is a broken arm an ALS or BLS call?

[46Young]

^^^ I actually prefer to give Fentanyl that way because of its shorter duration. I usually give a loading dose, and then 2-3 smaller doses after that (or more depending on transport time) so that there is a slight chance it won't wear off before the ER can give them anything.

I prefer fent as well. We have the choice.

 

[Veneficus]

ummm, because definitive medical care is an MD?.

Yea, I keep hearing that, but I don't know if I really believe it.

It's BLS because "prehospitally" (you know, before you get to the hospital) it can be manged safely by BLS

I think the point of the argument is whether or not the guy with the broken arm wants the minimum safe level or the maximum medical care available when a level higher than basic exists.

(unless you get a patient who refuses to move until you call for a paramedic, but I digress), packaged, and transported to a hospital (you know, with doctors) where X-rays can be taken, and permanent interventions can be applied, at least until their PMD can follow up with them.

If I could just share my experience on how this plays out?

Patient arrives at hospital (by whatever means) is examined by staff, some times a doctor, sometimes somebody else.

If required pain is controlled chemically. If possible by PO.

xray is taken, usually for later comparison. If the fx was complex it creates a whole different event, but lets stick with simple. Whether there is a strain, a sprain, actually a simple fx, or no x-ray finings at all, the patient will receive a plaster splint, and an appointment to follow up with ortho. Then they get bounced.

Most patients I have ever seen don't have a PCP. For those who do the PCP probably wouldn't want to see them anyway and would direct them to ortho.

Some patients actually show up for the ortho appt. There is a follow up x-ray looking for bone reforming. (scaphoid fx don't actually show up on xray, but the bone healing oes later) If there is evidence of a fx and the splint is well applied, it is left on. If not it is cut off and a circumferential plaster cast applied.

If no signs of fx, then the splint comes off and a usually expensive commercial splint applied.

While all that sounds rather glorified, I am sure it could be handled by a NP and probably even by a PA at an urgent care.

In a few words: pain meds, xray, splint, ortho follow up, DC.

If you are going to pay for the ambulance ride, (in theory anyway) don't you think that the person would want something done? If not, what is the point of paying to staff an ambulance?

A $300 taxi ride where nothing is done seems like a terrible waste of money. In many cities I have been, yo could get a cab before an ambulance for such a call.

The point is though, if you want people to pay for EMS, via taxes or any other way, you have to demonstrate the value of the service. There is no value in paying for nothing.

I know, there is a splint and o2. But the funny thing about injured people, they like to find the position of comfort and stay there. Amazingly enough the position of comfort (or relative comfort) is the position where the body is suffering the least amount of damage. That could be considered self splinting.

What's the o2 going to do? Nothing.

Now if even a patch factory medic showed up and gave you some drugs that "helped," people might find more value in EMS. Otherwise, it is hard to convince them to support "nothing" at the prices required.

It comes down to protecting/promoting EMS jobs.

One of the reasons the FD usually has so much more than EMS is because they advertise. People actually perceive value and they pay for it.

A different perspective from pt. advocacy I know. But it sounds better than "all you need," "all you deserve," and "the minimum required."

 

[jjesusfreak01]

I think that the reason some medics are hesitant to give narcotics is because they're either phobic of screwing up the administration.

I don't get that. In a worst case scenario if you overdose a patient you can just titrate with naloxone, right? In fact, of all the drugs carried by medics, narcotics are one of the easiest to fix if you mess up. Hate to see a medic thats afraid to give narcotics ever work a complex cardiac arrest.

 

[46Young]

I don't get that. In a worst case scenario if you overdose a patient you can just titrate with naloxone, right? In fact, of all the drugs carried by medics, narcotics are one of the easiest to fix if you mess up. Hate to see a medic thats afraid to give narcotics ever work a complex cardiac arrest.

It's true. I've had fights with partners that didn't want to crack open the box. They think that they're going to hit a bump and spray everything all over the bus, or slightly over dose the pt, get sued, and do 10 years in prison or something.

 

[Aidey]

I prefer fent as well. We have the choice.

Oh no no no no, don't misunderstand me. I do not in any way shape or form prefer to give fent. But since it is all I have that dosing method is how I prefer to give it.

