# Upgrade or transport?



## emscrazy1 (Jan 2, 2012)

I work for a private company who provides BLS transport for the county. My company's protocols say any fall with +LOC is an ALS call. Today we're dispatched to a 61 y/o who fainted and fell. He had +LOC, Hx of head trauma years back, also Hx of seizures. His BP was 150/70 pulse 60. He had a pretty nice sized Lac on the side with previous head trauma. The engine on scene cancelled the rescue and wanted us to transport. We advised that this was an ALS call under our protocols. The crew got pissed. They ended up sending their medic with us.  Was it wrong to upgrade or would you have transported? Keep in mind I'm at the BLS level. We were 20 min from the closest ED and traffic was heavy.


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## firetender (Jan 2, 2012)

emscrazy1 said:


> My company's protocols say any fall with +LOC is an ALS call. .


 
Who do you want to be in more trouble with? The ALS crew who you'll see now and againn, or the people who sign your check?


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## EMSLaw (Jan 2, 2012)

I would have transported and met medics line-of-sight - if medics were even necessary.  What your patient ultimately needs is evaluation at a hospital.  Protocols are advancing, but an ALS unit with a portable CT scanner isn't something I've heard of yet. 

Of course, we have tiered response here, and the medics would have ridden the call to the hospital in my rig anyway.  In your case, your remaining employed means that you want to follow your company's protocols.  As someone under no such compunction to your employer, I will say that the protocol doesn't make much sense to me.  

Patients, in almost all cases, benefit from safe and rapid transport.  Some number of them benefit from the services of a more advanced provider.  All of them benefit from the services of an acute care facility staffed with MDs and others who can see problems that I won't see, and do things that I don't even know the name for, let alone have the ability to do.  The time you spent on scene would have benefited the patient more in getting to the hospital.


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## DesertMedic66 (Jan 2, 2012)

Follow your protocols. 

But as per my protocols I would have taken that call as BLS. But sadly our protocols are basically once any patient has had an ALS assessment they must get transported by ALS (unless it's a MCI).


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## DrankTheKoolaid (Jan 2, 2012)

*re*



EMSLaw said:


> I would have transported and met medics line-of-sight - if medics were even necessary.  What your patient ultimately needs is evaluation at a hospital.  Protocols are advancing, but an ALS unit with a portable CT scanner isn't something I've heard of yet.
> 
> Of course, we have tiered response here, and the medics would have ridden the call to the hospital in my rig anyway.  In your case, your remaining employed means that you want to follow your company's protocols.  As someone under no such compunction to your employer, I will say that the protocol doesn't make much sense to me.
> 
> Patients, in almost all cases, benefit from safe and rapid transport.  Some number of them benefit from the services of a more advanced provider.  All of them benefit from the services of an acute care facility staffed with MDs and others who can see problems that I won't see, and do things that I don't even know the name for, let alone have the ability to do.  The time you spent on scene would have benefited the patient more in getting to the hospital.



Maybe the protocol has to do with the fact that it could have been an arrhythmia that caused the syncope in the first place that self converted.......  It's ALS because the patient may not be so lucky again and a BLS truck is not going to have a clue what to do if it happens again other then speed through traffic and risking everyones life.  When a paramedic can simply do their job and provide care


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## 46Young (Jan 2, 2012)

The fact that they sent their engine medic with you, rather than have that medic do an eval and then pass the pt back to you for txp tells me that they also know that the pt could experience a deterioration in status during txp. To me, it sounds like they didn't want to be inconvenienced by having to drive the engine to the hospital to pick up their medic, and also wait for the medic to finish their report. 

Your protocols clearly state what you're to do in that scenario, and the FD isn't giving you your check, so you did nothing wrong.


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## Akulahawk (Jan 2, 2012)

46Young said:


> The fact that they sent their engine medic with you, rather than have that medic do an eval and then pass the pt back to you for txp tells me that they also know that the pt could experience a deterioration in status during txp. To me, it sounds like they didn't want to be inconvenienced by having to drive the engine to the hospital to pick up their medic, and also wait for the medic to finish their report.
> 
> Your protocols clearly state what you're to do in that scenario, and the FD isn't giving you your check, so you did nothing wrong.


