Would you be able to start BLS, then just switch roles and make it ALS if pain management is needed? We have a policy that if BLS rides as attendant to the hospital, and the pt needs ALS, we can switch, no repercussions for initially judging the pt. BLS.
Staff Systems with More EMTs and Fewer Paramedics
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Would you be able to start BLS, then just switch roles and make it ALS if pain management is needed? We have a policy that if BLS rides as attendant to the hospital, and the pt needs ALS, we can switch, no repercussions for initially judging the pt. BLS.
RocketMedic
Californian, Lost in Texas
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We certainly could, but an all-BLS or tiered system cannot do that.
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Basics can't do anything for pain?
RocketMedic
Californian, Lost in Texas
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Tylenol PO here.
Cold packs, padding, and positioning isn't going to cut it when IV/IN pain management is required, especially when the pt at the sending facility had pain mgmt on board, and needed a maitenance dose enroute, as was the case with Rocketmedic.
A burn victim, someone with abd. pain, or an injury needs Fentanyl or MS. Versed for cardioversion or someone with repeated IACD firings. A feW months ago, while waiting for the helo, I gave a double GSW victim Fentanyl to take the edge off.
There was a thread here a while back about whether or not to give drug seekers pain management. The conclusion is that it's barbaric to allow a patient to remain in suffering, even if it's withdrawal instead of a more proper reason, and it's also barbaric to slam narcan to totally take away an opiod's effects on an addict. Just enough to keep them breathing well.
BLS'ing a junkie that c/o pain in order to get some opiod on board, even though it's wrong, is still barbaric.
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In that scenario, the sending should have used a more appropriate analgesic, or timed it better. Perhaps they would have if they knew the patient was going by BLS.
None of those examples are good arguments against a tiered system, since every one of them would have a paramedic dispatched anyway.
Honestly, I think the pendulum has swung too far in this area. It used to be that analgesia rated as a very low priority and we did a poor job of providing it even when really needed. Now though, I think we take the "everyone deserves fentanyl" sentiment too far. Not every twinge of discomfort requires an opioid. I would agree that it's generally better to err on the side of providing analgesia when it isn't really needed vs. not often enough, but the shotgun approach where we narc everyone up isn't necessarily a good thing. But this is a topic deserving of its own thread.
OP
OP
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I would also submit that tiered systems do not have much of a place in rural areas. Here if the paramedic was not on the first arriving ambulance, it would frequently take half an hour to get a paramedic if a BLS ambulance requested it once they arrived on scene and that is not effective.
If they don't seem to be in any significant amount of pain, I'll defer pain management to the ER. "10/10" said with a straight face and a 0 to 2 on the FACES scale can wait until after triage, for example. I'm liberal with pain management only if it appears that they can really benefit from it, not so much for every little thing. If they appear comfortable, I reason that the ED can hopefully find a non-opiod route to treat them, so that they're not impaired afterwards. I lump in Zofran with comfort care - it's miserable to be nauseous, and even more uncomfortable to vomit. I'm more liberal with Zofran than anything else, for the most part. I don't even need to drop a lock for that one.
I greatly favor a tiered system over an all-ALS system. If a patient needs pain managemernt, call for ALS. For sick calls and abd. pain, if they're stable with no orthostatic changes and clear L/S, they can go BLS. A 12-lead should be performed for any pain between the neck and umbilicus, as well as possible atypical MI signs such as dizziness and nausea. You don't need medics for that either - put a monitor on every BLS unit, have the BLS obtain a 12 -lead, preferably two, and transmit to the receiving ED for interpretation. That's what they do in rural areas where ALS coverage is inconsistent or non-existent. The cost of the monitor should be less than the pay differential between a medic and an EMT, as well as the cost to stock ALS equipment and meds.
Even strokes were BLS in NYC. If they could maintain their airway, and were not hypotensive, they went BLS, a diesel bolus being the priority. That's actually how I roll here - quick vitals and stroke assessment, move to the rig, check BGL, then a line and 12-lead if I have time. That's the only time I don't get the 12-lead on-scene within 5 minutes.
