# When to Upgrade to ALS!



## RanchoEMT (Jan 5, 2011)

When running BLS when do you guys upgrade to ALS?
(obviously when you're not comfortable running the call, but what other tips, tricks, advice and General Rules do you guys have for upgrading code3?)


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## Ewok Jerky (Jan 5, 2011)

Mostly when your pt has an ALS complaint. For us that is things like chest pain, ALOC, BP<90, in some cases difficulty breathing. Now if I am a block away from the ER and ALS has a 10 minute ETA then I might go BLS code 3


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## medicdan (Jan 5, 2011)

It's also, to a certain extent, about how long you are going to wait at triage in the ED. I had a chest pain about 1/4 mile from the ED yesterday, and ended up grabbing an ALS crew clearing from a call at the same facility--which I wouldn't have done 2 years ago-- simply because we waited nearly 30 minutes for a bed, and it was good to have a 12-lead before arriving at the ED, which was well worth sitting on scene for a few minutes. We tried several times for an IV as well, but nobody could get one, so we held off on the nitro and stuck with Aspirin. 
It was unexpected, but the EDs were absolutely packed today, and partially as a result of the DPH ban on diversion, we knew we would be waiting. 

Long story short: based on a lot of factors, to include distance from ED, patient complaint, patient condition, crew comfort, ED wait time, etc.


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## Melclin (Jan 5, 2011)

A pt that requires ALS treatment: 
- Cardiac Arrest (obviously).
- Head injuries with GCS < 13/ hypoxic brain injuries.
- Hyperthermia >39.5 (103.1F) with poor response to cooling/fluids.
- VT
- Cardiogenic, Septic & obstructive (when T. pneumo) shock.
- Any paed need IV analgesia/fluids.
- Status asthmaticus.
- Any respiratory failure.
- Status epilepticus.
- Full field Acute pulmonary oedema. 
- Airway burns.

Might have missed something. The advantage we have is that, at least in theory, BLS and ALS ability to assess & develop a working dx for a pt is the same. So we don't have the "not comfortable with pt", "pulse over 100 type stuff".

Time to ED makes a difference in some of these. Except cardiac arrest. They stay where they drop.


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## emt_irl (Jan 5, 2011)

when my clinical practice guidelines tell me too.

as for spacific cases: anything cardiac, any major trauma, pain management beyond what otc's and entanox can handle.

then we have alot of consider als guidelines which puts the ball in our side of the field and lets us decide weather we want/need als or not.


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## LuvGlock (Jan 5, 2011)

Also when the pt has yakked/crapped/peed on themselves.  Automatic upgrade.


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## NomadicMedic (Jan 5, 2011)

LuvGlock said:


> Also when the pt has yakked/crapped/peed on themselves.  Automatic upgrade.



I hope you're kidding. 

If you are, it's not all that funny. 

If you're not, please leave my profession immediately.


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## AnthonyM83 (Jan 5, 2011)

We have specific protocols that state what falls under ALS criteria.

As a general guidelines, though, I like to say when the ALOC, airway, breathing, or circulation don't seem stable (that covers a lot). In addition, some should be ALS just by nature of complaint: Chest pain, MOI, mult-system trauma, certain poisons.

Welcome to hear if anyone has other general non-list explanations. This is a hard one for new EMT's or students if they don't have specific protocols.


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## Veneficus (Jan 5, 2011)

n7lxi said:


> I hope you're kidding.
> 
> If you are, it's not all that funny.
> 
> If you're not, please leave my profession immediately.



I thought it was funny. h34r: :unsure:

When I was working as a medic in the ED, my solution to that was usally to address the immediate needs of the pt then call a nurse.


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## mikie (Jan 5, 2011)

*No need when dispatch sends everyone!*

...when the second unit shows up (ALS, obviously) and says "We'll take it from here"


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## MrBrown (Jan 5, 2011)

Lets see .... when the patient requires more than some oxygen and a ride to the hospital?

Locally speaking Brown considers calling for an Intensive Care Paramedic provided they can locate significantly faster than the patient can be deliered to hospital for ....

- Life threatning asthma or resipratory problem
- Severely shocked patient of any etiology
- Advanced analgesia (ketamine and midaz)
- Severely compromised arrythmia requiring amiodarone, pacing or an adrenaline drip
- Sick paeds
- Patients who potentially or do require rapid sequence intubation
- Any patient who is status one (critical) or two (serious problem) with no obvious cause and severe physiologic abnormality 

Now Brown might also get an ICP along for a look if a patient is severely sick and/or Brown is not sure how to proceed however it must be balanced with do we stay here and wait for ALS to turn up and have a nosey vs delivering this patient to the hospital in thier current state?  

Is it better to stay on location with an emergently or potentially time or intervention critical patient or take one who is perhaps a bit unstable in thier current form to the hospital?


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## HotelCo (Jan 5, 2011)

Around here, I never do. I'm usually less than 10 minutes from a level 1, and ALS has an ETA of about the same... just to cover my butt, ill request and intercept, but they never end up meeting us in time to take the patient. 

