ALS units on BLS calls

[medic417]

This would not be a problem if the publics best interests were considered, rather than cheapest route as so many communitys choose. It would be best for all patients if every ambulance was a paramedic level ambulance. This would ensure that someone with the education and skills could properly evaluate and treat them. In fact if all ambulances were paramedic staffed perhaps more services would start allowing denial of transport to stubbed toes. Thus we would eliminate many transports thus lessening the load of all emergency services.

There is absolutly no justification to send a basic staffed ambulance on any 911 call. I have had to many calls to check a persons BP only to find an Acute MI. Or they just want checked out because not feeling well and code as we arrive. If basic only responded critical care would be delayed waiting on Paramedics to arrive or no care would be given while driving like idiots to the hospital if not waiting.

 

[Jon]

Keith,

Given the situation.. I can't see why ALS would release to you. It doesn't make sense to have the ALS crew wait onscene for an extended response of a BLS crew when the hospital is closer... although I've seen the same thing in the county where I work... there are some areas that are covered by BLS ambulances, with the primary or secondary ALS being a transport-capable ALS ambulance... unless the patient is critical, the ALS seems to wait for BLS to get out (or fail to respond), sometimes through multiple stations, until the "ALS" unit becomes due as the BLS unit as well.


Overall... I see an application for BLS ambulances with ALS chase cars... that is what we have where I volunteer. I like it, it works. We can recall medics on BLS calls, and call for the medics when a BLS call becomes ALS. Some systems are set up that way, and they work. Additionally... my county has a decent CAD and BLS vs. ALS coding system... this means that we get overtriage much, much more than undertriage... we recall ALS more than we need to request ALS.
Medic417... I agree that it would be nice to have a paramedic on every call... but there are calls were medics aren't needed. Additionally... there is almost never anything absolute in EMS .

 

[daedalus]

But see, its not basic vs. medic. We are a team. We need to work together. You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.

We are a team. There should be no doubt in anyone's mind that a paramedic is a higher education than EMT.

 

[JPINFV]

But see, its not basic vs. medic. We are a team. We need to work together. You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.

We are a team. There should be no doubt in anyone's mind that a paramedic is a higher education than EMT.

Turf battles? In medicine? It's more likely than you think.

Anne Boisclair-Fahey is used to patients doing a double take when she introduces herself.

She begins by carefully explaining she's a nurse practitioner, then adds "You can call me Dr. Anne."

Get ready to meet a new kind of hybrid at your local clinic: the doctor nurse. They sport name tags with the letters DNP for doctorate of nursing practice.

Some doctors object

For years, physicians have resisted the notion of a doctor nurse.

The American Academy of Family Physicians, for example, wants it made clear to patients that nurses with an advanced degree are not the same as doctors who have been to medical school.

http://www.startribune.com/business/18292444.html


As to the topic, I do believe that patients deserve, at the very least, a paramedic assessment. The simple fact is that while a lot of patients don't necessarily need a paramedic, a lot of those patients don't really need an EMT-B either. Claiming that Basics are good enough would be like walking into an ER and saying a RN is good enough. Sure, RNs can treat a good deal of medical conditions, but I still expect a physician, hopefully one board certified in emergency medicine, to be there too.

 

[firecoins]

You dont see Nurse Practitioners demanding to be seen the same as a doctor, and you dont see doctors telling them they are useless.

actually, you do see NPs, PAs and MD fighting turf battles all the time. Even different specialties of MDs fight. Seen it happen in the hospital during medic rotations.

 

[keith10247]

Wow, I must apologize for striking a bad nerve! Our dedicated medic units are 24x7 units paid for by the county. The BLS units are very rarely county paid personnel. Every unit is free of charge. If there is a call in my first due, for anything EMS related, a BLS unit is dispatched. Same way that if there is an EMS call in my first due and there is not a BLS unit in my first due, our engine will be dispatched along with a BLS unit from our 2nd due. If it is something that could be ALS, an ALS unit from our 2nd due is dispatched as well. Once the ALS unit arrives, the medics check out the patient and then there is a debate of "who wants to take them?" The medic points to us and wants us to transport...We have taken many of their transports.

