ALS or BLS?

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DownSouthMedic

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Just kind of looking for some opinions on a call I ran this morning...

Ok, I'll just give the basic scenario, I work for a private BLS company, we respond to a call for "sick person", ALS on scene requesting BLS.

PT ripped her trach out, stoma actively bleeding, significant enough to require almost constant suctioning, audible gurgling present, PT coughing up blood. PT bedridden, ventilator attached to the PT bed, nursing home staff reports is no longer required. PT appears to be breathing adequately on her own. PT Hx: Diabetes, COPD, Neuropathy, Stroke (cause of current deficits) V/S: BP 124/76 PR 64 RR 20, O2 Sat 92%, GCS 11 (Normal Mental Status for the PT). Anyways that gives you a rough idea of the scene.

Now...one of the medics from the rescue is hanging out in the hallway, the other is attempting to replace the trach when we arrive. The medic in the room eventually gets the trach replaced, turns to me and my partner if were ok while she goes and grabs the portable suction, then we can get the PT ready for transport. This is where things go south...THEY JUST LEAVE! No turn over, all Hx and V/S I have were acquired after this point. Now obviously they were wrong leaving, but should this have been a BLS call to begin with? The airway is compromised by active bleeding as far as I'm concerned. Our protocols are pretty much cut and dry, any airway compromise is ALS. I ultimately just suctioned enroute, provided O2 and prepared to assist with ventilations. Just wondering if some of the ALS providers in here would of ran this one in their selves, or turned it over to BLS. Not trying to rant, was a little bit heated after this one though.
 
Pt. on a vent with a trach installed, a compromised one no less?!?!?:o

ALS all the way around here.
 
DownSouthMedic said:
Just kind of looking for some opinions on a call I ran this morning...

Ok, I'll just give the basic scenario, I work for a private BLS company, we respond to a call for "sick person", ALS on scene requesting BLS.

PT ripped her trach out, stoma actively bleeding, significant enough to require almost constant suctioning, audible gurgling present, PT coughing up blood. PT bedridden, ventilator attached to the PT bed, nursing home staff reports is no longer required. PT appears to be breathing adequately on her own. PT Hx: Diabetes, COPD, Neuropathy, Stroke (cause of current deficits) V/S: BP 124/76 PR 64 RR 20, O2 Sat 92%, GCS 11 (Normal Mental Status for the PT). Anyways that gives you a rough idea of the scene.

Now...one of the medics from the rescue is hanging out in the hallway, the other is attempting to replace the trach when we arrive. The medic in the room eventually gets the trach replaced, turns to me and my partner if were ok while she goes and grabs the portable suction, then we can get the PT ready for transport. This is where things go south...THEY JUST LEAVE! No turn over, all Hx and V/S I have were acquired after this point. Now obviously they were wrong leaving, but should this have been a BLS call to begin with? The airway is compromised by active bleeding as far as I'm concerned. Our protocols are pretty much cut and dry, any airway compromise is ALS. I ultimately just suctioned enroute, provided O2 and prepared to assist with ventilations. Just wondering if some of the ALS providers in here would of ran this one in their selves, or turned it over to BLS. Not trying to rant, was a little bit heated after this one though.
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As it's portrayed here, this is definitely above the level of an EMT-B. I'm not ALS, but I definitely say ALS for this call was a necessity.
 
I'm finding out more and more I work in a horrible system unfortunately...I get a sketchy call like this almost every shift.
 
Would report the ALS crew for Abandonment... Def. ALS call, and at the very minimum at least following you to hospital with one in the rig with you.
 
Definitely a paramedic or RT call.
 
Ok, let me see... You have been handed a patient with a compromised airway, requiring tracheal suctioning because of bleeding. The rest of the patient seems generally baseline, but there is something significant to consider: your patient's airway bleed won't magically stop simply because the trach was replaced.

This was way above the level of an EMT, IMHO.
 
Even without the trach, basics around here can't transport patients on a vent.
 
ffemt8978 said:
Even without the trach, basics around here can't transport patients on a vent.
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Pt wasn't on the vent anymore the OP said.

But yea. I would of called ALS right back. And those medics would be in big trouble.

Def. An ALS call. If something would of went wrong, that's a lawsuit waiting to happeb.
 
