Chest pain in the young and tiered EMS

[wdballer2431]

What is everyone's take on chest pain in young patients when working in a tiered EMS system. I am trying to get a job in an ALS intercept system that covers a large population with a limited amount of ALS providers. Not talking about the 20yo female that is hyperventilating and anxious or the teenager that smoked weed and now has chest tightness. I'm speaking specifically on patients less than 40yo that activate EMS for chest pain. Example would be a 32yo male that presents with sharp non reproducible left sided chest pain associated with dyspnea. He has no cardiac risk factors, no medical hx, and is otherwise healthy. Vital signs are normal; no tachycardia, hypoxia, or respiratory distress, skin is p/w/d. Obviously an MI is low on my differential list based on age and hx. I am more thinking along the lines of PE, pericarditis, pleuritis, ect. However, working in an all ALS system I would perform a 12 lead and look for a STEMI or signs of pericarditis, or PE (s1q3t3) to not look lazy and cover my ***. My question would be...in tiered systems are medics doing a 12 lead rule out and then triaging to BLS? Furthermore, are ALS intercepts even making it to the scene to assess the pt or are they being canceled by BLS when EMTs determie pt's age, blood pressure and heart rate (not in an SVT based on vital signs). Obviously with limited ALS trucks and providers I think its important not to commit to a patient that is at very low risk for a STEMI....any when I say commit, I mean complete ALS workup, (IV, ect) and transporting to the ED. I think this also goes to say for other calls that some systems would deem an ALS workup and transport (syncope in young patient, stable SOB, seizures in pt's w/ sz hx w/ improving mental status, ect). Just looking for anyones input on this. Thanks in advance.

Wes

 

[VentMonkey]

Waiver: not an ALS intercept paramedic. While we technically do “intercepts”, we hardly have an option to odowngrade.

With that said, I think three words will sum up any well-to-do paramedic regardless of their respective system’s deployment model—Index Of Suspicion.

I don’t think a paramedic should ever feel pressured to downgrade a patient regardless of their age should your index of suspicion lead you down a differential work-up for a R/O PE, for example.

I can’t imagine having to explain to not only your service, but potentially said patients family, a judge, and/ or jury why you opted to downgrade a potentially high-acuity patient with a high risk for something as deadly as a saddle PE. Or blowing off the probability that your patient has pericarditis as “NBD” all because of their age.

I’m not implying this is what you’re eluding to, I’m just offering some food for thought.

Also, @NomadicMedic, and @chaz90 could probably offer up some firsthand insight into tiered ALS intercept services, good luck to you.

 

[wdballer2431]

Thanks for the reply VentMonkey. I do agree with you on the index of suspicion. In the above scenario I mentioned other things other than just age.I also specified medical hx, risk factors, and the 32yo pt have stable vitals signs. While sharp chest pain can present as a PE, I'd expect to see more things on the physical exam leading me down that road; tachypnea, syncope, tachycardia, low o2 sats, low end tidal CO2, ekg changes. Also, an MI can present with sharp chest pain. Based on that information, I consider the patient stable. Do you think the medics should be obligated to take this call rather than triage to the BLS crew in a tiered system? If the dx is pericarditis, why does an ALS unit need to take this patient to the ED as opposed to BLS? Even if this patient ended up having a small PE causing chest pain, what are paramedics going to do for this patient that would improve their outcome as opposed to BLS?

 

[VFlutter]

While sharp chest pain can present as a PE, I'd expect to see more things on the physical exam leading me down that road; tachypnea, syncope, tachycardia, low o2 sats, low end tidal CO2, ekg changes. Also, an MI can present with sharp chest pain. Based on that information, I consider the patient stable.

The symptoms you describe are usually suggestive of a massive PE with obstructive shock. There are many patients with submassive PEs that are relatively asymptomatic and stable but still have a high potential to become very sick quickly. It is not uncommon for the first symptom to be cardiac arrest.