His company doesn't want to incur any liability should something go wrong during transport with such a patient. The local EMS system probably allows for ALS to evaluate and turn the patient over to BLS for transport. The Fire medic rode in with the crew precisely because the BLS crew couldn't accept that patient per _company _protocols... If I were in their shoes, I'd choose to remain employed rather than worry about how irritated the fire guys were. I might, however, state that while _I_ am ok with the turnover, my _company_ is not, and apologize for that aspect of the problem.


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## emscrazy1 (Jan 2, 2012)

Akulahawk said:


> His company doesn't want to incur any liability should something go wrong during transport with such a patient. The local EMS system probably allows for ALS to evaluate and turn the patient over to BLS for transport. The Fire medic rode in with the crew precisely because the BLS crew couldn't accept that patient per _company _protocols... If I were in their shoes, I'd choose to remain employed rather than worry about how irritated the fire guys were. I might, however, state that while _I_ am ok with the turnover, my _company_ is not, and apologize for that aspect of the problem.



This is exactly the reason we chose to upgrade. The county usually trys to drop calls that are ALS on to BLS units on occasion. They don't like when we tell them we can't transport but they also don't know our protocols by heart. Some medics ask if we are comfortable transporting but some just transfer care and leave.


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## DrParasite (Jan 3, 2012)

46Young said:


> The fact that they sent their engine medic with you, rather than have that medic do an eval and then pass the pt back to you for txp tells me that they also know that the pt could experience a deterioration in status during txp. To me, it sounds like they didn't want to be inconvenienced by having to drive the engine to the hospital to pick up their medic, and also wait for the medic to finish their report.
> 
> Your protocols clearly state what you're to do in that scenario, and the FD isn't giving you your check, so you did nothing wrong.


agreed, 100%.

Follow your protocols.  if they say the patient needs ALS, and they cancelled the ALS truck, take the FD medic with you and drive to the hospital.

Let the FD be pissed.  even better. let them file a complaint with your supervisor, and your supervisor tells them to shove it.


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## MedicPatriot (Jan 3, 2012)

This was a great debate around the firehouse when I was a BLS provider not too long ago. Many times I would get a wrist slapping because I would transport +LOC patients BLS all of time, which is usually 7 minutes to an ER 10-15 to Level II trauma center and 7 minutes or so for ALS unit. 

Using a real example, the drunk that got puched in the face "blacked out" because he got punched hard in the face. It happens, and its not a cardiac issue and nothing that needs ALS. I also have transported +LOC medical patients, if no ALS was on scene/dispatched. In our system "Fainting Not Alert" is ALS and "Fainting Now Alert" is BLS dispatched even though I would always get criticized for transporting BLS by our chain of command. So syncope and [sometimes] seizures are fine to go BLS most of the time in my opinion. Also there are stroke patients that I believe should be transported BLS emergency instead of waiting on scene for ALS.

IMO it depends on the patients condition whether you need ALS or not. Also it depends if there is ALS on scene or not if you should wait for ALS or just take them to the hospital. The ER can indeed be your ALS intervention, and can sometimes be quicker to get to...depending on your area.


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## EMSLaw (Jan 3, 2012)

Corky said:


> Maybe the protocol has to do with the fact that it could have been an arrhythmia that caused the syncope in the first place that self converted.......  It's ALS because the patient may not be so lucky again and a BLS truck is not going to have a clue what to do if it happens again other then speed through traffic and risking everyones life.  When a paramedic can simply do their job and provide care



That may be true.  Depending on the patient, it could be a horse or a zebra - the patient could just as easily have passed out from a vasovegal reaction that is relatively benign.  However, my point is more this - if it will take ALS some period of time that is near or exceeds the transport time the hospital to arrive on scene, isn't it better to deliver the patient to definitive care, rather than wait for ALS?  Aren't we doing a disservice to the patient by lingering on scene waiting for paramedics?  That's why I disagree with the protocol.


