Anything could of done differently with this call?

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chickj0434

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BLS . So got called to a warehouse for an injury. 30 yo f got her left leg pinched between two forklifts. Sitting down on arrival. States pain is in her left shin. Remove shoe with trauma shears while maintaining stabilization. She has all csm in tact can wiggle her toes a bit and has feeling. She has a small indent in her shin area. She is screaming in pain for most of it. We use board splint and an ice pack and transfer to hospital.

Anything else we could have done different. Was thinking of calling als for pain management but they weren't called upon dispatch and hospital was less than 10 minutes away.
 
Sounds good to me.
 
Aprz said:
Sounds good to me.
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Thanks I guess the hospitals have been cracking down with bls units. I feel like I should of called pain management not sure if they were gonna be unhappy about that
 
So checked in and it ended up being a tib fib fracture so now I feel awful for not calling als
 
How long would it have taken for ALS to arrive? How long was it to get the patient to the ER? If "Time to ALS" > "Time to Transport" it's not unreasonable to transport.
 
planetmike said:
How long would it have taken for ALS to arrive? How long was it to get the patient to the ER? If "Time to ALS" > "Time to Transport" it's not unreasonable to transport.
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planetmike said:
How long would it have taken for ALS to arrive? How long was it to get the patient to the ER? If "Time to ALS" > "Time to Transport" it's not unreasonable to transport.
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They were not called initially by our dispatch team. Probably could of intercepted with us along the way but like I said it was a 9 min transport. Still wish I had done it though for the patients sake
 
chickj0434 said:
Thanks I guess the hospitals have been cracking down with bls units. I feel like I should of called pain management not sure if they were gonna be unhappy about that
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Just curious: What is it about BLS units that the hospitals have been concerned about?
 
chickj0434 said:
She has a small indent in her shin area. She is screaming in pain for most of it. We use board splint and an ice pack and transfer to hospital.
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Did the ice and rigid splint manage her pain? did her pain level change after you applied your interventions
chickj0434 said:
Anything else we could have done different. Was thinking of calling als for pain management but they weren't called upon dispatch and hospital was less than 10 minutes away.... Thanks I guess the hospitals have been cracking down with bls units.
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Isolated BLS trauma is likely a BLS dispatch, so ALS wouldn't have been sent on dispatch. could you have called them? sure, but did you need to, and would it be in the patient's best interest to delay assessment and treatment at the ER while you had your ALS assess and treat for a 5-minute ride? Personally, I wish BLS could give Fentanyl lollipops for pain control, but that's another topic altogether

I'm also curious... what are the hospitals cracking down on BLS units for? inappropriate BLS transports? wouldn't that be an issue for your agency's QA/QI person to handle?
 
chickj0434 said:
BLS . So got called to a warehouse for an injury. 30 yo f got her left leg pinched between two forklifts. Sitting down on arrival. States pain is in her left shin. Remove shoe with trauma shears while maintaining stabilization. She has all csm in tact can wiggle her toes a bit and has feeling. She has a small indent in her shin area. She is screaming in pain for most of it. We use board splint and an ice pack and transfer to hospital.

Anything else we could have done different. Was thinking of calling als for pain management but they weren't called upon dispatch and hospital was less than 10 minutes away.
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I think calling for ALS would have been a good idea for pain management. There are going to be many times that BLS will get on scene and find something that ALS is needed for, but were not dispatched to.

I'd also keep in mind that just because the hospital is 10 minutes away, doesn't mean that the patient is going to receive pain meds in 10 minutes. They have to be registered, brought to a room, triaged by the nurse, evaluated by the provider, and then the provider has to place orders. It could easily be 20-30 minutes before the patient gets pain meds. One of the things that we, as ALS, can do really well is symptom management, especially with pain. Never be afraid to call for ALS for pain management, that's what we're there for.
 
chickj0434 said:
BLS . So got called to a warehouse for an injury. 30 yo f got her left leg pinched between two forklifts. Sitting down on arrival. States pain is in her left shin. Remove shoe with trauma shears while maintaining stabilization. She has all csm in tact can wiggle her toes a bit and has feeling. She has a small indent in her shin area. She is screaming in pain for most of it. We use board splint and an ice pack and transfer to hospital.

Anything else we could have done different. Was thinking of calling als for pain management but they weren't called upon dispatch and hospital was less than 10 minutes away.
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Hospital's 10 min. away? If ALS is close enough, may be worth asking for them *if* you can't manage pain with BLS measures (ice, splinting) and there are no other indications for ALS. Sounds like ALS is not strictly necessary, but if I were, say, 30 min from the ED and ALS were 5 min away, I'd ask for ALS -- again, if pain was uncontrollable and/or any other ALS indications.
 
DrParasite said:
You might enjoy reading this thread from back in the day, especially if you are debating in your head if you should have called ALS: https://emtlife.com/threads/is-a-broken-arm-an-als-or-bls-call.14922/

Just swap out leg for arm, and it is pretty much the same question, with multiple opinions.
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I think there's also something to be said that there are some places where BLS providers can now offer pharmacologic pain control, namely PO APAP 1g, for things like isolated extremity fracture. Not sure if this was expressly permitted 10 years ago!

