# There are NO BLS patients.



## MedicPrincess (Aug 21, 2006)

We were having a discussion with our Shift Commander a couple shift back about giving pain meds to an ankle fx.  The patient stated he didn't want any, so the medic on that truck BLS'd the call.  Basically, if the patient would have wanted the Morphine, the call would have been ALS, complete with IV, Monitor, and O2.  Patient said no, so it was BLS.  Patient got a pillow splint and O2.  Essentially the EMT on that truck had come to my partner to complain about her Medic making that BLS.  My partner agreed.  No pain meds, and a non-complicated fx is BLS.  She puts me with them all the time.

Now we were talking to our Shift Commander about it.  He made the statment to the effect of "If it is possible that we can do more for our patients, then the person who is capable of providing that level of care should be attending to the patient, so that more can be given."  He says there are no could go either way patients.....cut and dry...BLS or ALS.

That being said, in my opinion, all patients who have called 711 are technically ALS patients then.  Even the guy we pick up at the bus stop who wants to go to the ER for eval of that mosquito bite.  I have been thinking about that.  On your "BLS" 911 calls, could you possibly do more for that patient?  They called for an ambulance, why shouldn't they get the highest level of care available on that truck?  And doesn't that relagate the EMT back to "Ambulance Driver" status?

I disagree with the cut and dry theory.  If a patient has refused pain meds, I am perfectly capable of sitting in the back and riding in with the patient.  I can monitor vitals.  I can assess and reassess.  And if the patient decides he just can't take the pain of my partner driving (heck, I have asked for Morphine after one of her finest drives), I am capable of sticking my head up front and telling her to pull over, he needs pain relief.

What do you think, are all or should all 911 patients receive ALS care all the way to the hospital?  All of ours get an assessment by the ALS person on scene, but IMO not everyone needs ALS level of care, even if we can technically "do more."


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## HFD EMS (Aug 21, 2006)

Ok, my agency is in a rural area thats pretty much county ran ambulance service.  We have BLS units around the county that are a volunteer service with three full time ALS rigs that are sationed in the middle of the county at a hospital that is located in our county seat.  When we are dispatched out based on the severity of the call the dispatcher actually makes the call on whether ALS or BLS shows up.  However, whatever the call may be if my BLS service is inservice then we are dispatched out regardless of the what the call is, but if its an ALS call then they will run dual response so they dispact both BLS and ALS and we usually arrive on scene much quicker than they do so we do a primary assessment and get the needed information so when ALS arrives on scene we give them the information and turn over care.  Only, if the call is severe or IV's are needed something that needs extended care we dont page out the ALS we run only BLS because we are trained enough to handled the situation without tying up the ALS service.  That is our service though and we are rural so i am sure things are completely different in your area, but thats what i can tell you from our stand point.B)


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## MMiz (Aug 21, 2006)

My service is owned by a large EMS provider that at one time was 100% ALS.  For a short period my service attempted to transition to an all ALS service, but failed.

Around here you either go in a wheelchair van, BLS ambulance, or ALS.  There are far too many dialysis patients and old ladies that need a ride home to make an all ALS service work.  Our ALS units were hating having to work the BLS calls, and our BLS patients weren't liking the ALS bills.

We provide ALS service to the communities we have 911 contracts with, and that's that.  BLS may end up transporting a psych or maybe a trauma during a large MCI, but the company believes that all patients should receive ALS care.

Since the great ALS craze of 2005, we've more than doubled our BLS units on the road.  BLS units almost always do the interfacility transfers, dialysis runs, and psych patients.

I think you may be comparing apples to oranges though.  The bread and butter of my service is the BLS runs, where it seems as though others focus more on emergency runs and rescue.

As I ramble on... and on... and on... I believe that a tiered EMS system, with both BLS and ALS capabilities, is the best system.  Unfortunately not all places have the ability to provide adequate BLS and ALS coverage at all times.


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## DT4EMS (Aug 22, 2006)

I agree it is either ALS or BLS. The person making that decision better do a darn good assessment.

There are people have called 911 for BS. Those people don't need a medic in the back. You all know the ones I am talking about..... toe pain , arse hurts etc.

I would make an assessment.....if they appeared stable where no ALS was needed  (or I wasn't going to start any) I would ASK my partner if they wanted to take it. 

If at anytime my partner stated they didn't want to or didn't feel comfortable, I still took the call.

Think about it though....a guy with an ankle fx that didn't want any pain meds or IV etc.... could have just as easily refused and said "Thanks for putting the pillow splint on, I would like to let my wife, mom, brother etc. take me to th EER to not tie you guys up"

I would say "Sir, I would prefer we take you, but sign here if you are sure."


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## Ridryder911 (Aug 22, 2006)

I agree there are BLS s a waste of and ALS, and having to have ALS to transport such time, money and resources. Compare this with the emergency department triaging those that can go  into "fast track or clinic side" to those that needs to go into the ER side. That is part of the problem with U.S. health care, thinking that all patients needs monitors, pulse ox, etc.. when a mosquito bite, rash (non- allergic reaction) etc.. way over use of equipment and inappropriate assessment and actually treatment. Does you when physician always apply ALS equipment to you when you see him at his office? 

There are several studies revealing we are still trying to treat patients as we did in the 70's and 80's..Studies have revealed that we are no longer seeing the old "typical" emergency patient, like we used to. Most EMS, ER patients would have been and should be considered minor, or clinic type injuries and should be treated as such.. overkill treatments and use of assessment tools, just increase costs and debt, that will never be paid. As others have mentioned, a good thorough history and physical should be performed, then and only then determination of ALS and its personal should be utilized. 