If it is something like a broken arm or something, an ALS unit will not be dispatched; it is a waste of resources in our county. We were at the hospital one day and a lady down the street rolled her ankle. There were no BLS units available at that time so they dispatched an ALS unit. The ALS responded to dispatch saying "What is the ambulance at the hospital currently doing?" (They saw we were finishing up our paper work and would be clearing soon). They went in service, we took the call. In that case, it was a valid decision.

I have seen too many times that our medics do not like to transport. I ran a call for difficulty breathing on a 6mo. The mother said the baby had started to turn blue and she had to do cpr on him. She also stated that the baby had the flu. The medic told her to give the baby a couple baby tylenol and to go to the dr the next day if he was still having issues. His justification was that babies tend to do that when they have the flu.

I was also on a call with a woman who was feeling ill and apparently had some kind of an allergy. She said she was taking benedryl already and the medic told her to double up her benedryl and contact the dr the next day if she continued to have a problem.

We had another call where a pt was in a MVA and we had him collared, he was complaining that he had pain in his neck. The medic uncollared him and told him it was just muscle pain and got a refusal.

Another call I remember was for chest pains. The guy gets ran a lot; he was a 75yo with history of heart attack. The medics came in, the second they stepped in, they said "Did you run out of medications again?!" The wife was so upset that she refused to let the medic transport and drove him to the hospital herself. It was against protocol for a BLS unit to transport a chest pain pt so we could not help.

I guess the point of my long post is that it sometimes appears to be a "need vs. want" decision.

 

[JPINFV]

I have seen too many times that our medics do not like to transport. I ran a call for difficulty breathing on a 6mo. The mother said the baby had started to turn blue and she had to do cpr on him. She also stated that the baby had the flu. The medic told her to give the baby a couple baby tylenol and to go to the dr the next day if he was still having issues. His justification was that babies tend to do that when they have the flu.

ALTE ("Apparent Life Threatening Event")=ALS, especially with an extended transport time.

Do not pass go. Do not collect $200

http://www.aafp.org/afp/20050615/2301.html

 

[medic417]

Medic417... I agree that it would be nice to have a paramedic on every call... but there are calls were medics aren't needed. Additionally... there is almost never anything absolute in EMS .

And that is where the right to deny transport would come in. With properly staffed paramedic ambulances you could triage patient and send them by pov to appropriate care rather than tying up an ambulance and the ER. It makes no sense to send a basic to any call as we all know how inaccurate callers are with descriptions. If they call and claim to be dieing odds are they do not even need an ambulance. But again the call comes in can you just come check my BP almost always turns out to be the call that really needs Paramedics. Your right there is no absolutes so we should always over respond with a paramedic rather than relying on a paramedic to respond if basic requests.

 

[KEVD18]

keith10247,

that medic(or medics) need to be taken out back an shot.

 

[jrm818]

All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine. I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.

Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.

The only exception to this that I can think of is the use of CPAP...but I think that is probably moving towards being a BLS skill. Many studies seem in indicate that "Swoop and Scoop" is probably the best treatment option for many or most patients.

So here's the challenge: find studies that prove me wrong, and post them up. This thread has been debated to death, so lets try something new - inject something more than personal posturing.

 

[medic417]

All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine. I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.

Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.

The only exception to this that I can think of is the use of CPAP...but I think that is probably moving towards being a BLS skill. Many studies seem in indicate that "Swoop and Scoop" is probably the best treatment option for many or most patients.

So here's the challenge: find studies that prove me wrong, and post them up. This thread has been debated to death, so lets try something new - inject something more than personal posturing.

Actually there are numerous studys that show better results of higher care over the scoop and run crap that has killed so many of our members. If you truly believe we need to just be taxi drivers get a new job as you are hurting our profession. The study you refer to as evidence has been shown to be very flawed while there have been numerous much more extensive studies showing positive outcomes from more aggressive advanced field care. Am I going to cite them? No. The only way you learn is to do some research rather than relying on the smoke blown up your rear by others. This is research that any quality education would have required you to do. I will give you a hint though many of those studys have been referenced in many EMS forums.

