is a broken arm an ALS or BLS call?

[medic417]

This exact issue has been proven time and time again. Pain is subjective, if the means to address an issue is available, then it is to be given. While you weren't addressing me in your post, I can tell you exactly the type of provider I am. I do let my patients dictate their treatment, why wouldn't I? Give me one good reason.

If I was this hypothetical patient, you will call for ALS, I will get a competent exam with treatment options discussed, and you will get off of your lazy pompous *** and treat me with the respect and dignity that all patients deserve. Or you will not continue to practice in your minimalistic medical position. Your attitude towards treating human beings in absolutely disgusting. You are not qualified to make an objective assessment of another humans suffering. If you cannot possess or acquire some compassion for your fellow man, you have no business being on an ambulance.

Excellent reply.

 

[usalsfyre]

I'm sorry, I can't let this go.

Pain management is still new in EMS. no, let me rephrase that; having ALS there solely for pain management is new to EMS

Pain management is not new in MEDICINE. Whether medicine is practiced in a doctors office, a hospital or the patients living room is irrelevant.

And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs.

PAIN indicates pain management. It may be as simple as positioning and an ice-pack. A good portion of pain doesn't need IV narcotics, but if the patient is in pain, it needs to be adressed.

I guess that shows what type of a provider you are. you let your patient's dictate how you are going to treat them.

You bet your sweet @ss I am going to let the individual patient presentation dictate how I treat them. Why would I waste my time doing an assesment otherwise?

If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again. If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic.

I would rather be a drug seekers dream medic, then let severe pain go untreated in one patient because I thought they were seeking. How do you know the patient in question is faking? As was stated before cultural factors play a role in response to pain. Are you going to let him hurt because his response to is distasteful to you? In addition, your pain tollerance is not this guy's. Unless you can do the Vulcan mind-meld with your patient, you have no way of knowing whether he's faking, or just has a really low pain tollerance.

I broke my wrist, my brother broke both his arms due to stupidity (one after the other), and we never called 911. and if I did break my arm, unless it's at a 90 degree angle, I'm probably going to end up walking to the ambulance once it has been splinted and secured in a position of comfort, and that is if I call for an ambulance at all. I might prefer to just drive myself to the ER, or even better, to my PMD's office

Again, YOUR response to a similar situation should not affect how the patient is treated.

DrParasite, I have worked in busy systems with a high load of abusers. I understand, it's easy to get jaded. What's truly lost if you medicate a chronic system abuser who doesn't need it? Are they going to call more? Doubtful. Patient condition? Most EMS service don't give narcotic doses that would even begin to produce respiratory depression. Some narcotics? Most narcotics are generic and dirt-cheap. I respect that your system has chosen a tiered model. However please stop using this to defend the absoloutely pitiful state of pain management in US EMS. It need to be fixed and telling folks the equivelent of "grow some" is not gonna help the situation.

 

[Aidey]

I would say that behavior is a good indicator of med seeking, I don't know where you got all that other stuff from.

I think Vene put it well, you might want a paramedic, but you don't necessarily need one. I also agree that you need to ask your patient, because for 2/10 pain they may not want pain meds. I can't force them to take them just in case it gets worse. If it gets worse, and they change their mind, that is their option.

 

[46Young]

You can sue all you want, you can try to get me fired; you will lose in court, and you will get laughed out of my bosses office when you want me fired because of it.
Regardless, whether it was at my old hospital, or down here in Virginia, that protocol violation would result in a pt care restriction and mandate a re-education. It would remain on the employee's permanent record, and would cause future pt care issues to be dealt with more severely.

Pain management is still new in EMS. no, let me rephrase that; having ALS there solely for pain management is new to EMS. If your medical director tells me that I should have one for an arm fx, then I'm sure that can be arranged. And if it's indicated (and I think we can disagree on what indicates prehospital pain management based on local protocols and local customs), and you withhold it, then the medic will have some explaining to do.
Being new shows progression. I used to think that BLS should be handling most everything not life threatening. The longer I work, the more I see our capabilities advance, the more I feel that a pt that may benefit from ALS interventions ought to be evaluated by a paramedic to make that determination. A basic's education isn't adequate to decide whether or not the pt should receive any advanced care, just to summon someone who can. If there isn't enough ALS units to go around, then that's a staffing and deployment issue, and therefore skews the discussion. We're not discussing or considering the availability of ALS, but rather if the pt deserves an ALS response and eval.

