MVA - BLS or Trauma alert?

[Carlos Danger]

For the sake that I am a higher level of care for the patient and should something go wrong, I can correct it immediately without stopping transport. Unfortunately, liability plays a huge role in my decision process only because my place of employment is too small and can't afford a malpractice lawsuit (even with liability insurance). They put such a heavy emphasis on higher levels of care and the less liability the better. Personally, the only calls I should be on are Trouble Breathing, Chest Pain, Syncope, Arrests, Diabetics, Unknowns, and calls concerning advanced airway management.

Just curious what you can correct in 120 seconds that an EMT cannot?

I understand doing things just to follow policy. Sometimes you have to do things just because the people who sign your checks tell you to.

At my company, the mechanism of injury and the high risk OB makes this an ALS patient irregardless of the transport distance. Also, the OP seemed very uncomfortable taking this pt in the first place, that right there make his paramedic partner very irresponsible and a poor excuse for a medic

Pretty judgmental stance considering you don't know the rationale for what happened.

Even if this were a poor decision, that doesn't necessarily make anyone "a poor excuse for a medic". That's just emotional drivel.

If anyone needs to some additional retraining, maybe it's the hypothetical EMT who is uncomfortable transporting a BLS patient 2 minutes?

 

[emtdansby]

Just curious what you can correct in 120 seconds that an EMT cannot?

I understand doing things just to follow policy. Sometimes you have to do things just because the people who sign your checks tell you to.




Pretty judgmental stance considering you don't know the rationale for what happened.

Even if this were a poor decision, that doesn't necessarily make anyone "a poor excuse for a medic". That's just emotional drivel.

If anyone needs to some additional retraining, maybe it's the hypothetical EMT who is uncomfortable transporting a BLS patient 2 minutes?

I stand by what I said, the mechanism of injury and high risk OB factors makes this patient an ALS patient. Any paramedic that would push a patient on their BLS partner who isn't comfortable taking the patient is a bad partner. Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.
As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.

 

[Carlos Danger]

Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.

It is simple logic:

If a patient does not require ALS intervention, it is not an ALS transport.

This patient did not require ALS intervention.

Therefore, this was not an ALS transport.

Even if you were 15 minutes away, it would still be a BLS call, because there would still be no indication for ALS intervention.

As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.

Basic EMT = BLS transport.

This was a BLS transport.

 

[emtdansby]

So you wouldn't put a large bore IV in this patient? 15 min away and you wouldn't even place an IV? 8 months pregnant, severe abd pain, unrestrained head on collision, and you wouldn't even place an IV?!? What happens when that pain she is having is her placenta tearing from the uterine wall and she starts to bleed out? You're up front and your basic starts yelling for help because the pt is unconscious and has no pulse? Great job Mr. Paramedic. A good paramedic doesn't sit around and what for an need for ALS intervention to be needed, we plan ahead.

 

[emtdansby]

*wait for a need for an ALS intervention. Also, I understand this call was 2 min for the hospital, I am responding to you saying that even 15 mins away, it wouldn't make a difference to you

 

[Akulahawk]

It is simple logic:

If a patient does not require ALS intervention, it is not an ALS transport.

This patient did not require ALS intervention.

Therefore, this was not an ALS transport.

Even if you were 15 minutes away, it would still be a BLS call, because there would still be no indication for ALS intervention.




Basic EMT = BLS transport.

This was a BLS transport.

All I can say is that there's a serious lack of good judgment in that above "simple logic" especially with regard to the specific patient. Your "simple logic" statement above shows me that you're the kind of paramedic that I've met way too often.

If you follow your "simple logic" long enough, you'll find your paramedic license in jeopardy. Serious jeopardy. I hope you never find out why, the hard way.

 

[Action942Jackson]

It is simple logic:

If a patient does not require ALS intervention, it is not an ALS transport.

This patient did not require ALS intervention.

Therefore, this was not an ALS transport.

Even if you were 15 minutes away, it would still be a BLS call, because there would still be no indication for ALS intervention.




Basic EMT = BLS transport.

This was a BLS transport.

As a paramedic, you are a higher level of care then your EMT partner. As a rule I set up when I'm on the rig. My license is my bread and butter. I will in no shape or form, jeopardize that fact. My family depends on me.

I can assure you, if your medical directors were part of this call, they would be rolling over in their scrubs if you even thought about BLSing this call. You don't treat MOI, I got that. But, that baby is another 6-8lbs of free floating weight inside a patient. Not only could you rupture the uterine wall etc, its possible a ruptured diaphragm, cardiac and lung contusions, not to mention an aortic tear can result as the motion of an unrestrained child inside the womb. It's about anticipating what the clinical course for this patient will be. You anticipate the need for ALS interventions as that was obviously going to be done in the ED based on OPs report.

