What Gets ALS?

[FLMedic311]

That's what makes it so challenging to really assess Medic One. Y'all are a fairly secretive group and the best information that we have is typically second-hand information from folks like NomadicMedic or you, and the information that we get from y'all may not be comprehensive or up-to-date.

It's funny you say that about being secretive.. I felt that way to prior to getting here. But now that I am (They gave me a lot of cool-aid, it was great!), I think most people would actually say that we aren't really.. We do things different then most places, and sometimes that is good and others maybe not so much. No body that I have met so far has claimed this to be a perfect system, and are also well aware of the short comings and are actively trying to improve in those areas. I am rambling now, but If anyone truly wants to know anything about us, we are an open book, you just have to do a little leg work.. A lot like this forum, right @VentMonkey ?? The fact of the matter is anyone could call up HQ and talk to one of the MSO's and they would answer any question you want, everyone with an EMS/Medicine background is welcome to come do a ride along and see us for themselves, and your reason doesn't have to be anything other then "I just want to". We have people from all over do it all the time. I also think most people here just don't care to engage on a public forum, because they simply don't care what others think, they enjoy their job, they know we mostly do good work and are truly to busy enjoying their live's outside of it. I decided to become engage to the try and help shed the light a little, because like I said I had felt the same way before. And I am on probation, and people know and have encouraged me to do so.. so alas here I am!!

 

[GMCmedic]

Slight thread derail, but Ive seen in other posts and the website that you have to go through KCM1 training to work there. Technically when I got me medic through IHM, at the time it was affiliated with the University of Washington in St Louis. I assume that would still be something I would have to do. Just curious, no intention of actually moving to the west coast.

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[FLMedic311]

Slight thread derail, but Ive seen in other posts and the website that you have to go through KCM1 training to work there. Technically when I got me medic through IHM, at the time it was affiliated with the University of Washington in St Louis. I assume that would still be something I would have to do. Just curious, no intention of actually moving to the west coast.

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Yes, everyone has to have gone through the University of Washington Harboview PMT Program

 

[GMCmedic]

Yes, everyone has to have gone through the University of Washington Harboview PMT Program

I figured. I was just curious cause of the affiliation the program had. Thanks!

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[RocketMedic]

Rocket, I think you should go investigate KCM1. They could probably get you a ride along or two... and a vacation in the PNW would be okay.

I'd like to, but have too much to do down here in Houston at the present time. With that being said, I'd love to do a 12-hour rotation up there and see how they run things.

 

[VentMonkey]

I know we have a diverse population and set of views here, so I wanted to ask this question: what gets ALS in your system, and why?
At the paramedics discretion, more often than not I "ALS" my patients, even if this just means cardiac monitoring, SPO2, and a glucose.

Additionally, here are some generic scenario questions- would these receive ALS in your system, and what would generally be done?
Here's what I generally do with these calls laid out @RocketMedic.

Psych?
This depends on their level of pyschosis. If they're under the influence of any drugs, illicit or other, and/ or cannot be controlled by less invasive means they get an IV and some Versed pushes titrated to calming levels. Silence is golden in my mind, and on the ambulance.

Isolated, non-life-threatening trauma?
Did they sustain an injury that is too painful for them to be moved without pain management?

If so pain management therapies are initiated prior to moving them whether, or not it is an "obvious" injury or not, otherwise they're given BLS pain management (cold packs, and splints).

Falls?
Ref: the above Q & A.

General medical sick calls (abdominal pain, pain, fever, weakness etc)?
Again, this all depends on several factors to include previous history, co-morbidities, current distress level, presentation, V/S and their respective trends, etc.

Respiratory/diabetic/cardiac?
Ref: the above Q & A.

Altered mentation?
ALS calls, and often legitimately and rightfully so.

Arrests/periarrests?
Without question ALS.

MVA?
Aside from the low-speed "parking lot" MVC's, general ALS scope is sufficient for me.

Additionally, in your system, if you request ALS for a non-life-threatening call for symptomatic management, what is their reaction, the reaction of your system, etc?
This question is not applicable to me.

What are you expected to do?
Provide the highest level of ALS care I can provide in the short amount of time I have with the patient (s).

For ALS providers, what is your general opinion on this?
I'd love if we were an ALS intercept system in QRV's. If the patient is in need of an ALS procedure, and it makes more sense to call for an ALS rendezvous/ intercept (read: I'm closer than the ED) there should be without question no reason to second guess or berate the BLS providers calling for help.

