is a broken arm an ALS or BLS call?

[medic417]

Nevermind then. Hopefully there's another ALS unit around who will take care of the heart attack across the street.

There is because we run nothing but ALS.

 

[Veneficus]

respectfully

Well let's see here. There was that laceration I had when I was younger, an easy 8/10 on the pain scale, no pain meds. My wife in intense back labor, 10+/10, no pain management because the nurses couldn't start an IV. My mother's occasional migraines that were so painful she was unable to walk, no pain meds, just lay down in a dark room... I could actually go on for a while with this.

Are you citing an example of poor care as an excuse to deny others care?

I don't really buy the "man up don't be a baby" argument myself. Consider also cultural aspects of pain. In some Asian cultures people need permission to complain about pain. It doesn't mean they don't have pain. Sometimes most grevious.

Likewise, in some other cultures, it is encouraged to express pain and is often done so disproportionately to the injury.

Pain isn't a vital sign, that is a very poor cliche. (I know you didn't start it) A vital sign is an objective finding. Pain is a subjective finding.

Treating pain is one of the earliest tennants of medicine. In my opinion, deciding for a patient what is painful and how bad it should be is poor patient care. Evidence of pain should be recognized and addressed.

Anyone who has read a protocol book know that this is a BLS call.

Is a doctor a BLS provider?

Using the argument that a physician is a definitive provider means that a patient can not be referred to a higher level of care and not be seen by a doctor. Clearly this is not the case. Otherwise even mid level providers would have to refer up.

Even among physicians it is commonplace to refer patients to somebody more educated or experienced when they are available. To do otherwise is not utilizing the best resources for the patient. As an example, an Emergency physician is more than capable of reducing a fx, splinting it, and referring the pt to an ortho follow up. But if there is an available orthopod in the facility, readily available, there is really no reason not to refer the patient. So what if an unstable injury might happen at any moment?

For a more EMS based example, if all ALS units are busy or otherwise unavailable, chest pain or any other call suddenly becomes BLS, with transfer to a higher level as soon as possible. That may mean BLS all the way to the hospital.

Sorry buddy, my CNA certification is the result of 240 hours of combined classroom and clinical experience in a variety of clinical environments. You can push the education point all you want, but I have twice as much education as most EMT-B's.

If your advanced education makes you a more capable care provider, why would you decide or advocate that a patient should not be worthy of a more advanced one?

Just some food for thought.

 

[46Young]

And thus, the fly car was born.
If a fly car is dispatched, then it isn't just a BLS dispatch, is it?

Well, I see you've taken everything I said seriously. I'm not the only one who "needs more education" evidently, but I suppose I can humor you.


I... um... yeah, you took everything I said seriously. Let's keep it simple then:

-The opening post of this thread states this is a simple fracture, no serious complications.
The post mentioned a long bone FX, not a digit.

-Therefore, unless the pt is in pain to the point where pain management is necessary, this is a strictly BLS call.
How can possibly know the true extent of the pt's pain if you're not onscene? No one's attempting to move them, splint, etc. during the initial call to 911.

Well let's see here. There was that laceration I had when I was younger, an easy 8/10 on the pain scale, no pain meds. My wife in intense back labor, 10+/10, no pain management because the nurses couldn't start an IV. My mother's occasional migraines that were so painful she was unable to walk, no pain meds, just lay down in a dark room... I could actually go on for a while with this.
The unavailabilty of pain management does not in any way diminish the indication for it.

It was incredibly stupid, and frankly I see no need to argue "my point". Anyone who has read a protocol book know that this is a BLS call.
Pain management is within the ALS protocols and guidelines, unless you're just using an icepack.

Sorry buddy, my CNA certification is the result of 240 hours of combined classroom and clinical experience in a variety of clinical environments. You can push the education point all you want, but I have twice as much education as most EMT-B's.

Still a far cry from a paramedic's level of education, the lowest level of education that qualifies to make a field determination to start pain management or withhold it. With all the three to five month medic programs, the paramedic level of medical education is arguably weak. What does that say about a CNA's level of education regarding pt assessment and decisions regarding pain management?

If my child were injured, and pain management was indicated, they better be getting it. I wouldn't sue for most things, but if you're going to intentionally hurt my child, by withholding available, indicated pain relief, I'll be going after your job and I'll also see you in court.

 

[46Young]

I never would wait for 8/10 pain. I would ask the patient to rate their pain on the scale and ask if they would like some pain relief, even if it's as low as 2 or 3. It's the patient's emergency and the patient's body.

So let's leave it at this: if this is a fracture with no additional complications, it is a BLS call unless the patient requests pain relief.

Wouldn't you have to be ALS to be able to offer pain management? If it's just a BLS call, then there's no medic onscene to offer that.

 

[aewin90]

Thanks for the civil response, Vene. I have no problem with liberal pain management but the "ALS Everything" crowd irks me, especially when this is a thread regarding a fracture of a BLS nature. And the OP was very clear it was BLS.

