MVA - BLS or Trauma alert?

[Handsome Robb]

"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.

Other's have pointed it out you're only looking at ALS from an intervention standpoint. ccmedoc pointed out the more in-depth knowledge of a competent paramedic which is a plus but even then, I will agree it's tough to do a real thorough assessment in two minutes without a language barrier. Someone was talking about a study about survivability of traumatic injuries when transported POV (homeboy life support), BLS or ALS. I'll see if I can find it. I know Philly cops used to and may still transport GSWs in squad cars.

Ok, I'll agree 30 seconds was a little ridiculous but yes, I will say I'm confident I could get a line started during transport without delaying it. Is it going to change her outcome at all? No, probably not but it's one less thing for the trauma team to do. In trauma our job is to get the patient to definitive care and help "kickstart" the process. Who care's if I don't use the IV, they generally will. I try not to go around starting IV's in patients that don't need them. With that said, who cares who starts the IV as long as it gets started? If I'm doing it enroute and not delaying transport why is it a big deal. If you want to base this on interventions than yea, it should be an ALS call because she's going to get a full abdominal workup.

As far as analgesia in this patient I agree you have to be careful, but there's no reason you can't start in small doses to "test the waters". Again, I'm not saying blindly give narcotics to this patient but without any absolute contraindications I see no reason smart, conservative dosing would be out of line. Fentanyl is a category C medication. The OP stated the patient was in "obvious abdominal pain". People always cite "their pulse and BP weren't elevated so they weren't really in pain". That's not true at all, I've seen plenty of people with "normal" vital signs with obvious, painful injuries. If you can get a decent translator to do a better assessment you're golden, if not then I agree with withholding narcotic analgesia. I'm referring to calls with a longer transport time.

I don;t really see the connection between fentanyl and bleeding. If she's going to start bleeding she's going to start bleeding, the fentanyl isn't going to make a difference either way...no I'm not going to flood her with crystalloids and no we don't carry blood but titrating NS for permissive hypotension is the only option we really have...

We don't carry terbutaline and I'd have to call for orders for mag, unless I have a decently long transport time there's no point, as you pointed out.

 

[Handsome Robb]

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.

For the sake of me feeling argumentative, a complete FBAO relieved with direct laryngoscopy and magills.

Sorry, my buddy had a cardiac arrest secondary to a choking yesterday so this popped out at me. Plus I'm in a shiesty mood after the day I had today at work so my apologies.

 

[NomadicMedic]

Cardioversion is another...

 

[Rialaigh]

There are obviously no absolutes but in the vast majority of calls (99.999%) a taxi driver can take someone 2 minutes as effectively as a doctor can from the standpoint of discharge outcome....you can always find a situation to fit the one exception...

 

[emtdansby]

All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view.
There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. With just those facts, would you ALS this patient or not?

 

[NomadicMedic]

I think you're missing the point of the argument. The length of the transport defiantly makes a difference. A two minute transport with no immediate life threat is not an ALS transport. Let's remember that ALS means advanced life support and if you don't support the patients life in an advanced manner, you're not performing ALS.

So it may be a paramedic riding in, but its still a BLS call.

I may ride across the street to the hospital with the patient, but I am not going to delay the transport or access to the doc so I can play "super medic".

 

[emtdansby]

I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient.
Also, there is now way you could tell the patient had no immediate life threats. That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.

 

[Handsome Robb]

I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient.
Also, there is now way you could tell the patient had no immediate life threats. That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.

Anything that's truly "immediately" life threatening will generally be revealed. Im talking something that is going to kill them in the next few seconds to minutes. Airway issues, uncontrolled external hemorrhage, tension pneumothorax, things of that nature. So yes, we can absolutely tell if there are any immediate life threats, from the EMS point of view.

 

[Rialaigh]

All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view.
There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. With just those facts, would you ALS this patient or not?

I would absolutely ALS the patient....for reasons that are nothing medical. If I'm the medic I'm running this patient 2 minutes in even if I don't say a word to the patient and do nothing, just so I don't get my butt reamed when I get back to the station or get off shift....sad but true...

