Difference between BLS and ALS calls?

[leoemt]

So what?! You carry a damn epi pen! You don't carry advanced airway equipment for when their airway closes? Think outside the box. Anaphylaxis is more than just allergic reaction. It's a true ALS emergency!

Have you ever seen Anaphylaxis in the field? Do you know the physiological process behind it? As mentioned Epinepherine is the gold standard for treatment. But hey I guess all those doctors who prescribe epi-pens to patients are wrong huh?

Here is a little insight into our thought process. A few years ago Epi was ALS only and Anaphylaxis was an ALS call. In Spokane a 9 year old boy came into contact with a peanut during lunch at school. The child went into Anaphylaxis. 911 was called and a BLS engine showed up. Unfortunately, EPI was not a BLS drug and they had to stand by for ALS. By the time ALS showed up the child was dead. Our statewide protocols were changed after that to allow Anaphylaxis to be treated at the BLS level with Epi-pen and rapid transport.

Many counties around here allow the Basics to use a Combitube or King. While not the same as an advanced airway, it is more than just doing nothing.

In my case, when I gave the Epi pen the effects were amazing. That stuff does work and it works fast. I would surmise that very few anaphylaxis patients require an advanced airway. Something else is ongoing if that is required.

BLS and ALS both have their role and knowing it is important. However, if your a BLS provider and you cannot at least start treatment of a critically ill patient then something is seriously wrong. Even on ALS calls, there are things I can be doing for the patient to improve their outcomes.

For all the ALS level patients that we transport in our BLS units we have very good patient outcomes. It works for us. I like Paramedics, I respect them and what they have gone through to earn the medic title. I have enough respect for them and their skill set to make sure I understand the ALS indicators and not waste their time. In the city of seattle, if you ride in a Medic unit you are REALLY, REALLY, REALLY sick.

 

[VFlutter]

Have you ever seen Anaphylaxis in the field? Do you know the physiological process behind it?

*Do you?

In the city of seattle, if you ride in a Medic unit you are REALLY, REALLY, REALLY sick.

Is that really something to brag about? Is a system pushing the limit of safe and prudent care by turfing everything to BLS and having under-qualified providers simply hall *** to the ER really acceptable?

 

[NYMedic828]

Do you know the physiological process behind it?

Careful with that one... It's pretty complicated...

Also I believe the proper terminology would be pathophysiologic. Physiologic would imply normal body function and not a disease process.

 

[DrParasite]

difference between an ALS call and a BLS call? on an ALS call, the assessment usually involves a cardiac monitor and a BGL check (which is now BLS in some states).

I'm not a medic, nor am I an ALS provider. But I'm pretty good at telling what patients need advanced and what patients are stable. Those people who are sick and dying need ALS care, usually to treat an acutely life threatening emergency or a chronic medical condition that has gotten to the point that it is not acutely life threatening.

You don't need to be a medic to know sick or not sick. Have I made mistakes? sure. Have paramedics made mistakes? sure Have I been on a BLS truck, and seen paramedics turf patients that are either sick/in need of ALS or deteriorate during transport? you betcha.

I really pity all the paramedics out there who can't trust their BLS providers to do anything. there is truly something wrong with your EMS system. NJ might have it's faults, but in every agency I have worked with that has ALS and BLS providers, if you are absolutely useless on a call, than you are usually advised to seek employment elsewhere.

 

[the_negro_puppy]

"Thats not going to happen"

So i subjected my patient to pain while this Medic unit literally held analgesics in their hands but wouldnt even try to get permission to administer it.

What a sick joke. Withholding analgesia for a fractured femur is barbaric. If you don;t give analgesia for a fractured femur, when do you give it? sigh

 

[systemet]

I'm not a medic, nor am I an ALS provider. But I'm pretty good at telling what patients need advanced and what patients are stable. Those people who are sick and dying need ALS care, usually to treat an acutely life threatening emergency or a chronic medical condition that has gotten to the point that it is not acutely life threatening.

You don't need to be a medic to know sick or not sick. Have I made mistakes? sure. Have paramedics made mistakes? sure Have I been on a BLS truck, and seen paramedics turf patients that are either sick/in need of ALS or deteriorate during transport? you betcha.

I recognise that you're a smart guy, but you need to also appreciate that not everyone acutely sick declares themselves in a clear manner. I'm sure we've both done lots of chest pain calls. Many of the guys I thought were dying turned out to have non cardiac etiologies, many had simple UA. Some of the mildest chest pain or weak and dizzy all over old ladies have ended up being STEMIs.

