ALS or BLS?

[NomadicMedic]

We play a lot of the "what if" game here.

It gets a little frustrating.

 

[DrParasite]

all of that said, the majority of calls we get could be BLS, but with a 35-60 minute transport the patients condition can change and we prefer to have ALS on board.

why? Can ALS do the stare of life any better than BLS?

don't get me wrong, if they are unstable, or you think they might die, than yes, ALS can help. If they are stable, and just need a ride to the ER, and don't need an imminent interventions, why not just have the EMT keeping the person company on the nice ride to the ER?

 

[mcdonl]

why? Can ALS do the stare of life any better than BLS?

don't get me wrong, if they are unstable, or you think they might die, than yes, ALS can help. If they are stable, and just need a ride to the ER, and don't need an imminent interventions, why not just have the EMT keeping the person company on the nice ride to the ER?

No arguments here DR.... It is just how we staff. We try to staff MEDIC / DRIVER and the Driver is selected in order of AEMT -> EMT -> Non licensed

So, on a day with a MEDIC all calls get ALS... on days with no medic, we just go Mutial Aid down the line to the hospital.

 

[Handsome Robb]

We play a lot of the "what if" game here.

It gets a little frustrating.

Samesies.

Many of the calls I've had kicked back at me telling me I should have attended that I triaged to my partner have been based off the patient's history and not my objective findings and the HPI.

 

[Clipper1]

This may sound rude but, whether it is ALS or BLS you are still giving the patient a provider with just a year or less of training. I could see this argument in the UK, Canada, Australia or any other country besides the US. The AEMT needs to be the minimum so at least a few things can be done. If it is a Paramedic service the charge should be by the assessment and not having to do an unnecessary IV just to call it ALS.

 

[EpiEMS]

This may sound rude but, whether it is ALS or BLS you are still giving the patient a provider with just a year or less of training. I could see this argument in the UK, Canada, Australia or any other country besides the US. The AEMT needs to be the minimum so at least a few things can be done. If it is a Paramedic service the charge should be by the assessment and not having to do an unnecessary IV just to call it ALS.

That's not rude -- it's correct. I think most of the Americans on this board would agree that AEMT should be the minimum. I certainly agree.

 

[Akulahawk]

This may sound rude but, whether it is ALS or BLS you are still giving the patient a provider with just a year or less of training. I could see this argument in the UK, Canada, Australia or any other country besides the US. The AEMT needs to be the minimum so at least a few things can be done. If it is a Paramedic service the charge should be by the assessment and not having to do an unnecessary IV just to call it ALS.

As long as there's appropriate safeguards in place to prevent fraud/abuse, Paramedics, AEMTs, and EMTs should absolutely be able to bill for assessment services independently of treatment or transport services provided. Of course, treatment/transport should also be billed for separately. This way, a Paramedic shows up, assesses the patient (one bill), determines that BLS care is all that's necessary and provides that care (BLS care bill), and transports the patient (mileage bill). That's just one idea...

Now I'm absolutely for the idea of having an EMS Paramedic always paired with at least an AEMT. An IFT Paramedic shouldn't need an AEMT and could get along quite well with an EMT, at the minimum. As an EMS Paramedic, I'd love an extra set of hands that can do almost anything I need them to do. That level of assistance isn't going to usually be necessary for an IFT Paramedic because the pace of things will be a bit slower, and can be done a LOT more deliberately.

 

[Handsome Robb]

Now I'm absolutely for the idea of having an EMS Paramedic always paired with at least an AEMT. An IFT Paramedic shouldn't need an AEMT and could get along quite well with an EMT, at the minimum. As an EMS Paramedic, I'd love an extra set of hands that can do almost anything I need them to do. That level of assistance isn't going to usually be necessary for an IFT Paramedic because the pace of things will be a bit slower, and can be done a LOT more deliberately.

I agree. I've honestly never worked with an EMT. Taken hand off from them at events and had EMT student riders but the minimum staffing in our county is I(or A)/P. our intermediates have a fair amount of skills in their scope to assist in "ALS care". All of our fire crews have at least one I/A on board if not two. It's very possible and has happened in the past where I've run an arrest without performing a single skill or given a single med. I like it because I can focus more on the cause of the what's going on and how I can fix it. I honestly couldn't imagine how it would be to have to do the airway, access, drugs and all the thinking at once. I have no doubt I could do it but I honestly feel it provides a higher quality of care o the patient being able to delegate my workload.