We are also, in the US, well behind the rest of the anglosphere in not making methoxyfluraneavailable to BLS providers...
 
EpiEMS said:
I think there's also something to be said that there are some places where BLS providers can now offer pharmacologic pain control, namely PO APAP 1g, for things like isolated extremity fracture. Not sure if this was expressly permitted 10 years ago!

We are also, in the US, well behind the rest of the anglosphere in not making methoxyfluraneavailable to BLS providers...
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I was actually shocked to learn that BLS provides in NC can give Ibuprophin, Tylenol and aspirin (along with benedryl, but that's another topic), but neither NJ or NY allowed their providers to administer it.

My former partner was a navy corpsman, and he said he gave out fentanyl all the time... and their education (on the medical side anyway) was on par with NREMT standards.
 
DrParasite said:
I was actually shocked to learn that BLS provides in NC can give Ibuprophin, Tylenol and aspirin (along with benedryl, but that's another topic), but neither NJ or NY allowed their providers to administer it.

My former partner was a navy corpsman, and he said he gave out fentanyl all the time... and their education (on the medical side anyway) was on par with NREMT standards.
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NY and particularly NJ are so backwards on BLS care.

Interesting point about the military side - I think the resistance on civilian side is probably more about controlled substance ease of access...no reason BLS couldn’t give fentanyl lollipops for pain control.
 
EpiEMS said:
NY and particularly NJ are so backwards on BLS care.

Interesting point about the military side - I think the resistance on civilian side is probably more about controlled substance ease of access...no reason BLS couldn’t give fentanyl lollipops for pain control.
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You really shouldn't be giving fentanyl unless you can deal with the potential decreased respiratory drive. Fentanyl lozenges in opioid naive people and under education is just a set up for disaster.
 
silver said:
You really shouldn't be giving fentanyl unless you can deal with the potential decreased respiratory drive. Fentanyl lozenges in opioid naive people and under education is just a set up for disaster.
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ok, I might be missing something, but what do you do? ventilate using a BVM? maybe give narcan? can't BLS do both of these things? Why do I feel like I'm missing some clearly obvious method to deal with a decreased respiratory drive.....
 
DrParasite said:
ok, I might be missing something, but what do you do? ventilate using a BVM? maybe give narcan? can't BLS do both of these things? Why do I feel like I'm missing some clearly obvious method to deal with a decreased respiratory drive.....
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Because you just turned an isolated extremity fracture into iatrogenic respiratory failure? Bagging and narcan administration are not 100% benign interventions.
 
MonkeyArrow said:
Because you just turned an isolated extremity fracture into iatrogenic respiratory failure? Bagging and narcan administration are not 100% benign interventions.
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I'm not disagreeing with you that you just made the situation worse, and bagging and narcan are not 100% benign (are you suggesting that EMTs shouldn't be bagging or administering Narcan to this patient?), however the statement was
silver said:
You really shouldn't be giving fentanyl unless you can deal with the potential decreased respiratory drive. Fentanyl lozenges in opioid naive people and under education is just a set up for disaster.
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so what would a more educated provider do in this situation? meaning, how is a CCT/flight/tactical/<insert advance knowledge> paramedic going to deal with a "potential decreased respiratory drive", which a "under educated" EMT is unable to do?

Is the implication that only an under-educated provider can cause iatrogenic respiratory failure? Because I think we can both agree that paramedics and doctors have done it too.
 
DrParasite said:
I'm not disagreeing with you that you just made the situation worse, and bagging and narcan are not 100% benign (are you suggesting that EMTs shouldn't be bagging or administering Narcan to this patient?), however the statement was

so what would a more educated provider do in this situation? meaning, how is a CCT/flight/tactical/<insert advance knowledge> paramedic going to deal with a "potential decreased respiratory drive", which a "under educated" EMT is unable to do?

Is the implication that only an under-educated provider can cause iatrogenic respiratory failure? Because I think we can both agree that paramedics and doctors have done it too.
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Are you suggesting that EMT's are just as equipped to manage respiratory failure as paramedics are? "But paramedics can safely give fentanyl, and EMT's have mostly the same tools for managing respiratory failure as paramedics, so why can't EMT's give fentanyl?" seems to be an accurate paraphrase of what you are getting at, and I kind of doubt you really mean that. It seems unlikely that if a family member of yours were experiencing a serious respiratory event, you'd be totally cool with EMS sending a BLS unit when an ALS unit was available.

A more experienced / highly trained provider is more likely to notice early signs of impending respiratory failure and not let it get the point that intervention is needed. If intervention does become necessary, a paramedic is likely to be more skilled at whatever interventions become necessary than is an EMT, not to mention having more treatment options, such as titrating small doses of naloxone rather than pushing 2mg, placing an LMA, possibly even intubating if it comes to that, etc.
 
Just along these general lines, there are few things anyone regrets as much as fully reversing narcotic in a patient with moderate to severe acute pain...no getting that back....
 
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