Code calls, load & go or wait for ALS?

[46Young]

What does the judgment of a paramedic unit that hasn't seen the patient add to your own decision-making? This is like asking dispatch if you should board somebody.

Is this a common practice in your area?

Where I work now we're 100% ALS unless the volunteers put a BLS unit in-service. But, I'll reference my previous experience in the NYC 911 system:

As BLS, I always operated from the mindset that no one is coming to help, that we are to assess, treat, then load and go. That's was our default. When we were packaged and ready to get out of the house, we would radio the medics, give a very brief report, and tell them that we're ready to leave unless they want us to stay. With calls that start out as BLS, we were required to request ALS under certain conditions. Fairly often, the pt really didn't need immediate ALS, so we would assess, quickly package,request ALS per protocol after that, then advise that we're going to txp two minutes later so that they can be cancelled and not have to waste their time.

If the pt was truly sick, I would just stay on-scene and not give the medics the option of cancelling themselves. Otherwise, the culture in that system was that if ALS was assigned to the call, it's their decision if BLS transports before ALS arrival. Typically, the medics would ask for a report a minute or two out and then advise to package and txp or to wait for them based on the BLS assessment.

If a call was typically given to only one ALS unit, if ALS had an ETA greater than ten minutes, BLS was automatically assigned. A good BLS unit could get demographics, a quick Hx, package, and be out the door in less than ten mins, and at the hospital 3-5 mins later, which is about the same amount of time it would have taken ALS to show up, grab their equipment, get in the house, do their own assessment and be preparing for ALS interventions.

Edit: We run mutual aid into a neighboring county that may send a BLS bus. We're typically only a minute or two behind them, so there's no transport decision to be made while we're en-route.

 

[Brandon O]

Otherwise, the culture in that system was that if ALS was assigned to the call, it's their decision if BLS transports before ALS arrival. Typically, the medics would ask for a report a minute or two out and then advise to package and txp or to wait for them based on the BLS assessment.

I find this utterly bizarre. So the BLS assesses the patient, then the ALS gets to decide whether they're needed using that information?

Is the idea that BLS is capable of asking questions and performing a physical, but not of making coherent decisions? Because otherwise, the medics giving their two cents based on a radio report seems like it adds nothing except their own personalities and prejudices. (Hell, most of us probably wouldn't sound too excited if you asked us whether we wanted to do more work.)

Who is responsible if a bad decision is made? If I were a provider asked to do this -- basically radio telemedicine -- the only appropriate response I think I could give is to decline to answer.

 

[hoeyxd]

bls transporting a full arrest? if i were enroute back to the snf with the patient on board, the patient went into arrest and my eta to the hospital is 3 minutes then sure. if i get on scene and the patient is in arrest, no way in hell.

 

[DrParasite]

bls transporting a full arrest? if i were enroute back to the snf with the patient on board, the patient went into arrest and my eta to the hospital is 3 minutes then sure. if i get on scene and the patient is in arrest, no way in hell.

why not? cops do it for baby's who aren't breathing all the time. they sometimes transport penetrating trauma victims too. It's called "the ambulance is taking to long, and the patient needs to go to the ER."

is it ideal? absolutely not. do I recommend it? not on a routine basis. but if the ER is closer than the paramedic unit, is it that bad of a thing? If the ER is 10 minutes away, and the ALS is 20-30 minutes away, what is the better option?

I'm not saying you should do it on a regular basis. but "no way in hell" is the wrong idea, especially if you have a good reason for doing what you are doing.

 

[hoeyxd]

why not? cops do it for baby's who aren't breathing all the time. they sometimes transport penetrating trauma victims too. It's called "the ambulance is taking to long, and the patient needs to go to the ER."

is it ideal? absolutely not. do I recommend it? not on a routine basis. but if the ER is closer than the paramedic unit, is it that bad of a thing? If the ER is 10 minutes away, and the ALS is 20-30 minutes away, what is the better option?