R/r 911


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## FF894 (Aug 26, 2006)

My fire department runs the BLS ambulance for our town.  We have a regional ALS intercept system in place.  We run 3 BLS EMTs in our rigs and the intercepting ALS truck usually comes with 2 Medics.  When we arrive on scene, collect the info on whatever the call is, I (or the crew) has to determine whether they want ALS to continue in to assess.  Anything heart, SOB, etc. they always do.  Once on scene, ALS does their assesment and determine whether they believe they should ride with us.  We are really lucky to have 2 great services that we work with a lot and we have a very good working relationship with both.  Like I said, anything heart, breathing, or obviously ALS needed they will ride.  If its questionable, they will ask us if we want them to ride or not.  They would never refuse to come with us if we said we felt like we needed them.  However, a situation like this, I would feel very comfortable going BLS and clearing them.  With 2 Basics in the back, they can handle an ankle.  We have to keep ALS available for a call actually requiring their services.  What if we had them xport with us and once they are commited there is an MI on the other side of town.  I would feel horrible.


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## RH3075 (Sep 5, 2006)

I would say I cancel ALS when i get to scene about 95 percent of the time.  Most of the call descriptions end up being wrong, and the "unconscious pt" ends up being a walkie-talkie with a headache wehn we arrive.  I also cancel them just based on ETA most of the time in PT who might be ALS pt's.  Being in the inner city, we are never more than three or four minutes to the hospital, and I can have a pt in the ED in 12 minutes from dispatch time to when Im walking in the doors with them.  The only times I am really not leaving scene before ALS arrives is for the cardiac arrest  because I have to work on ABC's first before going anyway.
RH


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## BossyCow (Oct 27, 2006)

RH3075 said:


> I would say I cancel ALS when i get to scene about 95 percent of the time.  Most of the call descriptions end up being wrong, and the "unconscious pt" ends up being a walkie-talkie with a headache wehn we arrive.  I also cancel them just based on ETA most of the time in PT who might be ALS pt's.
> RH



I'm rural EMS and my favorite scenario was having to call for ALS to evaluate 74yo female, ground level fall, "fallen and can't get up".  Arrive to find pt. screaming on any movement, HBD and on the floor in a locked mobile home. While the volunteer ff tried to determine if he could fit through the dog door, I got a halligan tool from the back of his rig and made an entrance. 

Now.. rural EMS generally means we know most of our pt's and this gal is not a whiner.  She is letting out involuntary screams of pain with any movement and is a tough old retired military broad who worked in law enforcement until retirement.  

I call ALS for evaluation because mainly, the voices in my head told me to, but also because she was hypothermic, down for about an hour before she called us, laying on an unheated water bed.  Yes she was drunk.. that's why she fell! 

I got all kinds of abuse for calling for an ALS eval on this one.  The medics who responded were fine, but captain back at the hall gave them and me a ration about 'abuse of the system' 'disturbing his sleep' and being a nervous nelly emt-b afraid to be alone with the pt. 

Turns out the gal had undiagnosed ("don't need no damn doctor's to tell me I'm old") osteoporosis and her ground level fall fractured 2 lumbar vertabrae and shattered her sacrum. Damn that diagnosis was sweet! The hardest part was being grown up and not doing the 'I was right neener neener' Dance


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## smalltownemt (Oct 30, 2006)

Our agency has had some of the same issues.  Often times BLS will tech if the pt refuses pain meds.  EMT-B's can start IVs with a cert here, so we don't have to worry about not doing an IV.  However, we still can't do ECGs.

After thinking about some of the calls that I have teched (I am a basic)  I felt the call probably should have been run by ALS.  I don't know if a couple of our medics just don't like running calls (or maybe it's writing reports), but they seem to push calls to BLS before really assessing the pt's needs fully.  Our agency has been working on updating protocols in order to distinguish whether a call should be run by ALS or BLS.  

I don't think ALS should always have to run the calls, they would tire out too quickly.  I feel that if you really have to question who should run the call, the ALS person should take it.  And as BLS, if I don't feel comfortable running the call for any reason, I tell my ALS partner and they take the call.


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## FF/EMT Sam (Oct 30, 2006)

*Als/bls*

Where I work, all units are ALS units, but depending on the volunteers who respond, there may or may not be an ALS crew.  If there's an ALS crew for a BLS pt, the ALS provider usually drives so that the BLS provider can be AIC.


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## EMTBandit (Oct 31, 2006)

Around here no, BLS and ALS are 2 separate entities. There are no transport ALS rigs. BLS responds to the scene, if ALS is needed we request it and the truck usually comes from a nearby hospital. ALS is also usually simultaneously dispatched for more urgent calls, (Ex: Cardiac, Respiratory calls.) Instead of being dispatched for common calls (Ex: Slip and falls, cut finger.) If we don't need ALS and it is something that can be handled entirely on a BLS factor BLS will cancel the ALS truck and BLS will transport to the hospital. But if we feel ALS is needed, ALS will come and evaluate, and if it is serious enough, they will ride with us to the hospital and the other medic will drive their truck following the Ambulance. Or in some cases, both medics will be in the ambulance and one of the EMT's will follow in the ALS truck.


