused enough damage to either her trachea (actually doubt that'd happen) or the tissue above it that air under pressure would start to enter the skin.  Or that happenign when the tube was replaced.

Did that make it more clear, or more confusing?


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## Veneficus (Jan 23, 2012)

triemal04 said:


> I don't know about decompression...I haven't seen subq air from this particular cause, but with others it was over a wide enough area that that wouldn't work.  Even in this case I don't think it would; the air is going to spread out under the skin and I don't see one needle fixing that.  Or did you mean something else?  And if you left the misplaced tube in place, how would you pass an ET tube into the correct pasage; your access to the stoma is blocked.  Standard oral intubation?  Crich?
> 
> The trach tube being in a false lumen (I think there's an actual term for when that happens but damned if I can remember) would be a concern, but I doubt it would be the cause; if it was it would be a problem almost immedietly after the trach tube was put in the wrong place, not later on.  And, yes, I would be a bit worried about the cause being someone being to forcefull in replacing the tube and causing more damage and potentially tearing the trachea, or creating a new passage between the skin and trachea.
> 
> ...



more confusing, but I think I got it.

I was thinking if the sub Q air was so massive it was displacing the trachea posterior to it because of a false lumen, there may still be airflow into the lungs at some level. 

I figured in such a case, laterally decompressing by pinching the skin to avoid impaling a critical structure like a carotid, would relieve enough air to return the trachea to a visible position. 

The stoma is usually wider than the tube, especially an ET tube, so it may not be fully occluded. You may also be able to cut and extend the stoma. (as an emergent airway maneuver if there was decompensation) 

As I eluded to earlier, because most trachs I have seen placed were because of nonpatent upper airways, I would not consider that viable. I also think you would have much better luck going through the surgical opening for the trachea than creating your own cric below it. There is a completely disproportionate size of the holes created in the 2 procedures, and the trach is much larger.


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## exodus (Jan 23, 2012)

Also, in what counties are paramedics authorized to replace trachs?


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## triemal04 (Jan 23, 2012)

Veneficus said:


> more confusing, but I think I got it.
> 
> I was thinking if the sub Q air was so massive it was displacing the trachea posterior to it because of a false lumen, there may still be airflow into the lungs at some level.
> That would be my concern, and while there probably still would be some flow to the lungs I'd still be very concerned with finding a way to resolve the issue of air entering the tissue; at some point it will compromise ventilations.
> ...


Sorry for the red, it's just easier.  I doubt this would be a very likely situation anyway; it's just one of the only, if not the only real reason I can see for taking a patient like this in by paramedic, if the EMT's are able to do tracheal suctioning.


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## triemal04 (Jan 23, 2012)

exodus said:


> Also, in what counties are paramedics authorized to replace trachs?


Oh...sorry, you're from California...I'll rephrase my answer.

In every STATE in the country that has a halfway average EMS system paramedics are allowed to replace trach tubes.

Not a clue about Cali.


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## Veneficus (Jan 23, 2012)

Veneficus said:


> I also think you would have much better luck going through the surgical opening for the trachea *than creating your own cric below it.* There is a completely disproportionate size of the holes created in the 2 procedures, and the trach is much larger.



completely my error, don't know what I was trying to type. 

What I was trying to get at though was if the anatomy above the trach is impaired for whatever reason, just like passing an ET tube, I do not think this would be a viable option. 

I think I may have been thinking of a superior trachiotomy, and somehow confused what I wanted to say.

Sorry, again, my fault.


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## triemal04 (Jan 23, 2012)

Well...by definition a crich would have to go in a certain spot anyway...


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## ScubaSteveEMT (Jan 26, 2012)

*Sh***y medics...*

I know that around here (MA), thats an ALS call 100%.

Regardless, however, there was no "handing down" of care by the medics. They left w/ no word to you or your partner. Abandonment. They should have their tickets pulled...around here, OEMS would have their asses.