 

[Aidey]

Yea, I keep hearing that, but I don't know if I really believe it.



I think the point of the argument is whether or not the guy with the broken arm wants the minimum safe level or the maximum medical care available when a level higher than basic exists.



If I could just share my experience on how this plays out?

Patient arrives at hospital (by whatever means) is examined by staff, some times a doctor, sometimes somebody else.

If required pain is controlled chemically. If possible by PO.

xray is taken, usually for later comparison. If the fx was complex it creates a whole different event, but lets stick with simple. Whether there is a strain, a sprain, actually a simple fx, or no x-ray finings at all, the patient will receive a plaster splint, and an appointment to follow up with ortho. Then they get bounced.

Most patients I have ever seen don't have a PCP. For those who do the PCP probably wouldn't want to see them anyway and would direct them to ortho.

Some patients actually show up for the ortho appt. There is a follow up x-ray looking for bone reforming. (scaphoid fx don't actually show up on xray, but the bone healing oes later) If there is evidence of a fx and the splint is well applied, it is left on. If not it is cut off and a circumferential plaster cast applied.

If no signs of fx, then the splint comes off and a usually expensive commercial splint applied.

While all that sounds rather glorified, I am sure it could be handled by a NP and probably even by a PA at an urgent care.

In a few words: pain meds, xray, splint, ortho follow up, DC.

If you are going to pay for the ambulance ride, (in theory anyway) don't you think that the person would want something done? If not, what is the point of paying to staff an ambulance?

A $300 taxi ride where nothing is done seems like a terrible waste of money. In many cities I have been, yo could get a cab before an ambulance for such a call.

The point is though, if you want people to pay for EMS, via taxes or any other way, you have to demonstrate the value of the service. There is no value in paying for nothing.

I know, there is a splint and o2. But the funny thing about injured people, they like to find the position of comfort and stay there. Amazingly enough the position of comfort (or relative comfort) is the position where the body is suffering the least amount of damage. That could be considered self splinting.

What's the o2 going to do? Nothing.

Now if even a patch factory medic showed up and gave you some drugs that "helped," people might find more value in EMS. Otherwise, it is hard to convince them to support "nothing" at the prices required.

It comes down to protecting/promoting EMS jobs.

One of the reasons the FD usually has so much more than EMS is because they advertise. People actually perceive value and they pay for it.

A different perspective from pt. advocacy I know. But it sounds better than "all you need," "all you deserve," and "the minimum required."

You need us, because we give you the good stuff!

lol, sorry. I understand what you are saying, I'm just not sure demonstrating usefulness by advertising that we give pain meds is the best way to go about things.

 

[rhan101277]

I can give up to 3mg per dose. No fentanyl where I work. 10mg max dosage over time.

In hindsight since I did not feel uncomfortable with giving it due to her history, I could have called med control.

That way if something did happen, it wouldn't all be on my shoulders.

If her heart rate was not so low and she wasn't on blood thinners and multitudes of other drugs I would have given it.

Yeah I could have bolused her, but its possible that if things were to go wrong, then her coronary artery perfusion would be affected, coupled with ST depression.

I guess its easy for me to backseat quarterback my own call.

-First, Do No Harm

 

[Veneficus]

You need us, because we give you the good stuff!

lol, sorry. I understand what you are saying, I'm just not sure demonstrating usefulness by advertising that we give pain meds is the best way to go about things.

I much prefer "help reduce pain and suffering." It has worked for practicioners of medicine for 1000+ years. It is also far more accurate than "saving lives."

 

[Aidey]

Like I said, I don't disagree. I'm just in an odd humor today, which has led me to imagine ad slogans like "you call, we haul, with some fentanyl".

 

[Handsome Robb]

Is ILS a choice? Nitronox would be indicated for pain relief, as long as it wasn't contraindicated, which in this scenario none are present...It would provide the pt some relief and keep the ALS provider from having to get involved. I might be way wrong too though.

 

[LonghornMedic]

Is ILS a choice? Nitronox would be indicated for pain relief, as long as it wasn't contraindicated, which in this scenario none are present...It would provide the pt some relief and keep the ALS provider from having to get involved. I might be way wrong too though.

