is a broken arm an ALS or BLS call?

[Luno]

Vent, as I figured, you'd pop up on here... Anyway, what I really want to see is better paramedic coverage in the area that would allow ALS response for pain management. I don't see that as a reality here however. That being said, our paramedics are far more advanced in scope and education than NREMT-Ps in general, and I'd almost question if we need a NREMT-P level in King County, and then the Medic One paramedics. I entirely agree that it is more than a couple of tricks, however the way that King County recognizes paramedics is entirely different then most of the country. A NREMT-P is only recognized in King County as a BLS provider. Given that lens, I'm not sure that it is a true 'intermediate' provider in the sense of EMT-I, rather it is an intermediate between strictly BLS and Medic One.

 

[wyoskibum]

broken radius/ulna, just the arm and nothing else, simple fx, an ALS or BLS call?

BLS. In my experience, proper immobilization and cryotherapy in most cases negate the need for pain management.

 

[Seaglass]

But they can tell you are in pain, there's a difference between that situation and one where a pt is laughing, joking and moving the ext. or the injured area and not complaining until you remind them that they are supposed to be hurt and then the Oscar winning performance comes out.

They can tell I'm in pain, but telling the severity of someone else's pain can be tough. Some patients will be crying and howling over a splinter, and I've seen a patient with double femur fractures who was straight-faced, coherent, and rating his pain as 10/10. If they're new and they've had the old "people in pain will take anything" saw drilled into their heads, I can see where their training would lead them not to take me as seriously.

 

[DrParasite]

bumping an old thread to see if new blood thinks differently.

oddly enough, the poll is 22 BLS 7 ALS, but the majority of posters who commented in the thread (to my eye anyway) seem to think that it should be ALS all the way.

 

[Jay]

Without overanalyzing I would have to say that it is a BLS call unless the PT presents with at least one of the following:

1. Pain 7/10 or above.
2. No or weak extremity pulse or sensation.
3. No capillary refill being present or refill being >2-3 sec.
4. Severe bleeding secondary to a complex fracture (or edema if justified).
5. PT is presenting that they are having those rare but sometimes founded cardiac complications due to the fracture, i.e. clotting that is causing some kind of a blockage in which ALS intervention will be critical.
6. I am sure that I can think of others but these are the basics that would justify getting ALS on-scene. Pain alone can be called in to the hospital along with a preliminary report (they can have MS or Dilaudid on standby) if not too debilitating (0-6/10) but severe pain or complications would definitely justify the intercept.

 

[slb862]

I truely believe that Fentanyl should be in the drinking water. :blink:





J/K

 

[18G]

On the basis of pain management calls for fractures should be ALS. I don't believe a patient should have to suffer and remain in pain without any relief until they get to a hospital.

If it were me with a fracture I would want analgesia ASAP and the same if it were one of my kids. If its a nasty fracture that is causing a lot of pain... think of the increase in pain through splinting, moving to the ambulance, and bumpy transport.

In my county however, most fracture calls are BLS only.

 

[akflightmedic]

Without overanalyzing I would have to say that it is a BLS call unless the PT presents with at least one of the following:

1. Pain 7/10 or above.
2. No or weak extremity pulse or sensation.
3. No capillary refill being present or refill being >2-3 sec.
4. Severe bleeding secondary to a complex fracture (or edema if justified).
5. PT is presenting that they are having those rare but sometimes founded cardiac complications due to the fracture, i.e. clotting that is causing some kind of a blockage in which ALS intervention will be critical.
6. I am sure that I can think of others but these are the basics that would justify getting ALS on-scene. Pain alone can be called in to the hospital along with a preliminary report (they can have MS or Dilaudid on standby) if not too debilitating (0-6/10) but severe pain or complications would definitely justify the intercept.

While I appreciate some points in your response, I would like to add a few of my thoughts for different perspective purposes and to stimulate discussion.

1. So the patient has to be a 7 before you consider calling for ALS? Pain is subjective and everyone handles it differently. A guy could calmly tell you he is an 8 with minor grimacing upon movement and this would prompt you to call for ALS versus the person who is squirming and crying but states the pain is only a 5??? Would you tell them they need to hurt "some more" so you can call for ALS and pain relief?

See the lack of logic in setting a number that would prompt you to call for help? Pain is pain and if we can treat it prehospitally, then we should.

2. Would this make you wait on ALS or would it prompt you to hurry up and BLS it all the way to get to more definitive care? In a few systems, they would benefit from ALS care, but this is a get to a hospital now situation, so technically it is BLS.

3. See #2

4. Bleeding control is a BLS skill, even severe bleeding. Now if they are getting hypotensive, tachycardic, pale, etc...all the signs and symptoms of shock (all from a fx arm mind you) then maybe call for ALS intercept if none of the BLS remedies are working, but still is a BLS call for the most part.

5. Well this is no longer a fx arm call is it? It is now chest pain or shortness of breath...so its a moot point in this discussion.

6. Doesn't every hospital have pain meds "on standby"? I doubt they would have it out of the locked cabinet and locked and loaded ready to inject without first conducting an assessment and checking them in.

So in short, ANY pain from an isolated fracture justifies ALS intervention.

 

[Aprz]

Without overanalyzing...

1. Pain 7/10 or above.

Well, he did say without overanalyzing, but when I saw this, I thought "What about guys that don't want to admit they are in pain or something is wrong?" I don't know why, but I am one of those guys, and I just do it. I am sure there are plenty others like me who don't admit or show what they are really feeling.