There are plenty of 20-30 y/o patients whom have STEMI, undiagnosed cardiac abnormalities, tamponade, etc. Do not let age deter you from a differential diagnosis.

Although many of these patients may not need ALS interventions it is still prudent to have them on a monitor with IV access.

Are you an EMT or Medic? Sounds like you are trying to justify keeping these patients BLS.

 

[wdballer2431]

The symptoms you describe are usually suggestive of a massive PE with obstructive shock. There are many patients with submassive PEs that are relatively asymptomatic and stable but still have a high potential to become very sick quickly. It is not uncommon for the first symptom to be cardiac arrest.

There are plenty of 20-30 y/o patients whom have STEMI, undiagnosed cardiac abnormalities, tamponade, etc. Do not let age deter you from a differential diagnosis.

Although many of these patients may not need ALS interventions it is still prudent to have them on a monitor with IV access.

Are you an EMT or Medic? Sounds like you are trying to justify keeping these patients BLS.

I think you read that wrong. I stated that the patient DID NOT have those symptoms. I said that patient had STABLE vital signs. RR 16, 02 sat 99%, BP 122/80, HR 80, skin p/w/d for example. If I did have a patient with those signs and symptoms then I would obviously be concerned for a large PE and treat the patient with ALS. Therefore, I stated the patient was "stable." Yes, I am trying to justify certain things being BLS in a tiered response system. That was my initial question in this forum. I am a medic trying to get a position in a hospital based EMS intercept service.

 

[Peak]

I think that it is important that STEMIs are not the only emergency source of chest pain, and that patients can have little if any symptoms. I have seen quite a few teens and young adults with significant pneumomediastinums of benign history and mechanism who only reported very mild chest pain, certainly these are rare but also cannot be dismissed only because they are uncommon. I have had teens arrest after their PE moved and who had initially had a normal exam with the exception of mild chest pain. I have had very significant pneumothoraces present with normal vitals, mild pain, and a mild cough.

I would also caution you on relying on 12 leads to exclude PEs, they are neither particularly specific or sensitive to PEs and I have had many small and very large (saddle with strain on ECHO) PEs with normal EKGs.

To answer if BLS transport is okay, I think that this will be situation dependent. If there are multiple ALS units, no high acuity calls pending, and ALS intercept isn't going to delay transport then I don't think there is a problem using the resource. If there are high acuity calls pending, only one ALS unit available, and intercept will delay transport then BLS may be the best option even though the patient is not receiving the highest level of care. While there are many people who abuse EMS there are also those who call because they feel like they are having an emergency, and they are often right. Would you want your family member transported BLS because they were "low risk," or would you want them to receive the highest level of care if it was available?

 

[wdballer2431]

I think that it is important that STEMIs are not the only emergency source of chest pain, and that patients can have little if any symptoms. I have seen quite a few teens and young adults with significant pneumomediastinums of benign history and mechanism who only reported very mild chest pain, certainly these are rare but also cannot be dismissed only because they are uncommon. I have had teens arrest after their PE moved and who had initially had a normal exam with the exception of mild chest pain. I have had very significant pneumothoraces present with normal vitals, mild pain, and a mild cough.

I would also caution you on relying on 12 leads to exclude PEs, they are neither particularly specific or sensitive to PEs and I have had many small and very large (saddle with strain on ECHO) PEs with normal EKGs.

To answer if BLS transport is okay, I think that this will be situation dependent. If there are multiple ALS units, no high acuity calls pending, and ALS intercept isn't going to delay transport then I don't think there is a problem using the resource. If there are high acuity calls pending, only one ALS unit available, and intercept will delay transport then BLS may be the best option even though the patient is not receiving the highest level of care. While there are many people who abuse EMS there are also those who call because they feel like they are having an emergency, and they are often right. Would you want your family member transported BLS because they were "low risk," or would you want them to receive the highest level of care if it was available?

