# ALS Upgrade refused



## flhtci01 (Jan 10, 2009)

Just want to vent on this one.

Basically working in a first responder type job.  80 something year old had a witnessed collapse.  On him within a minute, no respirations, no pulse, began CPR. Called 911. AED on within four minutes, no shock advised.  Worked him per local protocol. Called dispatch to see what service was responding, was told the local BLS service and requested ALS upgrade. 

Later, I was told dispatch radioed the responding BLS service that the scene was requesting an ALS upgrade.  The BLS service response was NO!  

FYI, the BLS unit was told "CPR in progress" when toned out. 

Given pt's PMH probably didn't make a different but still chaps my :censored::censored::censored: that they did not upgrade and refused the upgrade when they were not on scene.


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## ffemt8978 (Jan 10, 2009)

That call needs to be sent to your medical director for review...I hate to say it, but there may be some legal repurcussions that come out of that one for not sending ALS.


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## reaper (Jan 10, 2009)

Sounds like something that needs reported to your state ems!


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## KEVD18 (Jan 10, 2009)

cruicify who evers responsible.

it likely wouldnt have mattered, but the principle stands. hang em.


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## medicdan (Jan 10, 2009)

I'm certainly with you. Especially if there is an EMT or paramedic on scene, as in this case, there is no doubt ALS should have been activated, if even by the CC.
Some services (or regions) have set dispatch triage guidelines. One thing that I am just learning is fairly prominent is services sending BLS to everything to asses, then only after BLS assesment, calling ALS. I dont agree with it, but I see it being done.

Personally, I am working on the oposite problem (less problematic) I am working with a BLS FR service I am active in. We are all EMT-Bs, and the default in the area is an ALS response. We would like to be able to downgrade the response to BLS if we feel it is appropriate. I feel we should have that power... the city fire dispatcher does not.

One last note: OP, are you sure ALS just wasnt available?


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## marineman (Jan 11, 2009)

emt-student we have a similar problem. In Milwaukee we have 4 or 5 privates competing with Milwaukee county FD providing their own ambulance for ALS when possible. All of the privates have both BLS and ALS rigs. Our company dispatchers have absolutely no medical training beyond maybe CPR/AED and there are some BLS calls that they upgrade to ALS response if they think (again with no medical training) that we might be able to do ALS interventions and bill at an ALS level. I realize that the money push is something you have to deal with in a private service but it's ridiculous some of the calls they send ALS on.


Edit: To the OP, I'd definitely send that one up the chain. As a BLS provider if you haven't seen the patient yet and you know CPR is in progress there's no way they should be denying ALS. Especially with a non-shockable rhythm there is absolutely nothing other than CPR and transport that BLS can do, at least ALS has a slim chance of being able to correct asystole or PEA.


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## firecoins (Jan 11, 2009)

That is an automatic ALS call.


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## Epi-do (Jan 11, 2009)

Unbelievable.  How can you not send ALS to a cardiac arrest?  (Ok, I realize if the system is only BLS then it isn't an option, but that doesn't seem to be the case here.)


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## MedicPrincess (Jan 11, 2009)

Do you not have automatic ALS response on at least some calls?  It would seem Cardiac Arrest would be one of those that would warrant it, if even a Supervisor vehicle or chase car.


I am constantly reminded how fortuant I am to be in an all ALS response area.  We don't have BLS 911 units here.


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## Flight-LP (Jan 11, 2009)

MedicPrincess said:


> Do you not have automatic ALS response on at least some calls?  It would seem Cardiac Arrest would be one of those that would warrant it, if even a Supervisor vehicle or chase car.
> 
> 
> I am constantly reminded how fortuant I am to be in an all ALS response area.  We don't have BLS 911 units here.



And thus you can eliminate any question there is about who should respond. Get rid of the primary BLS 911 units in area that already have ALS and there wouldn't be any of this confusion, questioning, or b!tching about who should do what.

I'm sorry, but those who are complaining about ALS response maximizing a payment return need to understand some basic principles in business. $$$ is what allows a paycheck to go into your bank account. An EMS service is absolutely justified and it is a sound business move to send the personnel that they can submit the most charges for. At the same time, the pt. is getting a higher level of care with a more proficient assessment and possibly a higher level of treatment depending on their condition. ALS can downgrade if they wish, but despite the common EMT-B belief that Paramedic's "get sick of the B.S. calls", most have no issue riding them. I know I didn't. Sending ALS with intent to maximize financial return and provide the highest level of care is a win-win situation. Sorry if you disagree or don't see the logic to it...


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## flhtci01 (Jan 11, 2009)

emt-student said:


> One last note: OP, are you sure ALS just wasnt available?



ALS was in their rig waiting for the dispatch


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## flhtci01 (Jan 11, 2009)

MedicPrincess said:


> Do you not have automatic ALS response on at least some calls?  It would seem Cardiac Arrest would be one of those that would warrant it, if even a Supervisor vehicle or chase car.



It's not an automatic ALS response, even though it should be.

I think part of the problem is BLS and ALS are different services with a mutual aid agreement.  

FWIW The ALS service responds to everything as ALS and then downgrades on scene if they can.


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## medicdan (Jan 11, 2009)

emt-student said:


> I'm certainly with you. Especially if there is an EMT or paramedic on scene, as in this case, there is no doubt ALS should have been activated, if even by the CC.
> Some services (or regions) have set dispatch triage guidelines. One thing that I am just learning is fairly prominent is services sending BLS to everything to asses, then only after BLS assesment, calling ALS. I dont agree with it, but I see it being done.
> 
> Personally, I am working on the oposite problem (less problematic) I am working with a BLS FR service I am active in. We are all EMT-Bs, and the default in the area is an ALS response. We would like to be able to downgrade the response to BLS if we feel it is appropriate. I feel we should have that power... the city fire dispatcher does not.
> ...



Sorry, let me clarify. The one system I had in mind when writing this is an ALS-default systems. ALS is the primary response type, augmented by BLS. The feeling being that if BLS can handle the truly BLS calls, it frees up ALS for higher-acuity calls. Some calls are automatically ALS, a few others auto BLS, but just about all gets some form of ALS assessment. 

Boston, on the other hand is a mainly BLS system. Everything gets a BLS response, with some calls getting an auto ALS based on CC or BLS request. The feeling is that in an urban environment with many Level I hospitals never too far away, there isnt much difference in outcomes. Debate elsewhere.


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## traumateam1 (Jan 12, 2009)

*Lets play medic!*

Yup.. document and report!! Sounds like these EMT-B's were trying to play medic for the day. Should not have happened at all.

How'd the arrest p/t make out?


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## traumateam1 (Jan 12, 2009)

flhtci01 said:


> Just want to vent on this one.
> 
> Basically working in a first responder type job.  80 something year old had a witnessed collapse.  On him within a minute, no respirations, no pulse, began CPR. Called 911. AED on within four minutes, no shock advised.  Worked him per local protocol. Called dispatch to see what service was responding, was told the local BLS service and requested ALS upgrade.
> 
> ...





> How'd the arrest p/t make out?


*Disregard!*


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## flhtci01 (Jan 12, 2009)

traumateam1 said:


> How'd the arrest p/t make out?




Didn't live, pt had recent history of CABG and valve work x3.  

Spoke with the dispatch supervisor today and this also has him wondering what was going on.

Continuing to push this.


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## bambulanceman (Jan 13, 2009)

Wow, what a liability!!
Not me, brother!


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