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## Akulahawk (Jan 3, 2012)

EMSLaw said:


> That may be true.  Depending on the patient, it could be a horse or a zebra - the patient could just as easily have passed out from a vasovegal reaction that is relatively benign.  However, my point is more this - if it will take ALS some period of time that is near or exceeds the transport time the hospital to arrive on scene, isn't it better to deliver the patient to definitive care, rather than wait for ALS?  Aren't we doing a disservice to the patient by lingering on scene waiting for paramedics?  That's why I disagree with the protocol.


This is Santa Clara County's BLS utilization protocol for emergent patients when BLS is on scene under normal conditions:



> A patient determined to be "emergent" shall be transported to the closest emergency department (with RLS) if the time from arrival on the scene to arrival at the hospital is less than ten (10) minutes. In all other cases, the BLS crew shall dial "911" or contact County Communications and request an ALS response.



They used to provide for BLS transport on their own _if_ the closest available ALS unit (transport capable or not) would take longer to get to the sceen than the BLS transport time to the hospital. The 10 minute transport to the ED clock used to start at the time patient contact was made. Under the current protocol, basically if I can physically see the hospital when I arrive at scene and I determine that the patient is "emergent" then I can scoop and run and beat the clock, if I'm a BLS unit. 

This does not apply to ALS IFT ambulances though. For the most part, they seem to be treated similarly to 911 system units, other than they're called privately instead of via the 911 system. When I last worked in in SCC, non-911 ALS units were, quite literally, 1-2 years away from becoming reality.


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## emscrazy1 (Jan 3, 2012)

ALS was already on scene.


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## Tigger (Jan 3, 2012)

Akulahawk said:


> They used to provide for BLS transport on their own _if_ the closest available ALS unit (transport capable or not) would take longer to get to the sceen than the BLS transport time to the hospital. The 10 minute transport to the ED clock used to start at the time patient contact was made. Under the current protocol, basically if I can physically see the hospital when I arrive at scene and I determine that the patient is "emergent" then I can scoop and run and beat the clock, if I'm a BLS unit.



What an unfortunate protocol. Even if I was next door to the ER I'd still probably be cutting it close trying to asses and package the patient in 10 minutes. Seems like this just promotes crappy assessments and and driving. Waiting for ALS instead of just transporting to a nearby and appropriate ED strikes me as just dumb. 

I guess I'm happy to work in Boston where I can get to a hospital faster than the medics most of the time and am trusted to properly care for the patient in the interim. 

And no corky, I'm not risking everyone's life when I transport someone to the ER, most of the time we're transporting non emergent anyway.


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## JPINFV (Jan 3, 2012)

Tigger said:


> I guess I'm happy to work in Boston where I can get to a hospital faster than the medics most of the time and am trusted to properly care for the patient in the interim.



Does MA still require a base hospital contact to take a stable patient to an ED more than 20 minutes away?


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## Tigger (Jan 3, 2012)

JPINFV said:


> Does MA still require a base hospital contact to take a stable patient to an ED more than 20 minutes away?



I have never heard of that occurring but I can't say for certain that such a requirement does not exist. Much of the state's population is within 20 minutes of an ER so it has not come into play having worked in eastern mass.

I have taken a couple BLS emergencies farther than 20 minutes but that was by patient choice and I felt fine with that decision. The company I work for holds a 911 contract for a town with no ED within 20 minutes for some areas and BLS coverage will transport routinely, though like every ambulance regardless of level they must call in a c-med note for entry to the hospitals in they area. That's contacting a nurse, not a doc though.


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## JPINFV (Jan 3, 2012)

Tigger said:


> I have taken a couple BLS emergencies farther than 20 minutes but that was by patient choice and I felt fine with that decision.



I believe it used to be near the top when there was an extensive listing of general care principals, but it's been removed sometime in the last 3 years.


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## d0nk3yk0n9 (Jan 3, 2012)

How varied the protocols on this are is interesting. In NY, most of the BLS protocols say at the top in bold letters: 

Note:
Request Advanced Life Support if available. 
Do not delay transport to the appropriate hospital.


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## JPINFV (Jan 3, 2012)

d0nk3yk0n9 said:


> How varied the protocols on this are is interesting. In NY, most of the BLS protocols say at the top in bold letters:
> 
> Note:
> Request Advanced Life Support if available.
> Do not delay transport to the appropriate hospital.