I am not debating that there are multiple sources of chest pain. Where does the ALS provider make a difference in chest pain patients other than STEMI? Especially very low risk patients based on their age, medical history, cardiac risk factors, and stable vital signs. Should abdominal pain patients be required to have a cardiac montior, IV, ect? Abdominal pain could be an ectopic pregnancy or an appendicitis about to rupture? Is that not dispatched as a BLS call? Or the drunk patient on the sidewalk? Does he need an ekg and iv lock from medics because there could be potentially something more ominous going on? If my grandmother develops chest pain at my house and a BLS unit shows up, then yes, I would be pretty upset. If my 28yo healthy brother tells he has chest pain, I would be pretty shocked if he reached for the phone to call 911. Maybe he has a rare significant pneumomediastinum, like you said. Would medics make any difference if he called 911? No, I don't see how they could. I'm not trying to be lazy or justify not working someone up. I'm simply asking in a tiered system where ALS units are limited do I need to provide "precautionary ALS care" to low risk patients whom are stable? For example, Boston EMS operates 5 ALS units during a daytime population of 1.2 million. They have a fantastic reputation. Are they missing atypical STEMIs, PEs, sepsis, ect?

 

[VentMonkey]

Again, it’s system dependent, but more so provider dependent. What kind of paramedic provider do you want to become, and/ or work amongst?

None of us are on here can tell you personally what will work for you. A lot of these calls are your discretion to work through within your respective services scope, as well as along with your equally trained, and qualified paramedic partner.

It sounds to me like you’d be a good fit for, say, KCM1. There are other ALS providers on here that would beg to differ that this is an “ideal” tiered system, and that atypical presentations, and things such pain management should be provided via ALS; different strokes, different folks.

Before you ingest a whole lot of butt-hurt over nothing just understand this. FWIW, I’d argue that BEMS reputation is hardly “fantastic” when even compared to, say, KCM1.

 

[VFlutter]

This is all about risk stratification. If ALS is a limited resource then obviously you will have to triage and use it where it will do the most good. This is by no means a perfect system and there is no right answer. Different providers will have different opinions on what is acceptable risk. You are playing a game of probability. You will have patients who went ALS that could have been BLS and vice versa. Do you use ALS for a patient that is borderline or do you save your ALS for the next potential critical call that many not happen.

You can't ALS everyone out of fear of "What if" and you can't turf everyone to BLS or you will get burned. This is where experience and assessment skills come into play but as already said it is very provider dependent.

 

[wdballer2431]

Again, it’s system dependent, but more so provider dependent. What kind of paramedic provider do you want to become, and/ or work amongst?

None of us are on here can tell you personally what will work for you. A lot of these calls are your discretion to work through within your respective services scope, as well as along with your equally trained, and qualified paramedic partner.

It sounds to me like you’d be a good fit for, say, KCM1. There are other ALS providers on here that would beg to differ that this is an “ideal” tiered system, and that atypical presentations, and things such pain management should be provided via ALS; different strokes, different folks.

Before you ingest a whole lot of butt-hurt over nothing just understand this. FWIW, I’d argue that BEMS reputation is hardly “fantastic” when even compared to, say, KCM1.

I don't know much about KCM1, and I am far from being butt-hurt about BEMS. I don't work for them nor am trying to get hired by them. However, I do have friends that work there. I work metro Boston for a private ambulance company that does 911 for approximately 12 communities. I think most people, myself included, consider BEMS to be one of the better municipal urban EMS systems for large cities when compared to places like FDNY, LAFD, New Orleans EMS, ect. Their BLS are highly trained and the medics deal with high acuity patients on a regular basis, allowing them to perform to perform some of the rare interventions on a regular basis. I'm saying this from an anecdotal view and I thought that was the general consensus in regards to their reputation. I have no problem if you disagree with me. I don't know much about other systems nation wide that may be more progressive. The hospital based system I have been looking at is north of Boston and provides non transporting ALS intercept to approximately 200,000 people with two units, sometimes three. They also have a reputation of being one of the best services in the northeast as they have pioneered RSI, green light from STEMIs, and hypothermic resuscitation for cardiac arrest in region. I appreciate your input regardless.

