So the service I am interning at is looking to implement BLS trucks (EMT-EMT) into the 911 system. The only problem we are having is that there is a high rate of "BLS calls" becoming "ALS calls". Does anyone know what their system might do to prevent that from happening?
Dispatch BLS v. ALS
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18G
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Are they using the Medical Priority Dispatch system and screening the calls properly? I have spent my career in a two-tiered response system (with ALS and BLS units) and rarely did I ever arrive to find a patient in desperate need of ALS.
Also, are the EMT's doing proper assessments and know what they are doing? Are they falling back on calling for ALS out of not knowing what is going on?
These are just two places I would start to look.
Also, are the EMT's doing proper assessments and know what they are doing? Are they falling back on calling for ALS out of not knowing what is going on?
These are just two places I would start to look.
usafmedic45
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Besides getting rid of paramedics or critical patients? No.
usafmedic45
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And this is a problem why? It sounds like you're just annoyed that you (as an EMT-B ) aren't getting your jollies because the "good calls" are going to dual medic ALS crews.
I'm just interning there, so I'm not running calls on a daily basis. I can always just jump on an ALS truck and see all the blood and guts i want. I think the problem is the tying up of ALS units (medics don't like it?). It wasn't my idea, I'm just doing the research to implement it.
usafmedic45
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If they have a problem running ALS calls (including those that are arguably borderline BLS calls), then they probably should question their career choice. "Tying up" units is just another way of EMS providers saying "I didn't get into this to transport granny to and from the hospital. I got in it for the excitement." Sadly, a lot of people get into the field before realizing that the interesting calls (by those sorts of standards at least) are few and far between.
Good luck. EMS desperately needs more research. I think you're going to come up on the short end of the stick for your goal because basic EMTs have a habit of being overzealous when it comes to upgrading calls in hopes of seeing something more "interesting" be done to the patient (and maybe getting to help!) and a significant number of ALS providers tend to spend a large swath of their time trying to find ways of downgrading the marginal patients to BLS cases when they are allowed to do so. Sadly, there is little evidence to back up the latter approach.
HotelCo
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I completely agree with you, and it seems to be ingrained in every new EMT's head that I've come across. Hell, even in my own EMT class it was common practice to (during scenarios) simply tell the proctor you're calling for an ALS intercept, and that was good enough for the proctor, almost whatever situation you were simulating.
I find this to be the case among new EMTs I meet, and it's a true shame that their trained this way, instead of focusing on what they CAN do, while the patient is in their care.
[/speech]
Damned if you do, damned if you don't.
If an EMT calls for ALS, he is incompetent.
If an EMT fails to call for ALS he is negligent.
Perhaps BLS response is not the answer?
If I nderstand correctly it is a system where there are 2 medics on the ALS trucks?
That solution is really simple, it's called the medic/basic truck. Everyone gets assessed by ALS. The calls not requiring ALS are attended by the basic, so they get experience with patients. Making their ability to decide later who is ALS or not better.
You cannot just lunch providers ot into the world and expect them to be great. There has to be some guidance and coaching.
If an EMT calls for ALS, he is incompetent.
If an EMT fails to call for ALS he is negligent.
Perhaps BLS response is not the answer?
If I nderstand correctly it is a system where there are 2 medics on the ALS trucks?
That solution is really simple, it's called the medic/basic truck. Everyone gets assessed by ALS. The calls not requiring ALS are attended by the basic, so they get experience with patients. Making their ability to decide later who is ALS or not better.
You cannot just lunch providers ot into the world and expect them to be great. There has to be some guidance and coaching.
reaper
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Vene hit it right on. That is why a basic/medic system works the best.
I have worked every type of system. I always felt dual medic systems were a waste of money and resources.
I have worked every type of system. I always felt dual medic systems were a waste of money and resources.
Is your supervisor planing on hiring experienced emt's with 911 experiencing or someone that is green and hope they know what they are doing? It sounds like your supervisor should do 2 step system before introducing bls in to the picture. As Veneficus suggested go from dual medic to basic/medic. Get emt's experienced in how to do assessment properly and then transfer them to bls truck with another basic. That way you will have at least 1 person with experience of proper assessment and can decide if als need or if they can just handle it them self.
Also you said you are close by hospital's, what is the code 3 travel time to the nearest hospital vs calling for als intercept? That might be also something to look at.