 

[MrBrown]

*Brown breaks down and cries uncontrollably alternating between sobbing between sadness and blind rage

If only ALS has pain management then its an ALS job

 

[TransportJockey]

For me I'd say ILS/ALS for pain control (In NM ILS is allowed narc's for pain control with an online order)

 

[MrBrown]

For me I'd say ILS/ALS for pain control (In NM ILS is allowed narc's for pain control with an online order)

In Kiwi we have

BLS (EMT) - Methoxyflurane/entonox
ILS (Paramedic) - morphine
ALS (Intensive Care) - midaz and ketamine

.... so take your pick really

 

[medicRob]

I'd have to answer this with another question, I'm afraid.

Does this have arterial involvement? A patient spurting bright red blood at a steady rate could be ALS, whereas a simple break would be BLS, but wait...

That's right, we do not have X rays on the ambulance, so unless we see the bone protruding through the skin, we can't really say whether or not it is a simple fracture, etc.

 

[usalsfyre]

This is why every patient deserves an ALS assesment, but may not necessarily need an ALS intervention. First line of pain control SHOULD be splinting and ice. If that takes care of the problem (or at least makes it bearable with a somewhat comfortable patient) then I have no problem with a basic riding it in. If further assesment reveals the need for IV opiates then we will control it that way.

What's important is that pain control is high on the list of priorities. I recently got to be an EMS patient who between the ambulance and the ED got to spend the better part of an hour and a half immobilized with painful injuries and NO pain control. There's a lot I don't remember about that day due to a concussion, but I do remember the pain. This made a fairly ardent suppouter of pre-hospital pain control into a dyed-in-the wool believer. "Pain never killed anyone" is NOT an acceptable excuse anymore.

 

[akflightmedic]

Does this have arterial involvement? A patient spurting bright red blood at a steady rate could be ALS

Does this still make it ALS?

I mean a tourniquet is a tourniquet be it a medic or EMT who places it, no?

And not many ALS providers routinely carry FFP or packed RBCs, so, does a spurt make it that much different? I think not..

(just stirring the pot folks, don't mind me)

 

[medicRob]

This is why every patient deserves an ALS assesment, but may not necessarily need an ALS intervention. First line of pain control SHOULD be splinting and ice. If that takes care of the problem (or at least makes it bearable with a somewhat comfortable patient) then I have no problem with a basic riding it in. If further assesment reveals the need for IV opiates then we will control it that way.

What's important is that pain control is high on the list of priorities. I recently got to be an EMS patient who between the ambulance and the ED got to spend the better part of an hour and a half immobilized with painful injuries and NO pain control. There's a lot I don't remember about that day due to a concussion, but I do remember the pain. This made a fairly ardent suppouter of pre-hospital pain control into a dyed-in-the wool believer. "Pain never killed anyone" is NOT an acceptable excuse anymore.

Pain level should be treated as another vital sign, in my opinion. It should be assessed just as often as one takes a blood pressure. Usually this is only the case with Chest Pain and Burns. Pain management is a big part of prehospital medicine now. Could you imagine enduring a 30 minute flight to a trauma center with severe burns (with some nerves still intact) without Fent or Morphine. Yikes.

 

[medicRob]

Does this still make it ALS?

I mean a tourniquet is a tourniquet be it a medic or EMT who places it, no?

And not many ALS providers routinely carry FFP or packed RBCs, so, does a spurt make it that much different? I think not..

(just stirring the pot folks, don't mind me)

I am basing this off of the fact that most EMT-B cannot even start an IV. If a patient was losing blood, you would at least want a line until you could get them to the appropriate level of care. Moreover, what if the patient has been bleeding for a while and lost enough blood to go into decompensated shock (example, hiking trip in a rural area where it takes providers upwards of an hour to get there). I understand that this is a big, "What if", but I am only stirring the pot as well.

I do, however understand what you are saying akflightmedic. There are a lot of variables to consider.

Also, if I have a broken arm, I want pain meds and lots of them.

 

[Sassafras]

I don't think there is a one answer fits all. I've broken bones. Ibuprofen was fine in spite of having multiple fractures. I could have easily made it to the hospital without ALS. But other breaks are going to be more complex or present more pain and need more intervention.

Regarding the patient who won't admit their pain level, well, I can't really help that. I can only go off of information given me sadly and then infer what I think best at the time.

 

[usalsfyre]

Pain level should be treated as another vital sign, in my opinion. It should be assessed just as often as one takes a blood pressure.

Amen, absoloutely.

Could you imagine enduring a 30 minute flight to a trauma center with severe burns (with some nerves still intact) without Fent or Morphine. Yikes.

Yikes indeed.

There's probably something to be said for sedating this type of patient (midazolam would be a wonderful choice) in addition to massive amounts (protocols allow 2mcg/kg of fent? nows a great time...) pain control. While you can't ensure retrograde amnesia, at least they might forget the circumstances surrounding the pain.

 

[Aidey]

Also, if I have a broken arm, I want pain meds and lots of them.

I know earlier in this thread I voted for ALS because of the pain med issue, but I do have a personal anecdote to add.

I've had two broken arms, 10 years apart. The first one involved tripping and falling with a concussion to boot.* School called my mom, my mom picked me up and drove me to our family doc's office. I don't think I was given Rx pain meds. The second one was from slipping and falling on ice in college. I walked around for 3 days before I got it x-rayed (urgent care center) and it was fractured in 2 places (stable fractures). I got T3 for that one.

Anyway, so the point of this is is that some fractures don't need the emergency medical system, let alone ALS just for pain meds. When I think of medicating fractures, I'm thinking of the obvious deformity types.


* Had this event occurred today I would have been back boarded and probably gotten a CT to rule out any bleeds. Since I actually had LOC, I may have even been admitted for observation.