My system currently requires a paramedic to tech every call on an ALS ambulance regardless of the route taken (ALS vs. BLS) so this is my personal spin, and what I have come to expect as "the norm".

I do hear we're in the process of working on restructuring our system to possibly include the EMT to "tech" BLS-level calls while the paramedic drives to the ED.

I also think every paramedic is different, so is their level of experience and confidence; both of which typically dictate their modalities. The prudent ones learn from their mistakes, follow their instincts, and grow from learning opportunities.

 

[Tigger]

There's a medic on every ambulance at all four services I work for. Most of these places are pretty rural or at least suburban and that patient population seems to lead to more ALS attends. And while it might not be possible to give pain meds in a 5 minute transport with an isolated ortho or "uncomplicated" abdominal pain, it's a lot harder to make that argument when the transport time is 40 minutes.

We have a lot of leeway on how much of an ALS assessment we can do and still have the EMT attend. Abdominal pain that doesn't want medication? Ensure that the 12 lead is unremarkable and that the patient has not a sniff of cardiac symptoms and the EMT can take that. Our EMTs also have pretty broad scope, they can start IVs, give fluids, and zofran IV so that certainly takes some of the medic's workload down. The key is that the paramedic is still participating in the assessment.

 

[EpiEMS]

In my system, every call gets a medic, who can downgrade to the BLS (or ILS) ambulance crew. I don't love this set up - most calls don't need much more than a BLS response, frankly. Part of the beauty of a BLS ambulance backed up by ALS fly car system is flexibility - but having the fly medics respond to every call, regardless of the nature, is a misuse of resources (and harms the skills of the BLS providers).




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[Tigger]

In my system, every call gets a medic, who can downgrade to the BLS (or ILS) ambulance crew. I don't love this set up - most calls don't need much more than a BLS response, frankly. Part of the beauty of a BLS ambulance backed up by ALS fly car system is flexibility - but having the fly medics respond to every call, regardless of the nature, is a misuse of resources (and harms the skills of the BLS providers).




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To me the problem with tiered systems has always come down to "you don't know what you don't know." I am not comfortable with our lowest educated providers making the determination that the patient needs a higher level of care.

 

[NomadicMedic]

To me the problem with tiered systems has always come down to "you don't know what you don't know." I am not comfortable with our lowest educated providers making the determination that the patient needs a higher level of care.

Worse, in many tiered systems, the BLS providers have the ability to cancel the medics before they arrive on scene. I think that's a HUGE problem.

 

[Bullets]

I know we have a diverse population and set of views here, so I wanted to ask this question: what gets ALS in your system, and why?

Additionally, here are some generic scenario questions- would these receive ALS in your system, and what would generally be done?

Psych?

No, not even a BLS truck. PD transports unless they arent ambulatory

Isolated, non-life-threatening trauma?

No

Falls?

With a head injury, yes
Otherwise no

General medical sick calls (abdominal pain, pain, fever, weakness etc)?

No

Respiratory/diabetic/cardiac?

Yes

Altered mentation?

Yes

Arrests/periarrests?

Yes

MVA?

With reported trauma criteria, yes (Head injury, chest pain, amputation, rollover)

Additionally, in your system, if you request ALS for a non-life-threatening call for symptomatic management, what is their reaction, the reaction of your system, etc?

What are you expected to do?

Depends on the individual medics, usually not well

For ALS providers, what is your general opinion on this?

I personally like the tiered, regional system of ALS we have in NJ. It ensures that about 90% of the time the patient in front of me requires some kind of intervention. I know that i will have the opportunity to do all the critical skills dozens of times in a year and that keeps me sharp[/QUOTE]

 

[EpiEMS]

Worse, in many tiered systems, the BLS providers have the ability to cancel the medics before they arrive on scene. I think that's a HUGE problem.

To me the problem with tiered systems has always come down to "you don't know what you don't know." I am not comfortable with our lowest educated providers making the determination that the patient needs a higher level of care.

While I don't disagree with the knowledge gap and undertriaging issues, given that there is evidence that all of us in EMS aren't super great at determining priority/acuity, I would say that if there are acceptable protocols, dispatch, and QA/QI in place, I have to imagine that BLS providers can adequately uptriage if dispatch has some sort of failure to EMD appropriately. I don't love the idea of canceling medics if the nature of the call could be ALS - but with a decent list of exceptions where it might be appropriate to cancel the medics, I don't see it being problematic without qualification.


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[VentMonkey]

I have to imagine that BLS providers can adequately uptriage if dispatch has some sort of failure to EMD appropriately.