Sometimes it's as important to recognise the limitations of our knowledge, technology and ability to assess the patient in the field. Medic school taught me as much about what I didn't know as it did anything else.

I really pity all the paramedics out there who can't trust their BLS providers to do anything. there is truly something wrong with your EMS system.

Me too. But, part of the responsibility as a paramedic is stepping in when the patient needs an advanced provider, and part of the responsibility as any level is knowing when a patient requires a higher level of care.

With respect.

 

[Clare]

I don't think I really understand what you are discussing so perhaps my input will be a little off the mark.

Of course there is a difference between somebody at different practice levels can do; an Intensive Care Paramedic (ALS) can do far more than an Emergency Medical Technician (BLS) but that is because they have put in an extra four years at University to gain the knowledge and have the experience applying that knowledge.

As to who drives and who attends it really depends upon the patient; if the patient has some critical problem such as post-cardiac arrest, traumatic brain injury or whatever then the higher level Ambulance Officer will be in the back with them; however this is often not the case as stable patients build experience so the ICP will drive.

 

[systemet]

In my case, when I gave the Epi pen the effects were amazing. That stuff does work and it works fast. I would surmise that very few anaphylaxis patients require an advanced airway. Something else is ongoing if that is required.

Are you extrapolating from n=1? You're aware that even with aggressive ED and ICU care, anaphylaxis still kills people, right? Why does it surprise you that an anaphylactic patient might require intubation? Do you understand that a symptom of anaphylaxis may be rapid laryngedema leading to total airway obstruction?

Have you considered that an anaphylactic reaction may interact with other pathology - e.g. anaphylaxis in the asthmatic patient?

Are you aware of the myriad different presentations of anaphylaxis that may occur? Have you encountered patients that present with massive angioedema, but little bronchospasm, hypotension, or GI symptoms? Have you seen the patient who has profound hypotension, emesis, diarrhea, but no uriticaria or pruritis? Have you met the patient whose first presenting symptom is severe bronchospasm leading to respiratory failure? All of these guys are out there.

An epi pen for EMTs is not a bad idea. But it doesn't mean that ALS care is no longer necessary, or that you're equipped to deal with every anaphylaxis patient coming your way.

 

[VFlutter]

Do you understand that a symptom of anaphylaxis may be rapid laryngedema leading to total airway obstruction?

It's all good they got combitubes h34r: I bet they work great with bronchospasms and intact gag reflexes

 

[NYMedic828]

Should probably make a new topic but here's a side question

In the case of severe laryngoedema, how much swelling occurs to the lower airways?

Obviously keeping a patent opening to the glottis/trachea is vital but what goes on beyond that? Is it only spasm/mild inflammation or can complete blockage occur in the bronchi as well?

 

[abckidsmom]

Should probably make a new topic but here's a side question

In the case of severe laryngoedema, how much swelling occurs to the lower airways?

Obviously keeping a patent opening to the glottis/trachea is vital but what goes on beyond that? Is it only spasm/mild inflammation or can complete blockage occur in the bronchi as well?

Yep, that's a total threadjack. Go ahead and ask your question in a new thread, anaphylaxis is a great topic for us to discuss. It's one of the true life-threatening emergencies we face.

 

[AnthonyTheEmt]

Yep, that's a total threadjack. Go ahead and ask your question in a new thread, anaphylaxis is a great topic for us to discuss. It's one of the true life-threatening emergencies we face.

My thoughts exactly. In the system I work in, echo level is the highest level call and to my knowledge there's only 2-3 things that get an echo response
1. Cardiac arrest
2. Anaphylaxis
Not sure after that

 

[NYMedic828]

My thoughts exactly. In the system I work in, echo level is the highest level call and to my knowledge there's only 2-3 things that get an echo response
1. Cardiac arrest
2. Anaphylaxis
Not sure after that

Really? theres nothing on par with anaphylaxis? That is poor system design.

 

[AnthonyTheEmt]

As the poster said he/she is close to many hospitals. Transporting to a hospital is a better idea then waiting for ALS if the hospital is closer.

I dont know how things work where youre at (not at meant to sound judgmental, because its not), but the county I work in, not everywhere is a STEMI or CVA center. If you rush a stroke pt to the nearest hospital because ALS is too far out, youre actually hurting your patient instead of helping them. I have made this mistake unfortunately and luckily it didnt come back to bite me in the butt

 

[DesertMedic66]

I dont know how things work where youre at (not at meant to sound judgmental, because its not), but the county I work in, not everywhere is a STEMI or CVA center. If you rush a stroke pt to the nearest hospital because ALS is too far out, youre actually hurting your patient instead of helping them. I have made this mistake unfortunately and luckily it didnt come back to bite me in the butt

My area is not an issue. Out of 3 hospitals all 3 of them are STEMI and Stroke centers. 1 is a trauma center and 2 are OB centers.