I'm not saying you should do it on a regular basis. but "no way in hell" is the wrong idea, especially if you have a good reason for doing what you are doing.

i guess it depends on where you work and your protocols. in la county everytime i've called als it's never taken over 10 minutes, usually around 5 minutes. i'd rather work the pt for 5-10 minutes with good quality 2 man cpr and have als come to give the pt everything the er would give them in a full arrest.

 

[chaz90]

why not? cops do it for baby's who aren't breathing all the time. they sometimes transport penetrating trauma victims too. It's called "the ambulance is taking to long, and the patient needs to go to the ER."

is it ideal? absolutely not. do I recommend it? not on a routine basis. but if the ER is closer than the paramedic unit, is it that bad of a thing? If the ER is 10 minutes away, and the ALS is 20-30 minutes away, what is the better option?

I'm not saying you should do it on a regular basis. but "no way in hell" is the wrong idea, especially if you have a good reason for doing what you are doing.

Going back to an earlier point from this thread, the issue is working the arrest on scene is better. Nothing to do with ALS or the hospital at this point. BLS on scene providing quality CPR and defibrillation is the best option here people. If you insist on using times, let's use the example of hospital is 3 min. away and ALS is 10. Does your pt. benefit from almost non-existent CPR for 30 second to 1 minute periods during movement to the ambulance, poor CPR during the transport, and more pauses going into the hospital? Work on scene, transport if ROSC, or allow ALS to arrive and continue working to ROSC or pronouncement.

Let's not compare apples to oranges either. Working an arrest vs. transporting is a completely different issue than cops transporting penetrating trauma prior to EMS arrival.

 

[46Young]

I find this utterly bizarre. So the BLS assesses the patient, then the ALS gets to decide whether they're needed using that information?

Is the idea that BLS is capable of asking questions and performing a physical, but not of making coherent decisions? Because otherwise, the medics giving their two cents based on a radio report seems like it adds nothing except their own personalities and prejudices. (Hell, most of us probably wouldn't sound too excited if you asked us whether we wanted to do more work.)

Who is responsible if a bad decision is made? If I were a provider asked to do this -- basically radio telemedicine -- the only appropriate response I think I could give is to decline to answer.

A lot of times BLS is there first because they have to call ALS based on certain complaints, even though even a lay person could see that the pt doesn't need immediate time sensitive interventions. BLS will report the pt's mental status, C/C, vitals, and then ask for an ETA for ALS. If the medic's ETA is around the same time that it would take to get to the ED, and the pt is not in extremis, it makes little sense to ask BLS to stay on scene.

Of course, if the pt has Cx discomfort, a severe asthma attack, can't protect their airway, no one's going to leave the scene before ALS comes. The system's changed a little since I worked there five + years ago, but BLS ran certain asthma calls, a single Sz, intox if conscious (but not necessarily A&Ox4), etc.

 

[46Young]

Didn't get a chance to finish the last post.

BLS are used to seeing moderately sick pts by themselves, and should be able to tell when a pt may need ALS to run a protocol on them. BLS would often get chastised by ALS when they request them for a non-acute pt, so the BLS quickly learn when they should really be calling. If BLS needs to call per protocol, but the pt isn't really that sick, a good BLS crew will spare the medics by assessing, packaging, getting almost to the bus, and then requesting ALS, so that they can get off scene way before the medics can get there. That way they've covered themselves by technically calling for medics.

Really, unless you're talking about running a 12-lead, unless a pt is expected to need timely ALS intervention (using a protocol), there's little pt benefit when the hospital is 3-5 minutes away.

In my newly all-ALS system, maybe one out of 20 pts get a protocol run on them (meds, ALS procedures other than an IV). Most of these calls would turn out the same if it were just BLS, or POV to the ED. It's V.O.M.I.T. tx all day every day for the most part here. In NYC, it's really the same thing if the pt is reasonably stable. All the medics are going to do is Vitals, O2 (maybe), Monitor, IV, Txp. It's better to keep them in-service and let them run something that they can actually use their protocols on.