As already mentioned most calls do not need ALS heck they do not even need a doctor if you want to be honest. If all ambulances were staffed paramedic then a movement could go to denying transport of people that do not need us and honestly are not going to pay us either. We need EMS to get back to being for emergencys not taxi rides, but that will require enough education to do an accurate evaluation. Sorry Basics do not have enough education that medical directors will ever feel safe allowing them to deny transport. I do not mean to offend I just speak from many years experience, yes I started as a first responder then a basic, then etc.

 

[MAC4NH]

That is why all "worst headaches" get either a CT scan & or a LP. Sorry, even ER Doc's will not even touch that one...

Last I heard, there are 0 ALS units in the country equipped with a CT scanner or a procedure room for an LP and all BLS units are equipped with an engine, 4 wheels and oxygen.

 

[Flight-LP]

All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine. I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system acutally improves patient outcome.

Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.

The only exception to this that I can think of is the use of CPAP...but I think that is probably moving towards being a BLS skill. Many studies seem in indicate that "Swoop and Scoop" is probably the best treatment option for many or most patients.

So here's the challenge: find studies that prove me wrong, and post them up. This thread has been debated to death, so lets try something new - inject something more than personal posturing.

Here you go....................

http://content.nejm.org/cgi/content/full/356/21/2156

http://pediatrics.aappublications.org/cgi/content/full/112/4/976?etoc

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1342973

Just to graze the surface. Now put your money where your mouth is and show us your many studies that prove "swoop and scoop" is the best method of dealing with our patients.

While your at it, why don't you enlighten us to the "numerous pathological events which studies have suggested shows no significant (meaning statical significance) change" with an ALS response.

Eagerly awaiting your response.........................

 

[Flight-LP]

Last I heard, there are 0 ALS units in the country equipped with a CT scanner or a procedure room for an LP and all BLS units are equipped with an engine, 4 wheels and oxygen.

Actually some have 6 wheels, depends on the chassis................

A curious question for you, why do you mention oxygen? Would you give it to your "worst headache I've ever had" patient?

 

[JPINFV]

Does the Level of Prehospital Care Influence the Outcome of Patients with Altered Levels of Consciousness?

Abstract

Hypothesis: Significant differences exist in the outcome of patients with altered level of consciousness (ALOC) cared for by advanced life support (ALS) compared with basic life support (BLS) prehospital providers.

Methods: Patients transported by ambulance to a community teaching hospital during an 11-month period were studied retrospectively. Study patients were those considered not alert by prehospital personnel. Exclusion criteria included: trauma, intoxication, drowning shock, and cardiac arrest. Data were abstracted from the ambulance reports and hospital records.

Results: Two hundred three patients with an ALOC were identified; 113 were transported by ALS providers (56%) and 90 (44%) by BLS providers. Prehospital levels of consciousness, according to the "alert, verbal, painful, unresponsive" scale (ALS vs BLS) were: "verbal" (40% vs 51%), "painful" (23% vs 23%), and "unresponsive" (37% vs 25%). The mean value for scene time was 15 ±6 minutes for ALS versus 10 ±4 minutes for BLS (p <0.001). On arrival in the emergency department, the LOC of 72 (64%) ALS patients and 58 (64%) BLS patients had improved to "alert." The level of consciousness in one ALS patient worsened. Fifty-two ALS (46%) and 38 (42%) BLS patients were admitted. Principle final diagnoses were seizure (27% ALS vs 38% BI.S.), hypoglycemia (23% ALS vs 23% BLS), and stroke (22% ALS vs 20% BLS). Remaining diagnoses each constituted less than 7% of total discharge diagnoses. No statistically significant differences in measures of outcome were noted between ALS or BLS patients. Diagnoses of seizure, stroke, and hypoglycemia were studied individually. No differences in admission rate, mortality rate, or disposition were identified. Hypoglycemic patients conveyed by ALS providers had significantly shorter emergency department treatment times than did those transported by BLS providers (160 ±62 minutes ALS vs 229 ±67 minutes BLS [p <0.005]).

Conclusion: Advanced life support levels of care of patients with an ALOC does not significantly change outcome compared with those receiving BLS care with the exception of shorter emergency department treatment times for hypoglycemic patients.

