ALS upgrade for no reason

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kurtemt

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Just had a good call but wondering why ALS upgrade was ordered. Call went like this...

Just got to work, called into work because someone's partner didn't come in. So my partner for the night had the rig up and ready to go. We were at dispatch when a call came in for a seizure. Our ALS crew was working a call so we were dispatched (we are a private bls ambulance). We respond to scene code 3.

Upon arrival we find a 76 y/o M laying in bed, not actively seizing. My partner grabs history from RN staff and I asses. Pt is A Ox3 but slow to respond, possibly postictal. Bp 126/58 R 14 HR 58 reg. pulse ox 94 on 4 lpm n/c. Skin normal. Pupils Perrl. Lungs clear. Pt Denys falling or loc. siezure witnessed by RN lasting aprox 1 min in bed.

We put pt on cot and give 12lpm. Check bgl and its 57. We give oral glucose and load pt into ambulance. We recheck bgl 5 min later and it's up to 60 so we are good to transport for our sop's. as we call medical control to go to the er our ALS unit shows up. They come check in on us and say nice job see what medical control says.

My partner calls med control and gives a report saying our findings and interventions to the ecrn saying we are comfortable transporting pt to er 6 min eta. She says hold on she has to check with the doc because its a seizure pt. our ALS says just tell them that we are en route since its only 6 min away. Ok. So we pull off and don't get out the driveway when the ecrn says the pt has to go ALS. We explain we are en route and 5 min away but still are told to upgrade to ALS. What gives?

I followed the ALS crew to hospital while my partner rode with them. The only other thing they had time to do was 1 unsuccessful iv attempt.
 
kurtemt said:
Just had a good call but wondering why ALS upgrade was ordered. Call went like this...

Just got to work, called into work because someone's partner didn't come in. So my partner for the night had the rig up and ready to go. We were at dispatch when a call came in for a seizure. Our ALS crew was working a call so we were dispatched (we are a private bls ambulance). We respond to scene code 3.

Upon arrival we find a 76 y/o M laying in bed, not actively seizing. My partner grabs history from RN staff and I asses. Pt is A Ox3 but slow to respond, possibly postictal. Bp 126/58 R 14 HR 58 reg. pulse ox 94 on 4 lpm n/c. Skin normal. Pupils Perrl. Lungs clear. Pt Denys falling or loc. siezure witnessed by RN lasting aprox 1 min in bed.

We put pt on cot and give 12lpm. Check bgl and its 57. We give oral glucose and load pt into ambulance. We recheck bgl 5 min later and it's up to 60 so we are good to transport for our sop's. as we call medical control to go to the er our ALS unit shows up. They come check in on us and say nice job see what medical control says.

My partner calls med control and gives a report saying our findings and interventions to the ecrn saying we are comfortable transporting pt to er 6 min eta. She says hold on she has to check with the doc because its a seizure pt. our ALS says just tell them that we are en route since its only 6 min away. Ok. So we pull off and don't get out the driveway when the ecrn says the pt has to go ALS. We explain we are en route and 5 min away but still are told to upgrade to ALS. What gives?

I followed the ALS crew to hospital while my partner rode with them. The only other thing they had time to do was 1 unsuccessful iv attempt.
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In our system a seizure is a mandatory ALS transport. If he had another ALS has the drugs to stop it with benzodiazepins. Some sort of brain damage is happening diring a seizure so you always want to stop it ASAP.
 
Was this a nursing home or a SNF? Usually if the patient is a seizure patient, they do not get concerned unless the seizure lasts somewhere between 2 - 5 minutes. Then there might be a protocol to give a med. The same holds true for schools with known seizure patients. So, EMS in reality may not even see or hear about most seizures which occur in their area.

The question to ask the RN would be what was different this time with the seizure that required a transport to the ED? What that the fastest way to get his med levels checked by lab? Were there other acute or chronic disease concerns? Had the patient previously been on oxygen? Was the patient on insulin? Tube feeds? Aspiration risks?
 
What's the patient's medical history?
 
He had no seizure history. My point was why delay transport for ALS when there is really nothing more they can do for him. He didn't need ALS meds he needed to get to the er ASAP. We can get him to definitive care faster and all other interventions were bls already done by us. Just seems like wasting time for the pt.
 
kurtemt said:
He had no seizure history. My point was why delay transport for ALS when there is really nothing more they can do for him. He didn't need ALS meds he needed to get to the er ASAP. We can get him to definitive care faster and all other interventions were bls already done by us. Just seems like wasting time for the pt.
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You said ALS was already on scene with you, right? There's always the chance that the patient could have another, or several more seizures. Seizures are not always one and done. What's your plan if the patient begins seizing as soon as you start driving? I'd imagine it's just drive faster. ALS would be able too monitor and terminate the seizure, while proceeding slowly and safely to the hospital. If ALS is already there (the way you make it sound), there should have been no question that the patient should've been loaded into the ALS unit.

Now if ALS was not on scene and needed to be requested, then I say just transport the patient yourself, considering the transport time.
 
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kurtemt said:
He had no seizure history. My point was why delay transport for ALS when there is really nothing more they can do for him. He didn't need ALS meds he needed to get to the er ASAP. We can get him to definitive care faster and all other interventions were bls already done by us. Just seems like wasting time for the pt.
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It probably was just wasting time for the patient. A lot of these things are protocol driven and don't really have a deeper logic behind it. In this case, the protocol probably says something about all seizure patients must be an ALS transport. You're right in saying that if you were already loaded and the hospital was closer than ALS it should make more sense to just transport.

Get to the hospital ASAP though is probably a bit of an overstatement. This sounds like a relatively simple seizure call, and the pt. wasn't harmed by waiting another couple minutes for ALS.
 