This is just my opinion, but its patient care focused. Not focused on wether or not its ALS or BLS. It's about thinking ahead to know what the hospital will be doing and starting the process during transport.

 

[Handsome Robb]

Short ride, A&O, pink warm and dry and no obvious life threats or anything requiring immediate ALS intervention I've got no issue letting my Intermediate partner ride this call in. With that said my last few partners are all well above average knowledge and skill-wise when it comes to many intermediates I've worked with.

She can toss the NIBP cuff and SpO2 probe on then drop a line in 2 minutes, I wouldn't do anything different...

Now if I've got a shiny new 2 riding with me I'd probably take this call.

From what you described she needs an immediate assessment from a physician. It'd be a trauma activation here. "Trauma Pre-alerts" in my system are different, only can be called with a gsw to the torso, profound hypotension after a traumatic injury or unconscious with a unilaterally blown pupil. Everything else the charge nurse decides which team to activate based on their protocols and my report.

Fetal heart tones/rate along with a FAST exam are high on my list of things I can't do but would like to see done on this patient immediately upon our arrival, this fetus is very viable. That's my 12-hours-of-getting-throttled-at-work brain talking though.

 

[Handsome Robb]

It is simple logic:

If a patient does not require ALS intervention, it is not an ALS transport.

This patient did not require ALS intervention.

Therefore, this was not an ALS transport.

Even if you were 15 minutes away, it would still be a BLS call, because there would still be no indication for ALS intervention.




Basic EMT = BLS transport.

This was a BLS transport.

Pain management is an ALS intervention. Sounds like she needed some and I personally would have no issue giving her some fent provided the transport was longer.

Also unless basics in your area can start IVs your medic should be attending this patient. While we aren't going to use it unless she needs fluids and the aforementioned analgesics it helps the ER out and "kickstarts" the process.

This is all in the event of a longer transport than 2 minutes. If I didn't ride with an I I'd take this call and drop a line on the way in. Takes 30 seconds to do...

 

[Handsome Robb]

Sorry for multiple replys, not trying to do more than one on my phone.

I stand by what I said, the mechanism of injury and high risk OB factors makes this patient an ALS patient. Any paramedic that would push a patient on their BLS partner who isn't comfortable taking the patient is a bad partner. Everyone justifies this as a BLS patient because of the transport distance, which is not and should never be a factor in deciding if a patient is ALS or BLS. If the patient had been 15 min from the hospital, everyone would be saying she's an ALS patient and the only thing thats different is the transport distance.
As for your statement that the basic should consider retraining because he wasn't comfortable taking this patient, I don't see anything wrong with any basic being uncomfortable with taking this patient.

What about an ILS provider attending if your protocols don't allow or the patient refuses narcotic analgesia?

MOI and OB risk factors doesn't automatically make it ALS in my opinion. If you can show me a reason other than "she got in a decent MVA and is pregnant with abd pain" I'm all ears. You can disagree if you like, I'm open to criticism.

My question is, am I a poor excuse for a medic by allowing my partner who's more than qualified and capable to act within their scope of practice? If they weren't comfortable then absolutely, I'm riding it in, if they're comfortable with it why not?

Did an emergent IFT for an "active miscarriage" the other day. Orders were for NS titrated to SBP >90 and code 3 transport. No monitor, no ALS medications, vitals all WNL (please don't shoot me for that one) so the line was running TKO. You bet your *** I drove code and let my partner do her thing in the back. Supervisor and QA/I didn't have an issue with it.

 

[Action942Jackson]

For your agency who allows Is in the field to tech. That might be acceptable. But unfortunately, I come from the land that a paramedic has to take every run.

 

[Action942Jackson]

For your agency who allows Is in the field to tech. That might be acceptable. But unfortunately, I come from the land that a paramedic has to take every run.

 

[Carlos Danger]

As a paramedic, you are a higher level of care then your EMT partner. As a rule I set up when I'm on the rig. My license is my bread and butter. I will in no shape or form, jeopardize that fact. My family depends on me.

I can assure you, if your medical directors were part of this call, they would be rolling over in their scrubs if you even thought about BLSing this call. You don't treat MOI, I got that.

Great job Mr. Paramedic. A good paramedic doesn't sit around and what for an need for ALS intervention to be needed, we plan ahead.

Your "simple logic" statement above shows me that you're the kind of paramedic that I've met way too often.