 

[VentMonkey]

The hospital based system I have been looking at is north of Boston and provides non transporting ALS intercept to approximately 200,000 people with two units, sometimes three. They also have a reputation of being one of the best services in the northeast as they have pioneered RSI, green light from STEMIs, and hypothermic resuscitation for cardiac arrest in region. I appreciate your input regardless.

Hmmm, this sounds a lot like Lowell General Hospital EMS. Also, no hard feels here.

FWIW, RSI and TH are hardly still considered progressive, maybe more aggressive. TH has fallen out of favor in place of a more cautious TTM approach.

Progressive systems (IMO) are ever-evolving, and require a stringent QA/ QI process coupled with a Medical Director who actually does much more than rubber stamping protocols.

 

[wdballer2431]

Correct on Lowell. I agree with the term aggressive. Massachusetts is pretty limited on scope of practice for most EMS regions unfortunately. The exception being Boston, Worcester, Lowell, and Lawrence. They are also pretty selective in whom they hire, especially per diem/part time. As a full time buckethead that is all I can commit to. I see you have you critical care certification. I've been studying for a few weeks with one text book and Anthony Baca's crash course. I am mainly trying to get the cert to make myself look better on the resume. I also have CT certification and have been considering applying at Windham Hospital whom requires their medics to have CCP-C. Not sure if you know anything about that system. You seem very knowledgeable. Any advice for the test and preparation for it?

 

[VentMonkey]

@wdballer2431 I don’t have any specific info about the service that you’ve mentioned, and will now in fact (thanks to you), add it to my list of “color-me-interested” intercept services.

I do have my FP-C, and have taken the CCP-C...unsuccessfully, lol. My advice to you for the exams would be study to for them like they matter, or don’t bother at all.

For the record, can you share with the group your experience level?

Much of my knowledge is from networking with the good folks on this forum (hence my “don’t get butt hurt” advice), the rest is from my time in and around the field itself.

 

[wdballer2431]

Thanks for the advice. I've been trying to study an hour or two each day for the next few weeks along with some practice exams. I would consider my experience average. I'm 29yo and began in EMS at 19, working BLS for a few years and got my medic in 2010. Worked for AMR in Brockton, MA for 6 years until they lost the contract in a busy all ALS system (4 trucks for approximately 18,000 EMS runs) and part time for Cataldo Ambulance on the north shore of Boston since 2012. Have been a fire/medic for about five years for a suburban ALS department that does 5500 calls per year (combined fire and ems runs) between two ambulances. Still work per diem for Cataldo Ambulance. Looking to get involved in some more aggressive EMS services in the area if possible. I start my second semester of nursing school in June. I've been a member on this site for awhile but rarely come on and post. Hoping to get more involved.

 

[Tigger]

I am not debating that there are multiple sources of chest pain. Where does the ALS provider make a difference in chest pain patients other than STEMI? Especially very low risk patients based on their age, medical history, cardiac risk factors, and stable vital signs. Should abdominal pain patients be required to have a cardiac montior, IV, ect? Abdominal pain could be an ectopic pregnancy or an appendicitis about to rupture? Is that not dispatched as a BLS call? Or the drunk patient on the sidewalk? Does he need an ekg and iv lock from medics because there could be potentially something more ominous going on? If my grandmother develops chest pain at my house and a BLS unit shows up, then yes, I would be pretty upset. If my 28yo healthy brother tells he has chest pain, I would be pretty shocked if he reached for the phone to call 911. Maybe he has a rare significant pneumomediastinum, like you said. Would medics make any difference if he called 911? No, I don't see how they could. I'm not trying to be lazy or justify not working someone up. I'm simply asking in a tiered system where ALS units are limited do I need to provide "precautionary ALS care" to low risk patients whom are stable? For example, Boston EMS operates 5 ALS units during a daytime population of 1.2 million. They have a fantastic reputation. Are they missing atypical STEMIs, PEs, sepsis, ect?