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## Jon (Oct 31, 2006)

EMTBandit said:


> Around here no, BLS and ALS are 2 separate entities. There are no transport ALS rigs. BLS responds to the scene, if ALS is needed we request it and the truck usually comes from a nearby hospital. ALS is also usually simultaneously dispatched for more urgent calls, (Ex: Cardiac, Respiratory calls.) Instead of being dispatched for common calls (Ex: Slip and falls, cut finger.) If we don't need ALS and it is something that can be handled entirely on a BLS factor BLS will cancel the ALS truck and BLS will transport to the hospital. But if we feel ALS is needed, ALS will come and evaluate, and if it is serious enough, they will ride with us to the hospital and the other medic will drive their truck following the Ambulance. Or in some cases, both medics will be in the ambulance and one of the EMT's will follow in the ALS truck.


Where are you...Jersey?


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## MedicPrincess (Nov 1, 2006)

FF/EMT Sam said:


> Where I work, all units are ALS units, but depending on the volunteers who respond, there may or may not be an ALS crew. If there's an ALS crew for a BLS pt, the ALS provider usually drives so that the BLS provider can be AIC.


 
How does this work?  Here in Florida if the ambulance is "stickered" ALS by the state it must be able to perform as an ALS unit.  If there is not a paramedic on our ambulance then that unit is not in service.  

Now our BLS units can used for ALS calls, so long as the medic rides the call in.  There is not a single piece of "ALS" equipment (Meds, IV supplies, needles, intubation gear, etc.).  The EMT's that work the BLS units take manuel BP's, no need for a Lifepack.  They carry the same AED as the BLS FD's carry.  If the BLS truck is sent on a 911 call, there must be a paramedic responding with them.  Either an ALS FD or the shift commander.


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## EMTBandit (Nov 2, 2006)

Jon said:


> Where are you...Jersey?



How'd you guess, lol.

It's a pretty good system. Works out well.


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## wolfwyndd (Nov 2, 2006)

I don't believe in any cut and dry BLS or ALS, however, it is largely determined by WHERE you run, HOW you run, your PROTOCOLS and whoever is in charge.  

Where I run BLS or ALS is determined by patient status, mental, medical, etc, who is on the call and which squad it is.  Pt. status is determined by the first person to contact them.  Given the same situation as yours where your patient had a possible fracture and did NOT want any drugs, we would have BLSed it too.  IF it was our first out squad.  We only have TWO squads so if the first one got BLSed our P would have gone back to the station and awaited a second out call as long as there were two other B's aboard.  Which happens sometimes.  On the other hand if it was one P and one B the P would have decided whether or not they wanted to drive or do pt. care.  

This could go on and on and on.  I'm just saying in our jurisdiction it would have gone the same as yours went.  BLS.  And no one would have said a thing.


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## FF/EMT Sam (Nov 2, 2006)

EMTPrincess said:


> How does this work?  Here in Florida if the ambulance is "stickered" ALS by the state it must be able to perform as an ALS unit.  If there is not a paramedic on our ambulance then that unit is not in service.
> 
> Now our BLS units can used for ALS calls, so long as the medic rides the call in.  There is not a single piece of "ALS" equipment (Meds, IV supplies, needles, intubation gear, etc.).  The EMT's that work the BLS units take manuel BP's, no need for a Lifepack.  They carry the same AED as the BLS FD's carry.  If the BLS truck is sent on a 911 call, there must be a paramedic responding with them.  Either an ALS FD or the shift commander.



In Virginia, the ambulances can be certified as either ALS or BLS transport units.  Both of our ambulances are ALS units with a full set of ALS equipment (intubation kit, drug box, IV box, etc.)  If a BLS volunteer crew shows up, we can respond as a BLS unit.  If an ALS volunteer crew shows up, we respond as a Medic unit.  We have paid ALS crews M-F 6AM-6PM, and are all volunteer from 6PM-6AM M-F and all day on the weekends.  However, the county does pay for one ALS provider to assist the three rescue squads in the county during "off hours" ie. when the stations don't have a paid ALS crew on duty.


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## BossyCow (Nov 3, 2006)

Most of the rural areas here have BLS units as part of their volunteer fire departments.  The first choice for ALS support is a private ambulance company in town.  They only have one ALS rig so if they are doing another call or a transport, we just hope one of the 3 paramedics who also volunteer are available for a mutual aid.  Otherwise its 'scoop and run' otherwise known as 'go like hell' 
This has caused some rather interesting billing issues.  Medicare won't allow the ALS agency to bill a patient that they did not transport.  But, at O'dark thirty,  in the pouring rain, do you transfer an MI from one stretcher to another on the side of the road so the private company can bill them? We would have the paramedic jump into our rig but then our department would get the bill for the paramedic service from the private company and we didn't bill for our services.


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## yowzer (Nov 10, 2006)

My area is mostly BLS. There's (deliberately) very few medics; Seattle, with over 500000 people, normally has 7 medic cars, and that's dense coverage.

Most EMS calls get a BLS fire company, and often a private ambulance as well, to transport. Medics go to possibly severe things where they can be useful, like chest pain or difficulty breathing or shootings. They can be cancelled by the first-on BLS unit. Lots of times, someone will get a medic eval, and they'll send the person in to an ER by BLS ambulance, sometimes after doing minor ALS level interventions (Breathing treatments and IV glucose are the most common of these).

I really don't think asking for medics to transport someone just because they're in pain would go over very well.