I guess the answer I would give to the question (since I am the OP after all), if you are an all ALS system, and you have the pain meds available to you, by all means give them. but if you are in a tiered systems, which a lot of the busier systems are, then I wouldn't be requesting a medic simply for pain control, when their skills can be better used treating the chest pain or asthmatic.
Again, a staffing and deployment issue.

you are getting off topic.... It's pretty clear you don't like EMD. fine, we get it. have you ever dispatched? I'll take a 12 hour shift on the road in medium speed system dealing with maybe 14 patients, to a 12 hour dispatch shift dealing with close to 100+ patients, many screaming at you trying to get help, and all you can do is tell them the ambulance is on the way. If you think you can do a better job, by all means you can have my seat. Also, while I agree with you that that question causes a lot of unnecessary upgrades to ALS dispatches, I will say that more educated people than you and I wrote those questions, and your boss and my boss approved those cards, and your dispatchers are told to follow them. And if they do deviate from the cards, and send BLS on what turns out to be a patient needing ALS, then the dispatcher gets hung out to dry by the dispatch agency, as well as the medical director and company who makes the cards.
In Dutch-EMT's system, along with RAA in Richmond, phone triage and alternatives to ground ambulance txp are used with success, so clearly EMD alone isn't the holy grail. It is safer to up triage everything rather than delve a little deeper, gain a clearer picture, and a more appropriate dispatch, I suppose.

and the question isn't do you have difficulty breathing, it's "are you breathing normally." same results occur. but back to the topic at hand....
You're splitting hairs

woooow. I have had patients with a stubbed toe who said their pain was 10/10. ditto a broken swollen finger. or abdominal pain. or a headache. or an ear ache. it's always 10/10 on the pain scale. I guess they needed pain meds, going by your thinkingsee, I guess that shows what type of a provider you are. you let your patient's dictate how you are going to treat them. If I show up to your broken arm, and you tell me you are just going to just lay there screaming in pain until I request ALS and they give you pain meds, I am either going to pull up a chair and wait for your to grow up, tell you "if you want to be treated, you need to let me treat you, or can can just lay there the pain", and if you still don't want me going anywhere near you, I am going to say "sign the RMA," and next time, have the cops and a supervisor respond when you call again. If you are going to let the patient dictate how you are going to treat him (not his condition based on your assessment, his desires), than you are a drug seekers dream medic.
Part of my paramedic level of assessment is knowing who genuinely deserves pain meds and who's a drug seeker. I worked in a busy system too, with prescription addicts and plenty of junkies.

I broke my wrist, my brother broke both his arms due to stupidity (one after the other), and we never called 911. and if I did break my arm, unless it's at a 90 degree angle, I'm probably going to end up walking to the ambulance once it has been splinted and secured in a position of comfort, and that is if I call for an ambulance at all. I might prefer to just drive myself to the ER, or even better, to my PMD's office
We've discussed this already, just because you can take the pain, doesn't mean that pain meds are indicated, and it certainly doesn't mean that it's ethical to withhold them.

EMD is akin to cookbook paramedicine. It works for anyone, since you don't have to think much, just follow the algorithm blindly. Dispatch ought to be much more than that, as should a paramedic's field treatment.

 

[Aidey]

Would it not be cookbook medicine to give everyone with pain of 1/10 or higher fentanyl automatically? That is the only option I have, which sucks. It leaves me stuck with an all-or-nothing approach.

Honestly, here is how I look at it. Pain management is important. However, if fentanyl is your my option it means that if I medicate all pain, I end up giving a potent narcotic to someone who could have benefited more from a different medication. If medical directors/hospitals/etc want us to be more aggressive with pain management, then we need to be given more options so that we can give appropriate pain management. For me, it isn't that I don't want to manage my patient's pain, I don't want to manage it inappropriately. And when all you have is fent, it is a crappy situation.

 

[medic417]

Would it not be cookbook medicine to give everyone with pain of 1/10 or higher fentanyl automatically? That is the only option I have, which sucks. It leaves me stuck with an all-or-nothing approach.

Honestly, here is how I look at it. Pain management is important. However, if fentanyl is your my option it means that if I medicate all pain, I end up giving a potent narcotic to someone who could have benefited more from a different medication. If medical directors/hospitals/etc want us to be more aggressive with pain management, then we need to be given more options so that we can give appropriate pain management. For me, it isn't that I don't want to manage my patient's pain, I don't want to manage it inappropriately. And when all you have is fent, it is a crappy situation.

Man I feel bad for you and your patients. Do they at least let you adjust dosage? We have multiple types and choices. What is funny is that most pain meds are dirt cheap so cost should not play a part in deciding what to carry. I hope you can work with your medical director to increase your options.