In terms of morbidity/mortality outcomes, I doubt it matters whether or not BLS is Boston misses these. Most of these patients go to the hospital, and the transport time is reasonably short. Could other outcomes be improved with ALS? Possibly. Chest pain when you're 28 is still pain, are these patients candidates for analgesia? Probably. Will that show up in most of the data as an improvement? I doubt it. Urban systems also justify BLS transport with "the hospital is closer than ALS." Which is true because there are simply not very many ALS ambulances. If every ambulance had a paramedic onboard would things change? Maybe. But at a certain point the region becomes used to tiered systems and that's just how the system is designed, to overcome a relative scarcity of ALS. We have no idea if a tiered system in Boston is better than P/B because it has never been and likely will never be that way.

I think there is also something to say about resource management with ALS transport. Hopefully, if I come in with a nonsense patient and tell the doctor that I am pretty sure it's nonsense, that patient gets worked up differently/less urgently than if a BLS crew comes in and says they have no idea what is going on.

As to the original question, I hardly ever downgrade chest pain to my EMT partner, regardless of the EKG. The above scenario is not likely to be a seriously ill patient, but if I am wrong I am entirely screwed. There isn't much gray area there, if you don't take it seriously there's going to be a problem for you and honestly as a percentage of my calls it just isn't that much to worry about.

 

[RocketMedic]

Here's my take (being someone who has worked in semi-tiered systems).

1. Risk stratification matters a lot in systems where we measure outcomes, but in terms of overall morbidity/mortality, it probably isn't that big a deal considering that the default in most systems is transport. Frankly, even sick patients often won't die in short periods of time, and in all honesty, I think that there's something to be said for rapid transport. Speaking as someone who works in a fairly aggressive system, there are often times when I question the efficacy of ALS on time-sensitive patients when said ALS is often provided at a ten- or fifteen-minute delay in transport to definitive care. I would even go so far as to say that many patients do not require ALS care when they are sick- sepsis comes to mind, as do the majority of strokes (excluding cases requiring RSI, but those are generally low-survivability anyways). If the system is concerned about overall mortality in the trucks, has a reasonably short window of transport time, and has a good hospital system to back it up, I don't see a huge issue in terms of mortality. However, these are generously described as 'medical' systems- the imperative here is always going to be speedy transport to a close, appropriate-ish facility- and there's going to be people that slip through the cracks in the overall system.

*For what it's worth, I recently had a 29 y/o F die on me of a massive PE that I identified as soon as I made contact, but couldn't do anything about.

I think that the prerequisites for robust risk stratification and successful triage in a tiered system are something we can find in most busy urban systems, but I think that there are significant obstacles in tiered systems. If anything, I think that the 'best' tiered systems would front-load paramedics whenever possible to identify those marginal cases, while using BLS to deal with the obviously sub-acute patients and potentially those for whom rapid transport is essential.

**I think that it is also possible to allay a lot of these concerns if EMTs are allowed to place EKGs, etc, and consult remotely with physicians to triage more effectively. That's not really saving costs though, it's just redistributing them to the already-burdened MD.

2. Personally, I'm comfortable triaging patients to BLS if I've assessed them and there's not a whole lot to be done.

A lot of this also depends on training, experience and instinct. I know that's a challenge to quantify and is inherently unreliable, but I feel better about tiered systems with well-educated EMTs who can pick up on subtle findings than I do about strictly-textbook ones of any stripe. Frankly, I'd rather have complete dotards who know how to load, scoop and run than people trying to be gatekeepers to the emergency healthcare system based on EMT-B education and prevalent attitudes.

