ALS units on BLS calls

[JPINFV]

As a rule, definitive diagnosis and treatment are in the domain of doctors, and EMS should provide critical, simple interventions proven to influence positive outcome, and rapidly transport in an ALS ambulance. EMS should leave definitive treatment to the hospital.

Ah, but if only it were that simple. The fact is that paramedics are required, if not in written word, but by the reality of their function, to produce a differential diagnosis. Not all patients with shortness of breath need Albuterol while not all chest pains need nitro. The decision on what the patient has, and the development of a proper treatment plan due to that, is in simple terms, a diagnosis. Yes, EMS is not definitive care, but there are plenty of conditions in systems with the right tools, training, and education where EMS is definitive emergency care.

 

[daedalus]

Agreed. I am speaking about advanced therapies such as tPA and Heparin. Im am not putting down the education and abilities of a paramedic. Most of which are very well capable of differential dx and should be as well.

 

[firecoins]

Okay, here we go again. Lower level and those without the medical expertise that assume they know what medications are dangerous, what is best for the patient.

All drugs are dangerous in the hands of untrained professionals. They are even dangerous to medical professionals who don't pay attention. The misuse of heparin has been the subject of many lawsuits. But yes, Heparin is not dangerous to a trained professional who is careful in his opr her use.

http://www.drugs.com/pro/heparin.html

 

[ffemt8978]

5. Admin eventually steps in and locks thread.

Sorry, I've been busy the past couple of days with a new job. In catching up on this thread, that is exactly where it is heading unless everyone takes a deep breath and calms down.

 

[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.

http://pdm.medicine.wisc.edu/adams.htm

 

[BossyCow]

Okay, I'm really confused now! How can a thread that starts out with an EMT-P, Paramedic, ALS unit determining that a call is only BLS and turfing it to a BLS unit for transport turn into EMT-B bashing????

In the original post, the pt was assessed by a Medic, so what does any of this have to do with EMT-B educational standards or levels of training? Higher level made the call and its still a matter of EMT-Bs overstepping their authority? I really don't follow the logic on this one!

 

[keith10247]

First of all, this thread has gone crazy!

I just want to clarify something. I did not start this thread in any way to start a debate. My question was simple; is it common for ALS to downgrade calls and request BLS to come and transport the pt or will they transport a BLS patient to the hospital if there are no BLS units within a 10 mile radius.

I am in no way implying that ALS is useless. We get calls every once in a while where a pt will degrade during transport and we will ask a medic to rendevouz(sp) with us so they can provide ALS care to the pt. If it is a call that we do not feel comfortable taking because it is out of our scope, we call for a medic.

In my county, BLS units are not allowed to transport ALS pt's unless a medic tells us it is a BLS call and they release the pt to us or if it is quicker for us to get to the hospital before they can get to us (ie, during times we are low on medic units).

I am not sure how this got in to a debate of "who's is bigger" thread and I apologize for starting the topic.

I am very greatful for most of our medics!

 

[skyemt]

Okay, I'm really confused now! How can a thread that starts out with an EMT-P, Paramedic, ALS unit determining that a call is only BLS and turfing it to a BLS unit for transport turn into EMT-B bashing????

In the original post, the pt was assessed by a Medic, so what does any of this have to do with EMT-B educational standards or levels of training? Higher level made the call and its still a matter of EMT-Bs overstepping their authority? I really don't follow the logic on this one!

if you read the thread, it should be obvious to you... posts, which reveal a
lack of knowledge.... opinions, based on no experience and innaccurate information, the usual culprits, but not necessarily from the OP.

you've been out here long enough to know what sends these threads this way and why...

 

[Jon]

OK FOLKS.

MOVING ON.

Here is the original post... so look at it again and see if you can answer the question. Is it normal for ALS to downgrade to BLS? How does it occur?

We've got enough BLS vs. ALS threads - we don't need another.

Rather than knock holes in each other... why don't we all recognize that our systems are NOT perfect worlds... and we've got lots of stupidity in our EMS systems and protocols... nationwide... so stop critizing others, and post what YOU do to answer the OP's question!

Good evening, I have been noticing a trend in the county I run in and I wanted to know if it was common everywhere else.

In our county, we have ALS units that are dedicated to being medic units 24x7. On many occasions, I have been dispatched to many BLS calls that were downgraded from an ALS call and the medic unit did not want to transport.

For example, my favourite was one evening the chief and I were doing a little grocery shopping and we get a call to assist a medic who was about 10 - 15 miles away in the next city. The pt was an adult female who had a minor seizure. We jump on the interstate and it turns out the medic and the pt's location were less than 2 miles from the hospital. The thing that got me was that the grocery store we were at was in our 2nd due. Our 2nd due did not have a BLS unit staffed. This call put us in our 3rd due which means their BLS unit was on a call or not staffed. Being at the edge of the county, that left the west end without a free BLS unit.

Is this normal? It seems that we should all have the same mission which would be to get people who need to go to the hospital there to the hospital in a timely fashion. The 10 - 15 mile drive put us on a busy street that has stop lights every 100 yards or so.

 

[NJWhacker]

NJ makes the whole BLS and ALS thing weird. ALS can only be hospital based. There is only one ALS transport company that I know of in the state. I could be incorrect but its the only one Ive seen or heard. So BLS is the many source of transport in the state. I know with our town we have the list of what kind of calls, based on dispatch nature, will have ALS dispatched along with us. Most of the time they get cancel on scene, but Id rather having them rolling in case SHTF then having to call for them.

 

[MAC4NH]

NJWHACKER wrote:

NJ makes the whole BLS and ALS thing weird.

It gets more weird. A SCTU is staffed with a nurse (MICN) and a paramedic (some units add an EMT-B driver) so they can do the critical care transports as well as answering ALS calls. Although this is an ambulance, if it gets sent on an ALS call, the patient still goes in a BLS rig. If it doesn't have a paramedic (just the Basic and the RN), it can do BLS transports in addition to the SCTUs. It never does ALS transports except as follows: In Newark and Jersey City (and probably other cities too) where ALS and BLS both work for the same hospital, ALS ambulances do transport. In Hudson county, ALS ambulances generally will transport only within Jersey City so they don't step on out of town BLS toes. In an extreme case they will transport a patient from outside the city but only if the patient is in bad shape and there really isn't any BLS available. The units answering calls outside the city are usually non-transport capable Tahoes.

While this seems to make little sense, there are two reasons for this mess. 1: In the volly areas, it's a turf battle. The volunteers see ALS transporting as an intrusion on their turf that is really just a money-making scam for the hospital. 2: In paid areas, there is a lot of truth to reason #1. Medicare rules at this time will only pay the Transporting agency for the call. So if the ALS unit works up a patient, renders treatment and sends a bill, said bill is ignored by Medicare if the ALS unit did not transport. Now the BLS provider who primarily transported the patient will get paid the full amount allowed. In Jersey City or Newark, it doesn't really matter who transports as the bill comes from the same agency. In the North County, only the transporting agency's bill is paid. That is why the ALS providers want to transport and the BLS providers are trying to block them. BTW, whatever Medicare does is generally followed by other insurance providers.

In NJ, if something doesn't make sense, follow the money and the picture gets much clearer.

 

[MAC4NH]

I forgot one thing: If the transporting agency is a volly, the ALS provider gets paid because the transporting agency doesn't bill. Medicare will pay for a transport but they see paying for both ALS and BLS as paying twice for the same service.