I never force pain meds. If they say they hurt I explain that I would like to administer X ( drug I feel is best based on all factors I am aware of ) for pain. Surprisingly some patients that are even 9/10 will so no to pain meds. Now if they change there mind later I am still there so I then give them what is needed.

 

[Aidey]

The dosage is variable, but as it is fentanyl, low doses don't seem to do one bit of good. Even in small patients 25mcg doesn't seem to have much (if any) affect. I've had to give some larger patients the max dose just to get them to the hospital. I would LOVE to have a variety, a longer acting opiate, a non-opiate or two, nitrous, a muscle relaxant. That way I could actually treat my patients appropriately.

Aside from abuse/misuse concerns, there is the fact that our protocols apply to the county, including all the non-transport FDs. While our agency's doctor would probably be open to adding stuff, it won't happen unless the FDs all agree, and the regional EMS council. Anytime we try and add stuff the FD's don't have/don't get to use there are issues.

I think that may be part of the issue in this debate, no one is discussing what pain management options they have. So for me, I'm highly unlikely to end up doing pain management beyond BLS on a simple fracture, but that is because all I have is fent. If I had other options, I would be more likely to medicate becuase I could medicate appropriately.

 

[medic417]

The dosage is variable, but as it is fentanyl, low doses don't seem to do one bit of good. Even in small patients 25mcg doesn't seem to have much (if any) affect. I've had to give some larger patients the max dose just to get them to the hospital. I would LOVE to have a variety, a longer acting opiate, a non-opiate or two, nitrous, a muscle relaxant. That way I could actually treat my patients appropriately.

Aside from abuse/misuse concerns, there is the fact that our protocols apply to the county, including all the non-transport FDs. While our agency's doctor would probably be open to adding stuff, it won't happen unless the FDs all agree, and the regional EMS council. Anytime we try and add stuff the FD's don't have/don't get to use there are issues.

I think that may be part of the issue in this debate, no one is discussing what pain management options they have. So for me, I'm highly unlikely to end up doing pain management beyond BLS on a simple fracture, but that is because all I have is fent. If I had other options, I would be more likely to medicate becuase I could medicate appropriately.

Don't hold back because Fentanyl still helps take the edge off which is better than nothing. In some patients it lets them sleep away their pain. A big plus in trauma is it usually does not bottom them out.

I agree more choices would be helpful. I would hate to be in a situation like yours where everyone gets stuck with basically nothing because a few can not comply.

 

[Aidey]

I miss having more options, I used to have morphine, valium and nitrous. Between valium, versed and ativan I feel that the valium was the best for relieving muscle spasms, which helped significantly in dislocations. The nitrous was awesome because I could use it until the morphine kicked it, or use a lower dose of morphine overall. I also used it several times in patients who were adamant about no needles.

 

[jjesusfreak01]

Two things to remember: Your patient could be a drug seeker, or your patient could be an ex addict. Giving drugs to the former of these without evidence they are in pain is bad, and giving meds to the latter of these without helping them make an informed decision is much much worse. All drugs have side effects, and all drugs have aftereffects. Overmedication is one of the bigger medical problems we face in the United States now, better not to compound the problem if you can help it. Be compassionate and make informed treatment decisions based on what a patient needs.

 

[Jay]

Without over analyzing? You have 6 bullet points!?! :lol:

LMFAO

Go back and read a handful of my posts and you will sadly come to the realization that for me this is not over-analyzing.

 

[Jay]

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.

If they are not admitting pain and don't appear to be in pain than it is definitely BLS. I used 7/10 as an example because local hospitals use this to expedite triage because pain management is a primary concern however if the PT is complaining of severe pain, regardless of the number than ALS would be warranted. Aside from the number you would have other indicators using OPQRST to determine the severity of the injury and how much pain they *should* be experiencing even if they only report little or no pain. I had a PT a couple of weeks ago that was in bad shape, he is on chemo and has stage 4 kidney failure, severe right sided pedal edema and a hernia that would not go back in. He was grimacing and looked like he was in pain but initially said that he had no pain, then he reported 3/10, I bluntly told him that we can make him more comfortable and to stop lying to me and then he finally reported 6 or 7. By that point, once he jumped from 0 to 3, ALS was already in route. It's a common sense thing and not really a numbers thing but my initial response was more in the lines of who would get expedited via triage due to the severe pain and thus also would warrant to be expedited in the field. It should be noted that I gave him 12 LPM via NRB and his pain went down to a 2 in about 5 minutes!!! We also repositioned him and it helped as well. Both are BLS interventions which should be noted. Another indicator is elevated BP, pain tends to do that to a person, his was 200/120 and I knew there was no way that his pain wasn't *severe*.