If you follow your "simple logic" long enough, you'll find your paramedic license in jeopardy. Serious jeopardy. I hope you never find out why, the hard way.

Let's not be quite so dramatics, gents. Reminds of a clique of 14 year old girls when someone tells them their nail polish isn't pretty.

I've been practicing for a long time and my license has never been in jeopardy, nor have my medical directors "rolled over in their scrubs", whatever that means.

Sorry, but you guys are all dead wrong if you think that ALS is clinically indicated for a patient 2 minutes from the hospital. It may be indicated by policy, or tradition, or the expectation of the ED, or what you were taught in school, but it is not indicated clinically. Distance absolutely does make a difference, because transport time is a real factor in the equation that estimates the likelihood of interventions needing to be performed, as well as the time that you might have to perform those interventions.

"I can get an IV in 30 seconds". Give me a freaking break. It takes longer than that just to spike a bag and flush the line. On an easy patient in good circumstances with everything already set up, yeah, maybe. On a pregnant, emotional, fluid overloaded patient, it will likely take longer than 2 min. Are you really going to delay transport for that?

And more importantly, even if you DO get an IV during the 2 minute ride, so what? You are backing up to the ED doors now. Have your magic ALS skills now saved the patient? Did you really do anything important that a basic couldn't have done? Have you made any impact at all on the patient's clinical course?

Now, extend the distance out to 15 minutes, and that changes things a little, I guess, but 15 minutes is still a pretty short transport time. If I were in the back of the ambulance with the patient described, and had a 15 minute ride, would I start an IV? Yeah, probably, primarily for analgesia. You need to be quite cautious about using narcs in a patient like this, though, especially if you can't communicate with her about her history and orientation and pain level. What if she does start to bleed a little a few minutes into the ride? Gonna flood her with crystalloids? Do you carry blood? What if she starts to contract? You gonna giver her terbutaline? A mag load? Really - in 10 minutes? In all reality, if you are honest, you are probably just going to expedite to the ED. Just like a basic would.

You guys should probably keep in mind the very narrow type and % of patients who have been shown to benefit from ALS intervention, and think realistically about how often your interventions make an actual change in the patient's outcome.

 

[medicsb]

So I had a call yesterday that I thought was BLS (I'm an EMT) but ended up being a trauma alert according to the ER. What do you guys think?

Got called to a MVA right across the street from the ED. Two cars involved, head on collision, moderate front end damage, no airbag deployment (don't know why, should have been), no windshield damage, and no compartment intrusion. There were 7 passengers in a 4 door sedan, all unrestrained. 1 person spoke english, my patient did not. Also, my patient was the only patient "injured".

Pt was a 26 y/o female 8 months pregnant c/o abdominal pain. She was unrestrained in the back seat. No obvious injuries found except a small abrasion on the top of her forehead. Unknown LOC. Non english speaking but in obvious abdominal pain. Vitals stable: BP 120/82, P 90, R 20.

Now let me explain what type of system I work in. My partner is a medic and the fire dept has medical control and they have 1-2 medic on an engine. The pt was handed over to me with no spinal immobilization, no IV, not even a SPO2. So this patient was handed over to me with no interventions and no concern from 2-3 medics. Was this an ALS call?

When I arrived at the ED (in 2 mins) there was a trauma team activated and I almost :censored::censored::censored::censored: in my pants! I was so nervous and I did my hand off speaking a million miles per hour. I felt like an idiot! Do you think my partner is going to get in trouble (I actually hope he does) and maybe the fire dept because they have medical control in the field? Do you think this should have been a trauma alert?

Thanks! I needed to get this call off my chest.

Despite knowing that the hospital called it a trauma "alert", I don't see anything that would warrant ALS... Even if you were 20 minutes from the hospital. I spent 3 months at a level II for my surgical rotation and they had a hair-trigger for calling "trauma alerts". A lot of patients had ALS (i.e. an IV) initiated, but, honestly, it was usually meaningless.

Also to consider is that if there is an EM or surgery residency at the hospital, they will make a lot of stuff "trauma" as it is practice for the residents. Hospital that don't have to train docs on how to run traumas are likely to call alerts much less (in my experience).

 

[ccmedoc]

OB trauma is an ALS pt. Should have had a Paramedic in the back for transport, if there was one on scene. Fancy skills and ability to perform procedures aside, the increased "assessment knowledge" that the paramedic is supposed to posses, as well as the ability to recognize decompensation better than the basic EMT warrants this. A lot can happen in two minutes, and some of the subtle changes in condition that may escape a basic assessment should be noticed by a competent Paramedic and communicated to the ED staff. Hemorrhage for this pt is likely NOT to be external, and subtle advanced assessment would provide her with the best care. If time warranted, IV would be appreciated..anybody ever seen a DIC pt decomp and try to establish peripheral access?? You'd be surprised how fast this all happens in the pregnant pt, as they are already coagulopathic..