Anjel1030 said:
Pt wasn't on the vent anymore the OP said.

But yea. I would of called ALS right back. And those medics would be in big trouble.

Def. An ALS call. If something would of went wrong, that's a lawsuit waiting to happeb.
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Oops...missed that part.
 
So did you tell your supervisors about it? Or just us?

If the facts aren't skewed, and I'm not saying they are, what those medics did was negligent and abandonment. If it had gone south even a brand new, bottom of the barrel lawyer could prove it.

Trached patient doesn't automatically equal ALS, however with the complications you stated it needs to be an ALS run.

Basic scope of practice is supraglottic suctioning if im not mistaken. Tracheal suctioning is not supraglottic...

You got the patient to the hospital and made it happen with the bummer of a hand of cards and the tools available to you, you did a good job. Personally I think now it's time those medics are held accountable for their actions. This doesn't seem like something that should just be brushed under the rug in order to not create waves between agencies or departments.
 
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You got the patient to the hospital and made it happen with the bummer of a hand of cards and the tools available to you, you did a good job. Personally I think now it's time those medics are held accountable for their actions. This doesn't seem like something that should just be brushed under the rug in order to not create waves between agencies or departments.
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This
 
For certain this was an ALS call. It should have been handled by competent ALS providers. If this is an accurate rendition of events, it was definately unprofessional behavior on the part of the medics. Fleeing the scene is generally not professional behavior.

But in the absense of a competent ALS provider, with the ability of tracheal suctioning, a basic skill in some places like my home state, what exactly makes this way above an EMT?

Bleeding? It needs to be controlled, it is likely doable with some basic dressing.

Suction? Like I said, if it is a basic skill where you are, does a paramedic suction any better?

Restraint? Chemical restraint is much prefered over physical, but in a pinch, tie the pt. up.

A trach patient with a chronically depressed mental status. Not easily made better by starting an IV, tube is in place, doesn't need electrical therapy, could use some versed, but no "life saving medications."

Sounds to me like the medics were out of their element. They were not able to handle such a patient from their described lack of familiarity, and they punted to the first available provider. Aka the OP, who appears equally uncomfortable.

But really, aside from some versed, what exactly was the ALS provider to do that couldn't be done by said basic?

The tube is probably there to prevent adhesions and likely will later be removed, leaving a stoma. In the few minutes to an hour or so, adhesions will not form, so what is the issue? It would probably help if bleeding was addressed, but that is a wound edge issue. Excess secretions would be no different than bleeding, suction.

The trachea is in the mediastinal fascial plane, not the lung pleura so a pneuno or tension pneumo is not really a plausable scenario.

Once the blood gets in the deep airways, what is the ALS treatment for that?
Nothing.

What is this call really? An altered LOC patient who yanked a tube.

"Oh no! OMG!"

Restrain, control bleed, suction airway, transport.

Yes ALS has better tools and should have handled it. No, they didn't act professionally, but what would you have done if there was no ALS available?

I keep hearing stuff like "EMTs save medics, BLS before ALS," and "EMTs are more than a taxi with basic first aid training,"

Put up or shut up.
 
Considering ALS was available (and already on scene no less) I would have expected them to ride.
 
Basics can suction trachs here.

And.to vene..

How the pt right at that moment wasn't way above BLS. But if something would of went wrong, like airway swelling, or swelling of the stoma from the trauma. There wouldn't of been a way to suction or bag.
 
Anjel1030 said:
But if something would of went wrong, like airway swelling, or swelling of the stoma from the trauma. There wouldn't of been a way to suction or bag.
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You are a paramedic student, what would you have done?
 
Umm...ive been a student for three weeks. All ive learned is how to handle death and dying and what the mitochondria is.

But there would have to be something a medic could do. A cricotomy? if what they had was swollen shut? I'm not sure.
 
Anjel1030 said:
Umm...ive been a student for three weeks. All ive learned is how to handle death and dying and what the mitochondria is.

But there would have to be something a medic could do. A cricotomy? if what they had was swollen shut? I'm not sure.
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A trach is a superior procedure to a cric, which is temporary and converted to a trach.

If the airway starts swelling closed, all you can do is put a tube in it. Since there is already a tube in there, what can be done has been.
 
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