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## sarahharter (Nov 11, 2006)

*BLS with ALS*

Where i run PA (mont, Berks, and northhampton counties) we have ALS and BLS squads. Depending on which county i am running in ALS is almost always dispatched with BLS. However if the call is the ALS territory they run by themselves. But if it's in our area they are dispatched as a medic responder to assisst the BLS crew. I run with both an ALS and BLS crew.  I havent reall yhad any calls where there was no medic dispatched. actually i find it kinda, well, like they think EMT's don't know their job because i think we could have handled alot of the calls as BLS, i mean a cardiac or something liek that i would understand a medic but not the normal run of the mill calls.


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## Airwaygoddess (Nov 11, 2006)

AMR is the service provider here in Santa Barbara Co. it is all ALS rigs with a EMT and paramedic. We just started having a CCT rig with  a CCTRN and 2 EMTs to try to do all of the critical care transports from hospital to hospital. This helps to keep the 911 rigs from getting so tied up. Some times if an EMT calls off they will staff a medic with the nurse and the EMT.  But as we all know that always does not work out perfect but it does help alot!


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## Jon (Nov 11, 2006)

sarahharter said:


> Where i run PA (mont, Berks, and northhampton counties) we have ALS and BLS squads. Depending on which county i am running in ALS is almost always dispatched with BLS. However if the call is the ALS territory they run by themselves. But if it's in our area they are dispatched as a medic responder to assisst the BLS crew. I run with both an ALS and BLS crew.  I havent reall yhad any calls where there was no medic dispatched. actually i find it kinda, well, like they think EMT's don't know their job because i think we could have handled alot of the calls as BLS, i mean a cardiac or something liek that i would understand a medic but not the normal run of the mill calls.


Around here, we get medics for "ALS Nature" calls... Cardiac/Respiratory, Arrests, Elderly Pt. fall (either 80 or 90 y/o+), Head injuries, MVA reported Serious, Entrapment, Ejection, w/ Fire, or Motercycle, Aircraft incident, Shootings, Stabbings, any fall or assualt with a possible Loss of consciousness, Overdose EXCEPT For BS ETOH overdoses.

That is MOST of the list of what gives us an ALS response.

Most anything else is BLS - Fall, generic sick person, etc.


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## BossyCow (Nov 14, 2006)

yowzer said:


> I really don't think asking for medics to transport someone just because they're in pain would go over very well.



Our protocols state we are to call for ALS for pain management. Perhaps due to our long transport times.


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## FFEMT1764 (Nov 15, 2006)

I work for a county service which employs all levels of EMT's (B,I,P). We have a medic on every truck, but that doesnt mean the medic rides all the calls. If it is a basic call the basic or intermediate can ride the call in. That allows the medics to not be tired when a true ALS call occurs. We feel that letting the BLS partner run the BLS calls allows for development of better assessment techniques for the basic and intermediate EMT's.


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## Jon (Nov 15, 2006)

BossyCow said:


> Our protocols state we are to call for ALS for pain management. Perhaps due to our long transport times.


Around here it varies... Some places and/or providers NEVER give narcotics for analgesia, a few give them out like candy.

The big question in many heads is "Is this a drug-seeker, or are they REALLY in pain?"


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## BossyCow (Nov 16, 2006)

Jon said:


> The big question in many heads is "Is this a drug-seeker, or are they REALLY in pain?"




I had a new EMT ask me how I knew someone was looking for pain meds and probably not really in pain.  

Hmmm let's review the events.......  Called to 22 yo female c/o 10:10 back pain.  We arrive to find her sitting on the front porch, bent over tying her shoes.  There was drug paraphenalia on the coffee table and her last oral intake was.. ."Um.. some chips, popcorn, a few cookies, some leftover pizza, candy bar, ....." Her back pain was so severe that she was almost unable to retrieve her purse from behind the sofa. Also, on the walk to the ambulance, she mentions.. "Oh by the way..... you should probably call my parole officer, I'm not supposed to leave the house" and shows us her government issue ankle bracelet. 

Why did we transport? Because our protocols state that we in the field are not to make a determination about a pt's pain level.  That we are to take them at their word.


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## FFEMT1764 (Nov 16, 2006)

Um, yeah, gotta love the ankle jewelry...makes me glad that we have a Reeves sleeve!


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## jeepmedic (Nov 16, 2006)

One thing you have to remember is that all calls are not ALS no matter who is riding in the back with the pt. If I ride in with a Pt with a broken ankle who refuses pain medication does that make it a ALS pt? NO. It is a BLS pt. with a paramedic in the back as AIC. And if I have an inexpirenced EMT-B on the truck then it is a good way for them to get expirence with Pt. assessment. The thing alot of ALS providers forget is where they came from. You are always a BLS provider first.


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## trauma1534 (Nov 16, 2006)

I would like to address both topics.  

1.  No, not all calls are ALS.  There are a couple reasons for this.  If the ALS provider takes over all calls, than this leaves not room for EMT-B's to define thier skills.  Many times in the department where I work, EMT-B's try to use ALS providers as thier crutches.  This should never happen.  EMT-B's should be in some ways thrown in and made to perform at thier skill level.  Us ALS providers can sniff out when something is logicly ALS and when it is not.  I am all about teaching new providers and helping EMT-B's define thier skills.  This does not happen with I am gung-ho and want to start an IV on every patient just because I can, or when I want to AIC everycall because I am ALS.  That is rediculis.  I was once a BLS provider.  I would not be the ALS provider today if someone had not put me in the back and said do it when I was comming along.  

