I am an EMT-B working in OC/LA, California. Yesterday I had a BLS call in OC which I'm having afterthoughts about. Without going into the details, I'm trying to figure out if I missed any signs to upgrade it to ALS. I've been scouring my resources from training and the web for strict standards for BLS to ALS upgrade; things like BP cut-off ranges, specific chief complaints, etc., but I'm not having luck finding an authoritative breakdown of ALS/BLS. Is there a go-to source for these standards anywhere?
Standards for upgrading BLS to ALS
- Thread starter BenP
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You can go into some details. Don't give a name, company, or exact location. Otherwise, we're not exactly in danger of figuring out which BLS call in OC was you...
This is all situationally dependent without strict guidelines.
This is all situationally dependent without strict guidelines.
It's not that I'm worried about being associated with the call. I think I handled it to the best of my abilities without an ALS assist. For my own knowledge, I want to know the guidelines for what constitutes an ALS vs a BLS call. The call itself is not why I'm asking for a resource to help make the distinction. The fire department paramedics I've worked with have medical guidelines for handling calls and judging whether they are BLS or ALS. I get sent to a call like this, and similarly I need to have a better idea of what requires an upgrade. I know I have more senior EMT-B supervisors who can help me make the call and take some of the responsibility away from myself, but how are they better qualified than me to make the decision if there are no clear guidelines in place?
LACoGurneyjockey
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There are absolutely clear guidelines. They're called protocols. Both LA and OC ems have them on their respective websites. There is no BP cut off, no matter how many people will tell you. There is "shock symptoms", but a BP less than 90 does not constitute shock alone. There is no max BP.
Off the top of my head, and LA being the only county of the two I worked for, ALS criteria includes chest pain, difficulty breathing, ALOC, and signs/symptoms of shock. I'm sure there's a few more I'm forgetting. Basically, is the patient sick/not sick?
Sick? Call ALS and remain on scene for Fire, unless your ETA to the nearest ER is less than the ETA for ALS (5-7min in most parts of LA/OC), then transport code 3 ALS to the nearest.
Not sick? Transport BLS code 2.
What was the call? Everyone wants details and we can actually give you actual feedback and advice.
Off the top of my head, and LA being the only county of the two I worked for, ALS criteria includes chest pain, difficulty breathing, ALOC, and signs/symptoms of shock. I'm sure there's a few more I'm forgetting. Basically, is the patient sick/not sick?
Sick? Call ALS and remain on scene for Fire, unless your ETA to the nearest ER is less than the ETA for ALS (5-7min in most parts of LA/OC), then transport code 3 ALS to the nearest.
Not sick? Transport BLS code 2.
What was the call? Everyone wants details and we can actually give you actual feedback and advice.
I had typed it out for the last comment, but decided to wait for someone to post the resource before I gave out details.
For those interested in the call: I responded to an 80-some-year-old patient who mechanically fell at home, under supervision early that morning. Reportedly, she had been caught during her fall. She had left hip and knee pain, was completely A&O and had good vitals that fell WNL. After an assessment that didn't turn up any trauma red-flags aside from pain in the left leg, my partner and I attempted to carry her out to the gurney on a flat; however, the layout of the house wouldn't allow it. Neighbors on scene brought in a seated-walker and suggested she stand and sit on it to be wheeled out. I was uncomfortable with having her sit on anything, but thought a broken flat might be the best option as we already had her on the flat and wouldn't need to GS her or have her stand. She ended up standing with assistance from my partner and a bystander, without pain, and sitting on the walker. No problem. When we got her to the gurney, she stood and was in IMMENSE pain. Said she felt "cracking." I was mortified. We loaded her and I drove. At the hospital, the nurse said he saw shrinking in the left leg, and sure enough I saw it as well. I didn't see it on scene prior to moving her, but in retrospect I know I would have if we had reassessed her leg in the back of the ambulance. No doubt in my mind, it would have been ALS at that point.
For those interested in the call: I responded to an 80-some-year-old patient who mechanically fell at home, under supervision early that morning. Reportedly, she had been caught during her fall. She had left hip and knee pain, was completely A&O and had good vitals that fell WNL. After an assessment that didn't turn up any trauma red-flags aside from pain in the left leg, my partner and I attempted to carry her out to the gurney on a flat; however, the layout of the house wouldn't allow it. Neighbors on scene brought in a seated-walker and suggested she stand and sit on it to be wheeled out. I was uncomfortable with having her sit on anything, but thought a broken flat might be the best option as we already had her on the flat and wouldn't need to GS her or have her stand. She ended up standing with assistance from my partner and a bystander, without pain, and sitting on the walker. No problem. When we got her to the gurney, she stood and was in IMMENSE pain. Said she felt "cracking." I was mortified. We loaded her and I drove. At the hospital, the nurse said he saw shrinking in the left leg, and sure enough I saw it as well. I didn't see it on scene prior to moving her, but in retrospect I know I would have if we had reassessed her leg in the back of the ambulance. No doubt in my mind, it would have been ALS at that point.
LACoGurneyjockey
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The only indication for ALS there is maybe pain control. LACoFD would have sent that BLS. When you say found at home, are you a BLS company responding to falls at home without an ALS FD also responding in LA/OC, or by at home do you mean at a care facility?
Brandon O
Puzzled by facies
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As said, the only point of ALS there (or in most isolated trauma) is pain management. And in many places medics are very unimpressed at being called for that, since they don't like doing it anyway.
If there's a question of a hip fracture, two excellent ways to test are 1) ambulation (as you found) and 2) stressing the femur.
Example:
(I would use the bottom hand to grab the other leg rather than just resting it on the bed; and of course you can ideally do this while they're lying flat.)
If there's a question of a hip fracture, two excellent ways to test are 1) ambulation (as you found) and 2) stressing the femur.
Example:
LACoGurneyjockey
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Considering it's LA/OC, that's a tad sketchy. Your dispatch didn't forward that info to 911?