With all that said, I love jumping in and getting my hands dirty. The rare and/or "cool" skills are mine unless we have a medic student.

 

[mcdonl]

Now I'm absolutely for the idea of having an EMS Paramedic always paired with at least an AEMT. An IFT Paramedic shouldn't need an AEMT and could get along quite well with an EMT, at the minimum. As an EMS Paramedic, I'd love an extra set of hands that can do almost anything I need them to do.

Paramedics are like guns. When you NEED them... you NEED them FAST!!

I should clarify that my comment about how we staff is at a Municiple Fire/EMS service where FF is required regardless of license level.

 

[NomadicMedic]

I agree. I've honestly never worked with an EMT. Taken hand off from them at events and had EMT student riders but the minimum staffing in our county is I(or A)/P. our intermediates have a fair amount of skills in their scope to assist in "ALS care". All of our fire crews have at least one I/A on board if not two. It's very possible and has happened in the past where I've run an arrest without performing a single skill or given a single med. I like it because I can focus more on the cause of the what's going on and how I can fix it. I honestly couldn't imagine how it would be to have to do the airway, access, drugs and all the thinking at once. I have no doubt I could do it but I honestly feel it provides a higher quality of care o the patient being able to delegate my workload.

With all that said, I love jumping in and getting my hands dirty. The rare and/or "cool" skills are mine unless we have a medic student.

We run dual medic chase vehicles and I've been paired with another medic for almost 3 years. Now, I don't think I'd like it any other way. Not because I need "another medic to bounce things off", but because it's nice to have another set of trained hands helping with busy calls. Sadly, the EMTs here are not much more than glorified stretcher fetchers. Most attempts to get them involved beyond placing a 12 lead is met with blank stares or disdain. When I ask them for a set of vitals, they automatically reach for my monitor. When I say I'd like a manual BP, they look like a deer in the headlights.

Is it any wonder why most of our calls become ALS?

 

[DrParasite]

Is it any wonder why most of our calls become ALS?

out of curiosity (since I don't work or know anyone fro DE), are you dispatched to all the EMS calls in your state? or just ones that meet certain criteria? Are you often cancelled while enroute or on scene by BLS? How often do you triage a stable patient to the BLS for transport, since their is no acute emergency that you can intervene with? after all, if the person is stable, can't a simple "stretcher fetcher" handle the comfortable transport to the ER?

Just for numbers, my system gets about 70,000 EMS calls a years. Of that, maybe 21,000 and 14,000 are ALS dispatches, and around 7,000 calls result in ALS treats. the rest are either cancelling ALS due to not being needed (the vast majority), cancel ALS due to proximity to ER, pt DOA, or pt will be RMA and does not require ALS prior.

So again, do you treat every call you get result in an ALS treat (according to medicare rules), every call you make it to the scene result in an ALS treat, or is every call in your state result in an ALS treat? Just asking for clarification on your statement.

 

[TransportJockey]

In my rural system, my service dispatches an ILS or ALS truck on every run. The last few months I can count on two hands how many calls my basic partner attended. The vast majority are ALS actually. Part of that is I work in a very rural, very poor county with the nearest hospital being in the city one county north (at least a twenty five minute drive) or one county south (a bandaid stand general hospital about thirty five minutes from our southern boundaries).

 

[medicsb]

We run dual medic chase vehicles and I've been paired with another medic for almost 3 years. Now, I don't think I'd like it any other way. Not because I need "another medic to bounce things off", but because it's nice to have another set of trained hands helping with busy calls. Sadly, the EMTs here are not much more than glorified stretcher fetchers. Most attempts to get them involved beyond placing a 12 lead is met with blank stares or disdain. When I ask them for a set of vitals, they automatically reach for my monitor. When I say I'd like a manual BP, they look like a deer in the headlights.

My god, if an EMT ever tried to reach for the NIBP button on a medic's monitor, without knowing the medic well or asking first, they would be at risk for a near-death experience. At least when I was still working, most medics wanted at least one manual pressure done, which EMTs usually knew.

Does BLS ever cancel ALS in your area and are you able to triage to BLS?

 

[RocketMedic]

Here, as I reckon is the case in most other places, we run P/B. I think that most of our patients could be BLSd, even the serious ones, and that a fly-car or tiered system could work from a strictly operational point of view as an ambulance service. However, I think that care would suffer for it.