Flipping through it, it looks like the BLS protocols only covers major emergencies and nothing else. Also, it makes clear in the intro that the protocols are not an excuse to not use good clinical judgement.


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## DrankTheKoolaid (Jan 3, 2012)

Tigger said:


> What an unfortunate protocol. Even if I was next door to the ER I'd still probably be cutting it close trying to asses and package the patient in 10 minutes. Seems like this just promotes crappy assessments and and driving. Waiting for ALS instead of just transporting to a nearby and appropriate ED strikes me as just dumb.
> 
> I guess I'm happy to work in Boston where I can get to a hospital faster than the medics most of the time and am trusted to properly care for the patient in the interim.
> 
> And no corky, I'm not risking everyone's life when I transport someone to the ER, most of the time we're transporting non emergent anyway.



You have to remember that not everyone can remain calm in the case of a crashing patient. Even worse would be a rookie who either panics or his adreniline gets the better of him while he/she is behind the wheel.

  But i do have to remind myself when reading these things most of you have ETA to the hospital shorter then some of the driveways I go on.  And this definatey effects my view and opinions on the Als/bls arguments.


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## Tigger (Jan 3, 2012)

Corky said:


> You have to remember that not everyone can remain calm in the case of a crashing patient. Even worse would be a rookie who either panics or his adreniline gets the better of him while he/she is behind the wheel.
> 
> But i do have to remind myself when reading these things most of you have ETA to the hospital shorter then some of the driveways I go on.  And this definatey effects my view and opinions on the Als/bls arguments.



Yes not not everyone will remain calm with a patient circling the drain, but this phenomenon transcends all levels of providers. Being a medic does not make anyone immune to freezing up and making an irrational or reckless care decision. 

There are also systems where the ALS/BLS argument barely exists I might add. Not everywhere is the same as your area, some places actually trust their BLS providers to do the patient right by the first goal of EMS--getting the patient to definitive care as safely and comfortably as possible.


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## d0nk3yk0n9 (Jan 4, 2012)

JPINFV said:


> Flipping through it, it looks like the BLS protocols only covers major emergencies and nothing else. Also, it makes clear in the intro that the protocols are not an excuse to not use good clinical judgement.



Yeah, I just wanted to make the point that while in some places you get in trouble for realizing that it's a better idea to transport instead of waiting for ALS, in NY the protocols have the idea of using your judgement to make that decision built in.


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## DownSouthMedic (Jan 4, 2012)

emscrazy1 said:


> I work for a private company who provides BLS transport for the county. My company's protocols say any fall with +LOC is an ALS call. Today we're dispatched to a 61 y/o who fainted and fell. He had +LOC, Hx of head trauma years back, also Hx of seizures. His BP was 150/70 pulse 60. He had a pretty nice sized Lac on the side with previous head trauma. The engine on scene cancelled the rescue and wanted us to transport. We advised that this was an ALS call under our protocols. The crew got pissed. They ended up sending their medic with us.  Was it wrong to upgrade or would you have transported? Keep in mind I'm at the BLS level. We were 20 min from the closest ED and traffic was heavy.



Kinda curious what county your in...I'm with a private BLS company as well, we transport for the city and the county, I keep a copy of both departments ALS to BLS protocol in my clipboard..sooo if there's ever a question I can pull out their own protocol..which many of them have never seen.  Unfortunately we've had quite a few sketchy calls dropped on us..that's what led me to start carrying the protocols.


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## Cup of Joe (Jan 10, 2012)

d0nk3yk0n9 said:


> Yeah, I just wanted to make the point that while in some places you get in trouble for realizing that it's a better idea to transport instead of waiting for ALS, in NY the protocols have the idea of using your judgement to make that decision built in.



Thats because in highly populated areas, like NYC and Nassau county, you can be at a hospital quicker than you can get an ALS unit to scene.  And then there are areas where transporting to the hospital could be 30+ minutes.  This is one of the reasons almost every county has either their own set of protocols, or their own revisions to the state-wide protocols.


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