Am I wrong?? Being in this position, I would NEVER pass this to a basic..Just not a good professional decision..


On a side note, I have been a member here for many years with hundreds of posts before the forum change...before anyone sends the newb flame...LOL Just been "inactive" for a while here..

 

[medicsb]

OB trauma is an ALS pt.

Too absolute. If the patient has "normal" vital signs and a largely benign exam, why do they HAVE to go ALS? We can "what if" anything, but what is the approximate chance of "deterioration" in this patient for which recognition would not be expected of most EMTs? I think <5% (wouldn't be surprised if it were actually <1%).

 

[ccmedoc]

would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, the best chance of recognizing them is by the higher level provider. Although I do recognize there are outliers in every group.

 

[Carlos Danger]

would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, the best chance of recognizing them is by the higher level provider. Although I do recognize there are outliers in every group.

And the fact that a paramedic may recognize a problem quicker than a basic is going to change the outcome?

On a 2 minute transport?

 

[Rialaigh]

OB trauma is an ALS pt. Should have had a Paramedic in the back for transport, if there was one on scene. Fancy skills and ability to perform procedures aside, the increased "assessment knowledge" that the paramedic is supposed to posses, as well as the ability to recognize decompensation better than the basic EMT warrants this. A lot can happen in two minutes, and some of the subtle changes in condition that may escape a basic assessment should be noticed by a competent Paramedic and communicated to the ED staff. Hemorrhage for this pt is likely NOT to be external, and subtle advanced assessment would provide her with the best care. If time warranted, IV would be appreciated..anybody ever seen a DIC pt decomp and try to establish peripheral access?? You'd be surprised how fast this all happens in the pregnant pt, as they are already coagulopathic..

Am I wrong?? Being in this position, I would NEVER pass this to a basic..Just not a good professional decision..


On a side note, I have been a member here for many years with hundreds of posts before the forum change...before anyone sends the newb flame...LOL Just been "inactive" for a while here..

Honestly. I can't think of a single, not one single, situation in which there could be a patient loaded in an ambulance with 0 interventions done, a 2 minute transport time to ER doors, and ALS would make a difference. Not even extremely severe anaphylactic shock. I can have someone with an ER doc in 2 minutes, it would take half that long or as long to draw up the epi, as long to cric. And the body can compensate for not breathing over 2 minutes in anaphylatic shock.

I would just as well have a taxi driver or a firefighter or any layperson that could apply a tourniquet in that ambulance. No MEDICAL reason for ALS ever on a 2 minute transport with 0 interventions done when the clock starts...

Now to cover your butt, follow protocol, and reassure the patient, then yes, highest care provider goes with the patient in a head on MVA with unrestrained persons...



On topic for me - I understand the trauma alert. Even if you take the pregnancy and abd pain out of it you have a unrestrained patient in a head on collision with a head injury and unknown LOC. In most systems this would be "enough" to activate a trauma alert of some form. Now if the patient can clearly communicate they did not hit their head that hard and they had no LOC then sure, but with a patient that does not speak english...trauma alert most places. Not saying its right or good, but its true...

 

[medicsb]

would hate to be the <5-<1%...OB pts are complex to begin with, let alone with trauma Hx and abd pain. 8 months and MVC should increase index of suspicion for injury and bladder rupture, abruption or uterine rupture would be a concern; she would require a higher level of observation initially IMHO...It is situational, I agree, but why not err on the pt side and the probability of a more complex case than it appears on the surface. Subtle signs and complaints can elude any provider, the best chance of recognizing them is by the higher level provider. Although I do recognize there are outliers in every group.

Well, no one wants to be that 1/X patient in any situation. The mention of "c/o abdominal pain" is a vague complaint without physicial exam findings. For the prehospital interval, it is highly questionable as an indication for ALS. Sure, bladder injury is a possibility, but it is unlikely to bleed enough to require ALS. (Yes, I have seen a bladder injury - managed with a foley catheter alone.) Uterine rupture is a very remote possibility (not much ALS is going to do). Abruption is not something that ALS is going to make much of a difference on either. An EMT says "abdominal pain" and they'll be looking for the above - they don't need a paramedic to increase their suspicion (they probably don't know the difference, anyways).

Abd. pain + h/o trauma will likely get this patient watched by Ob/gyn
(and worked up by trauma) no matter what, but that it is not a reason to make the patient ALS in and of itself.