2.  As for BossyCow's post, sounds like this patient needed to be introduced to the ole refusal form.  No, we can't technicly make a determination of someone's pain level, however, as I always tell people, LOOK AT YOUR PATIENT.  If your patient looks sick, then they are sick.  I know some people can present asymptomatic, but you can sniff out BS.  This was a pure case of a BS call.  I would inform them that the Dr. office would be open at whatever time.  I would inform them also that they would be placed in triage.  If they are in major pain, then they can't walk to my truck.  They would get a bench seat ride in, IF I did transport them, and they would be seated in the ER waiting room.  ER would be advized enroute that you have a stable and triagable patient.  People like that like to think that if they are transported by ambulance then they will get seen quicker.  I like to prove them wrong.  But, ultimatly, I will push for a refusal with this idiot.  This will accomplish a couple things.  #1.  It will get me more down time.  I can go back to the station, kick back, watch TV, take a nap.  #2.  It will put my perfictly good ALS truck back in service for a real emergency call.  Why take a ALS truck out of service for BS when you don't need to?  #3.  This is the best one yet... it will keep the county from obsorbing another bill that obviously will not get paid, so that they can afford to put another truck on the road, this will give me even more down time, or they will be able to sent more providers to our state EMS conferance so that we can become more educated on the finer things in the EMS world.  

That is my opinion.


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## jeepmedic (Nov 16, 2006)

trauma1534 said:


> I would like to address both topics.
> 
> 1.  No, not all calls are ALS.  There are a couple reasons for this.  If the ALS provider takes over all calls, than this leaves not room for EMT-B's to define thier skills.  Many times in the department where I work, EMT-B's try to use ALS providers as thier crutches.  This should never happen.  EMT-B's should be in some ways thrown in and made to perform at thier skill level.  Us ALS providers can sniff out when something is logicly ALS and when it is not.  I am all about teaching new providers and helping EMT-B's define thier skills.  This does not happen with I am gung-ho and want to start an IV on every patient just because I can, or when I want to AIC everycall because I am ALS.  That is rediculis.  I was once a BLS provider.  I would not be the ALS provider today if someone had not put me in the back and said do it when I was comming along.
> 
> ...



 Well said my young Jedi. Welcome to the dark side. ckb


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## yowzer (Nov 17, 2006)

trauma1534 said:


> I would like to address both topics.
> 
> 1.  No, not all calls are ALS.




Heck, MOST calls are BLS. There isn't anything useful that can be done that involves ALS skills and knowledge for the vast majority of calls, that can't wait till the hospital... Today so far: Old lady fell out of bed, done broke her hip.  It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER. Younger lady who slipped on wet sidewalk. 50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time. That one's just lazy on their parts. Chronic back pain. Siatica. Old guy who fell, probably breaking his hip, wife helped him into bed, then he started getting really shaky and weak. Might have been worthy of a medic eval, but a) the hospital he goes to is 2 miles away, b) there's a multiple partial structual collapse downtown, so all the local ones are busy. 1 ALS-involved response out of 6, which pretty typical. 

I'd hate to work in a system where you can't poke a stick without hitting a medic. Save them for sick people, please!


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## trauma1534 (Nov 17, 2006)

So true and very well said!!!


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## jeepmedic (Nov 17, 2006)

I was once told by the best paramedic that I know (if I forgot who it was all I had to do was ask him) out of 100 calls we are not needed on 90 of them, we make no diffrence in the out come of 8 of them, but its that 2 out of 100 that makes this job worth it. So Als only matters on 2% of the calls.

And by the why this paramedic stood toe to toe with James Page on calls and precepted most of the paramedics in the GSO area at one time or another and his reach has far exceded his sight because some of the things he taught me I teach to my students now.


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## BossyCow (Nov 17, 2006)

trauma1534 said:


> I would like to address both topics.
> 
> 2.  As for BossyCow's post, sounds like this patient needed to be introduced to the ole refusal form.



An introduction is no guarantee that both parties will agree to dance!  

We are a publicly funded agency. When someone insists they need to go to ED, we have to take them. We can strenuously emphasize our opinions on the matter, but the end result will be in the hands of the pt.  I do document on my report the inconsistancies in the pt's behavior vs. stated problems, terms like... 'not in any obvious pain or distress' or.. 'pt's movement clearly shows full range of motion' followed by 'pt insists on transport'

This one ended up being a teaching moment for the new EMT on the call with me so had some value.


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## FFEMT1764 (Nov 17, 2006)

trauma1534 said:


> I But, ultimatly, I will push for a refusal with this idiot.
> That is my opinion.


 

Doing that here would end your career as our director has made it abundantly clear that we are to do everything short of kidnapping the patient to get them to go to the ER. If we are caught pushing the ole refusal form out we end up out the door, and would probably get a nice visit from the state EMS office and one of their fun investigators...

As we have learned here recently, talking people out of going will get you in serious trouble, no matter how "petty" the complaint may seem. We have transported a toothache at 2 am just because the patient wanted to go, and we knew that if we mentioned the refusal that she would call the supervisor, and we all know where that goes from there...


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## FFEMT1764 (Nov 17, 2006)

yowzer said:


> Today so far: Old lady fell out of bed, done broke her hip. It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER.
> 
> 50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time.