On the whole, probably not. The constant evidence of lack of clinical judgement only echoes this sentiment.

I'm not saying that all EMT's can't, but let's face it, more often than not what they think requires ALS versus what doesn't isn't exactly evidence-based. How could it be? They aren't ALS-trained or educated?

Heck, as I've eluded to in an earlier post, many paramedics struggle with "uptriaging".

 

[Grozler]

Arrests
Drowns
Chokes
Chest Pain
Difficulty breathing (which is somehow different than the BLS-level respiratory distress)
Altered mental status
Unconscious
MVA with entrapments
Only arrests, drowns, and chokes get automatic BLS response with ALS. Otherwise, ALS is solo (unless their computer-generated ETA is greater than 10 minutes).

Falls
Generic "sick"
N/V
Straight up asthma symptoms (with a history of)
Trauma
Psych
Aforementioned respiratory distress
Welfare checks w/PD
Any other nonsense I can't think of get BLS.
Amazingly, many calls get up-triaged. I know I am just as shocked as you are.

 

[DrParasite]

Currently, everything gets ALS, which results in a bunch of paramedics that are really good at dealing with BLS patients.

If you want to see a tiered system, here are the NJ EMS guidecards http://www.nj.gov/911/home/highligh...nj.gov/911/home/highlights/emdguidecards.html

 

[EpiEMS]

On the whole, probably not. The constant evidence of lack of clinical judgement only echoes this sentiment.

I'm not saying that all EMT's can't, but let's face it, more often than not what they think requires ALS versus what doesn't isn't exactly evidence-based. How could it be? They aren't ALS-trained or educated?

Heck, as I've eluded to in an earlier post, many paramedics struggle with "uptriaging".

For BLS providers to determine what requires ALS or not should just necessitate protocols that describe the criteria for an ALS assessment - plus QA/QI to make sure this is found out. Admittedly, I agree - many (if not most) EMTs are probably not capable of making such a determination with systems and protocols that they have now, so perhaps it is a unrealistic for me to assume away poorly-written protocols. At the moment, you are very likely right - but it doesn't preclude the "request ALS as needed" (if ALS isn't already dispatched by EMD) if, again, systems were organized differently.
Obviously, undertriaging is probably the biggest risk here - the good ol' Type II error bites hard here.

I will say, though, there is a strong body of evidence that ALS interventions improve outcomes (at least in the urban and suburban setting) in only a limited range of conditions (e.g. ACS and respiratory distress) - so assuming decent EMD, I wouldn't be too concerned (in urban and suburban settings).

 

[medic493]

ALS calls in PA are any which incur life threats upon the patient. Resp, cardiac, AMS, LOC, signs of shock, etc. However, whether the patient gets a paramedic to provide care is an entirely different question. We go from areas where every unit is 1 EMT + 1 Medic, and is transport capable. To areas, where volunteer BLS transport is 25 minutes from your house, and your medic fly car is 1 hour away from your home. Although, some companies have decided that regardless of the call type, als or bls, only paramedics can attend to the patient.

 

[medicsb]

I get to reminisce... (It's been nearly 7 years since I worked as a medic)

I know we have a diverse population and set of views here, so I wanted to ask this question: what gets ALS in your system, and why?

Additionally, here are some generic scenario questions- would these receive ALS in your system, and what would generally be done?

Psych? No.

Isolated, non-life-threatening trauma? No.

Falls? Depends on how far and if vital sign or mentation abnormality. Usually no.

General medical sick calls (abdominal pain, pain, fever, weakness etc)? Those things in isolation? Generally no.

Respiratory/diabetic/cardiac? Generally yes.

Altered mentation? Yes.

Arrests/periarrests? Uh, yes.

MVA? Usually BLS, but certain criteria would dictate ALS (e.g. vehicle rescue).

Additionally, in your system, if you request ALS for a non-life-threatening call for symptomatic management, what is their reaction, the reaction of your system, etc? Some medics did not appreciate this, some (like me) did not mind. If it was junk, we'd triage back to BLS.

What are you expected to do? Assess the patient then initiate treatment or triage to BLS.

For ALS providers, what is your general opinion on this?

As a physician, I think most calls are appropriately over-triaged to ALS, but inappropriately over-treated as ALS.

 

[RocketMedic]

I get to reminisce... (It's been nearly 7 years since I worked as a medic)



As a physician, I think most calls are appropriately over-triaged to ALS, but inappropriately over-treated as ALS.

In terms of what sort of treatment?

 

[DrParasite]

I think the thread from about 8 year ago might be applicable to the topic at hand: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/