.


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## Sasha (Jan 5, 2011)

Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.

Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.


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## AnthonyM83 (Jan 5, 2011)

Sasha said:


> Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.
> 
> Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.


My patient has a broken pinky. Paramedics are closer than the hospital. Should I call ALS or transport on a BLS unit? 

I know you know that one. Just stating his question was more about asking what qualifies as a patient who needs ALS (whether it's ALS from the ER or from a paramedic unit).


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## truetiger (Jan 5, 2011)

+1 for emt.dan for mentioning wait time. On average it can take a doc 10-30 mins to make it in to see a pt once they have received a room depending on what other pt's they have. If it takes an extra 5-10 mins to get ALS and its not life threatening, consider ALS. The nurses I work with appreciate that as it cuts down on their workload as during busy times.


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## JPINFV (Jan 5, 2011)

Sasha said:


> Best and only time to call for ALS on a BLS unit: When the time it takes you to get to the hospital is longer than the time it would take for ALS to get to you and take over patient care.
> 
> Other wise why are you calling for ALS? The patient is in need of definitive care which is provided by the hospital, not by ALS.



I think there's a few kinks with this attitude, albeit I do largely agree with it. The really big one are patients who might meet criteria for a specialty center (such as chest pain patients) where the closest hospital is not a specialty hospital for that issue. In that case, what's important is not transport to nearest facility, but transport to the specialty center.


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## jjesusfreak01 (Jan 5, 2011)

Veneficus said:


> I thought it was funny. h34r: :unsure:
> 
> When I was working as a medic in the ED, my solution to that was usally to address the immediate needs of the pt then call a nurse.



Hah...on a call the other day. Pulled into the ambulance bay at the hospital, opened the doors, and then the medic paused to say,

"Are you feeling any pain or nausea right now, cause this is your last chance to get drugs before you get into the hospital where it's going to take a lot longer?"


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## Sasha (Jan 5, 2011)

JPINFV said:


> I think there's a few kinks with this attitude, albeit I do largely agree with it. The really big one are patients who might meet criteria for a specialty center (such as chest pain patients) where the closest hospital is not a specialty hospital for that issue. In that case, what's important is not transport to nearest facility, but transport to the specialty center.



Ok, when transport time to the closest appropriate facility exceeds the time it would take  for ALS to meet you and transfer care. Better, oh technical one?


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## Sasha (Jan 5, 2011)

AnthonyM83 said:


> My patient has a broken pinky. Paramedics are closer than the hospital. Should I call ALS or transport on a BLS unit?
> 
> I know you know that one. Just stating his question was more about asking what qualifies as a patient who needs ALS (whether it's ALS from the ER or from a paramedic unit).



I think transport time is one of the qualifications and something to take into account.  You cheeky bunny!


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## LuvGlock (Jan 6, 2011)

n7lxi said:


> I hope you're kidding.
> 
> If you are, it's not all that funny.
> 
> If you're not, please leave my profession immediately.



Of course I'm joking.  Obviously I failed @ comedy, which is why I save lives for a living now.


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## Phlipper (Jan 7, 2011)

LuvGlock said:


> Also when the pt has yakked/crapped/peed on themselves.  Automatic upgrade.



ROFL!  

Glock people are naturally witty.


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## Phlipper (Jan 7, 2011)

n7lxi said:


> I hope you're kidding.
> 
> If you are, it's not all that funny.
> 
> If you're not, please leave my profession immediately.



If I remember correctly, for anal impalement we are supposed to run the ABCs and a rapid trauma assessment and then immobilize the object and package pt for xport, with detailed assessment and monitoring vitals in the truck on the way.  What's your location?  How big is the stick?


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## CMillican (Jan 8, 2011)

RanchoEMT said:


> When running BLS when do you guys upgrade to ALS?
> (obviously when you're not comfortable running the call, but what other tips, tricks, advice and General Rules do you guys have for upgrading code3?)


When I note any type of AMS, ALOC or any issues with ABC's except for things that I know can be addressed within my scope


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## Devilz311 (Jan 9, 2011)

With the particular unit I'm on, we'll respond solo to ALS or BLS calls. If there's a complaint on a BLS call that can be resolved with ALS treatment, I'll upgrade.  Example, a BLS dispatch for a sick person. I'll gladly upgrade to ALS in order to administer some Zofran if the Pt is feeling nauseous, in order to prevent them from puking all over my rig.

Note that "upgrading" to ALS doesn't mean turing all of the lights on and driving like a bat out of hell to the ER... In most cases around here, the difference between using L&S, or just driving cold is a MAX 1 minute difference in transport time.