 

[rescue1]

How long are your transport times? If they're not that long and you're not expected to hold the wall for hours while a bed clears up then it probably doesn't make sense to wait on scene for ALS, have them do an assessment, and then transport when you could already be at the hospital. This goes double (or even triple) for major trauma.

That being said, early STEMI recognition is one of the few ALS skills that has been shown to actually reduce mortality, so don't discount it completely. If you're going to sit in the waiting room for 30 minutes with your "maybe chest pain" before they get an EKG it might be worth it to call ALS.

(Also as others have said, there is no way to reliably diagnose or rule out a PE on EKG, especially the S1Q3T3 presentation, which only appears in 20% of PEs and is not diagnostically useful).

 

[wdballer2431]

Here's my take (being someone who has worked in semi-tiered systems).

1. Risk stratification matters a lot in systems where we measure outcomes, but in terms of overall morbidity/mortality, it probably isn't that big a deal considering that the default in most systems is transport. Frankly, even sick patients often won't die in short periods of time, and in all honesty, I think that there's something to be said for rapid transport. Speaking as someone who works in a fairly aggressive system, there are often times when I question the efficacy of ALS on time-sensitive patients when said ALS is often provided at a ten- or fifteen-minute delay in transport to definitive care. I would even go so far as to say that many patients do not require ALS care when they are sick- sepsis comes to mind, as do the majority of strokes (excluding cases requiring RSI, but those are generally low-survivability anyways). If the system is concerned about overall mortality in the trucks, has a reasonably short window of transport time, and has a good hospital system to back it up, I don't see a huge issue in terms of mortality. However, these are generously described as 'medical' systems- the imperative here is always going to be speedy transport to a close, appropriate-ish facility- and there's going to be people that slip through the cracks in the overall system.

*For what it's worth, I recently had a 29 y/o F die on me of a massive PE that I identified as soon as I made contact, but couldn't do anything about.

I think that the prerequisites for robust risk stratification and successful triage in a tiered system are something we can find in most busy urban systems, but I think that there are significant obstacles in tiered systems. If anything, I think that the 'best' tiered systems would front-load paramedics whenever possible to identify those marginal cases, while using BLS to deal with the obviously sub-acute patients and potentially those for whom rapid transport is essential.

**I think that it is also possible to allay a lot of these concerns if EMTs are allowed to place EKGs, etc, and consult remotely with physicians to triage more effectively. That's not really saving costs though, it's just redistributing them to the already-burdened MD.

2. Personally, I'm comfortable triaging patients to BLS if I've assessed them and there's not a whole lot to be done.

A lot of this also depends on training, experience and instinct. I know that's a challenge to quantify and is inherently unreliable, but I feel better about tiered systems with well-educated EMTs who can pick up on subtle findings than I do about strictly-textbook ones of any stripe. Frankly, I'd rather have complete dotards who know how to load, scoop and run than people trying to be gatekeepers to the emergency healthcare system based on EMT-B education and prevalent attitudes.

Well said Rocketman, I agree. Rescue1 transport times would be 5-20minutes. I understand that s1q3t3 is not very specific for PE. But back to my original question. It sounds like Tigger is not comfortable triaging a chest pain to BLS regardless or age, onset, history, risk factors, vital signs ect where as Rocketman seems okay with it based risk stratification and the patient being low risk. Like I said, I have worked in an all ALS system that was not tiered. I think we have all got the call for the 20-30ish healthy year old w/ a c/o of chest pain that is not an anxiety attack. For example, you walk in the patient is resting comfortably. They have 5/10 left sided chest pain described as sharp and non radiating that began 4 hours ago at rest. The pain is not worse with palpation or movement. Patient denies recent illness/fever or trauma. Pt admits to mild dyspnea but is not in any respiratory distress. Pt denies nausea, vomiting, sweating, or previous episodes similar. Pt denies any recent travel, surgery, and has no risk factors for PE. Pt denies any recent drug/stimulant use. Pt has no medical hx, takes no medications, does not smoke, and has no family cardiac hx. Vital signs are 100% wnl. 12 lead ekg is non diagnostic. What is wrong with triaging that to BLS in a tiered system? I am not going to be treating this patient with aspirin and nitro and the 12 lead is normal. I don't see the point of medics riding this one in just because it is chest pain. Found a perfect example online.