Problem with that is there are only a few EMS systems that let EMT-I's administer Nitronox. For that matter, there aren't that many systems that let Paramedics do it either.

 

[usalsfyre]

Nitronox....

...is an accountability nightmare. I think that's why you rarely see it in the US. Imagine a non-controlled, non-schedule drug, which gives a decent high, wears of quickly, is tough to track use of and doesn't show up on standard drug screens. I give you nitrous!

Seriously, the one system I carried it in we had to weigh the bottles daily to make sure it didn't "leak" into providers. Considering we were a fire-based EMS who had to through a heavy duty background/polygraph I really doubt it would have been a problem, but admin still didn't trust us. Entonox may be less of a pain (I imagine you could have a single pressure gauge), but is not approved for US use because it's premixed. Add in the fact I'm not sure the Nitronox blenders (which are heavy and awkward themselves) are available anymore and you have a great drug that got a raw deal in the US due to the system being awkward to use and bosses not trusting their employees.

 

[Handsome Robb]

Thanks for clearing that up. Theoretically, if it were within protocol would it be a viable option? They keep teaching us to manage pain and thats our only drug that allows us to do that. Teaching for NREMT rather than real life I guess?

 

[akflightmedic]

...is an accountability nightmare. I think that's why you rarely see it in the US. Imagine a non-controlled, non-schedule drug, which gives a decent high, wears of quickly, is tough to track use of and doesn't show up on standard drug screens. I give you nitrous!

Seriously, the one system I carried it in we had to weigh the bottles daily to make sure it didn't "leak" into providers. Considering we were a fire-based EMS who had to through a heavy duty background/polygraph I really doubt it would have been a problem, but admin still didn't trust us. Entonox may be less of a pain (I imagine you could have a single pressure gauge), but is not approved for US use because it's premixed. Add in the fact I'm not sure the Nitronox blenders (which are heavy and awkward themselves) are available anymore and you have a great drug that got a raw deal in the US due to the system being awkward to use and bosses not trusting their employees.

In my system, the bottle was sealed in a heavy duty plastic bag. You literally had to work hard to tear the plastic or cut it to get to the bottle.

Once it was opened and used on a patient, you notified supervisor and they either brought out a new one already sealed or we went by main station and picked up one and sealed it. The tank which was used was then drained to empty and witnessed, just like any other type of narc administration procedure.

They do have small compact blenders, was very light and had a nice little case with shoulder strap.

 

[swissmedic]

If you have an open fracture or any acute pain it is ALS call.
In my opinon are any other fractures also an ALS call but without light and sirens....
Matt

 

[Dutch-EMT]

If you have an open fracture or any acute pain it is ALS call.
In my opinon are any other fractures also an ALS call but without light and sirens....
Matt

Thinking about this subject about ALS or not ALS...
Isn't it stupid that there are differences in BLS, ILS or ALS calls?
Why not draw a line like this:
Interclinical transport, discharge transports: BLS ambulances
All 911 calls: ALS ambulances

 

[emt_irl]

if it was a simple fx with no major complications or moi, im going to say bls, keep als for more important calls.

emt's here can give entanox for pain relief and paracetamol.

 

[swissmedic]

Thinking about this subject about ALS or not ALS...
Isn't it stupid that there are differences in BLS, ILS or ALS calls?
Why not draw a line like this:
Interclinical transport, discharge transports: BLS ambulances
All 911 calls: ALS ambulances

Dear Dutch-EMT
I think your way is the best !
BLS Units for any clinical transports
ALS Units for any emergency calls, so there is notany dead time for the patients.
Here in Switzerland we have only ALS Units and in some counties the have also emergency doctor units too.
Matt

 

[MrBrown]

I agree, most of our vehicles are ILS or ALS

ILS is capable of cardioversion, 12 leads, morphine, adrenaline, GTN, salbutamol, naloxone, IV fluids etc whereas ALS can do RSI, atropine, ketamine etc etc ....

The American ALS vs BLS is hillariously ridicolous from an international standpoint

 

[DrParasite]

Since we have some new people here, would anyone like to contribute their opinion to this thread (and vote in the poll)?