 

As to the first one, here if you have a hip fracture, and the patient is not allergic to morphine, it is an automatic ALS call, pain managment is required, as per our protocols. Not to mention that a hip fracture in the elderly usually means a femur head fracture, which can lead to a lacerated femoral artery...see where this is going.

As to the second one, one ALS is started (12 lead), ALS must continue to the ER, after all, that is the national standard...and ALS giving a CP patient after they felt the patient needed a diagnostic 12 lead is abandonment...and illegal...and leads to lawsuits...etc, etc, etc...


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## trauma1534 (Nov 17, 2006)

FFEMT1764, you have very very good points!  Yes, once we start ALS precedures, we are bound to riding in with that patient.  Very well said.  Every call can be turned into ALS, no doubt.  Alot of the calls though, can be handled by an EMT-B.  Your Resp distress calls, although we are able to start a saline lock, administer Neb tx, in some cases, Lasix, depending on the transport time, an EMT-B can handle some of those mild cases by just placing the patient on high flow 02.  

As fo rhte refusals, well... I guess this will have to vary from state to state and what your protocol says.  Our area, the ED and OMD for that matter is glad for you to get a refusal from those who do not need to come in by EMS.  I'm not saying that all patients should be offered a refusal, however, if they can safely be transported via POV, then we have the right to suggest that, and push for that, for that matter.  It all depends again on where you are at as to how you handle refusals.  In the state of NC, they are starting to do what is called "referals".  This is when an ALS responce vehicle responds with a BLS truck.  They triage the patients, and decide if that patient warrents an ambulance ride to the ER, or if they can go by taxi, or POV, or any other form of transportation other than by ambulance.  This is a great way to keep trucks available in a busy system for true emergency calls.  My friends and I joke all the time about getting refusals, but when it comes down to it, we actually get very few, fewer than we should, actually.  Again, it all depends on the area you are practiacing in.  

Great points though FFEMT.  You are a very contious provider, I can tell.  I like that.  You are not burned out, and you still care about your patients.  I just don't want to dismiss the fact that BLS providers are still greatly needed in the field of EMS.  In all practical cases, they are our future paramedics, atleast that is how it is here in Virginia.  We need to utilize them when at all possable so that thier skills will grow.  We don't need to be thier crutch, yet we should be thier resorce, thier teachers, thier influances, and thier motivation to become good providers.


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## Ridryder911 (Nov 18, 2006)

yowzer said:


> Heck, MOST calls are BLS. There isn't anything useful that can be done that involves ALS skills and knowledge for the vast majority of calls, that can't wait till the hospital... Today so far: Old lady fell out of bed, done broke her hip.  It doesn't take a medic to pick someone up off the floor on a clamshell and drive 'em to the ER. Younger lady who slipped on wet sidewalk. 50ish guy, crushing chest pain for 3 days before he decided to go to a clinic, whose doctor invoked 911. Medics do a 12-lead, shrug, give him to us, even though the hospital he's going to is the one they're stationed at, and we get there at the same time. That one's just lazy on their parts. Chronic back pain. Siatica. Old guy who fell, probably breaking his hip, wife helped him into bed, then he started getting really shaky and weak. Might have been worthy of a medic eval, but a) the hospital he goes to is 2 miles away, b) there's a multiple partial structual collapse downtown, so all the local ones are busy. 1 ALS-involved response out of 6, which pretty typical.
> 
> I'd hate to work in a system where you can't poke a stick without hitting a medic. Save them for sick people, please!



Does the patient with a hip fracture does not need analgesics for pain?.. 
Do you know what the call medic who rule out an AMI with an XII lead?......
Defendants. I agree, it was probably not .. but an ECG cannot rule one out. 

Yes, there is a lot of bull.. but that is nature of the beast. BLS non-emergency calls should be teched by Intermediate or Basics so they can obtain experience for later on advance level calls.  

R/r 911


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## yowzer (Nov 18, 2006)

FFEMT1764 said:


> As to the first one, here if you have a hip fracture, and the patient is not allergic to morphine, it is an automatic ALS call, pain managment is required, as per our protocols. Not to mention that a hip fracture in the elderly usually means a femur head fracture, which can lead to a lacerated femoral artery...see where this is going.



She had good CMS in her feet, and decent vitals. In my area, asking a medic to transport just to give morphine would likely result in a complaint against you. 



FFEMT1764 said:


> As to the second one, one ALS is started (12 lead), ALS must continue to the ER, after all, that is the national standard...and ALS giving a CP patient after they felt the patient needed a diagnostic 12 lead is abandonment...and illegal...and leads to lawsuits...etc, etc, etc...



Doing ALS stuff is not a good enough reason to do an ALS transport here. I've taken in people who've been woken up by IV glucose, narcan, given breathing treatments, having heart attacks... King County medics refuse to transport BLS patients, and they have a rather unique definition of such. It's been that way for decades, so I suspect it's held up in court.


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## fm_emt (Nov 18, 2006)

Ridryder911 said:


> Yes, there is a lot of bull.. but that is nature of the beast. BLS non-emergency calls should be teched by Intermediate or Basics so they can obtain experience for later on advance level calls.



BLS 911 calls would be just fine with me. Even the BS calls are still a chance to use some skills. Someone has a toothache and wants a trip to the ER? Ok, no problem. As long as they're there, they can have some vitals taken on the way to the hospital. Who knows, maybe there's more behind it, like "my tooth hurts because I hit my head after falling down the stairs." Or maybe they just didn't brush.


