To be an ALS1 rate the paramedic has to at minimum assess the patient and perform an "ALS intervention."
So yes, technically they could do an assessment, run an ekg, turn the patient over to the EMT and bill it as an ALS1 call. I think.
But if they did nothing, and just were there, that couldn't be billed as ALS1.
While this is the way a P/B is supposed to work it rarely works that way, In areas around here where a ALS squad is the primary provider they are dispatched for everything from stubbed toes to cardiac emergencies the ALS provider is supposed to assess the patient and appropriately triage to BLS or continue with ALS assessment and interventions. Is it right that we can legally charge an ALS1 rate for a patient who requires no ALS interventions no do we yep
I medicate patients that NEED the pain medication to be treated, moved, transported, extreme pain that is affecting vitals or breathing..etc... Other medication of patients in pain is not a NEED...it is a luxury just like a blanket to keep them warm or fluids to rehydrate them a bit before the ER.
Blankets are not a luxury, its primary care, If we showed up to your house to lets say take your mom to the hospital for weakness and flu like symptoms and throw her on the stretcher strap her in and take her to the hospital no pillow, no blanket just a sheet on the litter, because blankets are a luxury.. would you feel that we provided excellent service?? Probably not. Our job is to assist patients in treating their symptoms, and providing care, sometimes just comfort measures like blankets or positioning is providing care.
That is one thing I like about my system. If a paramedic is on scene (which is most of the time as we are a rural system so most of the few ambulances we have are ALS) then the paramedic rides in the back with the patient.
Personally, as a medic, I like this rule because in 2014 we are not just there for life and death emergencies. Being a medic is about more than pushing medications. Sometimes we are the only people who take the time to explain to our patient's how to take care of themselves. There are so many people lacking primary care, or having primary care MDs that are too busy to explain things. For example, the other day, I had a patient with a history of CHF on diuretics. She said she had not been taking them. When I asked why, she said she did not think it was important. I explained what CHF was and why taking medications as prescribed was so important. It was like a light went on in her head and she promised to take better care of herself so she could be there for her grandchildren. Did I do anything remotely ALS on that call besides Monitor/IV? Absolutely not. Was I able to use my knowledge to help someone better themselves? Yes I was. Not that some EMTs can't do the same' but a lot do not have the knowledge base of that disease process and pharmacology to have that discussion with the patient.
I came from the LA county system where fire responds in either an ALS engine or ALS squad and the ambulance is BLS. The fire medic has the choice to turf the patient to BLS and go back to the station. I can't even begin to describe the number of chest pain calls that became "chest wall discomfort" shortness of breath that became "cough and congestion" and altered that became "general weakness" so the paramedic could justify shipping the call BLS. To me that is both unethical and downright wrong.
Now I understand every system is different and what works for me might not work for someone else in a different system. However, I like the way we do things in my system because I believe it puts the patient first.
IMHO if a primary care physician "doesn't care to explain what they are treating their patients for, or tells the patient they don't have time to explain things" Its time to find a new physician. I am sorry its my body, I have the god given right to know whats going on with me, what the medications you are prescribing are going to do for me, and if I don't have a clear understanding as a non medical person, as my Primary care physician you should be more open and helpful,
To initially respond to the OP's post. most of what you are stating is a judgment call, to withhold interventions from any patient is unethical. But in the same way it comes down to HPI and a solid assessment. why is the patient sick with N/V. are they a cancer patient receiving chemotherapy? are they sick with a viral infection? etc. If N/V is motion sickness related anti-emetics like Zofran are ineffective. Also take in consideration sometimes the closest ALS is a ED. I.E. we provide primary coverage for a town that the hospital is in and 3 minutes away so to have a ALS truck dispatched and enroute to the scene I can have the patient at a higher level of care faster.
As far as the pain management portion of this thread. This is subjective to the patient. not everyone needs to be pumped full of narcotics to subside their pain. we simply forget that pain management is all or nothing with drugs, there is other interventions first. Often patients can have their pain subside with positioning comfort, and even things like heat or Ice. I've had patients with hip and extremity fractures that had pain relieved by proper positioning for comfort. or simple interventions like ice. and to continue no need to dump the drug box for pain management you can titrate up to the max for pain management depending on your transport time. If a patient pain subsides with 2mg of morphine or 50mcg of fentanyl why should I use the max dosages available to me?
