ALS Transfers

[VentMedic]

It wasn't until I worked for a 3rd tier ambulance service, where intra-facility transfers and ALS monitered Dialysis transport were the commpanys bread and butter, that I discovered the other side and I honestly felt more than a little ashamed.

Even for the dialysis patient, few look past the diagnosis of "renal failure" to see what actually caused the patient to need dialysis. Some don't realize the patient may not have had any kidney disease but rather they may have had some catastrophic event such as a cardiac arrest or a trauma which initiated the events that severely damaged their kidneys.

Not all "saves" turn out perfectly even if they are able to walk out of the hospital. But again, some EMT(P)s fail to acknowledge them as worthy patients or even as people on some ambulances if they are no long having a situation that stimulates the adrenaline.

 

[Scubamedic]

Not all "saves" turn out perfectly even if they are able to walk out of the hospital. But again, some EMT(P)s fail to acknowledge them as worthy patients or even as people on some ambulances if they are no long having a situation that stimulates the adrenaline.

Agreed.

 

[Shishkabob]

40 hours in, and 1 ALS transfer, which was of a STEMI pt who had cardiac arrest a week prior. Essentially just had to maintain an infusion of .45% NS, and keep them on an EKG.


Wondering why it was .45% NS and not .9%, but the nurse I spoke to had no clue and Google has turned up nothing.

 

[46Young]

40 hours in, and 1 ALS transfer, which was of a STEMI pt who had cardiac arrest a week prior. Essentially just had to maintain an infusion of .45% NS, and keep them on an EKG.


Wondering why it was .45% NS and not .9%, but the nurse I spoke to had no clue and Google has turned up nothing.

Sounds like a really high speed shift. Was the rest BLS discharges and such, or did you just have one call in 40 hours?

Was the pt hypernatremic? If so, maybe the 1/2 NS was being used as a corrective measure?

Also, what pumps are you using? Just curious. We used the Abbott Plum pumps. We had to deal with frequent cassette test failures. Reston Hospital in Fairfax County uses them and they told me they have the same issue. At my IFT gig here we use the Baxter 3 channel. It doesn't give me much of a problem. If you change over the pumps, and get a proximal air occlusion, you're supposed to back prime. If it's too much air for the pump to do that, you can use a syringe at a nearby port to aspirate the air without having to run all of the med through the tubing. Some drips can't be interrupted for long, and this will resolve the occlusion quickly.

Another piece of advice, it would be wise to know the typical loading dose and infusion ranges of common drips, such as heparin and tridil, for example. You may catch a med error. If you txp a pt with a dose range that's way off, you may be on the hook for not knowing any better, not just the sending RN.

 

[Shishkabob]

My shifts are currently 16/16/8 Mon/Tues/Wed during my FTO time. The ALS transfer was Monday. We had a decent amount of BLS calls the rest of the time. My FTO said I'm doing well and as soon as we start getting more ALS calls I should be cleared.



Looking back I guess the .45%NS was because of the hypernatremia... should have critiqued the pts files more.


The pumps we use are the Alaris MedSystem III

I'm going to probably end up buying an ALS / CCT fieldguide for the odd drips. I have my Drug Guide for Paramedics pocket book, but those rely more on EMS use of drugs and not the hospital uses.

 

[46Young]

Good idea with the CCT guide. I haven't seen those pumps yet. Are they user friendly?

 

[DrParasite]

forgive my ignorance, but what is an ALS (paramedic) transfer? I am about 98% sure that we don't have them in NJ.

Most of our IFTs are of the BLS kind. hospital to hospital of stable patients, hospital to rehab centers, home to doctors offices, etc.

any time the patient has running drips, needs to be on a cardiac monitor, or anything of the sort, an RN is required, which makes it a critical care transport. this includes transfer pre-surgery, STEMI/Trauma transfers, and other potentially life threatening and pre-scheduled stuff. a medic is NOT required, and many/most are done by private companies with an EMT/RN and an EMT or 2 EMTs and an RN.

if a vented patient is transferred, it sometimes involves a BLS crew (2 EMTs) with a resp therapist from the sending facility, depending on the patient's condition (but can go with nurse and monitor if the situation warrants.

 

[46Young]

Also, Linuss, check out the small print on the fluid bags. They tell you the osmolarity of the fluid. It will give you a clue as to their hydration status, hydration goals, and/or treatment goals in general. And while we're on the subject of small print, take a look at your IV catheters. They tell you the flow in ml/min for that size.

 

[Shishkabob]

Good idea with the CCT guide. I haven't seen those pumps yet. Are they user friendly?

Pretty straightforward with drip set up... press the corresponding "A/B/C" button to choose the chamber, then you set the drip rate, amount left to infuse etc etc. It's pretty picky with it's air bubbles though.