Not quite sure how it works in other areas but all EMTs and Medics know what hospitals can do what.

Call dispatch and get an ETA for ALS and know your ETA to the hospital. If ALS is the same ETA or longer then your transport time to the appropriate hospital then BLS transports.

ALS isn't able to do much more for a stroke patient than BLS can (12-lead, IV, BGL (pretty much a BLS skill in my area), and blood draws is about it for my area).

 

[AnthonyTheEmt]

My area is not an issue. Out of 3 hospitals all 3 of them are STEMI and Stroke centers. 1 is a trauma center and 2 are OB centers.

Not quite sure how it works in other areas but all EMTs and Medics know what hospitals can do what.

Call dispatch and get an ETA for ALS and know your ETA to the hospital. If ALS is the same ETA or longer then your transport time to the appropriate hospital then BLS transports.

ALS isn't able to do much more for a stroke patient than BLS can (12-lead, IV, BGL (pretty much a BLS skill in my area), and blood draws is about it for my area).

See, youre very lucky then. In my county, I worked BLS for 3 1/2 years before working as a medic. I can say from experience, as horrible as this sounds, alot of the EMT's who work for private companies dont know which hospital is a CVA center or STEMI center, or trauma center. Its really sad, because the companies do not force their employees to learn hospital specialties, much less protocols. And patients suffer for it. You get some BLS crew who thinks they are being heroes because they bring in the hot stroke to the nearest hospital, which may or may not be a stroke center, only to be told "good job jackass, now we have to transfer them before the 4 hour window is over", whereas if they had transferred that to an ALS crew, the ALS crew wouldve known to take them to the appropriate hospital. Also, I work in California, which lives up the reputation of neutering the BLS scope and things like Pulse ox and BGL (oh gosh, that is waaaaay too complicated for knucklehead EMT's :/ ) are technically outside of the BLS scope

 

[Aidey]

It isn't always that simple. What if it isn't a CVA, it is Todd's paralysis post seizure, and the pt starts seizing again? Or has a seizure because of the neurological insult? If the pt meets certain criteria and has certain interventions, like bilateral IVs, some hospitals will bypass the ED and go straight to CT. There is always the potential airway issue too. You get the idea.

 

[JPINFV]

I wonder how many "CVAs" encountered by EMTs are hypoglycemic patients, where if they called for paramedics when right down the street from the hospital they'd be told "Good job delaying care [and getting us out of our lazy boy]... jackass."

Of course that's why I'm a fan of using the "can we get an updated blood glucose level? You know... for the hospital..." line on SNFs.

 

[DesertMedic66]

It isn't always that simple. What if it isn't a CVA, it is Todd's paralysis post seizure, and the pt starts seizing again? Or has a seizure because of the neurological insult? If the pt meets certain criteria and has certain interventions, like bilateral IVs, some hospitals will bypass the ED and go straight to CT. There is always the potential airway issue too. You get the idea.

But once again this comes down to the time issue. Now you have to wait for ALS to get on scene, assess the patient, start treatments/interventions, and then transport. If the hospital is closer then the nearest ALS unit why wait for ALS? Transport the patient to definitive care at the ER.

Hospital and ALS unit are 20 minutes away. Is it better to transport the patient BLS to the hospital (20 minutes total) or wait for the ALS unit to get on scene (20 minutes) + the time to assess the patient (5 minutes) + the transport time to the hospital (20 minutes). So 20 minutes to the hospital vs 45 minutes to the hospital.

 

[abckidsmom]

But once again this comes down to the time issue. Now you have to wait for ALS to get on scene, assess the patient, start treatments/interventions, and then transport. If the hospital is closer then the nearest ALS unit why wait for ALS? Transport the patient to definitive care at the ER.

Hospital and ALS unit are 20 minutes away. Is it better to transport the patient BLS to the hospital (20 minutes total) or wait for the ALS unit to get on scene (20 minutes) + the time to assess the patient (5 minutes) + the transport time to the hospital (20 minutes). So 20 minutes to the hospital vs 45 minutes to the hospital.

Some might advocate for sending ALS immediately on dispatch. Sounds like most of the issues in this discussion come not from provider deficiency but system design issues.