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## Bullets (Jan 26, 2012)

Just out of curiosity, how far are you from a hospital? If this was in my area,  5min from a Level II, I say screw it, package transport and suction, NOTIFY and get a RT on the phone or at the door

Once I'm done with the call, then I call my Supervisor

Also EMTs in NJ are taught to suction a stoma, at least we are ahead in something


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## DrParasite (Jan 26, 2012)

DownSouthMedic said:


> The medic in the room eventually gets the trach replaced, turns to me and my partner if were ok while she goes and grabs the portable suction, then we can get the PT ready for transport.


this might be the only thing that lets them leave.  key word is MIGHT.  if the trach is replaced, and returned to a properly functioning position, than it MIGHT be a BLS call (since the airway is no longer compromised).

Regardless, I would have wanted ALS to come with me, even if it was just so if the trach fell out they could put it back in again.  the whole M+T and do the stare of life with the BLS crew.


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## edash (Jan 27, 2012)

sounds like you work in King County..this is business as usual for us..ABLS..hahaha


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## jjesusfreak01 (Feb 5, 2012)

DrParasite said:


> this might be the only thing that lets them leave.  key word is MIGHT.  if the trach is replaced, and returned to a properly functioning position, than it MIGHT be a BLS call (since the airway is no longer compromised).



As a BLS provider (convalescence), I have my own rule that regardless of the cause of the patient's injury or illness, if they have been stable for a number of hours or days without anything being messed with, and I don't expect ALS interventions to be needed, i'll take the call. 

Example 1: Pt having a sustained allergic reaction (itching and hives) from a nursing home. Initial start of reaction appx 8 hours prior to the call. I can reasonably suspect that the pt will not develop airway compromise due to the length of time since the start of the reaction. It doesn't mean they wouldn't benefit from some IV benadryl or solumedrol, but they can do without until we reach the hospital.

Example 2: Diabetic patients. If they have received insulin immediately before transport, I will not take them, as I don't carry even oral glucose on my truck. If they had insulin an hour prior and are just finishing lunch, we're great.

Example 3: Trach patient needing suctioning for an hour and a half transfer. Trach was changed by an ENT before transport, and I sat with the patient for a good half hour and made the RT suction him once before we left. No complications during that time, so we were good to go. I did suction his trach a few times enroute without issue. This call was borderline just due to a possible need for deeper suctioning.

So, my thinking is always a very simple, "what are the chances this patient will need ALS intervention enroute". In the OP's post, the first sentence made it quite clear that the pt was at a significant risk for needing ALS care sometime during transport. I wouldn't have taken that call unless I legitimately thought staying at the facility (waiting for the medics to return) would have been more dangerous for the patient than rushing to the hospital.


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## systemet (Feb 5, 2012)

jjesusfreak01 said:


> Example 1: Pt having a sustained allergic reaction (itching and hives) from a nursing home. Initial start of reaction appx 8 hours prior to the call. I can reasonably suspect that the pt will not develop airway compromise due to the length of time since the start of the reaction. It doesn't mean they wouldn't benefit from some IV benadryl or solumedrol, but they can do without until we reach the hospital.



I think this is ok, but just be aware that some patients can have a biphasic response, with a second wave of symptoms some hours later.  Just be alert for any changes.  I think this is only an issue going BLS if they're going a long distance.

[Then again, your level says EMT-I --- all the EMT-I scopes confuse me, but don't some of them include epinephrine anyway?]


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## jjesusfreak01 (Feb 5, 2012)

systemet said:


> I think this is ok, but just be aware that some patients can have a biphasic response, with a second wave of symptoms some hours later.  Just be alert for any changes.  I think this is only an issue going BLS if they're going a long distance.
> 
> [Then again, your level says EMT-I --- all the EMT-I scopes confuse me, but don't some of them include epinephrine anyway?]