ALS transfers here at my branch are ones that cannot be maintained by an EMT, but dont require the service of CCT. Mainly just infusion of common Paramedic drugs, maintaining IVs, and EKG monitoring. The drugs that aren't typical to EMS are done through CCT, and CCT around here is usually a CCEMT/P and either an RN or RRT, depending.


Like the other day, we get dispatched priority one to a local hospital for a transfer of an active head bleed, and CareFlite HEMS couldn't be used because of weather. We got canceled less then 5min out because it was found out the pt was on Cardizem and so CCT had to transfer them.

 

[46Young]

forgive my ignorance, but what is an ALS (paramedic) transfer? I am about 98% sure that we don't have them in NJ.

Most of our IFTs are of the BLS kind. hospital to hospital of stable patients, hospital to rehab centers, home to doctors offices, etc.

any time the patient has running drips, needs to be on a cardiac monitor, or anything of the sort, an RN is required, which makes it a critical care transport. this includes transfer pre-surgery, STEMI/Trauma transfers, and other potentially life threatening and pre-scheduled stuff. a medic is NOT required, and many/most are done by private companies with an EMT/RN and an EMT or 2 EMTs and an RN.

if a vented patient is transferred, it sometimes involves a BLS crew (2 EMTs) with a resp therapist from the sending facility, depending on the patient's condition (but can go with nurse and monitor if the situation warrants.

Depending on the area, medics do many xfers that nurses do in NJ. Back at North Shore LIJ, the medics did everything from baloon pump jobs to the vented, sedated neurosurgery xfer. These were double medic in the back jobs, one of which was a CCM, of course. We also did some minor PICU txps. The NICU's and other PICUs would have an RN, RT, MD Fellow or some combination of the three.

IMO, these xfers should be the domain of the RN instead of the medic. They'll have the background and specialization for that particular pt, where the medic is just a "Jack of all trades." This is a major reason why I don't see the medic's education increasing significantly past the EMS AAS for some time. If you want to do real IFT, you're not going to increase your medic clinical education (currently unavailable in the US and it won't result in better salary anyway) when you could just become a nurse and have all the pay, scope, prestige, benefits and such that are deserved with the educational investment. It wouldn't be so with a four year medic degree (not the EMS BA, which is mostly admin stuff, not clinical). 911 prehospital medicine doesn't need much past the two year degree, unless your agency is initiating their own studies and trials.

 

[46Young]

Pretty straightforward with drip set up... press the corresponding "A/B/C" button to choose the chamber, then you set the drip rate, amount left to infuse etc etc. It's pretty picky with it's air bubbles though.



ALS transfers here at my branch are ones that cannot be maintained by an EMT, but dont require the service of CCT. Mainly just infusion of common Paramedic drugs, maintaining IVs, and EKG monitoring. The drugs that aren't typical to EMS are done through CCT, and CCT around here is usually a CCEMT/P and either an RN or RRT, depending.


Like the other day, we get dispatched priority one to a local hospital for a transfer of an active head bleed, and CareFlite HEMS couldn't be used because of weather. We got canceled less then 5min out because it was found out the pt was on Cardizem and so CCT had to transfer them.

Your scope sounds like what a medic "one" was back at my old hospital in NY. A medic one only did simple non emergent cardiology xfers, a single drip, etc. No emergency calls or vent discharges, though. A medic one is a new, inexperienced medic. The medic 'two" is a medic one off probation, and can handle the active MI cath lab jobs, some PICU xfers alone, emergent calls, two drips, vent discharges, etc. Vented/sedated, baloon pump jobs, more than two drips, other emergent vent jobs, post arrest > 24 hours, are the domain of the CCT. Many of these require two medics, a one or a two to accompany the CCM. We only saw in hospital staff on NICU's and PICU's. CCT's could titrate tridil, propofol, and some other meds on standing order, whereas the medic two could not. It would seem that North Shore's ALS was on the higher end of scope when compared to the industry as a whole from what I can gather.

 

[Shishkabob]

AMR Dallas isn't too progressive with their medic protocols. We don't even have IOs for adults... have em for kids under 6 though! I'm so screwed if I get a code with no veins... one of our trucks had an ROSC code the other day. But we can do up to 3 simultaneous infusions using the pump.

I know I read somewhere the defining criteria of ALS vs CCT... I just can't find that form.


We do nursing home emergencies with some frequency, like the usual chest pain or sob, and also get called out to the Dallas county jail on emergencies too. We only have a handful of Paramedic trucks on shift at any time, with most trucks being dual EMT, so they spread us medics around, but we still do a fair portion of the BLS transfers.