As I reread your post, how is transport even delayed for ALS? Sounds like they were on scene too, so I imagine the pt. was transported just as quickly.
 
No they showed up just as we were rolling out. Spent about 5 min on the phone with medical control figuring out who can take the pt. by the end of that 5 min convo with med control we could have been pulling up at the er. Maybe you are right I'm not saying you are not. Just looking for other opinions
 
Clipper1 said:
Was this a nursing home or a SNF? Usually if the patient is a seizure patient, they do not get concerned unless the seizure lasts somewhere between 2 - 5 minutes. Then there might be a protocol to give a med. The same holds true for schools with known seizure patients. So, EMS in reality may not even see or hear about most seizures which occur in their area.

The question to ask the RN would be what was different this time with the seizure that required a transport to the ED? What that the fastest way to get his med levels checked by lab? Were there other acute or chronic disease concerns? Had the patient previously been on oxygen? Was the patient on insulin? Tube feeds? Aspiration risks?
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You're assuming the patient has a history of seizures. And you're assuming that if he has a history of seizures, it is of a certain type of seizure. A 1 minute generalized tonic-clonic seizure could be of concern if the pt has only ever had simple partial seizures in the past. The point of concern varies significantly from patient to patient, and is set by their doctor. So you shouldn't make assumptions about how long a seizure needs to last before it is considered concerning.
 
Interesting to hear about other systems. Here it's all provincial and ALS is targeted to certain calls based on dispatch criteria. The on scene PCPs (EMT-ish) assess and either keep ALS coming or cancel them based on their findings. When ALS arrives they will assess and carry or assist or leave the pt with the other crew.

I've worked a busy ALS car for years and I doubt I would have transported that patient given the vitals provided.

However....A first time seizure in an elderly patient concerns me. While it may be strictly neurologically mediated there are other reasons for the seizure to occur. There's nothing to say that the pt didn't have a run of VT. Warrants close investigation.
 
No seizure history in and of itself would be an indication for ALS to ride with a patient where I worked. Truth be told, only once or twice out of many many seizure patients that I have ridden with had a seizure recur if they weren't seizing upon arrival. I'm pretty confident that many seizure patients could safely go via BLS (mostly the known seizure history and currently medicated ones). No history and still post-ictal most likely should have ALS ride along. Unfortunately, there is not much (if any) research to guide any decision making.
 
kurtemt said:
He had no seizure history. My point was why delay transport for ALS when there is really nothing more they can do for him. He didn't need ALS meds he needed to get to the er ASAP. We can get him to definitive care faster and all other interventions were bls already done by us. Just seems like wasting time for the pt.
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If paramedics were on-scene with a primary seizure patient, then they need to go along. I agree with not waiting if they weren't on scene, but disagree with any sort of emergent transport for a patient who is presenting as stable at this time.
 
Aidey said:
You're assuming the patient has a history of seizures. And you're assuming that if he has a history of seizures, it is of a certain type of seizure. A 1 minute generalized tonic-clonic seizure could be of concern if the pt has only ever had simple partial seizures in the past. The point of concern varies significantly from patient to patient, and is set by their doctor. So you shouldn't make assumptions about how long a seizure needs to last before it is considered concerning.
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Maybe that is why some of us are asking for more history.

If the patient has a history of a seizure, what is different about this one?
That was my question which you quoted. I also asked what type of facility it was since some can treat and some can not.

Read the full posts including what you quoted before criticizing that I am assuming. If I was just assuming I would have made a statement rather than asking a dozen questions which some could be used in an assessment.
 
Important to remember that a seizure is a sign, not a diagnosis.
 
Merck said:
Important to remember that a seizure is a sign, not a diagnosis.
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Uclabruin103 said:
In our system a seizure is a mandatory ALS transport. If he had another ALS has the drugs to stop it with benzodiazepins. Some sort of brain damage is happening diring a seizure so you always want to stop it ASAP.
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Same here. Seizure equals a mandatory ALS attendant or ALS AMA.


I don't agree with brain damage happening with every seizure though. If they become hypoxic then yes or seize for extended periods of time, yes.

A short seizure with a hx of doesn't really worry me, especially with those vitals the OP gave.
 
Like most ED physicians who are answering the radio, I usually have to interrupt an exam, procedure, phone call, or coffee to do so. Now, when EMS protocols require my decision, or if it's a complex medical issue that the medic wants my input on, great! That's what I'm there for, it's my job.

But calling up med control to decide "who has to take the patient" seems like the worst way to resolve the issue. If I'm getting pulled out of a patients room because a paramedic is looking to bow out of a transport, I'm not going to be very impressed with their judgement.

I suspect that their protocols call for ALS with altered mental status or seizures (they should), and so I am being called to excuse them from a 6 minute transport? Not cool.

Edit: As for the medical necessity of ALS for a 6 minute transport, valid points could be made either way. But if you already have protocols, and it's not an especially unique situation, just follow them.
 
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We are in Chicago so we are never far from an emergency room. This was a nursing home facility we were called for. Our sop for any transport to an emergency room is to call medical control first, give report of findings and interventions, and give our closest and then desired er. In this case we were heading to the closest.

ALS just happened to get on scene as my par partner was on the phone with med control. Our protocol for a seizure pt say consider ALS upgrade but its not mandated.

Since our pt was stable with good vitals, a ox3 were comfortable with the short transport. And our medics were comfortable with our interventions stating there was nothing more they would have done besides start an iv, which they did try 1 time in there rig but blew out the vein.

Either way it was a good call and I feel we did a good job with our interventions.
 
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