 

[Brandon O]

BLS are used to seeing moderately sick pts by themselves, and should be able to tell when a pt may need ALS to run a protocol on them. BLS would often get chastised by ALS when they request them for a non-acute pt, so the BLS quickly learn when they should really be calling. If BLS needs to call per protocol, but the pt isn't really that sick, a good BLS crew will spare the medics by assessing, packaging, getting almost to the bus, and then requesting ALS, so that they can get off scene way before the medics can get there. That way they've covered themselves by technically calling for medics.

You're really describing systems identical to many I've worked in, but the key difference seems to be that I've never worked anywhere that didn't let the crew on scene with the patient determine the need for ALS. Even if everybody on the air is a bit puzzled and amused to hear somebody calling for medics for the toe pain patient, whatever, they're there and you ain't.

The only equivalent I can think of is some systems where the field supervisor responds to certain calls, and although he can be requested, will also self-dispatch to help out depending on how it sounds.

 

[feldy]

That's true. My B, as they say. To be fair, my system's medics don't do that either. Haven't seen a system's protocols that allow for it. Any areas that do?

We can do Therapeutic Hypothermia in the field.

 

[EpiEMS]

We can do Therapeutic Hypothermia in the field.

Do you happen to have a link to the protocols?

 

[Brandon O]

Do you happen to have a link to the protocols?

http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001.pdf

Go to Appendix V.

 

[EpiEMS]

http://www.mass.gov/eohhs/docs/dph/emergency-services/treatment-protocols-1001.pdf

Go to Appendix V.

Thanks, interesting stuff!

 

[Smash]

And yet more reason not to waste time doing CPR in an ambulance

Lipman, S. S., Wong, J. Y., Arafeh, J., Cohen, S. E., & Carvalho, B. Transport decreases the quality of cardiopulmonary resuscitation during simulated maternal cardiac arrest. Anesth Analg, 116(1), 162-167.

 

[Handsome Robb]

Why is BLS being dispatched to a cardiac arrest rather than ALS? I understand them being simultaneously dispatched, especially if BLS is going to beat ALS to the scene, but why on earth is BLS showing up to a arrest or peri-arrest call then having to request medics? Why aren't they already on the way with the initial dispatch?

I guess I'm not used to having BLS ambulances. Where I work every ambulance has an EMT-I and Paramedic on board, sometimes two Paramedics.

A medical cardiac arrest generally needs to be worked on scene then transported if ROSC is obtained or pronounced on scene. I'm sure people will call me out on saying this since I transported a cardiac arrest with CPR in progress last week but that was a individual situation and I knew I wasn't going to get any physician to grant my request to terminate with the presenting rhythm, patient age, ETCO2 and proximity to the ER. There is no hard and fast rule that will fit every situation but in general, an arrest needs to be worked on scene, even if it's witnessed by EMS unless there's indications that the patient needs definitive care that EMS cannot provide (read: STEMI that arrests on you or a can't ventilate/can't intubate situation in systems that don't allow for surgical or needle cricothyrotomy in close proximity to an ER, for example)

If you're using a mechanical CPR device then transporting with CPR in progress is a totally different situation.

 

[DrParasite]

Why is BLS being dispatched to a cardiac arrest rather than ALS? I understand them being simultaneously dispatched, especially if BLS is going to beat ALS to the scene, but why on earth is BLS showing up to a arrest or peri-arrest call then having to request medics? Why aren't they already on the way with the initial dispatch?

Because is sucks working a cardiac arrest with just a paramedic and an Intermediate? Because in many places you have many BLS ambulances, and only a few ALS ambulances, letting the BLS ambulances handles the minor stuff, and ALS can only treat sick people? Because many places the BLS ambulance will make it to the scene before ALS? Because many places don't have the FD on every job? Because I would rather tie up a BLS ambulance and an ALS ambulance, instead of an ALS ambulance and a fire engine (who more often than not doesn't want to be there), especially when they are tied up for an hour while the report of a working fire comes in on their first due?

any cardiac arrest should immediately dispatch ALS and BLS. and we all know that you will never have a cardiac arrest that is dispatched as something other than an unconscious or cardiac arrest.

 

[Aidey]

He said rather than. As in why is BLS getting dispatched without ALS.