To me, one of the best things about being a paramedic is that I can actually fix a few things. Hypoglycemic crisis? No big deal. Seizures? Can't breathe? Too nauseated to stand up? In pain? Dying from some allergy? I can fix any and all of those, or at least take a good stab at it. Could these by solved by an EMT with sufficiently advanced protocols, such as the 68W standard? Absolutely. Could one bucket along with an AEMT or EMT-only ILS/BLS standard? Once again, absolutely, and plenty of people live with one of those answers. I would even go one step further and readily admit that many EMTs are as good or better at 97% of this job as I am. But then there's that three percent that separates EMS from stretcher aid and Yellow Cab.

EMTs, as I have seen in three states and four jobs, are not well-trained. That is not to say that there are not well-trained or competent EMTs, nor is it a claim that my gold patch confers immediate mastery of all things EMS, but it is a start. From what I have seen and remember of my own time as an EMT and AEMT/EMT-I, 'competence' was measured by rote performance of a few skills of questionable value and 'skill' was measured directly by time 'served in the field', which was totally independent of what was actually done in the field. Education for EMTs generally consists entirely of repetition of dogma- 'immobilize, oxygenate, transport', etc. There is an active discouragement of critical thinking at all levels of our field, but it is particularly focused at EMT. (Check out the AHA's neutering of the CPR/ACLS education and its drive to standardization). There is also a lack of real leadership taught in EMT classes; most EMTs I have met are somewhat slow to really assert themselves. I am told that all-BLS systems like DrParasite's are different, but once again, I have not yet seen EMTs consistently provide timely, accurate and in-depth assessments of medical patients. Lastly (and I think this may be an individual system failure as opposed to a national EMT failure), I am not thrilled with the attitudes and performance levels of many EMTs to the point where I trust them to be individual providers. My first partner here would be a great paramedic, and he has the intelligence, critical-thinking and drive to do it. But I have not seen that from other EMTs here, excepting ones that are taking or have passed the paramedic course. My current partner is tolerable, drives safely (which is why I requested her) and does what I ask- but her heart is not in it, and I can already see her burning out, to the point where I picked up some attitude when I asked her to call in a report for a psych call. "Why don't you do it" is not an answer I want to hear from a partner when I am preoccupied and somewhat concerned about crew safety. Having the same EMT who views it as an intrusion to call report or to waste an ambulance on a literal taxi ride want to take the 'cool calls' like "drunk guy put his car in a ditch" is not wrong- after all, both are completely BLS and could be ran as such- but there is a level of proactive effort that is needed, and I have not yet seen solo-EMTs without years of experience or additional training put out that effort spontaneously in a timely manner. Part of this malaise is the fault of the paramedics- I know mine is, since I have all but given up until the next shift bid on Showing the Cool Stuff, and I eagerly hope my next partner responds better to "let's play with the toys" than my last one has. We should teach our EMTs better on a national scale- but the lack of a common educational base and the widespread indoctrination of dogma cannot be rectified with some OJT and a dash of hope.

All of these issues could be fixed with a proper EMT training curriculum, aggressive protocols and the fielding of essentially automated ALS- we can see this in the UK's EMS system, where 'paramedics' are essentially AEMTs with a wider formulary, backed by real doctors on critical calls. They could mirror King County, where Trendelenberg and field central lines and the Harborview God Complex will never steer you wrong. They could be resolved at great cost by a fire-like model, where current-standard EMTs approach medicine as a team sport and overcome individual weaknesses with officer-led group activities. All three of these approaches are in use right now, and all three have similar effectiveness. With that being said, I would hope that I never present with anything that hasn't been blatantly described in the well-read pages of Brady's or Mosby's in most of these places.

Properly educating EMTs to a standard I feel is appropriate is functionally identical to training a paramedic, and that's why I feel that we should, as a national standard, maintain an all-ALS standing on 911 transport ambulances. It's not just for the tubes, fluids and emergent medications. It's for the relief of pain and suffering by compassionate care and the provision of a superior level of training and treatment to our patient. Sure, it almost certainly is a BLS trip, with little chance of rapid deterioration and no life threat- but even those can benefit from some advanced measures, and everyone benefits from the critical thinking that more paramedics are able to do (now if only we all would...)

To the original question, most of what we do is BLS.