Prehospital and Disaster Medicine 1996;l1(2):101-104.

Now let's consider something about this study. The 3 major final diagnosises were stroke, hypoglycemia, and seziure. Strokes are essentially untreatable in the field past insuring ABCs (which, even here, will vary from location to location. One area's medics might be able to provide surgical/needle airways, another gets to pray if the patient can't be intubated) and making sure it isn't some other pathology (i.e. hypoglycemia).

Seizures was the second category. Well, all seizures stop, eventually. Personally, I'd rather have someone who can stop a seizure treating a seizure patient than one who is limited to making sure the patient doesn't hit their head. On the other hand, a small subset of patients (status epilepticus) would see a paramedic as being worth their weight in gold. Otherwise, there probably isn't much difference between the outcomes if a patient was treated by an EMT-B or a boy scout with an hour of first aid training covering seizures.

Finally, there is hypoglycemia. A pathology that is successfully treated by paramedics and decreases time in ER by a little over an hour.

Finally, a word about study design. Unfortunately I don't have access to the entire article. It would be nice to see what the actual results were past a simple thumbs up/thumbs down that is statistical significance.

 

[jrm818]

If you truly believe we need to just be taxi drivers get a new job as you are hurting our profession

Thanks for the career advice. If you can't accept that it may be scientifically proven that you need to make a major adjustment to act in the best interest of the patient you do far more harm than do I by suggesting the heresy that ALS may not be worth the expense.

The study you refer to as evidence has been shown to be very flawed while there have been numerous much more extensive studies showing positive outcomes from more aggressive advanced field care

I meant studies PLURAL. There are a whole bunch of them. Most are for trauma or sudden cardiac arrest, I don't recall ever reading a more generalized study - but there are MULTIPLE studies that support my argument. What one study are you referencing? My guess is the OPALS study? (which looked decent to me)

Also: Who "showed" the study to be flawed? It's pretty rare in the scientific community for there to be such unquestionable consensus about a study.

Am I going to cite them? No. The only way you learn is to do some research rather than relying on the smoke blown up your rear by others.

This isn't smoke blown by others, this is a result of my own research motivated by my own curiosity. I've read numerous articles and many many more abstracts, and they all seem to be saying sort of the same thing.

Sorry....the literature that my research turned up tends to disagree with you. And yes, I have experience doing this sort of research, and while I have not done an exhaustive literature search, I would be very surprised to find that my skills were so deficient that I completely missed a scientific consensus that ALS works.

If that is the case - I seriously want to be enlightened, and am apparently incapable of locating the literature you are referencing. Surely it would not be so onerous to give me a starting point.

 

[JPINFV]

To be fair, there's studies that show that "Home Boy Ambulance Inc" (POV) provides better prehospital care than any ambulance provider. Should we scrap EMS completely in favor of POVs?

 

[jrm818]

Here you go....................

http://content.nejm.org/cgi/content/full/356/21/2156

http://pediatrics.aappublications.org/cgi/content/full/112/4/976?etoc

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1342973

Just to graze the surface. Now put your money where your mouth is and show us your many studies that prove "swoop and scoop" is the best method of dealing with our patients.

While your at it, why don't you enlighten us to the "numerous pathological events which studies have suggested shows no significant (meaning statical significance) change" with an ALS response.

Eagerly awaiting your response.........................

Down, Sarcasm.

This is more brief than I intended because I need to sleep.

Your studies:
1. I've been looking for this actually. I've been embarrassed that I couldn't find this portion of OPALS. No clue how it slipped past me. I'll read it in the morning, at any rate. For now note that OPALS found no benefit to ALS in trauma or cardiac arrest...there's two of your "pathological conditions."

2. The kirby study isn't even about prehospital care. It's about in-hospital care and suggests that it may be hard to transfer lessons learned in childrens hospitals to normal hospitals, never mind to prehospital providers. ALS is only mentioned in terms of interfacility transport.

3. Haven't read this study, will later. Have read at least one similar study (from Spain as I recall), Peds may be one case where ALS is beneficial.


My counter list (chosen because OPALS is huge, and the other 2 are analyses of multiple other studies). Sorry, too late at night for me to get you links, you have to find them yourselves.