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## FFEMT1764 (Nov 19, 2006)

yowzer said:


> She had good CMS in her feet, and decent vitals. In my area, asking a medic to transport just to give morphine would likely result in a complaint against you.
> 
> 
> Doing ALS stuff is not a good enough reason to do an ALS transport here. I've taken in people who've been woken up by IV glucose, narcan, given breathing treatments, having heart attacks... King County medics refuse to transport BLS patients, and they have a rather unique definition of such. It's been that way for decades, so I suspect it's held up in court.


 
Here if you don't give morphine for a patient in obvious pain then you could count on an investigation by the med control doc, the service director, and the loving State EMS office's field investigation staff.  This all would likely lead to losing your job, and maybe your cert.

Secondly, I hope to never get sick in your area, as far as I know a basic cant transport an MI anywhere, at least not do it and meet the National Standard's, and I sure would be getting a lawyer to look into malpractice, negligence, and possibly criminal complaints...but this is just my personal thoughts on the matter.


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## Airwaygoddess (Nov 19, 2006)

To put it simple and to the point, In the last 10 years, the patients that are seen in the field and in house are much sicker and do require more care. Part of the BIG problem is lack of funding for health care, insurance companies cutting back services for "what is covered".  I know that it is frustrating to get a 911 call and it can turn out to be either BLS or bull.  The bottom line is the patients are the ones that need care.  The 911 provider is a good part of the time that patient's first contact with medical care.  Is the system perfect? no not by a long shot, but what is most important someone can call 911 for help and help will come, whether it is  first responders, BLS, or ALS.  It is a team that faces some pretty hard adversaries and responds to some of life's toughest plays.  From the little old lady that tripped and fell needing a medical assist to the 10 car accident, with 8 red tags, it is the patients that are relaying on "The Team".  Be safe everyone!


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## yowzer (Nov 19, 2006)

FFEMT1764 said:


> Here if you don't give morphine for a patient in obvious pain then you could count on an investigation by the med control doc, the service director, and the loving State EMS office's field investigation staff.  This all would likely lead to losing your job, and maybe your cert.



Different areas, different rules. Pain control in the field is not a priority here. If it becomes one, it could probably be handled at BLS via laughing gas.



FFEMT1764 said:


> Secondly, I hope to never get sick in your area, as far as I know a basic cant transport an MI anywhere, at least not do it and meet the National Standard's, and I sure would be getting a lawyer to look into malpractice, negligence, and possibly criminal complaints...but this is just my personal thoughts on the matter.



While BLS skills in King County are about the same as anywhere else, the impression I've gotten from the medics is that they don't want to lower their standards to a mere national level. (To work as a medic here, you have to go through the University of Washington's program, which goes way beyond the NR curriculum. Rumor is that they flunk their probationary period if they don't turf enough patients to BLS transport, as part of their 'We only transport SICK people' attitude.)  

I'm not sure how they consider someone having an MI (Even if it was 3 days ago) a BLS patient, but it happens on a fairly regular basis. I've never had one of these dumps get significantly worse before we get to a hospital, where they can get a definitive diagnosis and treatment -- which is the important thing.

It does make a nice change from the usual hospital discharges and stubbed-toe calls.


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## FFEMT1764 (Nov 19, 2006)

Well like I said, I hope I never get sick in King County, WA. As for the laughing gas, I wish we had it, but its very hard to maintain here as we tend to have patients whom can't hold the demand valve due to their pain, and usually because they are already holding a puke deflector.  

I am just glad that here pain management is a BIG deal, if I ever get hurt and need morphine, I sure want the medic treating me to give me some so I can bear the ride in the truck!


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## Pablo the Pirate (Nov 19, 2006)

i find this discussion quite interesting and i must say even an eye opener. i couldn't help but reply.  My first thing is WOW how spoiled we are in my neck of the woods.  I know that basics in most part of the country are not allowed to do much but i guess I never figured they actually operated on such a minimal level.  I am by no means belittling basics.  I just recently got my medic status but i don't feel that it's such a big deal.  Let me explain.  I work on a volunteer part time ALS service, meaning if we have a medic then we go with one otherwise we're BLS.  However, our basics on our service and many in this state are actually varianced upto Intermediate status...we just don't carry that title.  As a basic we are varianced to start normal saline IVs, give ASA, nitro, glucagon, and albuterol nebs, we also carry the zoll hm and defib and most of are basics know at least a little about interpreting ekgs, and we combitube.  with that said you see why it's such a "big whoop" that I'm now a medic.  I still use my basic skills way more than I do ALS procedures.  basics really do save medics. you can't get tunnel visioned with say intubating when your basic partner can tell you hey relax and here's a combitube you want me to do if for you? I think its great, I dont have to "worry" about everything.  Also since our basics have all these skills we run primarly as BLS and you know that 90% of the time if the crew is made up entirely of basics and they call for a medic its needed.  Our trucks aren't marked as ALS or BLS.  I guess were just an ambulance.  and a rural one to boot.


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## FF/EMT Sam (Nov 23, 2006)

FFEMT1764 said:


> Here if you don't give morphine for a patient in obvious pain then you could count on an investigation by the med control doc, the service director, and the loving State EMS office's field investigation staff.  This all would likely lead to losing your job, and maybe your cert.
> 
> Secondly, I hope to never get sick in your area, as far as I know a basic cant transport an MI anywhere, at least not do it and meet the National Standard's, and I sure would be getting a lawyer to look into malpractice, negligence, and possibly criminal complaints...but this is just my personal thoughts on the matter.