In this case, did the BLS interventions work? Absolutely.

Was ALS also warranted? Yes.

Just my $0.02 on the numbers.

...and after all this, I was trying not to over-analyze like on previous posts

 

[Charmeck]

How far from the hospital are you? Pain management?

 

[akflightmedic]

How far from the hospital are you? Pain management?

1. Does it matter? Pain is pain and if you have the ability to treat it do you delay/deny care based on how close you are to a facility or do you provide the level of care expected and capable of regardless of distance?

2. Yes, pain management. Is there more to this?


***I have to expand in regards to #1 above and I find it amusing how many times people do not consider the time delays.

Injury occurs-clock starts
911 activated- 0 minutes to 10 minutes on average
Dispatch/Ambo response Let us be kind and say 10 minutes on scene....now post injury 20 minutes
Assessment/Hx Isolated fx, so we can knock this down to 5 minutes (for greetings, SAMPLE, pmhx, etc)

Now decision time...hospital is 5 minutes away (to go with the close facility theory)
Load patient/store gear/check compartment doors/drive away 2-5 minutes
Transport time 5 minutes

We are now 35 minutes post injury for those counting

Unload at ER and wait to give report--- 5 minutes to ...unknown (Peak season in Orlando, Florida has created wait times of up to 2+ hours)...but lets be nice and say 10 minutes

You hand off care and leave.

Nurse does intake assessment and then uses standing orders or gets doc to ok some pain relief 5-15 minutes (we will say 10)

Nurse starts IV (cause we kept this BLS), then gets meds and verifies orders---this could be 10 minutes to 30 minutes on a good day.

Pt finally gets pain meds...1+ hours POST Injury

Now...had this been ALS...pt would have been receiving pain relief in less than 35 minutes post injury.

You tell me which is the better outcome for the injured? And this was only a 5 minute trip to the hospital and in a non-busy ER where the RN is able to do everything right away for this 1:1 ratio they maintain in all ERs (sarcasm).

 

[Aidey]

If they are not admitting pain and don't appear to be in pain than it is definitely BLS. I used 7/10 as an example because local hospitals use this to expedite triage because pain management is a primary concern however if the PT is complaining of severe pain, regardless of the number than ALS would be warranted. Aside from the number you would have other indicators using OPQRST to determine the severity of the injury and how much pain they *should* be experiencing even if they only report little or no pain. I had a PT a couple of weeks ago that was in bad shape, he is on chemo and has stage 4 kidney failure, severe right sided pedal edema and a hernia that would not go back in. He was grimacing and looked like he was in pain but initially said that he had no pain, then he reported 3/10, I bluntly told him that we can make him more comfortable and to stop lying to me and then he finally reported 6 or 7. By that point, once he jumped from 0 to 3, ALS was already in route. It's a common sense thing and not really a numbers thing but my initial response was more in the lines of who would get expedited via triage due to the severe pain and thus also would warrant to be expedited in the field. It should be noted that I gave him 12 LPM via NRB and his pain went down to a 2 in about 5 minutes!!! We also repositioned him and it helped as well. Both are BLS interventions which should be noted. Another indicator is elevated BP, pain tends to do that to a person, his was 200/120 and I knew there was no way that his pain wasn't *severe*.

In this case, did the BLS interventions work? Absolutely.

Was ALS also warranted? Yes.

Just my $0.02 on the numbers.

...and after all this, I was trying not to over-analyze like on previous posts

This was an ALS call for about 5 reasons besides pain management.

 

[FDNYRescueMedic]

In the NYC 911 system a broken arm will come in as a priority 5 call, non-critical injury and automatically dispatched as a BLS call. When the EMT's arrive and start treating the pt. they can request ALS response for pain management.

 

[Outbac1]

1. Does it matter? Pain is pain and if you have the ability to treat it do you delay/deny care based on how close you are to a facility or do you provide the level of care expected and capable of regardless of distance?

2. Yes, pain management. Is there more to this?


***I have to expand in regards to #1 above and I find it amusing how many times people do not consider the time delays.

Injury occurs-clock starts
911 activated- 0 minutes to 10 minutes on average
Dispatch/Ambo response Let us be kind and say 10 minutes on scene....now post injury 20 minutes
Assessment/Hx Isolated fx, so we can knock this down to 5 minutes (for greetings, SAMPLE, pmhx, etc)

Now decision time...hospital is 5 minutes away (to go with the close facility theory)
Load patient/store gear/check compartment doors/drive away 2-5 minutes
Transport time 5 minutes

We are now 35 minutes post injury for those counting

Unload at ER and wait to give report--- 5 minutes to ...unknown (Peak season in Orlando, Florida has created wait times of up to 2+ hours)...but lets be nice and say 10 minutes

You hand off care and leave.

