BLS transport of ALS emergency???

Was the supervisor in the wrong?

  • Yes.

    Votes: 4 20.0%

  • No.

    Votes: 11 55.0%

  • Partially.

    Votes: 5 25.0%
  • Total voters
    20
S

Shock

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I need a second and a third opinion on this. We received a call to an urgent care center for a 19 YOM with a confirmed spontaneous pneumothorax (did not appear to be tension). His chief complaint was chest pain, and was accompanied with SOB. It was dispatched by county as an ALS lights and siren response. My supervisor (EMT-P) sent out a BLS unit, and followed us in a sprint unit. However, he told us to respond non-emergency. So, we get there, and the patient appears ok. He's a little pale, no cyanosis, pulse ox reading at 93, and is on 15L non-rebreather. BP was elevated a bit, but looking at him, he pretty much looked and acted fine.

The supervisor then tells us to transport BLS, again, no lights or sirens. According to the urgent care, about 40% of the lung had collapsed. I strongly disagree with this decision, mainly to transport BLS. BLS in my state (and most as I understand) CANNOT decompress had the patient started to tension. It freaked me out a little.

Was the supervisor in the wrong? How should I handle this? How would you have handled it?
 
How far away is the hospital?
 
About 6 miles, medium traffic.
 
So you said that the supervisor, who is a paramedic, followed you in a sprint car. To help clarify, was he actually on scene with you guys and the patient?
 
He was on scene. He did not follow us to the hospital, however.
 
With the hospital so close, I wouldn't say the supervisor was wrong. As you said, the patient appeared fine and his sats are borderline acceptable. Since assuming that there was no accessory muscle usage, hyperventilation, or diaphoresis, there is probably little chance of him deteriorating in the 10-15 minutes that you are with him, especially because it was a spontaneous pneumo and not one of traumatic etiology. The fact that the patient presented to an urgent care as opposed to an ED tells me that he probably isn't in life-threatening amounts of distress, and that the condition has progressively developed over time (a few hours maybe) and will probably not culminate in him going into respiratory arrest in the back of the ambulance. Also, the medic saw the patient as stable enough to go without lights and sirens, furthering my opinion that I have outlined above. As I did not see the patient, I'm making some broad generalizations here.

If I was the medic intercept, would I have accompanied? Probably, but unless the unlikely event of him crashing occurred, I would not have provided any more treatment than you.
 
I would have stayed. Generally I also always make sure BLS is comfortable before I triage a patient.
 
The xray in the ED showed a 10% further collapse. SOB was worse at arrival, but not terrible. We didn't stick around too much longer but they were prepping him to be tubed stat as soon as we transferred him. The surgeon was paged when we called it in and they were xraying him while I was giving report. The ED was a lot more urgent than we were. It reminded me of a trauma alert.
 
From where I am in my career (very early), in that situation I would have ridden in with you. That being said, I know a lot of others that wouldn't have, especially with the hospital being very nearby. The picture you've painted (and like everyone else, I wasn't there) is of someone that, while they have a serious problem, are fairly stable and are probably going to stay stable for time it will take you to get them to higher level care.

Other things to consider, is your supervisor the only ALS resource available in your area? If he is it for ALS, then that also changes the criteria for who he rides with. If he ties himself up with a stable patient who doesn't require ALS treatment, what happens to the BLS crew that has to respond to the obstructed airway call without ALS backup? That isn't really fair to the other crew or the patient.
 
We had a total of 3 medics (including him) in station at the time. Supervisors, particularly this one, seldom respond to calls unless it is serious (bad MVA, arrest, juicy calls). I respect his decision to send it BLS, but I honestly think it should have been ALS. In the event that he did crash, we all would have been a whole lot of trouble.

*The receiving hospital also has a sprint medic (usually available) and physician (sometimes available).
 
Shock said:
I need a second and a third opinion on this. We received a call to an urgent care center for a 19 YOM with a confirmed spontaneous pneumothorax (did not appear to be tension). His chief complaint was chest pain, and was accompanied with SOB. It was dispatched by county as an ALS lights and siren response. My supervisor (EMT-P) sent out a BLS unit, and followed us in a sprint unit. However, he told us to respond non-emergency. So, we get there, and the patient appears ok. He's a little pale, no cyanosis, pulse ox reading at 93, and is on 15L non-rebreather. BP was elevated a bit, but looking at him, he pretty much looked and acted fine.

The supervisor then tells us to transport BLS, again, no lights or sirens. According to the urgent care, about 40% of the lung had collapsed. I strongly disagree with this decision, mainly to transport BLS. BLS in my state (and most as I understand) CANNOT decompress had the patient started to tension. It freaked me out a little.