You are correct.
I forgot to mention that a tiered system is most appropriate in a dense urban area, and that becomes more undesirable the more you move towards a rural system. The same goes for FD ALS first response - useless in the city, limited usefulness in suburbia, but invaluable out in the sticks where the ambo is 30-45 minutes away, and the fire station is 5-10 minutes away.
Documentation tip for pain scale - if the pt. calmly says 10/10, but is a 1 on a FACES scale, I go with the FACES scale instead of numeric. Our software gives that choice, but I suppose you could write that in if you need to. That way, QA/QI isn't trippin out over why I didn't medicate the 10/10 pain when it was really a 1 or a 2.
CentralCalEMT
Forum Captain
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I highly agree that tiered systems are extremely beneficial in urban areas. I think in some cases, in urban areas, ALS can be detrimental if you get a medic who wants to play paragod for 30 minutes on scene when a hospital that is a level 1 trauma center/STEMI center/stroke center, etc is a block away.
I also agree that this system has very limited usefulness in a rural setting, unless the rural area was well staffed with adequate numbers and types. I think it would be easier to find a unicorn than a well staffed rural system. Because there are so few ambulances, and ALS fire is non existent in many areas, I think rural systems should be all ALS if possible. My area is all ALS. But then again we have 4 ambulances for 1,200 square miles.
I also agree that this system has very limited usefulness in a rural setting, unless the rural area was well staffed with adequate numbers and types. I think it would be easier to find a unicorn than a well staffed rural system. Because there are so few ambulances, and ALS fire is non existent in many areas, I think rural systems should be all ALS if possible. My area is all ALS. But then again we have 4 ambulances for 1,200 square miles.
NomadicMedic
I know a guy who knows a guy.
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That's a QI issue. Any system that routinely allows it's medics to have 30 minute scene times when a "level 1 trauma center/STEMI center/stroke center, etc is a block away" has bigger issues.
MrJones
Iconoclast
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While I agree with the concept of fewer medics and more EMTs it's with a caveat. EMT as we know it today has to go away (actually, become the standard for First Responder), with what we currently call AEMT becoming the base level for EMTs.
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Why what do AEMT's do (that basics don't) that impacts outcomes?
NomadicMedic
I know a guy who knows a guy.
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I think the base level should be paranedic, with a PCT as an assistant. The PCT training would consist of EVOC, patient movement, customer service and tge skills needed to be a paramedic assistant.
Basic IFT would be done by two PCT and anything that required care would be attended by the paranedic.
But that's a perfect world.
Basic IFT would be done by two PCT and anything that required care would be attended by the paranedic.
But that's a perfect world.
Brandon O
Puzzled by facies
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The Wong-Baker scale is NOT meant as a "what does the patient look like?" chart that can magically transform a symptom into a sign. It's meant for patients who aren't in command of numerical scales to let them point at the icon representing their current pain.
EpiEMS
Forum Deputy Chief
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This is a really good point.
On one hand, it would bring us closer in line with international standards for minimum scope of practice...on the other, I would be hard pressed to think of many life saving level differences. Maybe D50? Maybe?
RefriedEMT
Forum Lieutenant
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I would have to agree with you on this a little because I worked in thurston county jumping calls in Olympia, Tumwater, Rainier, and Yelm and 99% of the time we needed a medic for an unstable pt or pt that was in extreme PX we would be policy 27'd which means that the medics are busy/too far away and we need to BLS them to the ED while they scream bloody murder all the way there.
escapedcaliFF
Forum Lieutenant
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I just read up on a company trying out Paramedic chase SUVs. Basically their thinking is have paramedics in chase SUVs available instead of overstaffing ALS ambulances. Idea is BLS can call for ALS if needed and a paramedic shows up in the SUV and assumes control while one of the basics jumps in the SUV and follows to ED. The company claims they have cut response times and cost associated with calls. Short of like what LA Fire dose but different in some aspects.
NomadicMedic
I know a guy who knows a guy.
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