Nurse does intake assessment and then uses standing orders or gets doc to ok some pain relief 5-15 minutes (we will say 10)

Nurse starts IV (cause we kept this BLS), then gets meds and verifies orders---this could be 10 minutes to 30 minutes on a good day.

Pt finally gets pain meds...1+ hours POST Injury

Now...had this been ALS...pt would have been receiving pain relief in less than 35 minutes post injury.

You tell me which is the better outcome for the injured? And this was only a 5 minute trip to the hospital and in a non-busy ER where the RN is able to do everything right away for this 1:1 ratio they maintain in all ERs (sarcasm).

Exactly!

 

[medic417]

Exactly!

I agree. We can speed time to relief and proper care by what we do in the field.

 

[DrParasite]

And you would lose in a court of law. You are showing yourself not to be very knowledgeable.

please cite cases where EMS personnel have been sued and found civilly liable for not giving pain medications prehospitally. I haven't heard of any, but if you actually have the information (as opposed to just posturing and saying you can and will lose) I am sure others would like to hear as well. I mean, after all, you are the knowledgeable one, not me

Pain management is not a new thing in EMS maybe in your area but not the rest of the country. We used to even administer pain meds, splint the broken arm, confirm good pulses and cap refill, verify no adverse affects to pain meds, then send them with their family or friend to the hospital or doctors office.

where? I have NEVER heard that, and would love to speak to a medical director who allows this, so I can give the info to my medical director so we can do the same thing. I would love to be able to take a traumatic injury, call for an ALS to give pain meds, and then be able to just send them to their PMD, it would take a huge burden off the ERs.

As to determining who gets pain meds since when have you been given the ability to see if I am actually in pain or just a drug seeker? How do you determine? Is it because of their skin color? Is it because they are poor? Is it because they have tattoos? Is it because they look like a biker? What?

So you are implying only poor people with a certain skin color who look like bikers and have tattoos are the only ones who are drug seekers? sounds pretty racist of you to make that determination, but hey, you said it not me.

Pretty much unless they tell you they just want a fix it is not your place to withhold pain meds. You do not know how a person responds to pain. What I might say is a 1/10 you might call an 8/10. My vitals do not fluctuate the way many claim they should when I am in severe pain. In fact when I got hurt on a job another medic thought I was faking until the x rays and cat scans were done at the hospital.

gotcha. I'm going to your area next time I want to get high, to complain of pain, so you can shoot me up until I am higher than a kite. Since you won't refuse to give them.

So if I am the drug seekers friend you must be the worst ems person ever.

Well, you are a drug seekers friend, but I'm far from the worst EMS person ever.

I'm sorry, I can't let this go...PAIN indicates pain management. It may be as simple as positioning and an ice-pack. A good portion of pain doesn't need IV narcotics, but if the patient is in pain, it needs to be adressed.

so you just supported my point, and for that I do thank you. Sometimes positioning and an ice pack are all you need to manage the pain, not narcotics which everyone wants to push.

You bet your sweet @ss I am going to let the individual patient presentation dictate how I treat them. Why would I waste my time doing an assesment otherwise?

see, that wasn't what I said. I said you are going to let the patient dictate what happens to them; you just told me that you are going to assess the patient and treat accordingly. Those are two completely different things. In the first case, the patient says "give me drugs because I say so", while in the second, you give drugs because you think they are warranted. There is a distinction there, and if you don't see it, then it's not worth me explaining it to you.

DrParasite, I have worked in busy systems with a high load of abusers. I understand, it's easy to get jaded. What's truly lost if you medicate a chronic system abuser who doesn't need it? Are they going to call more? Doubtful.

I'm sorry what? if a chronic junkie gets pain meds every time they call for the ambulance, you honestly think they aren't going to call more? Like anytime they want a fix and don't have the money to buy some, just call 911 and say their arm is broken and they need pain meds? and if you think that won't happen, then I question what type of busy system you have worked in.

Patient condition? Most EMS service don't give narcotic doses that would even begin to produce respiratory depression. Some narcotics? Most narcotics are generic and dirt-cheap. I respect that your system has chosen a tiered model. However please stop using this to defend the absoloutely pitiful state of pain management in US EMS. It need to be fixed and telling folks the equivelent of "grow some" is not gonna help the situation.

If the EMS system is broken, then get your MD, become a medical director, get on various national level steering committees and push for change.

 

[medic417]

Parasite you are a parasite. No point in wasting time with you. Have a great day.