Was the supervisor in the wrong? How should I handle this? How would you have handled it?
Click to expand...

Hm. Isn't it best practice for sirens / lights? Let's start there...
 
Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing. We just knew that without treatment at a hospital, or by a medic, he would have inevitably. I don't really like taking those kinds of bets with patient care. If he did crash, it would have been a disaster. Oxygen would have been useless, bagging him would have made it worse (and would probably not be possible), and CPR would be the only chance to circulate past the impinged vein or artery. A medic decompressing is a HIGHLY dangerous procedure, because the medic is blindly playing darts with a vital organ. But it would have been his best chance if he crashed. BLS is useless in that instance.
 
Shock said:
Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing.
Click to expand...
Young guy showing compensatory signs that aren't grossly out of normal limits.
Looks and acts fairly normal at the time of arrival.
Decent transport time/distance.
Treatment of condition is guided by current clinical picture, rather than the predicted size of pneumo.

I wouldn't go so far as to say your supervisor was making a bet.
 
Shock said:
Lights and sirens, in my opinion, was indicated. It was dispatched as an ALS highly urgent emergency. We couldn't really predict how fast he was crashing. We just knew that without treatment at a hospital, or by a medic, he would have inevitably. I don't really like taking those kinds of bets with patient care. If he did crash, it would have been a disaster. Oxygen would have been useless, bagging him would have made it worse (and would probably not be possible), and CPR would be the only chance to circulate past the impinged vein or artery. A medic decompressing is a HIGHLY dangerous procedure, because the medic is blindly playing darts with a vital organ. But it would have been his best chance if he crashed. BLS is useless in that instance.
Click to expand...
How much time would have going lights and sirens 6 miles in moderate traffic saved you? 30 seconds? 40 seconds?

I go to lots of calls that are dispatched as ALS high acuity, but assessment of the patient determines which car takes them to the hospital and whether routine or emergency.

You should do some more reading on tension pneumos and needle thoracentesis ... you're over stating the "HIGHLY dangerous" nature of it ... are there risks, of course, but I wouldn't consider it "HIGHLY dangerous."
 
I don't take it you have ever blindly inserted a 10g needle into the dermis, all intercostal muscles (they get thicker and tougher as you go deeper), and both pleura layers without even bumping the intercostal vein, intercostal artery (shout out to the ic nerve, for the sake of your patient jolting in pain), or the lung? It's dangerous for a surgeon to do in the OR, let alone a medic on a truck. Tension pneumos are killers, there is no question about that.

I just do not believe that this should not have been transported BLS. The doctor at the urgent care had also requested an ALS transport, I should mention.
 
On the topic of danger of inserting a needle, while probably more risky and bearing a higher rate of complications than most other procedures, if done right, needle thoracentesis is still relatively safe. The reason it is drilled to go along the top of rib is to avoid the neurovascular bundle. The military trains soldiers in its CLS class to do needle thoracentesis within a few hours (on that specific skill). They do a large number of them, as tension pneumo was at one time responsible for killing 33% of soldiers dying of preventable causes. And yet, we haven't heard of a massive number of complications for such a high reward procedure.

From your posts on here, it seems as though you were not looking for others opinions, but rather affirmation of your thoughts, and trying to dismiss any dissenting opinions.
 
In my protocols, and most that I'm aware of, the patient being conscious/alert is a contraindication for needle decompression (though medical control can override based on transport time). The contraindication comes not so much from the potential danger, but more of the shock caused by someone inserting a very large needle (or two) into your chest. With a six minute transport time and a fairly stable patient, no MC doc would have given the override; therefore the best intervention that could be provided if the patients SOB was truly severe would be positive pressure ventilation, which is a BLS skill.
 
1. If you aren't comfortable with taking a patient then you need to speak up.

2. Thoracentesis is not done blind and is not that difficult if you have the training, you just need the balls to do it, and hen done correctly is not HIGHLY dangerous.

3. I vote No supervisor was not wrong, but if BLS wasn't comfortable he (or she) should have done a more thorough handoff.
 
Shock said:
The xray in the ED showed a 10% further collapse. SOB was worse at arrival, but not terrible. We didn't stick around too much longer but they were prepping him to be tubed stat as soon as we transferred him. The surgeon was paged when we called it in and they were xraying him while I was giving report. The ED was a lot more urgent than we were. It reminded me of a trauma alert.
Click to expand...

I think everyone else missed this part...
Are you sure you're using the term tube the way we use the term tube? You mean chest tube?
A 50% pnuemo is an ALS emergency. Clinical outcome should have been taken into consideration prior to transport.
 
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