. Watch the chest pain call at the 20minute mark. I know VentMonkey was bashing BEMS earlier. I personally, would not triage this. A 44yo female who appears overweight, probably has underlying medical conditions, is hypertensive and tachycardiac, and has obvious chest pain. Maybe its anxiety from the grandchild but I don't think that is for us to decide on this call as the patient states she has never had pain like this before. The risk stratification is in my opinion much higher than the example I gave.

 

[DrParasite]

Based on that information, I consider the patient stable. Do you think the medics should be obligated to take this call rather than triage to the BLS crew in a tiered system? If the dx is pericarditis, why does an ALS unit need to take this patient to the ED as opposed to BLS? Even if this patient ended up having a small PE causing chest pain, what are paramedics going to do for this patient that would improve their outcome as opposed to BLS?

I've worked in tiered 911 systems for the majority of my career, working for ALS agencies as a BLS provider, and part time for BLS 911 agencies where ALS was always in an intercept vehicle. And I've underlined what the majority of paramedics (and prehospital nurses) generally stated is one of their dividing lines between patients they should treat and ones they will let BLS handle.

I'm confident that every paramedic can justify the "upgrading" of a stable patient to ALS, based solely on the "what if" factor. And I will also agree, and sometimes, it's better to have the paramedic do the stare of life than the EMT, especially for those patients who experience tells you might deteriorate quickly. But actual evidence based medicine shows that these are the vast minority of calls, not the majority.

We can go back and forth on what is ALS and what is BLS (and this is often determined by an agency's medical director, starting at dispatch and working down to field staff). And yes, there are times when I have had ALS triage a patient to BLS when the patient should have gotten that ALS stare of life (and yes, my partner and I were in agreement that this was a sick patient, and she did go into respiratory arrest enroute to the hospital), and others where BLS crews cancelled ALS when they really shouldn't have. I also know of paramedics who would say "why didn't you cancel us? now we have to work this patient up and transport them to the ER with the BLS crew."

Which is better? a tiered system where EMTs know how to differentiate sick vs not sick, without a paramedic holding their hand, or an all ALS system where the paramedics spend most of their time treating patients who don't require any ALS intervention at all, leading to skill atrophication? it all depends on where you work, what your medical director say, and how much confidence you have in the BLS providers in your area. That's an argument for another day and time.

 

[rescue1]

The only reason we wouldn't BLS chest pain in a young person with a (-) EKG and normal vitals is since the medic on the truck already needs to write a report anyway, now you're just making the EMT write a report as well.
I think especially in suburban/urban systems we overestimate the amount of patients who need ALS monitoring and we also overestimate what benefit ALS could provide for those patients if they did suddenly deteriorate. How many unremarkable EKG chest pains will you have to see to get one arrhythmia? What is ALS doing for someone whose PE worsens dramatically that BLS isn't? Other than intubate over BVMing them, which we all know can be controversial anyway.

Personally I would prefer to live in a world where BLS had more education and a little bit more diagnostic ability (4 lead interpretation, 12 lead transmission) so that things like syncope and low risk chest pain could be handled by BLS units, freeing ALS to respond to more acute calls, but for now that's just a pipe dream.

I will also say that even for low risk chest pain there's really no harm in giving ASA just in case, since it's a good benefit/minimal side effects kind of drug. And if turns out to just be a muscle strain (or pericarditis), NSAIDs are the treatment anyway.