1. The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity.
CMAJ. 2008 Apr 22;178(9):1141-52.
PMID: 18427089 [PubMed - in process]

2. Liberman M, Mulder D, Sampalis J: Advanced or basic life
support for trauma: meta-analysis and critical review of the literature.
J Trauma 2000, 49:584-599.

3. Isenberg DL, Bissell R.
Does advanced life support provide benefits to patients?: A literature review.
Prehosp Disaster Med. 2005 Jul-Aug;20(4):265-70. Review.
PMID: 16128477 [PubMed - indexed for MEDLINE]


I can post more random links later if you want me to keep proving myself.

Also that one posted above by JPINFV.

Ok time to sleep, adios for now all.

 

[Ridryder911]

All this anecdotal evidence is super, but since we're supposed to be trying to improve ourselves, lets try to to with some evidence-based medicine. I challenge any of the "All Medic All the time/BLS has no place in 911 response" to find me any scientific evidence that this sort of ALS system actually improves patient outcome.

Off the top of my head, I can think of numerous pathological events which studies have suggested shows no significant (meaning statical significance) change if ALS rather than BLS care is given -- or possibly even a NEGATIVE impact of ALS level care.

The only exception to this that I can think of is the use of CPAP...but I think that is probably moving towards being a BLS skill. Many studies seem in indicate that "Swoop and Scoop" is probably the best treatment option for many or most patients.

So here's the challenge: find studies that prove me wrong, and post them up. This thread has been debated to death, so lets try something new - inject something more than personal posturing.

Alike most medicine, injury prevention and treatment prophylacticly is the usual goal. It is hard to measure one's worth, if the injury or illness did not occur. The whole reason EMS was developed was because more injuries and deaths occurred from "scoop and swoop" methods, than was occurring in Vietnam conflict at the time. There is your answer on anecdotal incidents.

Amazing everyone tends to review the OPALS study, but when critiqued it is rarely cited for several reasons. Yes, it did have a numerous amount of participants and yes was lengthy in time. Maybe too much. Again, there study revealed that BLS should be within four minutes for every response... Wow! That would be nice, as well a comprehensive emergency department to receive the patient. And I would like McDonald's to give me free meals.. see which occurs first. OPALS study alike many other studies did not reveal ALS caused harm rather not much change in outcomes.

The same could be said about Level I Trauma Centers does not have any benefit in patient care over Level II. In fact when investigating American College of Surgeons (ACS) review, Level II has equal to better outcomes. Now, consider CPR with an outcome of <6-10%; would we consider this a success? But we still have both and still perform those measures as well ... Why? Until something better can be developed, we have to provide the best care possibly known at this time. BLS care success past the 4-8 minute response drops remarkably and again has to followed up with ALS care. So why not deliver both simultaneously? I am definitely all in favor for patient outcome based medicine, but we also have to place "common sense" in the factor. Costs, potential reduction of over burden to providers, are more than anecdotal factors that are not commonly placed in studies.

Now, consider this... if OPALS was such as success, why are they still pursuing ALS care (even more in-depth than U.S.)?

In regards to the Paramedic that informed the mother to see a PCP for her baby, I hope that this was turned in. His/her should be formally investigated and actions should be taken for gross incompetence.

As well in regards to my posts abut headaches, my intent was most headaches are "blown off" when in fact, they could be life threatening. BLS providers are not adeuately trained to determine if it is life threatning or not. Rarely, I ever see a physician that does not perform a whole work up on a "worst H/A ever" complaint. It only takes once .. and they won't do that again.

R/r 911

 

[daedalus]

actually, you do see NPs, PAs and MD fighting turf battles all the time. Even different specialties of MDs fight. Seen it happen in the hospital during medic rotations.

In my four years in public health and community medicine, I have seen PAs, NPs, and MDs work together like clockwork in simi valley, california. No turf wars except when the Kaiser residents would come in to volunteer, which one would get to remove the toenail.

Thats not the point. Team work is important. BLS first responder giving a seemless and competent report to the arriving paramedic ambulance, working as a team to load up, and things to that end.