 

[Carlos Danger]

All right, I think we are getting a little far off from the center point of this debate. Just to add, I am enjoying all the different points of view.
There seems to be a lot of focus on how far the patient was transported. Let's step away from that and look at just the patient and the MOI. 8 months pregnant, head on collision, obvious abd pain and an unrestrained passenger. With just those facts, would you ALS this patient or not?

If there was a paramedic on scene (i.e., you don't have to wait for one) and there was a significant transport time, say 30 minutes or more, yes.

If I'm 10 or 15 minutes from the hospital, no. The chances of something going bad that the paramedic can do anything about in that amount of time are very, very slim. The paramedic should stay in service in case a call comes out where he really can make a difference.

I am a proponent of EMS systems that are composed primarily of BLS ambulances which are staffed by well-trained EMT-B's who aren't afraid of sick patients and are augmented by paramedic (or physician) fly cars which are only dispatched for certain criteria.

I'm not trying to play super medic. I certainly not delay transport to piddle around. What I'm trying to say is the medic should've been the crew member taking care of the patient.
Also, there is now way you could tell the patient had no immediate life threats. That's why I am putting so much on MOI , risk factors and her CC. Only the hospital is really gonna be able to tell what is going on with this patient internally.

You could tell she had no immediate life threats because she was walking around and talking.

Deaths from trauma generally follow a try-modal distribution in terms of when they occur (actually, the research on this stuff is evolving, but even if not 100% technically correct, I think it's a useful conceptual model):

• Immediate deaths occur immediately or before anyone even arrives on scene. These are your classic "non-survivable injuries"; massive CNS injury, massive myocardial trauma, immediate exsanguination from large vessel transection, etc. The only "treatment" for these is prevention; nothing whatsoever can be done once they've happened. So these are of no concern for EMS.
  
  
• Early deaths occur secondary to severe injuries which will cause death within a few hours of the accident if not treated. This group is the focus of the "golden hour" concept.
  
  
• Late deaths occur several days or more after the trauma. They are a result of secondary complications which manifest in organ failure. This is your SIRS, sepsis, DIC, MODS, ARDS, etc. These are not really a concern for EMS.

The focus of EMS care is obviously on the 2nd group, the "early deaths".

The problem is, "early" does not mean "immediate". If someone looks fine right now, they are not going to be in extremis in 5 or 10 minutes. We've been waay oversold on the idea that someone can look fine now, but still need to be in surgery within an hour.

I'll give you that OB is a little bit of a wild card, because it is another opportunity for trauma and complications. But still, life-threatening conditions take time to develop, and even once they do, there is little effective treatment that can be rendered in the back of an ambulance, even by a paramedic.

Generally, if someone is really sick, they look it.

And the other thing is that we overestimate the difference that ALS makes in outcomes, anyway. There are very few times that having a paramedic vs. an EMT-B really affects how the patient turns out.

 

[LEB343]

After reading all the comments and talking about this situation with other medics, I completely understand why the hospital called a trauma alert. I guess with my limited "basic" knowledge, I didn't realize that at first. I also see why this was a BLS call, mainly because of the short transport time.

The system I work in is an overly cautious one. That's why I was so shocked when I arrived at the hospital and a trauma alert was called. Normally I wouldn't have attended on this call and I haven't had any experience attending on trauma alerts. Because there were 2 medics on scene, I am surprised that neither did an assessment. This call was hard on me afterwards because I should have done a better job. All I can do is learn from this call and do better next time. I appreciate everybody's advice!

 

[Wheel]

Nobody is disputing it is a trauma alert for a hospital, we are saying ALS is not going to make a difference.

Exactly. ALS will make no difference, except having access ready for the hospital (which they can do themselves if they need it.) Definitely a trauma alert on their end.

 

[Bullets]

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.

What would cannulating a vein do for this patient? No LOC, no immediate life threats, stable vitals, why does this patient need another hole in her? If the patient becomes unresponsive and pulseless then your Basic partner has all the tools and training needed to save the patient, his hands and an AED. And what if her abdominal pan is muscular?