My training is EMT-I, my certification is basic pending results from the EMT-I state test, and I work for a convalescence company full-time that doesn't stock anything past the state minimum on our basic level ambulances (no drugs). Also, very short transport. The EMT-I drug scope in NC is all the diabetic meds, all the first line cardiac arrest drugs, plus toradol, histamine-2 blockers, atrovent, IV benadryl/narcan, that kinda stuff.


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## RanchoEMT (Feb 6, 2012)

DownSouthMedic said:


> Just kind of looking for some opinions on a call I ran this morning...
> 
> Ok, I'll just give the basic scenario, I work for a private BLS company, we respond to a call for "sick person", ALS on scene requesting BLS.
> 
> ...



Have you not ran ALS before? 
In my company you work your way up to 911(ALS) from IFT(BLS)... So while working IFT/BLS we run what we call "code2" calls..... like downgraded to BLS(from dispatch) code3 or 911 calls. Seems like an efficient way to prioritize and make efficient use of the appropriate/available units in the system at the time... But there is a Major flaw... The Newbie IFT EMT's are not keen to what an ALS(911) call consists of. Nor are the idiots who triage these calls. No Body wants to be the guy that told the charge nurse/Dispatch to call 911 and have an ALS Ambulance and a Medic Fire Engine roll up, roll their eyes, and roll out.... So, I can say from personal experience I've taken calls far beyond my level of training/comfort many times when i first started out... thankfully all had ideal and positive outcomes as i can remember. 
But if i were you i'd make a strong effort to work some 911 or at least talk to a medic from your area(YOUR PROTOCOL) or even on this site and begin to piece together in the triage sense what is yours and theirs(ALS).. Before you Fuk up and kill someone.  I don't mean to be harsh towards you but please realize the level of importance and responsibility that occurs when you "accept" a patient, especially one your not comfortable with. 

A good rule of thumb: "If your not comfortable taking the patient, Don't."

As for the medics who dumped the call on you.... Alot of factors come into play that are not clearly stated in the OP, Same Company? Fire Medics? Etc... Maybe they had good reason to downgrade; protocols, politics, laziness. IDK, but I would be less than surprised to hear if it was the later. In which I would tell you to Report them.(Tho if you weren't comfortable onscene, should have been done to the On-Duty Sup. before transporting the patient)....


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## EMTBell (Feb 24, 2012)

*Abandonment all the way!*

Regardless of what the situation was, where I am, if ALS is on scene they cannot hand the call off to BLS unless its a masscal scenario.

Though it seems this should have been full ALS transport.


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## Medic Tim (Feb 24, 2012)

EMTBell said:


> Regardless of what the situation was, where I am, if ALS is on scene they cannot hand the call off to BLS unless its a masscal scenario.
> 
> Though it seems this should have been full ALS transport.



even if no als assessment or interventions are performed?


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## EMTBell (Feb 24, 2012)

Yeah, we can't hand off to a lower level of care once they are the patient of an ALS provider


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## Handsome Robb (Feb 24, 2012)

EMTBell said:


> Yeah, we can't hand off to a lower level of care once they are the patient of an ALS provider



I'd bet your Paramedics can if they deem it a BLS/ILS call depending on how your response system is set up.


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## emtchick171 (Feb 25, 2012)

That is ALS all day long where I'm from, and I'd hate to know I had turned this over to a BLS crew...bye bye job.


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## DesertMedic66 (Feb 25, 2012)

NVRob said:


> I'd bet your Paramedics can if they deem it a BLS/ILS call depending on how your response system is set up.



For us it's the same. Once the patient has been seen by a paramedic, the paramedic can not hand the patient over to BLS unless it's an MCI. 

So if fire is on scene first they have a medic. If BLS arrives on scene we have to either wait for a medic ambulance to arrive or transport with the fire medic in charge of patient care. 

Our paramedics can deem a call a BLS call however they still have to take the call. They will just not do any ALS on the call.


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