 

[NomadicMedic]

To answer some of those questions, we're automatically dispatched on Charlie, Delta and Echo calls along with a BLS ambulance. BLS can cancel medics with no questions asked, but once ALS is on scene we have to speak with a med control doc to downgrade a transport to BLS. We call it a "BLS release" and the many of the docs are not willing to downgrade. It's more of the "what if" mentality. Medics also have to write a full report on a BLS release, so in many cases, it's just easier to throw your gear in the ambulance and do an "ALS ride along". That's where the medic just sits on the bench and watches the stable BLS patient in case something bad were to happen. That would not be an "ALS treat", since no interventions were done. However, all of that is a moot point, as we don't bill for any ALS services at all.

So yes, the EMTs can transport very low priority calls without a medic, but if they don't cancel us before we get there, a medic will accompany them to the ED, simply because of the politics, protocols and docs involved.

 

[Handsome Robb]

My current partner is tolerable, drives safely (which is why I requested her) and does what I ask- but her heart is not in it, and I can already see her burning out, to the point where I picked up some attitude when I asked her to call in a report for a psych call. "Why don't you do it" is not an answer I want to hear from a partner when I am preoccupied and somewhat concerned about crew safety.

I would've lost it. We would've had a long conversation. Wait, strike that, I would have given her an earful and then she would be an ambulance driver for the rest of our time together. Like you said, this is a "team sport". I rarely ask my partner to call report for me and if I do I have a damn good reason. Argue with me or question me and your goose is cooked. I like to think that I'm a very laid back partner and let my partners do quite a bit compared to some other medics but at the end of the day it's my truck, I'm in charge and you do what I say unless it endangers us, corresponders, the patient or bystanders.

As far as triaging to my partner it's nice that I'm still in the same ambulance because if something changes all we have to do is pull over and swap places. Only time it's ever happened is when a patient refused pain meds on scene and then changed his mind as we bumped down the hanky roads around his house.

 

[RocketMedic]

I wasnt thrilled, but the Army taught me to move on.

 

[ZombieEMT]

As many of you might know, New Jersey runs an EMS system where BLS responds via ambulance and ALS responds in a chase unit. EMS crews are always EMT/EMT and Medic/Medic.

As an EMT, I admit that there are some of us that lack the skill and knowledge to perform effectively. What an EMT does is basic, hence why called and EMT Basic. I believe what makes a good EMT is an EMT that can make a baseline assessment and properly prepare the ALS team when they walk through the door with a full report. There are some of us that do this and do this well, others unfortunately no.

At the same time, they way many ALS teams function can be discouraging to a point that almost makes the EMTs fell like stretcher jockeys. When ALS walks through the door and you give vitals, report and history, and they just disregard it. It almost feels as if our assessment is not wanted anyway. Does anyone actually trust us?

 

[medicsb]

As many of you might know, New Jersey runs an EMS system where BLS responds via ambulance and ALS responds in a chase unit. EMS crews are always EMT/EMT and Medic/Medic.

As an EMT, I admit that there are some of us that lack the skill and knowledge to perform effectively. What an EMT does is basic, hence why called and EMT Basic. I believe what makes a good EMT is an EMT that can make a baseline assessment and properly prepare the ALS team when they walk through the door with a full report. There are some of us that do this and do this well, others unfortunately no.

At the same time, they way many ALS teams function can be discouraging to a point that almost makes the EMTs fell like stretcher jockeys. When ALS walks through the door and you give vitals, report and history, and they just disregard it. It almost feels as if our assessment is not wanted anyway. Does anyone actually trust us?

It's actually good to be redundant (can catch mistakes or build off the previous assessment). This happens to medics frequently when they deliver pts to the ED. It happens to residents by attendinds, to students by residents, and by a new service when a pt is transferred or when a consult is made.

It may or may not be about trust. Either way it is good to confirm previous findings.

 

[TransportJockey]

At the same time, they way many ALS teams function can be discouraging to a point that almost makes the EMTs fell like stretcher jockeys. When ALS walks through the door and you give vitals, report and history, and they just disregard it. It almost feels as if our assessment is not wanted anyway. Does anyone actually trust us?

Around here I listen and then redo it. Not because I don't trust our basics, I do... Mostly. But because I want to know first hand that I'm getting everything I need and have all the info and it's accurate. And there's some things that I might get from info that the basic doesn't so they can't convey that to me