At the risk of attracting more butt-hurt medics like flies to a bright light, I withdraw my presence from this thread. :usa:

 

[Dutch-EMT]

How accurate is the dispatcher's information? Here in the U.S. many dispatch centers use the EMD flip chart. These dispatchers typically have no medical experience and can only ask questions, refer to the appropriate page, ask a few more questions, and then arrive at the appropriate call type. Too many calls are given a higher level dispatch classification. Also, the dispatchers here don't have the authority to triage over the phone and deny the caller an assessment by the ambulance crew.

The dispatchers are mostly (former) ambulancenurses, (former) ambulancedrivers or former ER/CCU/ICU-nurses. They have authority to triage over the phone and can deny the caller an assessment by ambulance-crew.

 

[46Young]

Nevermind then. Hopefully there's another ALS unit around who will take care of the heart attack across the street.

Well run depts will acheive proper staffing and deployment objectives. Pain management is a function of the ALS level of pt care, as is the management of retrosternal cx pain. Who gets the first ambulance dispatched to their location is decided by the agency's protocols for call types. In all cases, I would think, a cardiac cx pain would receive a higher priority than cx pain. We all know this.

In addition, we could be dispatched to someone that said they have cx pain just to get a timely response, when they have anything but, in reality. There could be a cardiac arrest a block away. Once, this actually happened. We heard the arrest job come over, and then told the pt that someone is probably going to die because we're here because of your fraudulent cx pain claim, and the next available ALS is greater than 10 minutes away. At least in the case of the pain management case, we're providing legitimate ALS.

Another strawman argument.

 

[Sassafras]

Hmm, considering the only ALS unit around here keeps 2 crews total and many times end up having to run BS BLS runs because there are so few other units around here...we are probably not going to call ALS. However, there is an over dependance on ALS from other units and the medic unit is starting to complain that they can't help the serious needs due to running non stop BLS calls.

WIth that in mind though, I think whoever mentioned asking the patient may be on the right track. If the patient is fine with their pain level, who am I to force medication on them? However, again, if they request it, then I should call for back up.

Reminds me of the transport we did recently though. We were only BLS capacity interfacility transport. Hosp to nursing facility post fall that fx 3 ribs. Intense pain. Refusal to open eyes pain. Hosp said not due for more meds. We said 'she seems to need it'. Hosp said nursing home will dose at due time. Luckily it was a 5 minute transport but station was 30 minutes away so access to our medics was not there. She cried the whole way there and we started rooting through her paperwork looking for her last dose as soon as we could and told the nurses there what time the last dose was so they knew to help her ASAP. Hosp was lazy. She was due for more meds, and simply refused. Luckily nursing home got to her as soon as she was admitted and settled in bed.

She needed medication.

My 3 bones broken in my hand did not.

I think this all goes back to watch your patient, assess and reassess.

 

[46Young]

And the OP was very clear it was BLS.
No, the OP asked if it was BLS or ALS, which is the nature of the whole discussion.

At the risk of attracting more butt-hurt medics like flies to a bright light, I withdraw my presence from this thread. :usa:

Apparently you haven't read my signature:
When the debate is lost, slander becomes the tool of the loser."
— Socrates

 

[46Young]

The dispatchers are mostly (former) ambulancenurses, (former) ambulancedrivers or former ER/CCU/ICU-nurses. They have authority to triage over the phone and can deny the caller an assessment by ambulance-crew.

That would be highly desireable in our country. The problem is, we live in a severely litigous society. It's difficult to find any medical directors that would put themselves at risk for denying ambulance txp. It takes only one pt with an untoward outcome to derail any attempts at a telephone triage program. Tort reform would be necessary to do this.

 

[lightsandsirens5]

Too many variables for such a simple question.


How was it broken?
What type of pain is the pt experiencing?

That ^

It all depends on what is going on.

Caused by a crushing injury, took 30 minutes to extricate, open fracture, major blood loss, pt screaming in pain? Maybe a medic would be a good thing.

Caused by slipping on a puddle of water in the kitchen, no deformity, slight swelling, pt in some pain, but not debilitating? Prolly just a BLS call.

Just my $0.02

 

[rbromme]

After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call? Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction. I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level. I am just wondering how anyone learned to do anything before medic school.

 

[18G]

What route does everyone prefer when giving a pain med in the case of an isolated fracture? Do you just give an IM injection or do you always start a line?

I prefer to start a line in case of an adverse reaction or nausea. Granted Zofran can be given IM as well but an IV will save the patient an extra stick if they need it.

 

[TransportJockey]

What route does everyone prefer when giving a pain med in the case of an isolated fracture? Do you just give an IM injection or do you always start a line?

I prefer to start a line in case of an adverse reaction or nausea. Granted Zofran can be given IM as well but an IV will save the patient an extra stick if they need it.

For a little pedi, I'll consider IM, or some companies here are experimenting with IN fent. For adults, I'll usually go for a line

 

[Veneficus]

After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call? Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction. I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level. I am just wondering how anyone learned to do anything before medic school.

Part of the issue is that EMT-B at one time was meant to identify and make basic decisions about treatment and transport in a time when ALS was not as independant as it is now.

What is now going to be the 2 prior revisions of the EMT curriculum, in order to make the class shorter and easier to pass for the purpose of cheaply increasing the number of providers, a "skills" based curriculum was put in place.