Also you said you are close by hospital's, what is the code 3 travel time to the nearest hospital vs calling for als intercept? That might be also something to look at.
fast65
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Like someone stated earlier, I think one of the main causes for this "problem" is that it's drilled hard into the basics to "dispatch ALS" on every scenario they get in their labs and in their testing, so it just kind of becomes ingrained in their minds. That's my opinion at least.
I have to agree with you. It was hammered into my head that I would almost certainly fail my state practical if I didn't ask for ALS intercept. The problem was that we always simulated ALS calls in a basic class because the calls that Basics handle really are not fun and exciting (generally and not complaining...I love what I do).
How for the OP's issue, I have to agree with reaper. There are a lot of Basic-Medic trucks in my area (aside from volly BLS) and that generally seems to work well. If the medic on the truck needs help, they ask for their supervisor to respond out in a chase truck. Gives the patient the best level of care possible in my opinion, patients that are dispatched BLS, but are really ALS don't have to wait for an intercept.
We are looking to hire experienced EMTs so they will have some sense of what they need to do, and how real life differs from class. There is a Trauma, STEMI, Stroke, and Burn center with a less than 10 minute transport time.
Unfortunately its only Basic and Medic. There was talk about Advanced EMT coming at some point in the future, but state government isnt known to be too efficient.
DrParasite
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says who? the lazy medic who doesn't want to do his or her job? If a patient can be helped by ALS, then by all means call for ALS. if the ALS gets the, assesses and determines there is nothing he can do to help the patient, the patient is left in the care of BLS. it's not rocket science.
in most cases, yes. if the ER is closer than the nearest ALS, then the EMT is not negligent. but a good EMT knows when he or she is out of his league, and should be calling for "help." but not calling for help out of fear of appearing incompetant to the all mighty paramedics is negligence.
as for the OP, proper call screening at the 911 point is the answer. MPDS is one option, APCO and NECI are other call screening systems. Are they perfect? NO. 80% to 90% accurate is probably my guess. an all ALS system is a waste of resources and results in a poorer medic (think LAFD). Will ALS be sent to BLS calls? yes. will BLS be sent to ALS calls? yes. hopefully in a tiered system you can call for the other resource and handle appropriately, but that's system dependant. but in either case,you can pick up the radio and call for the proper unit, assuming one if available.
Do what you can, but many system do perfectly well with ALS and BLS systems, instead of reinventing the wheel, why not just see what they do?
I've worked in NYC, with around 30% double medic ALS, and 70% double EMT (or maybe a medic on OT, but no ALS allowed) BLS buses. If you're bored, you can count the actual number of units in total:
http://fdnyems.com/EMS Unit Location Charts.pdf
I've worked in Charleston SC, where it's 100% ALS, with minimum staffing of medic/EMT. It will be double medic only if a new hire has not yet attained crew chief status.
I now work in Fairfax in a system that has a core number of PTU's, I think 14, which are double medic units, intended as field training for new medics. The remainder of our 37 stations are medic/EMT. We also have four additional BLS units.
I found the NYC system to provide the best learning curve for both BLS and ALS, bar none. The ALS only gets ALS job types, and the call taking and job typing is done by FDNY EMT's and medics, so it's more accurate than other systems, in my experience. Medics see mostly cardiacs, diff breathers, alt ments, stat ep, munti trauma, and arrests. Their pt contact opportunities aren't diluted by injuries, sick calls, EDP's, the intox, single seizures, unk. medicals, non-critical CVA's, etc. Of course the call typing isn't going to be 100%, but I found it accurate enough to let me see mostly sick pts, and also to weed out the non acute, minor calls. The BLS got to handle most everything by themselves, and were also held accountable as when to call for ALS. If they don't call ALS for something they can't handle, they get jammed up. If they call ALS for something minor, they typically get an "education" by the medics. The BLS are dispatched if the ALS has a greater than 10 minute ETA. In addition, ALS will frequently call BLS for pt care assistance for a critical pt, since it's only a crew of two at pt contact. This was an urban, resource rich area, with units fairly close by, which bears mentioning.
I left there to go to Charleston. I saw a sick pt maybe once a week, on average, if I was lucky. I used to see several on each shift back home. The BLS were allowed to ride in the back with only the most minor of pts. The ALS learning curve was decidedly more flat in the medic/EMT system. The BLS don't learn much either, since anything remotely challenging is handled by the medic, and they're taking orders the whole time, anyway. I felt sorry for the medic students, doing all these hours of ride a longs, and seeing maybe one tenth of the "legit" ALS pts I worked in my program. How are you supposed to learn anything running a bunch of sick calls, neck/back MVA's, and stable V.O.M.I.T. (vitals, O2, monitor, IV, txp) pts?
