ALS or BLS?

[edash]

sounds like you work in King County..this is business as usual for us..ABLS..hahaha

 

[jjesusfreak01]

this might be the only thing that lets them leave. key word is MIGHT. if the trach is replaced, and returned to a properly functioning position, than it MIGHT be a BLS call (since the airway is no longer compromised).

As a BLS provider (convalescence), I have my own rule that regardless of the cause of the patient's injury or illness, if they have been stable for a number of hours or days without anything being messed with, and I don't expect ALS interventions to be needed, i'll take the call.

Example 1: Pt having a sustained allergic reaction (itching and hives) from a nursing home. Initial start of reaction appx 8 hours prior to the call. I can reasonably suspect that the pt will not develop airway compromise due to the length of time since the start of the reaction. It doesn't mean they wouldn't benefit from some IV benadryl or solumedrol, but they can do without until we reach the hospital.

Example 2: Diabetic patients. If they have received insulin immediately before transport, I will not take them, as I don't carry even oral glucose on my truck. If they had insulin an hour prior and are just finishing lunch, we're great.

Example 3: Trach patient needing suctioning for an hour and a half transfer. Trach was changed by an ENT before transport, and I sat with the patient for a good half hour and made the RT suction him once before we left. No complications during that time, so we were good to go. I did suction his trach a few times enroute without issue. This call was borderline just due to a possible need for deeper suctioning.

So, my thinking is always a very simple, "what are the chances this patient will need ALS intervention enroute". In the OP's post, the first sentence made it quite clear that the pt was at a significant risk for needing ALS care sometime during transport. I wouldn't have taken that call unless I legitimately thought staying at the facility (waiting for the medics to return) would have been more dangerous for the patient than rushing to the hospital.

 

[systemet]

Example 1: Pt having a sustained allergic reaction (itching and hives) from a nursing home. Initial start of reaction appx 8 hours prior to the call. I can reasonably suspect that the pt will not develop airway compromise due to the length of time since the start of the reaction. It doesn't mean they wouldn't benefit from some IV benadryl or solumedrol, but they can do without until we reach the hospital.

I think this is ok, but just be aware that some patients can have a biphasic response, with a second wave of symptoms some hours later. Just be alert for any changes. I think this is only an issue going BLS if they're going a long distance.

[Then again, your level says EMT-I --- all the EMT-I scopes confuse me, but don't some of them include epinephrine anyway?]

 

[jjesusfreak01]

I think this is ok, but just be aware that some patients can have a biphasic response, with a second wave of symptoms some hours later. Just be alert for any changes. I think this is only an issue going BLS if they're going a long distance.

[Then again, your level says EMT-I --- all the EMT-I scopes confuse me, but don't some of them include epinephrine anyway?]

My training is EMT-I, my certification is basic pending results from the EMT-I state test, and I work for a convalescence company full-time that doesn't stock anything past the state minimum on our basic level ambulances (no drugs). Also, very short transport. The EMT-I drug scope in NC is all the diabetic meds, all the first line cardiac arrest drugs, plus toradol, histamine-2 blockers, atrovent, IV benadryl/narcan, that kinda stuff.

 

[RanchoEMT]

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.

Have you not ran ALS before?
In my company you work your way up to 911(ALS) from IFT(BLS)... So while working IFT/BLS we run what we call "code2" calls..... like downgraded to BLS(from dispatch) code3 or 911 calls. Seems like an efficient way to prioritize and make efficient use of the appropriate/available units in the system at the time... But there is a Major flaw... The Newbie IFT EMT's are not keen to what an ALS(911) call consists of. Nor are the idiots who triage these calls. No Body wants to be the guy that told the charge nurse/Dispatch to call 911 and have an ALS Ambulance and a Medic Fire Engine roll up, roll their eyes, and roll out.... So, I can say from personal experience I've taken calls far beyond my level of training/comfort many times when i first started out... thankfully all had ideal and positive outcomes as i can remember.
But if i were you i'd make a strong effort to work some 911 or at least talk to a medic from your area(YOUR PROTOCOL) or even on this site and begin to piece together in the triage sense what is yours and theirs(ALS).. Before you Fuk up and kill someone. I don't mean to be harsh towards you but please realize the level of importance and responsibility that occurs when you "accept" a patient, especially one your not comfortable with.

A good rule of thumb: "If your not comfortable taking the patient, Don't."

As for the medics who dumped the call on you.... Alot of factors come into play that are not clearly stated in the OP, Same Company? Fire Medics? Etc... Maybe they had good reason to downgrade; protocols, politics, laziness. IDK, but I would be less than surprised to hear if it was the later. In which I would tell you to Report them.(Tho if you weren't comfortable onscene, should have been done to the On-Duty Sup. before transporting the patient)....

 

[EMTBell]

Abandonment all the way!

Regardless of what the situation was, where I am, if ALS is on scene they cannot hand the call off to BLS unless its a masscal scenario.

Though it seems this should have been full ALS transport.

 

[Medic Tim]

Regardless of what the situation was, where I am, if ALS is on scene they cannot hand the call off to BLS unless its a masscal scenario.

Though it seems this should have been full ALS transport.

even if no als assessment or interventions are performed?

 

[EMTBell]

Yeah, we can't hand off to a lower level of care once they are the patient of an ALS provider

 

[Handsome Robb]

Yeah, we can't hand off to a lower level of care once they are the patient of an ALS provider

I'd bet your Paramedics can if they deem it a BLS/ILS call depending on how your response system is set up.

 

[emtchick171]

That is ALS all day long where I'm from, and I'd hate to know I had turned this over to a BLS crew...bye bye job.

 

[DesertMedic66]

I'd bet your Paramedics can if they deem it a BLS/ILS call depending on how your response system is set up.

For us it's the same. Once the patient has been seen by a paramedic, the paramedic can not hand the patient over to BLS unless it's an MCI.

So if fire is on scene first they have a medic. If BLS arrives on scene we have to either wait for a medic ambulance to arrive or transport with the fire medic in charge of patient care.

Our paramedics can deem a call a BLS call however they still have to take the call. They will just not do any ALS on the call.