Compared to many of the original programs this new "advancement" took away a lot of educational components such as more advanced classroom clinical science and a field internship that was 50% or more of the the entire current EMT-B program.

With the skills approach also came the evolution that the EMT-B is best suited for rendering aid in the most extreme of emergencies. These types of emergencies are less than 5% of the total responses. That means the EMT has skills that will help in only a minority of situations they are called to respond to.

When you add in ALS response, it marginalizes the EMT-B even more. In tiered response systems and more rural areas, the EMT-B is still a primary contact for medical care, but these opportunities are becomming more scarce. Making a decent living at it even more remote. (not to say it can't be done, only that it can be done in a handful of places)

By default a paramedic is becomming the minimal level of training required to be employed or functonal in prehospital care from the practical point of view in modern US society.

That is why more and more, having any "experience" as an EMT prior to becomming a medic doesn't carry the benefit it once did.

In all societies as the collective knowledge of man increases so does the minimal education required in order to be of benefit to society, and therefore value.

In short, when EMTs became skill based, they basically eliminated themselves from the market.

 

[46Young]

After reading all these replies and starting off with the "I don't know crap" since I just got my cert, is there any call that is not an ALS call? Following some of the arguments one here, it would seem that EMT's should only be allowed patient contact after the medic has said so and maybe to take vitals at the medics direction. I will be the first to say that EMT training is very very basic and needs a huge upgrade in knowledge level. I am just wondering how anyone learned to do anything before medic school.

It depends on the area. Some systems are all ALS. Others are tiered to varying degrees. In NYC for example, a stable asthmatic can be BLS, a serious one is ALS. OD/intox - BLS, unconscious - ALS. Abd pain and sick jobs are BLS, Cx pain and the hypotensive are ALS. Injury major/minor are BLS, the confirmed multi trauma can be ALS. EDP's are BLS. AMS is ALS. An allergic reaction is BLS. The anaphylaxis is ALS. MVA's are BLS. The pin job will deploy ALS.

 

[DrParasite]

If my child were injured, and pain management was indicated, they better be getting it. I wouldn't sue for most things, but if you're going to intentionally hurt my child, by withholding available, indicated pain relief, I'll be going after your job and I'll also see you in court.

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.

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.

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.

How accurate is the dispatcher's information? Here in the U.S. many dispatch centers use the EMD flip chart. These dispatchers typically have no medical experience and can only ask questions, refer to the appropriate page, ask a few more questions, and then arrive at the appropriate call type. Too many calls are given a higher level dispatch classification. Also, the dispatchers here don't have the authority to triage over the phone and deny the caller an assessment by the ambulance crew.

For example, if you trip and fall, and injure your ankle, you may call 911. The dispatcher, in using the EMD manual, must ask a whole array of questions, such as "Do you have difficulty breathing?" and such. The pt, in dealing with the pain, may in fact be breathing heavily. Now it's an ALS call. Same thing for someone with a productive cough that's sore from days of dealing with the cough. Now, instead of a BLS sick call, it's now an ALS chest pain. The pt may be 20 years old with no other inclusion criteria suggesting a cardiac event, just the "chest pain."

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.

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....

Never wait for 8/10 pain. If they hit 3/10 sometimes less based on presentation they get pain meds. It is easier and safer to low dose pain meds early rather than trying to catch up later. And the pain may not be there at the start of transport so BLS crew cancels ALS then driver hits bump and wow pain is extreme now but basic can do nothing. That is why it should have ALS.

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 thinking

ALS intercepts are a bad idea. I do not want you splinting my broken bones until I get pain meds on board. And if a BLS ambulance shows up then I have to lay there screaming in pain while you request ALS and wait for them to get there.

see, 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.

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

 

[Outbac1]

Wow !! 10 pages for a simple question.

A simple closed arm fx w/o complications could be managed by someone with a first aid card and car. Doesn't mean thats the best way to manage it.

Here you would get the closest available unit, BLS or ALS. Keep in mind our BLS is not the same as the USA. Pain management needs to be a consideration and be properly assessed. I've had pts tell me they are in 10/10 pain(for whatever) and show absolutly no signs of being in pain. Conversly I've had pts with 4/10 that were obviously in agony. Pts need proper assessment and then appropriate treatment. If they need pn management, they need it, sooner not later.

How soon can they get the appropriate tx. Pts may wait in the ER a long time before being seen and treated. Perhaps it is better to have ALS intercept and give the pn management before the pt gets to the hosp and waits in line.

Should you pull in an ALS unit to intercept? Sure, the call you have always beats the call you might get.

Here just because an ALS unit gives pain meds does not mean they have to stay with the pt. Our BLS crews routinely transport pts with pain meds on board.

 

[medic417]

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.

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

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.

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? 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.

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

 

[Flight-LP]

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.

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.

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.

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

I'd love to be in that courtroom when you boast your uneducated BS. You are WRONG on all levels.

You will lose in court.

You will lose if reported to your responsible regulatory agency.

You will lose if pursued through an employer.

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.

Quit while you are ahead, you are giving your fellow EMT's a bad name with the ignorance you are spouting.