My current system isn't much better. Some medic officers treat you as an equal for pt care decisions, and others restrict you to just doing skills. Every house has an ALS unit, so everyone runs all that BLS, just like Charleston. Having been here for a few years now, I'll say that I would need more than ten years of ALS experience in either Charleston or FFX to even come close to what I did in NYC. Actually, not really. When you bounce from an APE to a stat ep, to the critical asthmatic, to a legit MI, to the multi trauma, and back to the diff breather, you get real sharp. Your pt questions roll out without much effort, and you're direction or questioning goes in the proper direction almost by instinct. Your hands get real fast when doing lines, drawing up meds, starting drips, etc. You can look at most pts and know that you need to get to work, before you even get next to them. Everything slowed down for me after I left. My interview isn't nearly as smooth, It takes me more time to draw up meds along with other skills. Tubes hardly happen any more, since nearly every unit is ALS. I used to get a tube a week, on average, maybe 3-4 on a good week.
The medic/EMT thing slows down the medic's learning curve since there are less opportunites to see acutely ill pts. The EMT is always guided by the medic, so they're really not thinking for themselves. I don't see how that benefits either one.
http://fdnyems.com/EMS Unit Location Charts.pdf
I've worked in Charleston SC, where it's 100% ALS, with minimum staffing of medic/EMT. It will be double medic only if a new hire has not yet attained crew chief status.
I now work in Fairfax in a system that has a core number of PTU's, I think 14, which are double medic units, intended as field training for new medics. The remainder of our 37 stations are medic/EMT. We also have four additional BLS units.
I found the NYC system to provide the best learning curve for both BLS and ALS, bar none. The ALS only gets ALS job types, and the call taking and job typing is done by FDNY EMT's and medics, so it's more accurate than other systems, in my experience. Medics see mostly cardiacs, diff breathers, alt ments, stat ep, munti trauma, and arrests. Their pt contact opportunities aren't diluted by injuries, sick calls, EDP's, the intox, single seizures, unk. medicals, non-critical CVA's, etc. Of course the call typing isn't going to be 100%, but I found it accurate enough to let me see mostly sick pts, and also to weed out the non acute, minor calls. The BLS got to handle most everything by themselves, and were also held accountable as when to call for ALS. If they don't call ALS for something they can't handle, they get jammed up. If they call ALS for something minor, they typically get an "education" by the medics. The BLS are dispatched if the ALS has a greater than 10 minute ETA. In addition, ALS will frequently call BLS for pt care assistance for a critical pt, since it's only a crew of two at pt contact. This was an urban, resource rich area, with units fairly close by, which bears mentioning.
I left there to go to Charleston. I saw a sick pt maybe once a week, on average, if I was lucky. I used to see several on each shift back home. The BLS were allowed to ride in the back with only the most minor of pts. The ALS learning curve was decidedly more flat in the medic/EMT system. The BLS don't learn much either, since anything remotely challenging is handled by the medic, and they're taking orders the whole time, anyway. I felt sorry for the medic students, doing all these hours of ride a longs, and seeing maybe one tenth of the "legit" ALS pts I worked in my program. How are you supposed to learn anything running a bunch of sick calls, neck/back MVA's, and stable V.O.M.I.T. (vitals, O2, monitor, IV, txp) pts?
My current system isn't much better. Some medic officers treat you as an equal for pt care decisions, and others restrict you to just doing skills. Every house has an ALS unit, so everyone runs all that BLS, just like Charleston. Having been here for a few years now, I'll say that I would need more than ten years of ALS experience in either Charleston or FFX to even come close to what I did in NYC. Actually, not really. When you bounce from an APE to a stat ep, to the critical asthmatic, to a legit MI, to the multi trauma, and back to the diff breather, you get real sharp. Your pt questions roll out without much effort, and you're direction or questioning goes in the proper direction almost by instinct. Your hands get real fast when doing lines, drawing up meds, starting drips, etc. You can look at most pts and know that you need to get to work, before you even get next to them. Everything slowed down for me after I left. My interview isn't nearly as smooth, It takes me more time to draw up meds along with other skills. Tubes hardly happen any more, since nearly every unit is ALS. I used to get a tube a week, on average, maybe 3-4 on a good week.
The medic/EMT thing slows down the medic's learning curve since there are less opportunites to see acutely ill pts. The EMT is always guided by the medic, so they're really not thinking for themselves. I don't see how that benefits either one.