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.

Sou you would start an IV just because you can? when the patient doesnt need IV fluids? Because you have the training is not a reason to stick her

I would absolutely ALS the patient....for reasons that are nothing medical. If I'm the medic I'm running this patient 2 minutes in even if I don't say a word to the patient and do nothing, just so I don't get my butt reamed when I get back to the station or get off shift....sad but true...

If you dont do anything besides get a base vital, then its a BLS treat and transport, regardless of your actual certification

 

[usalsfyre]

What would cannulating a vein do for this patient? No LOC, no immediate life threats, stable vitals, why does this patient need another hole in her?

There's something to be said for having access prior to circulatory collapse.

If the patient becomes unresponsive and pulseless then your Basic partner has all the tools and training needed to save the patient, his hands and an AED.

:rofl::rofl::rofl:

How is an AED going to treat arrest from blood loss? How is CPR?

And what if her abdominal pan is muscular?

Medics have drugs for that. Basics...not really.

Sou you would start an IV just because you can? when the patient doesnt need IV fluids? Because you have the training is not a reason to stick her

No, but my index of suspicion here is definitely high enough I would have a line in case it is warranted later. Think down the road aways.

If you dont do anything besides get a base vital, then its a BLS treat and transport, regardless of your actual certification

The problem is the majority of basics I know are WOEFULLY inadequate at recognizing early stage shock. Which is the key here.

 

[usalsfyre]

I am a proponent of EMS systems that are composed primarily of BLS ambulances which are staffed by well-trained EMT-B's who aren't afraid of sick patients

I want to focus on this line from Halothane's post. In an ideal world this is absolutely the way EMS should probably work. However, how many EMTs do you know that fit the criteria of well trained (think of the mean, not outliers on either end). It's very, very few. Further there's far too little Basics can do to help make patients comfortable.

Maybe the AEMT level is the answer, maybe not. Right now though there are far too few basics that are able to recognize and be comfortable with sick patients to make me think medics aren't needed on a wide scale.

 

[Bullets]

There's something to be said for having access prior to circulatory collapse.


:rofl::rofl::rofl:

How is an AED going to treat arrest from blood loss? How is CPR?


Medics have drugs for that. Basics...not really.


No, but my index of suspicion here is definitely high enough I would have a line in case it is warranted later. Think down the road aways.


The problem is the majority of basics I know are WOEFULLY inadequate at recognizing early stage shock. Which is the key here.

Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally

I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it.

Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep

 

[usalsfyre]

Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally

You prove the point of my last post rather beautifully here.

I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it.

Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep

2 min with no medic available, absolutely. 2 min with a medic? Interventions or not, it's pretty weak to have your lower level partner ride this call. 15 minutes? Abso-freaking-loutely this is a medic level call.

 

[Carlos Danger]

Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally

You prove the point of my last post rather beautifully here.

What was your point?

 

[usalsfyre]

What was your point?

Basics (heck, most medics) are woefully inadequate at recognizing issues early. A complete shot in the dark, but I would bet fewer than 20% of basics nationwide have the assessment acumen to figure out who might go bad without it slapping them in the face.

 

[Akulahawk]

Where are you getting circulatory collapse? Where are you getting cardiac arrest from blood loss? I dont see anywhere in OPs post that states she was bleeding, even vaginally

I would challenge any Medic to get a baseline, start a line, draw and push IV narcs in under 120 seconds and i feel pretty confident no one could do it.

Ultimatley with a 2 minute transport time, this is a BLS call in a two tiered response system. No point in waiting for MICU to arrive and do the advanced dance when you are on the Hospitals doorstep

Has everyone forgotten that this patient had (at least 2) medics on scene while waiting for the ambulance to arrive. There's much that those medics could have done prior to ambulance arrival. That's "free time" as far as transport time is concerned... Also, has everyone forgotten that the partner that didn't do anything was also a medic who, in all likelihood, didn't asses the patient himself either. So, yes, there was an MICU on scene.