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## High Speed Chaser (Jan 12, 2011)

Reading my notes, I have 2 "Recommendations" for when MICA (ALS in the US) should be called but this is not official so its not the gospel according to the Ambulance Service but these recommendations are


Patients do not respond to Ambulance Paramedic (roughly ILS in US) treatment within their scope of practice
Patients are not expected to respond to Ambulance Paramedic (roughly ILS in US) treatment based on scope of practice
Number 2 further goes on to specify 


Cardiac arrest
Cardiac chest pain
Arrhythmias
Major Respiratory distress
Hypotension
Hypovolemia
Major trauma


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## MrBrown (Jan 12, 2011)

Brown thinks the key point is patients who do not or are unlikely to respond to Paramedic treatment.  The kid who Brown picked up who was hypovolaemic coz he had really bad NVs didnt need Intensive Care.

Stay dry mate.


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## Melclin (Jan 12, 2011)

High Speed Chaser said:


> Cardiac arrest
> Cardiac chest pain
> Arrhythmias
> Major Respiratory distress
> ...



These points can be quite complex in actual practice. I'm glad they've actually talked to you about when you need MICA. We were never formally taught as far as I can remember. 

*Arrhythmia* - every second person we go to is in Af. Which ones need MICA? Some are brady, many are tachy, not too many need MICA. 
*
Cardiac chest pain *- I've been to plenty that didn't need or get MICA. That bit in a scenario when the person conveniently describes there pain as a dull, retrosternal crushing sensation and you turn to the CI and say, "Oh yes and I'll have MICA thank you", doesn't seem to happen. Even with chest pain, they've generally gotta have something extra. 

*Major Trauma* - I was chatting to someone on a placement the other day who said, "People get the colly-wobles when they get a sick pt and scream for MICA, when in actual fact, short of RSI and maintenance of a tension pneumo, MICA can do that we can't". The "ALS" package for AP was brought in for trauma. Still, one of the advantages is that they are more experienced providers though. Kinda like a junior doc calling their senior reg when they get a sick pt.

*Hypovolaemia* - MICA have nothing in their box to treat this that we don't. Again, its never a bad thing to have a more experienced provider, but MICA are in short supply so you kind of have to get used to the idea that you can't call them to hold your hand


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## Shishkabob (Jan 12, 2011)

Meh, just noticed you were responding to ANOTHER Aussie.


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## MrBrown (Jan 12, 2011)

Melclin said:


> MICA are in short supply so you kind of have to get used to the idea that you can't call them to hold your hand



Especially if you are in say, Essendon and the closest is oh Brown will say perhaps, MICA 7 in Dandenong .... true story


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## Jon (Jan 16, 2011)

I get to see this from both sides. In addition to working as Medic, I volunteer with a BLS service. I've upgraded BLS calls 2x this week. First was some impressive pain from a possible hip fx., with a family request for the 2nd closest hospital, and a 15-20 min eta there.

Second was diaphoretic and weak patient from home. No other complaints, just "I really don't feel good". History of NIDDM, HTN, and some CAD. No previous MI. Borderline hypotension (106/70?) borderline bradycardia (60-66). On a beta blocker.

Was looking at 15-20 minutes between loading Pt and getting to ED. I was kinda on the fence, and figured I'd add a medic out of an abundance of caution, and a desire to not bring that pt. Into the ED BLS, have them run a 12-lead and actually find something going on (and me having pissed away another 15 minutes of time by bringing them in BLS). While the medic didn't really like it, I explained this thought process to the doc, she concurred w/ my heightened suspicions.


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## RanchoEMT (Jan 24, 2011)

*Update.*

Had to Upgrade this week, 65 year old male at a nursing home normally responsive and talkative with ALOC.(originally admitted for dehydration)

Patient was obviously altered, he was confused, at times unable to answer my questions, unable to move extremities upon my requests. blood sugar level was in normal range. PIN-POINT PUPILS, UNRESPONSIVE TO LIGHT. 
Patient had a 148/84 B/P prior to our arrival.  Upon assessment B/P had dropped to 90/50... Took it a second time about a minute later and it had dropped to 84/48..  We got the PulseOx out and he was 80% room air.  Short little spurts of apnea(he almost appeared to forget to breathe every so often) we put him on oxygen and called for upgrade, further questioning with the charge nurse reveled he had not been eating for the past couple of days and he was given a dose of oxycodone earlier.  

ALS roled up on-scene and gave him Narcan, he Snapped to very quickly...

So i don't know much about oxycodone and other drugs but he was overdosed via the nursing staff i'm assuming.. iunno if he woulda' crashed but i guess it was a good upgrade.


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## Trip (Jan 26, 2011)

The VFD/EMS i'm with is BLS lvl, is 30 minutes from the closest facility and has a policy to ship everyone asap except MAJOR trauma. The reason is that the company I work for is also our ALS support and is close enough to the hospital to hit with a rock. We call for ALS after assessing necessity and they meet us along the way. My company's ALS fly car response is <60 seconds from call to out-the-door and meets along the way, hops on-board and off we go once they do their assessment.

Usually, the necessity is as has been previously stated (CP, VT, trauma, comp shock, etc....)

- Trip


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## Pittma (Jan 27, 2011)

n7lxi said:


> I hope you're kidding.
> 
> If you are, it's not all that funny.
> 
> If you're not, please leave my profession immediately.



Wow, bad mood much?


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