BLS transport of ALS emergency???

[medichopeful]

Hm. Isn't it best practice for sirens / lights? Let's start there...

No. This is a myth that must disappear, and soon, before it takes more lives.

http://www.emsworld.com/article/103...a-significant-amount-of-travel-time-and-lives
http://www.aapsus.org/articles/1.pdf

 

[medichopeful]

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.

I'm with you. Even with only a 6 mile transport distance, I'd be pretty uncomfortable transferring this call as a basic. 93% SpO2 is fine, but requiring a NRB at 15lpm to maintain this is concerning. 93% on RA would be a completely different story.

It's true that ALS might not be able to do much for this patient, but in the event they degrade further there's even less that a BLS crew could do. In addition, I would like to see this patient transferred on a monitor. I'm usually pretty liberal when it comes to use of BLS for short transfers, but I don't think this call is BLS appropriate.

 

[Akulahawk]

For a 6 mile transport, I'd rather send the patient with a BLS crew that I have on hand than wait a while for an ALS crew, but I'd also not downgrade to BLS and ride in with this patient if I were the medic on this call. I wouldn't call this patient "stable" but he's not crump right now unstable either. He'll need a chest tube very soon though.

 

[Shock]

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.

Yes, the ED placed a chest-tube, which is pretty much what we were expecting them to do. I didn't stick around long enough to see if he was decompressed before that. So, here's the kicker. According to the patient, if he leaned forward, he would start to black out. He didn't have LOC at any point, however. As I understand, this is a sure-fire sign of a tension pneumo in the making (enough pressure to compress vena cava). We kept him in full fowlers during transport, which was effectively a position of comfort. I've been doing a bit of research on pneumo's. We're taught about traumatic instances that even BLS can treat generally, but not so much when they happen for no clear reason. There's nowhere for the pressure to go. Onset was about 30 - 40 minutes before we had arrived to the UC. I'm listening to what everyone says, but I cannot convince myself that this was appropriate for BLS.

 

[ERDoc]

A known ptx with a sat of 93% in 15L, that seems pretty ominous to me. Even if it is a short ride, I would rather see this guy go with a medic. There is a potentially life threatening condition that a medic can actually do something about. Needle decompression is not dangerous by any means as long as you know what you are doing. If there was no ALS present on the scene then I would say diesel is the best treatment but why not have that person who can do something in the ambulance in case it is needed.

OP, keep in mind that not all pneumos become tension pneumos. Some people can walk around for days/weeks with a ptx and be fine.

 

[Tigger]

As said, first and foremost if you aren't comfortable accepting a patient from a medic, don't. There's not really any excuse to make there.

That said you'd think your supervisor might have raised an eyebrow at 15lpm maintaining 93% spO2. As for lights and sirens, no to both. There are few good reasons to respond to an urgent care or community ED emergent, it is after all a higher level of care than the ambulance you are about to place them in. And it really does not save a clinically significant amount of time.

 

[Bullets]

Sounds very similar to my town, if i was the BLS crew i would have no problem transporting the 6 miles from an SNF to the ER. i would however have taken a pulse ox on room air to get an idea of how bad this kid is, then probably switch to a NC and give the ER a heads up im coming. L&S isnt needed, but i would not fault you if you did.

If ALS was coming and on scene before i was loaded then i would expect them to hop in an treat en-route. If not, they are cancelled proximity. Nice to have, not absolutely required

 

[CANMAN]

Sounds very similar to my town, if i was the BLS crew i would have no problem transporting the 6 miles from an SNF to the ER. i would however have taken a pulse ox on room air to get an idea of how bad this kid is, then probably switch to a NC and give the ER a heads up im coming. L&S isnt needed, but i would not fault you if you did.

If ALS was coming and on scene before i was loaded then i would expect them to hop in an treat en-route. If not, they are cancelled proximity. Nice to have, not absolutely required

Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............

 

[Chewy20]

Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............

Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO

 

[medichopeful]

Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO

Unless they're breathing through their mouth. With everything described so far, it doesn't sound like breathing through the mouth in this situation is too far-fetched.

 

[CANMAN]

Well you see, the NC is actually INSERTED into the nostril with the two little tubes. So if you think about it, the pt has a better shot of getting that o2 in their system...or something like that. POTATO

So if you're trying to be sarcastic and I am not picking up on it I am sorry. But are you trying to tell me that someone in a high level of respiratory distress, and likely fairly substantial hypoxia on room air deserves a NC over a NRM? And if so is that your protocol for respiratory distress and hypoxia as an intervention prior to CPAP or intubation?

 

[Chewy20]

So if you're trying to be sarcastic and I am not picking up on it I am sorry. But are you trying to tell me that someone in a high level of respiratory distress, and likely fairly substantial hypoxia on room air deserves a NC over a NRM? And if so is that your protocol for respiratory distress and hypoxia as an intervention prior to CPAP or intubation?

C'mon man, my reply had the word "potato" in it.

 

[CANMAN]

Fair enough wasn't familiar with the term being used that way lol.

 

[Chewy20]

Go watch the movie "The Ringer".

 

[Carlos Danger]

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?

If it appeared that he required the 15 lpm to maintain a 93% sat, then he's pretty sick. In that case the paramedic should've rode along, because he's already on scene and even in a 10 minute ride, a patient on edge like this can change for the worse.

On the other hand, if he really is perfectly fine clinically - with a normal resp rate and effort - then my guess is that the 93% reading was errant. Or, maybe the reading was accurate, but he wasn't requiring the NRB to maintain it. The picture you paint just doesn't describe a person who is requiring high-flow oxygen to maintain a low-normal sat.

Why did he present to the urgent care initially?

Why did they put him on 15lpm - what was his initial Sp02 for them?

Did you have a pleth to go along with that Sp02?

 

[johnrsemt]

Thoracentesis is done blind quite a few times: I transported a patient that needed it from a small ED; they refused to do it, looking at it will 2 ultrasounds at the same time. When we got the pt to the larger ED, the staff doctor let the 1st resident stick the pt blind.

 

[ERDoc]

Thoracentesis is done blind quite a few times: I transported a patient that needed it from a small ED; they refused to do it, looking at it will 2 ultrasounds at the same time. When we got the pt to the larger ED, the staff doctor let the 1st resident stick the pt blind.

But the pt the OP transported had a pneumothorax, not a pleural effusion.

 

[Bullets]

Obtain a room air pulse ox, why? How will this guide your treatment of this patient? Switch to a NC, did you catch the patient is 93% on 100% 15liters non-rebreather already? If the patient is mildly hypoxic on a non-rebreather why take them off of that to obtain a room air SpO2? I can tell you what it's going to be, low..............

What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment

And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.

 

[ERDoc]

The last thing you want to do intubate this guy. This is one of the few times when you actually need 15L NRB and diesel. He has a confirmed pneumothorax. There is very little you can do in the field so get him to the hospital.

 

[systemet]

* I wonder why the sending ER didn't put one of these in? Is there a decent reason not to? http://epmonthly.com/article/pigtail-insertion/

* Also, I'd argue that this isn't completely blind if you have a CXR.

Ultimately, isn't it the sending physician's discretion as to whether this goes ALS? I ended up backing up a BLS crew a few weeks back to watch a completely resolved high-risk TIA (known DVT, on Xarelto), because the physician wanted a CT at a non-stroke center, and wanted a paramedic because he didn't trust the EMTs to recognise if the patient's symptoms recurred and divert to a stroke center. We had a discussion about the situation (a < 15 minute trip), and how the patient was asymptomatic, but ultimately the physician is the highest medical authority, the patient's under their care until they choose to transfer care, and it's not my decision.

Regarding this situation, if they haven't addressed the PTX, and have asked for ALS, I think I'd attend. Granted, it's likely nothing's going to happen, but if it does, you've got to justify why you created a cardiac arrest in transport, by not going with the BLS crew.