 

[Handsome Robb]

Because is sucks working a cardiac arrest with just a paramedic and an Intermediate? Because in many places you have many BLS ambulances, and only a few ALS ambulances, letting the BLS ambulances handles the minor stuff, and ALS can only treat sick people? Because many places the BLS ambulance will make it to the scene before ALS? Because many places don't have the FD on every job? Because I would rather tie up a BLS ambulance and an ALS ambulance, instead of an ALS ambulance and a fire engine (who more often than not doesn't want to be there), especially when they are tied up for an hour while the report of a working fire comes in on their first due?

any cardiac arrest should immediately dispatch ALS and BLS. and we all know that you will never have a cardiac arrest that is dispatched as something other than an unconscious or cardiac arrest.

Arrests come out as ALS calls the vast majority of the time. Whether it be an active seizure, unconscious, arrest, syncope, difficulty breathing whatever you want to make it. All calls that ALS should be dispatched initially. Sure on rare occasions they come out as a non-critical call but that's the minority, most will get upgraded as the call-taker gathers more information and calms the RP down, you as a dispatcher should know that. A cardiac arrest is not a "minor call" and should not have a BLS ambulance as the sole responder and you know that. You've been doing the dispatch and EMS thing long enough to know that working arrests rarely come out as non-life threatening calls. All a patient or RP has to say on the phone is they're or the patient having trouble breathing or breathing irregularly and it automatically bumps into a possibly/life threatening call. I'm not even a dispatcher and I know that.

How many working fires are there annually when compared to working cardiac arrest? Answer me that one. You not wanting to dispatch a fire apparatus to a cardiac arrest because they [I/might[/I] get a working fire in their first due is retarded. 80% if not more of FD runs are EMS related. I don't care if that fire crew doesn't want to be there, assisting EMS is part of their job description.

I didn't say we need fire on every run, but on a Delta or Echo level call (you could even argue Charlie level calls as well) they should be going. That's the point of EMD and MPDS, to appropriately allocate resources to EMS calls. Whether they like it or not fire is part of the EMS system. Especially since they are generally going to be faster than EMS since there are more fire units than EMS units in most systems.

An arrest should not tie up a fire apparatus for an hour. If you're working an arrest for that long something needs to be addressed. They come, they help, ride in if we transport or get released when we pronounce. If they want to sit around on scene with their thumbs up their asses after we are finished that's their own fault they aren't available to cover their first due, not dispatch or the EMS crew's fault.

So you're advocating tying up two transport units for one call that could easily be handled by an ALS ambulance and a two man light rescue? If you're so short on resources how does that even make sense? You always talk about how you consistently have pending 911 calls. If that's truly the case then why on earth would you advocate tying up two transport units rather than utilizing fire resources and keeping the second transport unit available for all those pending calls?

Sure BLS is probably faster than ALS, fire is just as fast if not faster than BLS most of the time. If you're so short on ALS resources your system needs to be restructured. It's not like it's difficult to find paramedics looking for an ALS gig in this country, hell we have plenty of medics working as Intermediates waiting for a medic spot to open up here.

I'd love to know what the community thinks about BLS ambulances staffed with glorified first-aiders (no offense to the basics on here) being the sole responder to a life threatening emergency, especially in an urban/suburban environment.

If BLS and ALS are simultaneously dispatched then BLS transporting shouldn't even be a question now should it?

Edited for grammar and to not be such an ***.

 

[Brandon O]

Arrests come out as ALS calls the vast majority of the time. Whether it be an active seizure, unconscious, arrest, syncope, difficulty breathing whatever you want to make it.

Although in general I agree with this statement, I think it's important to understand that almost all of the points you're making are regional and service-dependent. Not all areas even practice EMD, dispatch priorities vary, the involvement of first responders (such as fire and police) varies, the relative availability of BLS vs. ALS, and so on.

A lot of disagreements in this business seem to stem from the fact that what's standard for one person is unheard-of for another.

 

[chaz90]

A lot of disagreements in this business seem to stem from the fact that what's standard for one person is unheard-of for another.

Amen