You can't always get ALS where I work.  And I'd rather be transported BLS if I was having an MI than be transported after a long delay because ALS was unavailable.


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## FF/EMT Sam (Nov 23, 2006)

Pablo the Pirate said:


> Our basics on our service and many in this state are actually varianced upto Intermediate status...we just don't carry that title.  As a basic we are varianced to start normal saline IVs, give ASA, nitro, glucagon, and albuterol nebs, we also carry the zoll hm and defib and most of are basics know at least a little about interpreting ekgs, and we combitube. QUOTE]
> 
> 
> Holy cow.  You.  Are.  Lucky.


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## FFEMT1764 (Nov 24, 2006)

I realize that in in VA there are areas that only have BLS available. When that is the case I have no problem with BLS starting the transport and meeting the ALS enroute. I just have a problem with ALS providers dumping ALS calls on BLS providers. Where I work we hire all levels of EMT, and we have medics who will push an ALS call off on their basic or intermediate partner (we only operate at the I85 level thanks to our lovely med control).


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## RH3075 (Nov 24, 2006)

*Wow*

Not even transport and MI and wait for ALS?  that seems odd to me.I am in an urban setting with hospitals nearby, but i would never dream of not transporting someone suffering from and MI or other life threatening condition because ALS was not on scene. If they can make it and meet me in route great, if not, I am still going to the ER with them pronto.  As for not meeting national standards, I do not think that national standards require we let a patient die or suffer serious heart tissue damage because we did not transport....just my thought pn the matter.





Airwaygoddess said:


> To put it simple and to the point, In the last 10 years, the patients that are seen in the field and in house are much sicker and do require more care. Part of the BIG problem is lack of funding for health care, insurance companies cutting back services for "what is covered".  I know that it is frustrating to get a 911 call and it can turn out to be either BLS or bull.  The bottom line is the patients are the ones that need care.  The 911 provider is a good part of the time that patient's first contact with medical care.  Is the system perfect? no not by a long shot, but what is most important someone can call 911 for help and help will come, whether it is  first responders, BLS, or ALS.  It is a team that faces some pretty hard adversaries and responds to some of life's toughest plays.  From the little old lady that tripped and fell needing a medical assist to the 10 car accident, with 8 red tags, it is the patients that are relaying on "The Team".  Be safe everyone!


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## pbjjdm (Jan 31, 2010)

If you are a competent EMT-B you are trained to know when your patient is in more need than your training provides for.  The problem comes in when skills are not adequate for the job and you either think you can handle every call by yourself or you are the one that can't handle any call without your hand being held.  And while I am on the soapbox, the biggest problem with most Paramedics is that they forget that 90% of the time the basic skills will suffice but they always think that care starts with I.V. and Monitor.  This is becoming an epidemic as more schools are letting people begin training for paramedic before they have even gotten any basic skills utilized.  Love to watch them when they test on the practical side of the test and they fly through the advanced stations to fail on proper Fx care or they go through airway and they put the patient on 15 LPM via Nasal Cannula.


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## ExpatMedic0 (Jan 31, 2010)

Your guys system is so crazy up there! I went to medic school with a couple AMR EMT-B's in King County. They implied sometimes medic 1 ALS interventions where started such as IV or intubation and then the pt. was dumped on BLS for transport and ALS would just leave. I also herd they dumped gunshots and stabbing victims for BLS transport. Is any of this true? If so how do you avoid abandonment laws? 



yowzer said:


> Different areas, different rules. Pain control in the field is not a priority here. If it becomes one, it could probably be handled at BLS via laughing gas.
> 
> 
> 
> ...


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## MrBrown (Jan 31, 2010)

All this talk ot ALS vs BLS patients is foreign to us down here.  If I called up and said "oh send somebody else who is less qualified to transport this crew, they do not need Intensive Care (ALS)" I would probably get fired.

The crew that gets dispatched to the patient, be they Technicians, Paramedics or Intensive Care Paramedics will transport the patient.

As the OP said; THERE ARE NO BLS PATIENTS :wacko:


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## VentMedic (Jan 31, 2010)

pbjjdm said:


> If you are a competent EMT-B you are trained to know when your patient is in more need than your training provides for. The problem comes in when skills are not adequate for the job and you either think you can handle every call by yourself or you are the one that can't handle any call without your hand being held. And while I am on the soapbox, the *biggest problem with most Paramedics* is that they forget that 90% of the time the basic skills will suffice but they always think that care starts with I.V. and Monitor. This is becoming an epidemic as more schools are letting people begin training for paramedic before they have even gotten any basic skills utilized. Love to watch them when they test on the practical side of the test and they fly through the advanced stations to fail on proper Fx care or they go through airway and they put the patient on 15 LPM via Nasal Cannula.


 
I seriously doubt if this is the biggest problem with most Paramedics. 

For someone to be this bad they should have been washed out of EMT school. (See Scary Class Mates thread). If someone can not master the few skills taught in a 110 hour EMT class they have no business on either an "ALS" or "BLS" truck. It also shouldn't take one any longer than it takes to complete even the short Paramedic programs here in the U.S. to master those skills. If you need more than a year or even 6 months to be able to do first aid and take a set of vitals, you seriously need another profession that is not in health care.

Thus, this may be an example of how bad the EMT schools are in your area and not a reflection on the amount of time one should spend as an EMT before starting Paramedic school.


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